Corticobasal Syndrome (CBS) - Phenomenology Atlas

Corticobasal Syndrome (CBS) - Phenomenology Atlas

Video 6.1 (C6c1): Corticobasal Syndrome with Cortical Sensory Loss
Left-hand action myoclonus, impaired graphesthesia and stereognosis, and focal right perirolandic cortical atrophy.

Video 6.2 (C6c2): Corticobasal Syndrome with Limb Apraxia
Loss of proprioceptive control and impaired individuated finger movements of the left hand with reduced arm swing.

Video 6.3 (C6c3): Corticobasal Syndrome with Ideomotor Apraxia
Left-hand dexterity impairment, body-part-as-object substitution, and progressive hemispatial neglect.

Video 6.4 (C6c7): Corticobasal Syndrome with Apraxia and Cognitive Dysfunction
Ideomotor apraxia, impaired dexterity, head-thrust saccades, reduced arm swing, and inability to copy pentagons.

Video 6.5 (C6c12): Corticobasal Syndrome with Cortical Myoclonus
Left-arm myoclonus, athetosis, rigidity, cortical sensory loss, and stimulus-sensitive cortical reflex myoclonus.

Video 6.6 (C6c16): Advanced Corticobasal Syndrome
Continuous left-arm myoclonus, severe limb apraxia, rigidity, cortical sensory deficits, and gait impairment.

Video 6.7 (C6c17): Corticobasal Syndrome with Dystonic Pistol-Grip Hand
Severe right-arm rigidity, dystonic hand posturing, gait hesitation, and asymmetric parkinsonism.

Video 6.8 (C6c18): Cortical Reflex Myoclonus
Action- and position-induced myoclonus with stimulus-sensitive cortical reflex myoclonus and preserved parkinsonism-free examination.

Video 6.9 (C6c20): Corticobasal Syndrome with Fixed Limb Dystonia
Severe right-arm dystonia, apraxia, absent arm swing, and preserved gait.

Video 6.10 (C6c21): Corticobasal Syndrome with Cortical Sensory Loss
Marked right-sided rigidity, impaired stereognosis, foot dystonia, and severe gait dysfunction.

Video 6.11 (C6c22): Asymmetric Corticobasal Syndrome
Profound right-hand bradykinesia and loss of individuated finger movements with preserved language and sensation.

Video 6.12 (C6c23): Corticobasal Syndrome with Severe Limb Apraxia
Left-arm dystonia, ideomotor apraxia, rigidity, and marked gait impairment.

Video 6.13 (C6c24): Corticobasal Syndrome with Myoclonic Tremor
Asymmetric parkinsonism, action-induced myoclonus mimicking tremor, and prominent apraxia.

Video 6.14 (C6c25): Corticobasal Syndrome with Alien Limb Features
Severe left-limb apraxia, cortical sensory loss, involuntary limb elevation, and gait dysfunction.

Video 6.15 (C6c28): Corticobasal Syndrome with Hemispatial Neglect
Profound left-hand dysfunction, astereognosis, visuospatial neglect, and evolution toward alien limb syndrome.

Video 6.16 (C6c29): Corticobasal Syndrome with Mirror Movements
Bilateral cortical reflex myoclonus, oculomotor apraxia, severe left-arm apraxia, and mirror movements.

Video 6.17 (C6c30): Behavioral-Speech Variant Tauopathy
Aprosodic speech, mild asymmetric parkinsonism, emotional indifference, and frontotemporal metabolic deficits.

Video 6.18 (C6c32): Primary Progressive Aprosodia
Markedly abnormal speech prosody with minimal parkinsonian findings and preserved gait.

Video 6.19 (C6c33): Tauopathy Speech Syndrome
Isolated motoric, aprosodic speech with otherwise normal neurological examination.

Video 6.20 (C6c34): Progressive Aprosodic Speech Disorder
Severely impaired speech prosody with minimal bradykinesia and preserved mobility.

Video 6.21 (C6c35): Nonfluent Primary Progressive Aphasia with Parkinsonism
Aprosodic speech, word-finding difficulty, mild asymmetric parkinsonism, and left frontotemporal atrophy.

Video 6.22 (C6c36): Progressive Aphasia Syndrome
Expressive-receptive aphasia with paraphasic errors, preserved reading, and mild bradykinesia.

Video 6.23 (C6c37): Nonfluent Aphasia with Asymmetric Parkinsonism
Halting speech, impaired speech repetition, left-hand motor impairment, and preserved comprehension.

Video 6.24 (C6c38): Parkinsonian Nonfluent Aphasia
Limited speech output, rigidity, bradykinesia, and mild gait impairment without apraxia.

Video 6.25 (C6c39): Severe Nonfluent Primary Progressive Aphasia
Single-syllable perseverative speech, inability to repeat, preserved calculation ability, and normal gait.

Video 6.26 (C6c40): Aphasia with Apraxia and Asymmetric Parkinsonism
Language impairment, inability to imitate learned actions, right-sided rigidity, and dystonic hand posturing.

Video 6.27 (C6c41): Progressive Apraxia Syndrome
Severe bilateral limb apraxia and agraphia with preserved speech, gait, and strength.
-Pending

Video 6.28 (C6c42): Isolated Ideomotor Apraxia Syndrome
Profound bilateral hand apraxia with normal language, cognition, gait, and postural control.
-Pending

Multiple System Atrophy (MSA) - Phenomenology Atlas

Multiple System Atrophy (MSA) - Phenomenology Atlas

Video 5.1 (C5c3): OPCA with Cerebellar Ataxia
Mild scanning dysarthria, ocular dysmetria, appendicular incoordination, and wide-based gait with MRI evidence of olivopontocerebellar atrophy.

Video 5.2 (C5c4): OPCA with Mild Autonomic Involvement
Scanning speech, appendicular dysmetria, and moderately wide-based gait consistent with olivopontocerebellar atrophy.

Video 5.3 (C5c6): OPCA with Ocular Dysmetria
Scanning speech, end-gaze nystagmus, ocular dysmetria, limb dysmetria, and mild gait ataxia with vermian cerebellar atrophy.
-No Video

Video 5.4 (C5c7): MSA with Parkinsonian and Cerebellar Features
Symmetric parkinsonism, wide-based stance, severe gait impairment, and preserved saccadic eye movements.
-No Video

Video 5.5 (C5c9): Cerebellar-Predominant MSA
Severe dysarthria, prominent square wave jerks, marked limb dysmetria, and unstable wide-based gait requiring a walker.

Video 5.6 (C5c12): Mild Cerebellar MSA
Mild dysarthria, subtle cerebellar signs, preserved ocular movements, and mildly wide-based gait.

Video 5.7 (C5c16): Mixed Parkinsonian-Cerebellar MSA
Facial masking, symmetric bradykinesia, ocular dysmetria, gait freezing, and postural instability.

Video 5.8 (C5c17): MSA with Diplophonia
Symmetric parkinsonism accompanied by diplophonia, dysmetria, freezing on turning, and impaired balance.

Video 5.9 (C5c18): Parkinsonian-Predominant MSA
Moderately severe symmetric parkinsonism with diplophonia, preserved eye movements, and stooped gait.

Video 5.10 (C5c19): MSA with Parkinsonism and Cerebellar Dysfunction
Hypophonia, dysarthria, ocular dysmetria, bradykinesia, limb incoordination, and unsteady parkinsonian gait.

Video 5.11 (C5c20): MSA with Hot-Cross-Bun Sign
Asymmetric parkinsonism, wide-based gait, imbalance, and MRI evidence of cerebellar and pontine atrophy.

Video 5.12 (C5c22): MSA with Anterocollis
Parkinsonism associated with progressive anterocollis, hypophonia, and reduced arm swing.

Video 5.13 (C5c23): MSA with Severe Anterocollis
Moderate symmetric parkinsonism and marked chin-on-chest posture despite preserved neck extensor strength.

Video 5.14 (C5c28): MSA with Nocturnal Stridor
Parkinsonism with truncal lean and life-threatening nocturnal stridor preceding respiratory decline.

Video 5.15 (C5c30): MSA with Inspiratory Stridor
Severe inspiratory stridor improved after tracheostomy, with only mild residual parkinsonism.

Video 5.16 (C5c31): Acute Stridor in MSA
Marked inspiratory stridor with minimal parkinsonian signs requiring urgent tracheostomy.

Video 5.17 (C5c33): Advanced MSA with Pisa Syndrome
Dysarthria, diplophonia, atremulous parkinsonism, truncal tilt, and characteristic hot-cross-bun MRI sign.

Video 5.18 (C5c34): MSA with Parkinsonism and Ataxia
Scanning dysarthria, diplophonia, severe bradykinesia, appendicular dysmetria, truncal tilt, and micrographia.

Video 5.19 (C5c35): Advanced Mixed-Phenotype MSA
Severe parkinsonism, rigidity, square wave jerks, cerebellar dysmetria, and profound gait dependence.

Video 5.20 (C5c39): Pathologically Confirmed MSA
Asymmetric bradykinesia with preserved gait and prominent macrosaccadic oscillations; autopsy confirmed multiple system atrophy.

Video 5.21 (C5c40): MSA with Levodopa-Induced Dyskinesias
Asymmetric parkinsonism responsive to levodopa, with prominent on-state dyskinesias and later pathological confirmation of MSA.

Progressive Supranuclear Palsy (PSP) - Phenomenology Atlas

Progressive Supranuclear Palsy (PSP) - Phenomenology Atlas

Video 4.1 (C4c2): Early PSP with Freezing of Gait
Mild vertical saccadic slowing, impaired vertical OKNs, significant freezing on turning, and impaired postural reflexes.

Video 4.2 (C4c3): Early PSP-Richardson Syndrome
Rare square wave jerks, round-the-house vertical saccades, abnormal vertical OKNs, and otherwise preserved gait and appendicular function.

Video 4.3 (C4c4): PSP with Freezing and Postural Instability
Vertical gaze impairment, square wave jerks, severe freezing on turning, and failure to recover on pull test.

Video 4.4 (C4c5): PSP with Gunslinger's Gait
Quizzical stare, prominent square wave jerks, vertical supranuclear signs, gunslinger's posture, and impaired balance.

Video 4.5 (C4c6): PSP with Vertical Gaze Palsy
Frequent square wave jerks, clear vertical supranuclear gaze defect, absent vertical OKN quick phases, and applause sign.

Video 4.6 (C4c7): PSP with Mild Gait Impairment
Facial masking, dysarthria, slowing of vertical saccades, impaired vertical OKNs, and relatively preserved balance.

Video 4.7 (C4c8): Mild PSP
Square wave jerks, round-the-house saccades, vertical gaze slowing, and preserved gait.

Video 4.8 (C4c9): PSP with Quizzical Stare
Mild parkinsonism, frequent square wave jerks, vertical saccadic slowing, and slow but stable gait.

Video 4.9 (C4c10): Early PSP with Gunslinger's Gait
Square wave jerks, mild vertical gaze slowing, and arm abduction while walking.

Video 4.10 (C4c11): PSP with Freezing of Gait
Vertical supranuclear gaze palsy, hypophonic scanning speech, freezing on turning, and impaired postural stability.

Video 4.11 (C4c14): Advanced PSP-Richardson Syndrome
Moderate vertical saccadic slowing, appendicular parkinsonism, severe gait instability, and freezing.

Video 4.12 (C4c15): PSP with Tectal Atrophy
Prominent square wave jerks, round-the-house vertical saccades, and slow walker gait with MRI evidence of tectal thinning.

Video 4.13 (C4c16): Advanced PSP with Dysarthria
Severe parkinsonism, absent downgaze, broad-based gait, and prominent gunslinger's posture.

Video 4.14 (C4c17): PSP with Gait Failure
Square wave jerks, vertical gaze impairment, preserved hand movements, and severe gait dysfunction requiring a walker.

Video 4.15 (C4c18): PSP with Marked Vertical Gaze Palsy
Prominent quizzical stare, severe vertical gaze limitation, absent vertical OKNs, and gunslinger's gait.

Video 4.16 (C4c19): PSP with Dysarthria and Imbalance
Severe dysarthria, square wave jerks, impaired vertical eye movements, applause sign, and impulsive unsteady gait.

Video 4.17 (C4c20): PSP with Strained Speech
Vertical supranuclear gaze palsy, square wave jerks, strained dysarthric speech, and preserved arm swing.

Video 4.18 (C4c21): PSP with Eyelid Opening Apraxia
Eyelid opening apraxia, round-the-house saccades, mild appendicular parkinsonism, and poor pull-test recovery.

Video 4.19 (C4c22): Advanced PSP with Eyelid Opening Apraxia
Profound parkinsonism, severe eyelid opening apraxia, freezing of gait, applause sign, and absent recovery on pull test.

Video 4.20 (C4c23): Advanced PSP with Near-Absent Vertical Saccades
Strangled dysarthric speech, eyelid opening apraxia, severe vertical gaze palsy, and marked postural instability.

Video 4.21 (C4c24): PSP with Facial Dystonia
Marked vertical gaze paresis, facial dystonia, dysarthria, and relatively mild appendicular slowing.

Video 4.22 (C4c25): Advanced PSP with Blepharospasm
Marked vertical gaze palsy, eyelid opening apraxia, blepharospasm, retropulsion, and moderate appendicular bradykinesia.

Video 4.23 (C4c26): PSP with Severe Balance Failure
Profound vertical saccadic defect, spastic dysarthria, inattention, applause sign, and severe postural instability.

Video 4.24 (C4c27): PSP with Emotional Incontinence
Vertical supranuclear gaze palsy, emotional incontinence, severe balance impairment, and difficulty arising.

Video 4.25 (C4c28): PSP with Tectal Thinning
Hypophonic strained speech, marked vertical saccadic impairment, slowed limb movements, and gait requiring assistance.

Video 4.26 (C4c29): Wheelchair-Bound Advanced PSP
Profound vertical gaze palsy, spastic dysarthria, applause sign, severe retropulsion, and dependence for ambulation.

Video 4.27 (C4c31): PSP with Marked Turning Freezing
Mild vertical saccadic slowing, preserved stride, and severe freezing during turning.

Video 4.28 (C4c32): Pathologically Confirmed Early PSP
Mild facial dystonia, subtle vertical gaze slowing, mild bradykinesia, and preserved gait early in the disease course.

Video 4.29 (C4c33): PSP with Isolated Ocular Signs
Marked supranuclear vertical gaze deficit, square wave jerks, gunslinger's gait, and minimal limb parkinsonism.

Video 4.30 (C4c34): PSP with Facial Dystonia
Quizzical stare, facial dystonia, mild vertical gaze limitation, and preserved gait.

Video 4.31 (C4c35): PSP with Cognitive Dysfunction
Micrographia, impaired visuospatial function, vertical gaze impairment, and abnormal pull test with mild limb bradykinesia.

Video 4.32 (C4c36): Very Early PSP
Subtle quizzical stare, mild vertical saccadic slowing, minimal limb involvement, and preserved gait.

Video 4.33 (C4c37): PSP with MRI Tectal Thinning
Marked slowing of vertical saccades, absent vertical OKNs, positive pull test, and characteristic tectal atrophy.

Video 4.34 (C4c38): Mild PSP with Ocular Motor Abnormalities
Mild dysarthria, infrequent square wave jerks, and vertical gaze slowing with impaired vertical OKNs.

Video 4.35 (C4c40): PSP with Macrosaccadic Oscillations
Moderate parkinsonism, prominent square wave jerks, macrosaccadic oscillations, severe vertical gaze palsy, and leg rest tremor.

Other Parkinsonisms - Phenomenology Atlas

Other Parkinsonisms - Phenomenology Atlas

Video 3.1 (C3c1): Chemotherapy-Induced Parkinsonism
Profound akinetic-rigid parkinsonism following intrathecal methotrexate and cytarabine, with inability to move, speak, or swallow. Marked improvement occurred with levodopa therapy.

Video 3.2 (C3c2): Gemcitabine-Induced Parkinsonism
Subacute symmetric parkinsonism developing after gemcitabine treatment, characterized by gait impairment, hand posturing, and bradykinesia, which resolved after levodopa treatment and drug withdrawal.

Video 3.3 (C3c3): Drug-Induced Parkinsonism Unmasking PD
Bilateral rest tremor, bradykinesia, cogwheel rigidity, and postural tremor related to chlorpromazine exposure, later revealed underlying Parkinson's disease.

Video 3.4 (C3c4): Risperidone-Induced Worsening of PD
Marked deterioration of established Parkinson's disease with worsening tremor, rigidity, drooling, and gait after risperidone initiation.

Video 3.5 (C3c5): Aripiprazole-Induced Parkinsonism
Mild asymmetric parkinsonism associated with aripiprazole exposure, followed by progression consistent with underlying Parkinson's disease.

Video 3.6 (C3c6): Drug-Induced Tremulous Parkinsonism
Prominent bilateral resting tremor with mild asymmetric bradykinesia and preserved gait.

Video 3.7 (C3c7): Mild Drug-Induced Parkinsonism
Subtle parkinsonian features including mild rest tremor, left-sided bradykinesia, and reduced arm swing.

Video 3.8 (C3c8): Drug-Induced Parkinsonism with Tardive Features
Classic parkinsonian rest tremor with mild asymmetric bradykinesia, rigidity, and associated chewing dyskinesia.

Video 3.9 (C3c9): Osmotic Myelinolysis-Induced Parkinsonism
Mixed parkinsonism and dystonia with facial dystonia, dysarthria, and dramatic dopaminergic responsiveness.

Video 3.10 (C3c10): Osmotic Demyelination Syndrome with Dystonia
Bilateral bradykinesia accompanied by foot dystonia that improved during walking.

Video 3.11 (C3c11): Postanoxic Parkinsonism
Symmetric parkinsonism with hypophonia, rigidity, bradykinesia, severe freezing of gait, and impaired postural reflexes.

Video 3.12 (C3c12): PSP-Like Syndrome Following Aortic Surgery
Severe supranuclear gaze palsy, facial masking, dysarthria, and palilalia with only mild appendicular parkinsonism.

Video 3.13 (C3c13): Mitochondrial Injury-Induced Parkinsonism
Severe parkinsonism with jaw-opening dystonia, marked bradykinesia, absent arm swing, toe walking, and postural instability.

Video 3.14 (C3c14): Structural Hemiparkinsonism-Hemidystonia
Unilateral parkinsonian rest tremor with dystonic hand posturing and striatal toe.

Video 3.15 (C3c15): True Vascular Parkinsonism
Right-sided parkinsonism associated with ipsilateral third nerve palsy, featuring classic pill-rolling tremor and mild rigidity.

Video 3.16 (C3c16): Dorsal Midbrain Syndrome with Parkinsonism
Parkinsonism associated with shunt over-drainage, characterized by vertical gaze impairment, facial masking, and mild asymmetric bradykinesia.

Video 3.17 (C3c17): Parkinsonism-Hyperpyrexia Syndrome
Severe rigidity and myoclonus following interruption of dopaminergic therapy, with subsequent recovery.

Video 3.18 (C3c18): Lower-Body Parkinsonism
Predominant lower-extremity bradykinesia with hypophonia, abulia, severe freezing of gait, and spontaneous retropulsion.

Video 3.19 (C3c19): Severe Lower-Body Parkinsonism
Normal upper-body examination with profound postural instability, inability to stand independently, and severe retropulsion.

Video 3.20 (C3c20): Unilateral Freezing of Gait (Right Leg)
Isolated freezing of the right leg during walking, improving with visual and rhythmic cueing strategies.

Video 3.21 (C3c21): Unilateral Freezing of Gait (Left Leg)
Freezing of the left leg during gait with marked improvement during backward walking, running, and stepping over obstacles.

Video 3.22 (C3c22): Postanoxic Parkinsonism with Akinetic Mutism
Profound bradyphrenia, hypophonia, akinetic mutism, and severe impairment of voluntary movement despite preserved cognition.

Video 3.23 (C3c23): Abulia
Marked loss of initiative and speech with limited voluntary movement, increased tone, and preserved wakefulness.

Video 3.24 (C3c24): Catatonia Mimicking Parkinsonism
Psychiatric catatonia presenting with rigidity, posturing, immobility, and marked psychomotor slowing.

Video 3.25 (C3c25): Normal Pressure Hydrocephalus (NPH)
Wide-based hesitant gait with preserved seated examination, positive pull test, and ventriculomegaly on MRI.

Video 3.26 (C3c26): NPH Responsive to CSF Diversion
Wide-based shuffling gait and impaired turning that improved following lumbar drainage and ventriculoperitoneal shunting.

Video 3.27 (C3c27): NPH with Freezing of Gait
Magnetic gait, start hesitation, freezing, and postural instability that markedly improved after lumbar drainage and VP shunt placement.

Video 3.28 (C3c28): NPH with Severe Magnetic Gait
Profound gait ignition failure and magnetic gait with substantial improvement after CSF drainage and shunting.

Video 3.29 (C3c29): NPH with Long-Term Shunt Benefit
Magnetic shuffling gait and postural instability demonstrating sustained improvement after lumbar drainage trial and VP shunt surgery.

Parkinson’s Disease - Phenomenology Atlas

Parkinson’s Disease - Phenomenology Atlas

Video 2.1 (C2c8): Early Parkinsonism with Left Foot Tremor
Slight left-sided bradykinesia with decrement on finger and foot tapping, accompanied by a positional 4 to 5 Hz left foot tremor. Gait was preserved.

Video 2.2 (C2c27): Parkin-Associated PD with Foot Dystonia
Young-onset parkinsonism with marked symptomatic response to levodopa. Examination showed impaired left foot tapping and task-induced left foot dystonia during walking, while running and backward walking remained normal.

Video 2.3 (C2c31): Typical Asymmetric Parkinson's Disease
Classic parkinsonian features including facial masking, reduced blink rate, hypophonia, mild left-predominant bradykinesia, and reduced left arm swing.

Video 2.4 (C2c33): Off-State Parkinsonism with Micrographia
Right-sided rest tremor, bradykinesia, cogwheel rigidity, and reduced arm swing in the medication off state. Progressive micrographia was demonstrated during writing.

Video 2.5 (C2c43): Advanced PD with Rest Tremor
Moderate parkinsonism with facial masking, prominent right-hand rest tremor, bilateral bradykinesia, right-sided cogwheeling, and reduced right arm swing.

Video 2.6 (C2c50): LRRK2-Associated Parkinson's Disease
Asymmetric left-sided parkinsonism characterized by bradykinesia, impaired left foot tapping, and markedly reduced left arm swing. Genetic testing confirmed an LRRK2 G2019S mutation.

Video 2.7 (C2c51): Pseudo-Hemiparetic Parkinson's Disease
Marked unilateral slowness and rigidity producing a hemiparetic appearance, despite preserved ability to run normally.

Video 2.8 (C2c52): Parkin-Associated Early-Onset PD
Mild facial masking, bilateral resting tremor, appendicular bradykinesia, and left foot inversion during gait.

Video 2.9 (C2c56): Dopamine Agonist-Induced Anterocollis
Moderate anterocollis with preserved neck strength secondary to rotigotine therapy, which improved substantially after drug discontinuation.

Video 2.10 (C2c68): Advanced PD with Dyskinesia and Retro-Arm-Swing
On-state dyskinesias involving the head, neck, trunk, and left side of the body, with characteristic retro-arm-swing during backward walking.

Video 2.11 (C2c69): Severe Generalized Levodopa-Induced Dyskinesia
Profound generalized dyskinesias affecting the head, trunk, arms, and legs, with bilateral retro-arm-swing during gait.

Video 2.12 (C2c70): Advanced PD with Unilateral Retro-Arm-Swing
Moderately severe on-state dyskinesias of the arms and trunk, accompanied by prominent right-sided retro-arm-swing during walking.

Video 2.13 (C2c71): Early-Onset PD, Motor Fluctuations, and STN-DBS
Advanced early-onset Parkinson's disease with severe motor fluctuations and dyskinesias successfully treated with STN deep brain stimulation. Residual action-induced right foot dystonia improved with trihexyphenidyl and botulinum toxin.

Video 2.14 (C2c80): Orthostatic Tremor in Parkinson's Disease
Fine high-frequency leg tremor developing after standing, relieved by light touch and walking, consistent with orthostatic tremor.

Video 2.15 (C2c81): Parkinsonian Camptocormia with Sensory Trick
Walking-induced camptocormia that improved with sensory tricks including hand positioning, backpack use, and ski poles.

Video - Atlas

Video - Phenomenology Atlas

①. Intro (no video)






⑦. Essential Tremor

⑧. Other Tremors

⑨. Tics/Stereotypies

①0. Myoclonus

①①. Chorea

①②. Dystonia

①③. Ataxia

①④. Unusual Movement Disorders

①⑤. Functional Movement Disorders

US-guided LP

US-guided LP (Basics)

① Choosing right probe
-Linear probe 
>Better resolution, limited penetration (4-6cm)
>Best for non-obese patients
-Curvilinear or phase array probe
>Lower resolution, deeper penetration (>6cm)
>Best for patients with higher BMI

Finding the midline
-Place ultrasound probe in transverse plane
-Locate the spinous process (hyperechoic line with shadow below)
-Mark skin with a vertical line

Finding the interspinous space
-Rotate probe 90 degrees to put probe in longitudinal plane
-Identify spinal levels by starting from the sacrum and sliding the probe upwards
-Locate the interspinous space (valley between humps) 
-Mark skin with a horizontal line

Estimate needle depth
-Identify the ligamentum flavum either on transverse or longitudinal plane (hyper echoic line that can be seen below the spinous process or the interspinous space) and measure distance from the skin 

Locate needle entry target
-Connect both horizontal and vertical lines until they intersect
>US-assisted: insert needle at the intersection point using landmarks
>US-guided: insert needle while using ultrasound

MeVO

MeVo - Clinical Trials

Definition
Occlusions beyond proximal LVO: M2/M3, A2/A3, P2/P3
Typically: Lower NIHSS & Smaller infarct core

Trials
DISCOUNT (2024)
-No fx benefit, possible ↑ complications

DISTALS (2024)
-No fx benefit

ESCAPE-MeVO (2025)
-No fx benefit

DISTAL (2025)
-No fx benefit

Direct-to-Angio

Direct-to-Angio - Clinical trials

Basics
-Test workflow speed
(🚑 → Angio) vs (🚑 → ED → CT → decision → Angio)
-Goal: ⬇️ Door-to-puncture time→ improve outcomes (time-dependent EVT benefit)

Trials
Pfaff et al. (2020)
↓ DTP time, no fx benefit

ANGIOCAT (2021)
↓ DTP, improved fx outcome

DIRECT ANGIO (2026)
↓ DTP, no fx benefit
↑ ICH (safety sign)→ Stopped early (methodologic concerns)

DIRECT (Ongoing)
Cooper is a center

IV Fluids

IV Fluids

NS (NaCl 0.9%)
0.9% = 0.9 g NaCl per 100 mL
Molecular weight: Na = 23; Cl = 35.5; NaCl = 58.5
So sodium fraction: 23/58.5 = 0.39
1L NS has 0.39% of Na = 3.54g

LR
Total amount Na⁺ = 130 mEq/L
1 mEq Na = 23 mg
130 mEq/L x 23 = 3000 mg
1L LR has 0.30% Na = 3.0g

Summary
In sum, 1L
NS has 3.54g Na
LR has 3.0g Na

AHA recommendation
< 2300 mg sodium/day
Ideal goal: 1500 mg/day for most adults