Visual syndromes & cortical blindness

Visual syndromes related to cortical blindness

Syndromes
Anton syndrome
Balint syndrome
Charles Bonet
Capgras delusion
Cortical blindness
Fregoli syndrome
Prosopagnosia
Riddoch syndrome
Subjective doubles
Visual agnosia


Anton versus Charles Bonet
Anton - no insight, cortical lesion
Charles bonnet - insight, cataracts

Stroke - Lipids

Stroke - Lipids

Atorvastatin
10 mg/d - no stroke and LDL at goal, or stroke and low LDL
20 mg/d - stroke and LDL is at goal
80 mg/d -  stroke and LDL high or undefined

DSA - Preprocedure

Digital subtraction angiography - Pre-procedure
António Caetano de Abreu Freire Egas Moniz
Portuguese neurologist and the developer of cerebral angiography

Definition
- DSA means that everything that is not moving is subtracted

Pre-procedure
- anesthesia evaluation
> NPO for 6 hours
- informed consent
> if medical emergency, consent can be waived
- foley catheter insertion after anesthesia
- proper patient positioning
- handwashing
- cleaning of puncture site
- draping

Instrumentation
- test equipament w/ NS heparinized

Access needle
- size 18/19 G
- one versus two versus micro-puncture
one-piece
> sharp, guidewire direct introduction, both A&V access
two-piece
> blunt, before guidewire remove stylet, arterial access
micro-puncture
> small access, use dilator
- dilator
> plastic catheter for dilation

Sheaths
> open at one end w/ capped hemostatic valve in the other
> prevent bleeding

Guidewires
- double-cover, preventing unwinding if it breaks
- lower G than access
- SIM1, SIM2

Contrast
- normal eGFR - up to 800 ml omnipaque
- CKD - iodixanol

Radiation safety
- lead apron
- radiation monitoring batch

Technique
- every time you remove the catheter, you need to double-flush
- long-run or road map
- only two ways to manipulate cattheter, in-out or rotation

Stroke - Afib and LAAL and LAAO

Stroke - Afib and LAAL and LAAO

Considerations
- stroke due to Afib after full anticoagulation
- stroke due to Afib and cannot use anticoagulation

LAAO and LAAL
LAAO
- watchman and amulet

LAAL
- lariat and sierra


Clinical trial - APLS and stroke

Clinical trial - APLS and stroke

Clinical trials
APASS-WARSS (2004)
- warfarin has the same effect of ASA in preventing ischemic episodes

RAPS (2016)
- warfarin has the same effect of rivaroxaban in preventing ischemic episodes

TRAPS (2018)
- warfarin is superior to rivaroxaban in preventing ischemic episodes

ASTRO-APS (2022)
- warfarin is superior to rivaroxaban in preventing ischemic episodes

RISAPS (ongoing)
- warfarin versus rivaroxaban

Clinical trial - apixaban and stroke

Clinical trial - apixaban and stroke

Clinical trials
ARISTOTLE (2011)
- apixaban is superior to warfarin in stroke prevention and lower bleeding

AVERROES (2011)
- apixaban is superior to ASA in stroke prevention and same bleeding risk

ARISTOTLE INR (2014)
- apixaban is superior to warfarin in stroke prevention and lower bleeding

AUGUSTUS (2019)
- apixaban monotherapy is superior to VKA or a combination of apixaban to ASA, regarding bleeding risk

Stroke - ICH

Stroke - ICH

Hemorrhagic transformation scale


Clinical trial - aortic atheroma and stroke management

Clinical trial - aortic atheroma and stroke management

Considerations
- > 4 mm is high grade

Clinical trials
ARCH (2014)
- Aortic Arch-Related Cerebral Hazard
- ASA + clopidogrel is superior to warfarin


EEG - Basics

EEG Basics

International 10-20 system
> nasion & inion
> LORE system - left is odd, and right is even

How to place a routine EEG
- paper rule for 10-20 system
- mark w/ the pen the locations
- cotton swab to open the hair, place the gel, and place the paste, and last the sticker
> gel is nuprep (green); pasta is ten20
- start by middle back going to the front, then place the right, and after the left, and by last the ECG
- take the leads from near the machine, and follow to the end of the lead
- look at the monitor needs to turn green in machine
- last two leads are cardiac, one on each side of the thorax
- considerations
> can wrap the head, if the leads fall off; can wrap two times if needed
> can place the leads together near and distal, and place a wrap in all the cables
> eyelids leads are localized at sides


How to do a routine EEG
- calibrate the machine, and test impedance
- ask to open and close eyes
- ask orientation questions like the MMSE
- calm background sound to sleep, especially for kids
- photic stimulation, which does different photic frequencies, with eyes open and close
- channel test at the end
- remove leads with water
- considerations:
> all the modifications and patient positions should be described in the reading

Differences in home LTM EEG
- leads
> no eyelid leads or Fpz lead
> x1-x2 are ECG leads
> gel, paste, glue, and pressurized air
> to remove the leads you need the remover
- ground-ref: can be placed at any spot, usually on forehead
- RULL system: right lead is up, and left lead is low
- needs a backpack and a battery
- before patient leave, do a 30 minutes monitoring
- look at the machine, should be green, and blinking yellow

Cable length
- rEEG: 40 cm; home LTM EEG: 60 cm

Types of monitoring
- routine EEG (30 min)
- continuous EEG inpatient
- continuous EEG inpatient (EMU)
> look at LTM order about what to do
> CBC & BMP at arrival
> it is not a real admission, but it can be converted
- continuous EEG outpatient at home

Mechanism
- differential amplifier
- EEG is always relative

Montages
- channels; a mix of channels is called a chain
- average is used to look at where is coming the spike

- pediatric montages:
> double-banana peds
> reference peds
> trans peds

- adult montages:
> double-banana peds
> reference peds
> transversal (PFOT) peds

- other montages:
> bipolar montage
> common average reference montage

Stroke - ICAD

Stroke - ICAD

Etiology
- hypoperfusion
- artery-artery occlusion
- branch artery disease (BAD)

Observations
- MC east Asian; 2nd Brazil
- recurrence of stroke in ICAD is around 30% in one year
- asymptomatic ICAD vs no ICAD has the same stroke risk

Blood pressure trials
WASID 
- BP > 160/90 inc risk TIA/stroke

SAMMPRIS 
- BP > 140/90 inc risk TIA/stroke

Management trials
*BMM - best medical management

WASID
- warfarin vs ASA, no difference

SAMMPRIS
- BMM is supererior to stenting

CASSISS
- BMM is the same as stenting 3 wks after stroke

BASIS
- balloon angioplasty leads to restenosis frequently

PRINCE
- ticagrelor & ASA vs clopidogrel & ASA
> ticagrelor group had lower bleeding risk

CHANCE 2
- ticagrelor & ASA vs clopidogrel & ASA
> ticagrelor group is more effective

COMPASS
- rivaroxaban w/ or w/o ASA, no difference

CAPTIVA
- clopidogrel & ASA vs ticagrelor & ASA vs rivaroxaban & ASA
- being studied
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