1/5. Bow hunter's syndrome in the setting of contralateral vertebral artery stenosis: evaluation and treatment options.STUDY DESIGN: A case report. OBJECTIVE: To illustrate a rare case of bow hunter's syndrome in a patient with significant contralateral vertebral artery (VA) occlusive disease. SUMMARY OF BACKGROUND DATA: Bow hunter's syndrome is an uncommon condition in which the VA is symptomatically occluded during neck rotation. This case is interesting in that the patient had what appeared to be a normal right VA and occluded left VA when the head was in the neutral position. When the head was rotated 45 degrees to the left, the patient's right VA was occluded (bow hunter's finding), and it became apparent that the left VA was not completely occluded (as it appeared in the neutral position angiogram) but rather was 90% stenosed. The complete occlusion appearance in the neutral position was an angiographic phenomenon caused by competitive flow through the open right VA. When the patient rotated his head to the left, he occluded his right VA and had insufficient blood flow through the left VA, thus creating a symptomatic ischemic state. methods: This case was studied using dynamic computed tomography imaging, single-photon emission computed tomography, transcranial Doppler ultrasound, brain stem auditory evoked potentials, and dynamic range-of-motion cerebral angiography. RESULTS: The patient demonstrated bow hunter's syndrome as documented on clinical examination and history. Transcranial Doppler studies, dynamic computed tomography scanning, and cerebral/cervical angiography confirmed the diagnosis and revealed an interesting angiographic pattern, which explained the patient's symptoms and findings only when angiographic flow patterns were taken into consideration. CONCLUSIONS: Bow hunter's syndrome should be suspected when a patient presents with reproducible vertebrobasilar symptoms on rotating the neck. Quantitative documentation using imaging and electroneurophysiologic tests is important when assessing this subjective process. Careful evaluation of the angiographic imagescan often help explain an odd flow pattern and provide the physician with a range of treatment options.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/5. The "drip-and-ship" approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center.PURPOSE: Acute stroke therapy with intravenous (IV) tissue plasminogen activator (t-PA) is vastly underutilized. Increasingly, patients are being started on IV t-PA and being transferred to regional stroke Center programs, where additional therapies can be offered in a multimodal format. We describe our experience at the stroke Center at Hartford Hospital with interhospital patient transfers who received IV t-PA prior to transfer to our medical center. methods: A retrospective analysis of our Acute stroke Therapies database was undertaken, encompassing the intial four-year period of our stroke Center program (May 1, 2001 to April 30, 2005). We evaluated the patient characteristics, clinical outcomes, and adjunctive therapies of patients who were started on IV t-PA at referring hospitals prior to their emergent transfer to our stroke Center. RESULTS: From a total of 229 patients who received IV and/or IA thrombolysis and newer catheter-delivered devices or clinical trials at our stroke Center, a total of 33 (14.4%) were started on IV t-PA at an outside hospital prior to transfer. Symptomatic hemorrhage occurred in one of the 33 patients (3.0%), and in-hospital mortality rate for these patients was 6.1%. A total of 26 patients (78.8%) had a positive outcome in that they were discharged either to home or to acute rehabilitation. CONCLUSIONS: Use of IV t-PA in a "drip-and-ship" approach is growing at the regional stroke Center at Hartford Hospital. This protocol is safe and offers several advances for the care of patients with AIS: (a) empowering emergency physicians and neurologists at outside hospitals, via access to a 24/7 Acute stroke Hotline, to treat patients with AIS; (b) facilitating the early initiation of IV t-PA; and (c) offering adjunctive therapeutic approaches, following arrival at our facility, for patients not sufficiently improving with IV t-PA alone.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/5. Fatal epistaxis in craniofacial trauma.Facial trauma often results in minor and infrequently results in major bleeding in the structures of the face. We have recently observed two patients who suffered fatal hemorrhages which could have been controlled using relatively simple measures. Treating physicians often overlook this serious and potentially life-threatening source of hemorrhage until the patient has been in shock for long periods of time and irreversible ischemic brain damage and renal failure have occurred. With careful attention to examination of the face and oropharynx, hemorrhage from these sites can be identified early and the appropriate measures taken to control epistaxis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/5. Interphysician agreement in the diagnosis of subtypes of acute ischemic stroke: implications for clinical trials. The TOAST Investigators.To test interphysician agreement on the diagnosis of subtype of ischemic stroke, we sent subtype definitions and 18 case summaries (clinical features and pertinent laboratory data) to 24 neurologists who have a special interest in stroke, and asked them to determine the most likely subtype diagnosis. The overall agreement was 0.64 (Kappa [K] = 0.54). Interphysician agreement was highest for the diagnoses of stroke secondary to cardioembolism (K = 0.75) or to large-artery atherosclerosis (K = 0.69). Individual physicians varied widely; four agreed with the consensus diagnosis in all 18 cases, while six others disagreed with the consensus diagnosis in three to five cases. Our level of interphysician agreement is greater than that reported in other studies and was substantial. However, despite using subtype definitions and being given extensive information often not available in the acute setting, physicians still disagree about the etiology of stroke, particularly in regard to stroke due to small-artery occlusion or of undetermined etiology. physicians seem reluctant not to attribute stroke to a specific etiology. The uncertainty about subtype diagnosis will affect interpretation of the results of clinical trials in patients selected by the subtype of ischemic stroke and also suggests that results of treatment as affected by subtype should be cautiously interpreted unless efforts to assure uniformity are included in the trial's operations. Refinement of algorithms for determining subtype of ischemic stroke do improve interphysician agreement. Such criteria should be applied strictly, and trials should include measures to assure the most uniform diagnosis of stroke subtype possible.- - - - - - - - - - ranking = 10keywords = physician (Clic here for more details about this article) |
5/5. Causes of ischaemic stroke in the young.The causes of ischaemic stroke in young adults are many and diverse. Such patients usually require more extensive investigations in order to find an underlying cause than more elderly patients. It is important that a comprehensive search is made since many of the underlying disorders are treatable. Principal causes are extracranial arterial dissection, cardioembolism, premature atherosclerosis, haematological and immunological disorders and migraine. Drug abuse is becoming increasingly important but the risk of stroke in pregnancy remains unclear. Isolated angiitis of the central nervous system, heritable disorders of connective tissue and other genetically determined disorders (mitochondrial cytopathies, CA-DASIL) account for a small proportion of ischaemic strokes in the young. Management is probably best undertaken by a physician with a specialist interest and, if full investigation fails to elucidate a definite cause, the risk of future stoke is low.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |