Podcasts about Subarachnoid hemorrhage

On Episode 50 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the March 2025 issue of Stroke: “Impact of Subarachnoid Hemorrhage on Human Glymphatic Function: A Time-Evolution Magnetic Resonance Imaging Study” and “Thrombolysis for Ischemic Stroke Beyond the 4.5-Hour Window: A Meta-Analysis of Randomized Clinical Trials.” She also interviews Drs. Mayank Goyal and Michael Hill about the ESCAPE-MeVO trial, presented in February at the International Stroke Conference. For the episode transcript, visit: https://www.ahajournals.org/do/10.1161/podcast.20250314.838310

Show notes at pharmacyjoe.com/episode940. In this episode, I'll discuss whether tranexamic acid has a role in the treatment of aneurysmal subarachnoid hemorrhage. The post 940: Does Tranexamic Acid Have a Role In Aneurysmal Subarachnoid Hemorrhage? appeared first on Pharmacy Joe.

The critical care management of spontaneous subarachnoid hemorrhage (SAH) is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Recent trials are influencing practice and providing guidance for standardizing management. In this episode, Kait Nevel, MD speaks with Soojin Park, MD, FAHA, FNCS, author of the article “Emergent Management of Spontaneous Subarachnoid Hemorrhage,” in the Continuum June 2024 Neurocritical Care issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Park is an associate professor of neurology (in biomedical informatics) at Vagelos College of Physicians and Surgeons, Columbia University in New York, New York and medical director of critical care data science and artificial intelligence at NewYork-Presbyterian Hospital in New York, New York. Additional Resources Read the article: Emergent Management of Spontaneous Subarachnoid Hemorrhage Subscribe to Continuum: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @soojin_soojin Full episode transcript   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members, stay tuned after the episode to hear how you can get CME for listening.   Dr Nevel: This is Dr Kait Nevel. Today, I'm interviewing Dr Soojin Park about her article on emergent management of spontaneous subarachnoid hemorrhage, which is part of the June 2024 Continuum issue on neurocritical care. Welcome to the podcast. It's so great to be talking to you today.   Dr Park: Thank you so much, Kait. Nice to be here.   Dr Nevel: Before we get started, could you introduce yourself for the audience?   Dr Park: Sure. So, I am an Associate Professor of Neurology - also in Biomedical Informatics - at Columbia University here in New York City. I trained in vascular neurology and neurocritical care.   Dr Nevel: Great. And so, I always like to ask at the beginning of these interviews, you know, if we could take away one thing from your article — and this is specifically (I'll direct this) towards the neurologists out there that are covering inpatient consults and ER consults — and so, for our clinical neurologists listening out there, what is the most important thing that you think that they should take away from your article?   Dr Park: So, I guess the most important thing for the general neurologists out there is that it may have been a while since they were aware of some updates that have occurred. There are some recent trials that are influencing practice and will potentially influence practice in the next few years that readers should really know about, and it provides a little bit stronger guidance to drive more standardized management. There have been two recent guidelines published this year. But there remain several gray areas for management where you need to be a bit more nuanced, and so I'm hoping the article gives the readers a framework to deliver more expert care.   Dr Nevel: Yeah, and I really, of course, always urge the listeners to go back and read the article and reference the article, because I do think that you do that really nicely and are clear when there are things where there's more higher-level, evidence-based reasons for things and where there's, kind of, just more expertise and guidelines on certain things. So, could you tell the listeners a little bit more about yourself, what interests you about subarachnoid hemorrhage specifically, and how you approach that interest and clinical background in writing this article?   Dr Park: So, I mentioned that I trained in both vascular neurology and neurocritical care back when many people used to do that. As a result, I've trained or practiced in four different academic medical centers who have specialized neurointensive care units. And the patients with subarachnoid hemorrhage tend to have a substantial ICU length of stay, and the neurointensive care that we provide can have a very large impact on patient outcome. And what I saw, though (practicing across four different centers), was that the management of patients with subarach can be quite variable across institutions and across patients within institutions, and it's reflective of a couple of things. One, there's, like, complexity in detecting ischemia, even when your patient is a captive audience in their ICU room. Second, there's many clinical mimics that occur (the patients with subarachnoid hemorrhage, they have a risk for), such as hydrocephalus, seizure, and things like delirium. And then, finally, there's limitations in the technology that we even have available in terms of monitoring these patients. But, for me, it was this complexity and the variability of management that kind of posed an opportunity, and it really sparked my curiosity early on and has sustained me. So, I'm particularly interested in the role that, kind of, the complex analysis of existing monitoring technologies can play to improve outcome for patients with subarachnoid hemorrhage, and that's where the marriage of both being a neurointensive care physician and a biomedical informatics person comes in.   Dr Nevel: Yeah. That's really interesting, and I could see that, because I always felt, even during my training, that some of the management and, you know, what diagnostics were even ordered to follow patients throughout the ICU was expertise based and seemed to vary without a lot of really solid, again, high-level studies, guiding what was done. So how do you marry the bioinformatics with your interest in SAH?   Dr Park: Right. So, I have two grants on - basically, I guess you would say AI, but really data science - on how we can manage patients with bleeds, specifically ICH and subarachnoid hemorrhage and hydrocephalus. So, we use data that comes from the monitors and we process that in a multimodal fashion and apply signal processing and machine learning and we build predictive analytic tools. So, I'm very interested in this pipeline of developing clinical decision support (information that we don't really have), and we're trying to glean from all the data and turn it into information that clinicians might use. The problem in subarachnoid hemorrhage patients is that a lot of what we're looking for is subclinical - so, it's not quite obvious, either because you can't possibly be in the room to be constantly monitoring for it (and, currently, the best monitor is the human, is examination), but, specifically in patients who have disordered consciousness, even the examination can be somewhat limited, and that's where we rely upon some of our neuromonitors. So, my interest has come in taking those multimodal monitors - but even nonneurologic monitors (stuff about your physiology, like your heart rate and blood pressure, et cetera) - and able to find signals that might tell us that a patient is getting into a dangerous zone. So, that's what my research portfolio has been 100% about - it's about subarachnoid hemorrhage patients and trying to optimize management, both for prevention and intervening in a timely fashion.   Dr Nevel: Wow. That's really interesting and would be so wonderful, it sounds like, for this patient population, if, you know, something was able to be identified that you could easily monitor to kind of predict or catch things early. So, kind of segueing from that, what do you think are the most — and you outline these nicely in your article, and I'm going to reference the listeners to, I believe it's the first table (table 5-1) - but what are, just like in general, the most important initial steps a clinician should take when managing somebody with an aneurysmal subarachnoid hemorrhage?   Dr Park: So, I think it's sort of along the timeline. So, at the time of presentation of a patient with subarachnoid hemorrhage, the focus you should have should be really on differentiating the etiology of the subarachnoid hemorrhage. At the same time, if the patient has any coagulopathies, you should manage that coagulopathy reversal, blood pressure management, and then detection and management and treatment of hydrocephalus. That's first and foremost. But then there is a longer timeline of neurocritical care management, and that's really centered on prevention, detection, and treatment of delayed cerebral ischemia, and that can occur anytime from onset of subarachnoid hemorrhage to two to three weeks out. And then that period of neurocritical care is made challenging because you have early brain injury (which is the period of seventy-two hours after onset), cerebral edema, and then, like we talked about, disordered consciousness. This kind of knowing how to augment your management strategies with monitoring or imaging is really key.   Dr Nevel: Yeah. And you, you know, spend some time in your article really going through delayed cerebral ischemia really nicely. And I would love to hear your take on what is the most challenging aspects of delayed cerebral ischemia in both, you know, diagnosis and management - and you alluded to it a little bit earlier, I think, with some of your research, but I would love to hear you talk about that.   Dr Park: Yeah. And actually, this is probably one of - if there was a controversial area in this topic, it would be about this - because there does not seem to be one best way to operationalize how you either survey for, or monitor for, delayed cerebral ischemia. There has been, historically, a merging of these definitions of vasospasm and delayed cerebral ischemia, which are not the same thing.  And so, if you were to draw a Venn diagram, not all patients who have cerebral vasospasm end up having symptomatic or delayed cerebral ischemia, and not all patients who have delayed cerebral ischemia have any discernable vasospasm - and, so, to use the terms interchangeably leads to a little bit of confusion. I mentioned the clinical mimics - you know, the causes of which are myriad (could be delirium, or hydrocephalus, or early brain injury) - and so that also poses another challenge. And, so, what I always say is that delayed cerebral ischemia, sometimes - when you're thinking about it in the context of subarachnoid hemorrhage - is sometimes a retrospective diagnosis. And it really kind of came from a really earnest attempt to standardize what the community is talking about, so that we can better understand how to define (if you understand how to define it better, then you can tailor treatments, study treatments, you're talking about the same disease) - but we're still not there, and I think that's where a lot of the controversy or confusion comes from. My personal approach is really to focus on the symptomatology, so, if a patient has vasospasm - whether that is, you know, screened for with a transcranial Doppler (if your institution does use transcranial Dopplers, it might be a nice screening tool) - but the fact of the matter is that not all patients can get a transcranial Doppler every single day. You know, most of the institutions that I have worked in offer that technology Monday through Friday and not on holidays, not on weekends, and so you can't fully rely upon something like that. The advantage of it is that it has pretty high sensitivity but it does have a lower specificity (so it overcalls vasospasms), so to treat just based on a TCD would probably be erroneous. Not all people agree, but I think that's the majority of the sentiment - is that you should then be triggered to go look for confirmation with some neuroimaging and really potentially wait for symptoms so that it might be a trigger to optimize the patient in terms of volume and blood pressure, but not necessarily to treat. So, yeah, operationalizing that workflow of how do you trigger, you know, confirmatory neuroimaging, what type of neuroimaging you should then choose? This is where the variability exists. But, in general, I focus on symptomatology. The extra challenge comes in the patients who have disordered consciousness. And so, at an institution like mine, we do rely upon invasive neuromonitoring, and that's now called for in the guidelines as well.   Dr Nevel: And I imagine these are high-intensity situations where also I would suspect decisions, you know, need to be made quickly on some of these things that you're talking about, too.   Dr Park: That's right.   Dr Nevel: What do you think is a misconception - or maybe (I hate to call it a mistake, but for lack of a better term) like an easy mistake that one can make - when treating patients with aneurysmal subarachnoid hemorrhage?   Dr Park: Hmm, an easy mistake. I guess, you know, time is brain, so it's an opportunity to miss ischemia - or actually attribute everything to ischemia and ignore the possibility for things like seizure (so nonconvulsive seizures), a resurgence of more of a delayed hydrocephalus - and so, I think it's important as you're managing a patient not to get kind of pigeonholed into looking for one particular thing (only looking for delayed cerebral ischemia), but being really vigilant that there could be lots of different reasons for a neurological change of a patient. And so, timely monitoring - kind of figuring out the etiology of a change in neurological status - is really important. And then, also, on the flip side of that, is we're really good at being aggressive in both inducing hypertension or managing a patient (trying to prevent ischemia), we're not that great about starting to pull back - and so I think being vigilant about opportunities to reassess your patient's risk for ongoing ischemia and deciding when that period of risk is over and starting to peel back on therapies, because these patients are also at risk for the down sides of inducing hypertension, which is PRES - and we have seen that in patients, and, you know, the phenotype of that will look very much like ischemia.   Dr Nevel: Yeah, it's complicated because you're taking care of patients with often impaired consciousness who have a lot of symptoms that could represent many different diagnoses that you would treat very differently, so I could see that that might be easy to do to kind of fall into the mindset of thinking that it's definitely one thing without fully evaluating for everything. So, caring for patients with aneurysmal subarachnoid hemorrhage obviously can be really, you know, challenging from the medical perspective, but also from the perspective of, you know, communication with families, and families asking questions about prognosis and things like that (and you mentioned this in your article about prognostication a little bit) - and can you talk a little bit about our ability to prognosticate long-term outcomes for patients who are in that acute phase (maybe even early first, you know, couple of days or a week) with a subarachnoid hemorrhage?   Dr Park: I think one of the most rewarding aspects of caring for patients with subarachnoid hemorrhage is that these patients can look, really, very sick in the beginning, and they're quite complex to manage, but you can see some very impressive recovery. And from a neurointensivist perspective, seeing that recovery in kind of a rapid timeline is rare - and we get to see that in subarach patients. We see patients who just have refractory recurrent vasospasm and delayed cerebral ischemia getting all of the tools thrown at them and you're really kind of, you know, concerned that there seems to be no end - but there is this peak of that injury, and then after that window of secondary brain injury risk kind of resolves, the patient can very much recover (so seeing patients who look the sickest be able to leave and go home). I think there is a hidden cost to subarachnoid hemorrhage where, maybe on our gross measures of outcome, patients look great, but there are this hidden cost of social psychological outcome that is unmeasured the way that we are currently measuring it. And I think our field is getting better at adopting some of the ability to measure those kind of hidden costs, and we're able to see that, even a year out, patients are really not back to where they were before (even though on the scales we currently have, they do look great, right, in terms of motor function, and things like that) - so, I think as clinicians, we have to be sensitive to that. So, when we talk to families, we have to remain hopeful that they are going to have a remarkable potential recovery but prepare families that they really should be on the lookout for any opportunity to rehabilitate in all aspects of function.   Dr Nevel: Yeah. And you mentioned in your article that as we're moving into the future  - and even currently - that there is some focus on gathering more patient-reported outcomes for people who are, you know, out of the ICU back in their normal lives after subarachnoid hemorrhage (which speaks to this that you're talking about, that even if their motor function is normal, they may not be back to their normal lives). So, what is something you think that's really important that we've learned in the past ten years - I'll give it ten years, you can go back further, make that time frame shorter if you want, but about the past ten years - about subarachnoid hemorrhage's impact on patient care, and then what do you think we're going to learn in the next ten years that will impact the way we care for these patients?   Dr Park: So, you know, subarach - in terms of the literature that is forming, that has formed - like I said, the guidelines had not been updated for over a decade, and we're fortunate to have not just one, but two sets of guidelines from two professional societies that were published right next to each other this past year in 2023 - but the field is fast moving, so even after the publication of those guidelines, there was one of the first randomized controlled trials in the field to be published maybe a month or two after that (that was the early lumbar drain trial). So, the key areas that I think where the literature has really helped strengthen our practice in terms of bringing standardization is in the antifibrinolytics. And so, in that space, recently, there was a very nicely performed randomized controlled trial for early administration of antifibrinolytics. It's a practice that, even when I was training, was sort of based on old literature back when we used to treat subarachnoid patients very differently - so we were really kind of extrapolating from that literature into our practice, and we were all sort of just giving it uniformly to patients early on with the good intention to try to prevent rebleeding, (which we understood, prior to aneurysm securement, was a high source of morbidity/mortality). So, in trying to reduce that risk of rebleeding (which happens very early) as much as we could, we were giving it. But the length of treatment (you know, who should we give that medication to) was really kind of uncertain - and this recent randomized controlled trial really gave a definitive answer to this, which is that it probably makes no difference. It should be seen with a caveat, though, that the trial (like any trial) was a very specific population. So, it could probably be said that for patients who are secured very early, there's no role for antifibrinolytic therapy, but, potentially, for patients who may be in a lower-middle-income environment or lower-income environment or for whatever reason can't reach aneurysm securement within that seventy two-hour period - you could consider, you know, greater than twenty-four hours you should consider the use of antifibrinolytics - but largely has brought an end to uniform administration of antifibrinolytics. This is where that expert nuanced care comes to, right?   Dr Nevel: Mm-hmm.   Dr Park: Another area is, really, kind of something as basic as blood pressure management. I think we were taught very early on that we should be very rigorous, bring that blood pressure down - and so, I think, across all types of stroke now, we're realizing there is a little bit of nuance, right? You have to think about your patient, about prior existing renal failure, about prior existing chronic hypertension that's poorly controlled - and in subarachnoid hemorrhage, the additional impact of that early brain injury. If you have cerebral edema, you should be considering, do we really want to control our blood pressure that low? Because we might be inducing secondary brain injury from our presumed protective intervention. So, these types of things are being revisited - so, the language around that in the new guidelines is a little bit softer, and it does sort of refer more to, “let's consider the whole patient”.   Dr Nevel: Yeah, rather than making a blanket statement that doesn't apply to maybe everybody.   Dr Park: Yeah. And you also asked about future.   Dr Nevel: Yeah. Where do you think things are heading in the future? What's exciting in research, and if you had a crystal ball, what do you think we're going to figure out in the next ten years that's going to impact care?   Dr Park: Well, fortunately, for patients with subarachnoid hemorrhage and for people like me who are treating patients with subarachnoid hemorrhage, there's a lot going on. So, I mentioned lumbar drainage because there was a very nice trial that was published - I think we'll see in the next few years how much of that diffusion of innovation travels across the country in the world about the usage of this. There are some who point to prior studies that may have conflicting results and so want to wait and see it be validated. Others are pretty convinced, you know, by the quality of the study that was done and are trying to incorporate it into their protocols now. I think we're going to see more usage and more study of things like intravenous milrinone, early stellate ganglion blockade, intraventricular nicardipine, and even maybe optimized goals for cerebral perfusion or blood pressure - and this is for looking at a myriad of outcomes, including the prevention and treatment of vasospasm and ischemia, improving outcomes, and preventing infarction. There's also a lot to come about early brain injury (and I kind of talked about that). It's like a seventy-two-hour period window after subarachnoid hemorrhage, and it comprises processes like microcirculatory dysfunction, blood-brain barrier breakdown, and things like oxidative cascades, et cetera. While currently, there doesn't exist any practice besides, like, the nuance and expert determination of blood pressure goals prior to aneurysm securement, I think this will be an area that hopefully will become a target for intervention, because it has an independent and influential impact on poor outcomes for subarachnoid hemorrhage patients. So, watch the space.   Dr Nevel: Yes, absolutely. Looking forward to seeing what comes. Well, thank you so much for talking to me, Dr Park, and joining me on Continuum Audio.   Dr Park: It was my pleasure.   Dr Nevel: Again, today, I've been interviewing Dr Soojin Park, whose article on emergent management of spontaneous subarachnoid hemorrhage appears in the most recent issue of Continuum in neurocritical care. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining today.   Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice - and right now, during our spring special, all subscriptions are 15% off. Go to Continpub.com/Spring2024 or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members, go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

In this episode, we review the high-yield topic of ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Subarachnoid Hemorrhage from the Neurology section. Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets Linkedin: https://www.linkedin.com/company/medbullets

Once the diagnosis of nontraumatic subarachnoid hemorrhage (SAH) has been made, our job is not done. Mortality in SAH patients can be up to 30% even without neurological deficit. Paying attention to the time-sensitive details of ED management of SAH patients can have a significant impact on their outcome. In this second part of our 2-part podcast series on subarachnoid hemorrhage with Dr. Katie Lin and Dr. Jeff Perry we answer questions such as: what are the 4 critical priorities in the initial stabilization of the patient with a suspected massive subarachnoid hemorrhage? When is a CT plus CTA of the head indicated up front in the management of patients with suspected subarachnoid hemorrhage? What is the evidence for oral nimodipine in improving outcomes in patients with subarachnoid hemorrhage and how does it work? What can we do in the ED to prevent rebleeding in patients with subarachnoid hemorrhage? What are the simplest and best prognostic tools available for spontaneous subarachnoid hemorrhage to help counsel families and patients? and more...

Once the diagnosis of nontraumatic subarachnoid hemorrhage (SAH) has been made, our job is not done. Mortality in SAH patients can be up to 30% even without neurological deficit. Paying attention to the time-sensitive details of ED management of SAH patients can have a significant impact on their outcome. In this second part of our 2-part podcast series on subarachnoid hemorrhage with Dr. Katie Lin and Dr. Jeff Perry we answer questions such as: what are the 4 critical priorities in the initial stabilization of the patient with a suspected massive subarachnoid hemorrhage? When is a CT plus CTA of the head indicated up front in the management of patients with suspected subarachnoid hemorrhage? What is the evidence for oral nimodipine in improving outcomes in patients with subarachnoid hemorrhage and how does it work? What can we do in the ED to prevent rebleeding in patients with subarachnoid hemorrhage? What are the simplest and best prognostic tools available for spontaneous subarachnoid hemorrhage to help counsel families and patients? and more... Please consider a donation to EM Cases to ensure ongoing Free Open Access here: https://emergencymedicinecases.com/donation/ The post Ep 195 ED Management of Spontaneous Subarachnoid Hemorrhage appeared first on Emergency Medicine Cases.

Anton is joined by the world's leading EM researcher in subarachnoid hemorrhage diagnosis Dr. Jeff Perry and EM-Stroke team clinician Dr. Katie Lin for a deep dive into why we still miss this life-threatening diagnosis, the key clinical clues, proper use of decision tools, indications for CT, indications for CTA, indications for LP and CSF interpretation for the sometimes elusive diagnosis of subarachnoid hemorrhage... Help support EM Cases by making a donation: https://emergencymedicinecases.com/donation/ The post Ep 194 Subarachnoid Hemorrhage – Recognition, Workup and Diagnosis Deep Dive appeared first on Emergency Medicine Cases.

Patients with good motor function outcomes after aneurysmal subarachnoid hemorrhage treatment may still be left with neuropsychiatric effects. They can suffer from such difficult conditions as cognitive dysfunction, depression and sexual dysfunction. Not all of these patients will volunteer their symptoms unprompted on follow-up. This outcome type has had limited study, and became an interest of today's guest, Dr. Jose Danilo Bengzon Diestro (1). JNIS editor-in-chief Dr. Felipe Albuquerque speaks with him on this subject, based on the recently published paper, "Long-term neuropsychiatric complications of aneurysmal subarachnoid hemorrhage: a narrative review".   (1) Department of Medicine, University of Toronto, Toronto, Canada   Please subscribe to the JNIS podcast on your favourite platform to get the latest podcast every month. If you enjoy our podcast, you can leave us a review or a comment on Apple Podcasts (https://apple.co/4aZmlpT) or Spotify (https://spoti.fi/3UKhGT5). We'd love to hear your feedback on social media - @JNIS_BMJ. Thank you for listening! This episode was produced and edited by Brian O'Toole. 

In this week's episode, Dr Nick Morris is joined by Dr Jose Suarez to discuss the recently updated NCS subarachnoid hemorrhage guidelines. We compare them with the recently released American Heart Association subarachnoid hemorrhage guideline; and we discuss the purpose of guidelines in general and how guidelines map out priorities for research.

Trials of the Week: Landmark Nimodipine Studies Special Guest: Salia Farrokh, PharmD, BCCCP, FNCS @salia_farrokh   Salia Farrokh joins to highlight two landmark studies with nimodipine, “Cerebral Arterial Spasm – A Controlled Trial of Nimodipine in Patients with Subarachnoid Hemorrhage” published in NEJM in 1983 and “Effect of Oral Nimodipine on Cerebral Infarction and Outcome after Subarachnoid Hemorrhage: British Aneurysm Nimodipine Trial” published in 1989 in BMJ. We review aSAH treatments in the 1970's and 1980's and what evidence existed for nimodipine use before highlighting our two trials of the week. How does the study methodology compare from then to now? Where did our nimodipine dosing regimen come from? Is the term cerebral artery vasospasm out of date? Is it still appropriate to use evidence from the 1980's in the 2020's? Is there more to research with respect to nimodipine? What to do with missed nimodipine doses? We do a deep dive into all things nimodipine for aSAH, discussing the above and much more.   Reference list:  https://pharmacytodose.files.wordpress.com/2024/04/nimodipine-trial-of-the-week-references.pdf   PharmacyToDose.Com @PharmacyToDose PharmacyToDose@Gmail.com Learn more about your ad choices. Visit megaphone.fm/adchoices

Alis Dicpinigaitis (1) and Dr. Fawaz Al-Mufti (2) join JNIS Editor-in-Chief, Dr. Felipe C. Albuquerque, to discuss the study, "Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States". They explain the findings of their study, covering the predictive impact of factors including age, insurance status, race, and hospital ownership. Read the paper: https://jnis.bmj.com/content/early/2024/02/19/jnis-2023-021330  (1) New York Presbyterian - Weill Cornell Medical Center, New York, New York, USA (2) Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA Please subscribe to the JNIS Podcast via all podcast platforms, including Apple Podcasts, Google Podcasts, Stitcher and Spotify, to get the latest episodes. Also, please consider leaving us a review or a comment on the JNIS Podcast iTunes page: https://podcasts.apple.com/gb/podcast/jnis-podcast/id942473767  Thank you for listening! This episode was produced and edited by Brian O'Toole. 

Dr. Michael Veldeman (1) joins JNIS Editor-in-Chief, Dr. Felipe C. Albuquerque, to discuss the study, "Intra-arterial nimodipine for the treatment of refractory delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage". Dr. Veldeman explains the methods of the study, the growing significance of computerised tomography perfusion imaging in diagnosis of unconscious patients, the use of induced hypertension, and interventional complications that arose when treating subarachnoid hemorrhage patients. Read the paper: https://jnis.bmj.com/content/early/2023/12/16/jnis-2023-021151  (1) Department of Neurosurgery, RWTH Aachen University Hospital Aachen, Aachen, Germany Please subscribe to the JNIS Podcast via all podcast platforms, including Apple Podcasts, Google Podcasts, Stitcher and Spotify, to get the latest episodes. Also, please consider leaving us a review or a comment on the JNIS Podcast iTunes page: https://podcasts.apple.com/gb/podcast/jnis-podcast/id942473767  Thank you for listening! This episode was produced and edited by Brian O'Toole. 

Listen to the latest episode of NCS INSIGHTS series, this time on Subarachnoid Hemorrhage (part 2 of 2). The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®. This episode is sponsored by ceribell. Time is brain when it comes to seizures. Ceribell Point of Care EEG empowers the bedside team to detect or rule out seizure activity in minutes. To learn more, visit ceribell.com. The NCS Podcast is the official podcast of the Neurocritical Care Society.

Listen to the latest episode of NCS' INSIGHTS series on Subarachnoid Hemorrhage (part 1 of 2) The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®. This episode is sponsored by Biogen. Science that transforms patient lives. Science that seeks to solve societal problems. Science that acts with purpose. Science that is inspired by the diversity and passion of our people. Discover where science meets humanity at Biogen. The NCS Podcast is the official podcast of the Neurocritical Care Society.

"...stroke is characterized by having poor blood flow to part of the brain leading to cell death they are grossly divided into ischemic and hemorrhagic with around 15 to 20 percent of Strokes being hemorrhagic a hemorrhagic stroke results from the rupture of a blood vessel leading to bleeding compared ischemic stroke that have a sudden occlusion of a blood vessel within hemorrhagic Strokes there are two main types intracerebral meaning bleeding within the brain itself which can be intraparenchymal Hemorrhage weather is bleeding within the brain tissue or an intraventricular Hemorrhage where there is bleeding within the ventricular system of the brain around one intracerebral hemorrhage into the ventricles intracerebral Hemorrhage is most commonly caused by hypertension and age-related cerebral amyloid angiopathy which is where deposition of Lloyd Peter peptide in the vessels leads to a weaker vessel structure which is then therefore more likely to bleed the other main type is a subarachnoid with the bleed occurs between the arachnoid Mater and the Pia Mater subarachnoid hemorrhages can be due to trauma or can be spontaneous in 85% of cases in taneous subarachnoid hemorrhage is caused by rupture of a cerebral aneurysm with the most common locations being the anterior communicating artery in 35 percent of cases internal carotid artery in 30% and middle cerebral artery in 22% in 30% of cases there are multiple aneurysms the remaining maybe caused by rupture of an arteriovenous malformation coagulopathy or extension of an intraparenchymal bleed note that both of these types of hemorrhagic I considered intracranial bleeds however other types of intracranial bleeds such as epidural and subdural hemorrhages are not considered hemorrhagic stroke we take this few seconds off to inform you are valued loyal listener about the best health and fitness podcast shows from the Nez pod Studios join us as we give you the best of the best health and wellness updates you can rely on for the treatment of chronic classic functional medicine Back to Basics health tips and special updates from the best doctors in the United States of America check out this health and wellness podcast shows explore Health talk healthy lifestyle matters excellent Health digest healthy and free daily and last but not least weekly health and fitness Corner also check out nasty Boise see the truest story never told Fiction podcast for that real life on the go experience with the 27 year old Golden boy..." Learn more about your ad choices. Visit megaphone.fm/adchoices

"...stroke is characterized by having poor blood flow to part of the brain leading to cell death they are grossly divided into ischemic and hemorrhagic with around 15 to 20 percent of Strokes being hemorrhagic a hemorrhagic stroke results from the rupture of a blood vessel leading to bleeding compared ischemic stroke that have a sudden occlusion of a blood vessel within hemorrhagic Strokes there are two main types intracerebral meaning bleeding within the brain itself which can be intraparenchymal Hemorrhage weather is bleeding within the brain tissue or an intraventricular Hemorrhage where there is bleeding within the ventricular system of the brain around one intracerebral hemorrhage into the ventricles intracerebral Hemorrhage is most commonly caused by hypertension and age-related cerebral amyloid angiopathy which is where deposition of Lloyd Peter peptide in the vessels leads to a weaker vessel structure which is then therefore more likely to bleed the other main type is a subarachnoid with the bleed occurs between the arachnoid Mater and the Pia Mater subarachnoid hemorrhages can be due to trauma or can be spontaneous in 85% of cases in taneous subarachnoid hemorrhage is caused by rupture of a cerebral aneurysm with the most common locations being the anterior communicating artery in 35 percent of cases internal carotid artery in 30% and middle cerebral artery in 22% in 30% of cases there are multiple aneurysms the remaining maybe caused by rupture of an arteriovenous malformation coagulopathy or extension of an intraparenchymal bleed note that both of these types of hemorrhagic I considered intracranial bleeds however other types of intracranial bleeds such as epidural and subdural hemorrhages are not considered hemorrhagic stroke we take this few seconds off to inform you are valued loyal listener about the best health and fitness podcast shows from the Nez pod Studios join us as we give you the best of the best health and wellness updates you can rely on for the treatment of chronic classic functional medicine Back to Basics health tips and special updates from the best doctors in the United States of America check out this health and wellness podcast shows explore Health talk healthy lifestyle matters excellent Health digest healthy and free daily and last but not least weekly health and fitness Corner also check out nasty Boise see the truest story never told Fiction podcast for that real life on the go experience with the 27 year old Golden boy..." Learn more about your ad choices. Visit megaphone.fm/adchoices

"...stroke is characterized by having poor blood flow to part of the brain leading to cell death they are grossly divided into ischemic and hemorrhagic with around 15 to 20 percent of Strokes being hemorrhagic a hemorrhagic stroke results from the rupture of a blood vessel leading to bleeding compared ischemic stroke that have a sudden occlusion of a blood vessel within hemorrhagic Strokes there are two main types intracerebral meaning bleeding within the brain itself which can be intraparenchymal Hemorrhage weather is bleeding within the brain tissue or an intraventricular Hemorrhage where there is bleeding within the ventricular system of the brain around one intracerebral hemorrhage into the ventricles intracerebral Hemorrhage is most commonly caused by hypertension and age-related cerebral amyloid angiopathy which is where deposition of Lloyd Peter peptide in the vessels leads to a weaker vessel structure which is then therefore more likely to bleed the other main type is a subarachnoid with the bleed occurs between the arachnoid Mater and the Pia Mater subarachnoid hemorrhages can be due to trauma or can be spontaneous in 85% of cases in taneous subarachnoid hemorrhage is caused by rupture of a cerebral aneurysm with the most common locations being the anterior communicating artery in 35 percent of cases internal carotid artery in 30% and middle cerebral artery in 22% in 30% of cases there are multiple aneurysms the remaining maybe caused by rupture of an arteriovenous malformation coagulopathy or extension of an intraparenchymal bleed note that both of these types of hemorrhagic I considered intracranial bleeds however other types of intracranial bleeds such as epidural and subdural hemorrhages are not considered hemorrhagic stroke we take this few seconds off to inform you are valued loyal listener about the best health and fitness podcast shows from the Nez pod Studios join us as we give you the best of the best health and wellness updates you can rely on for the treatment of chronic classic functional medicine Back to Basics health tips and special updates from the best doctors in the United States of America check out this health and wellness podcast shows explore Health talk healthy lifestyle matters excellent Health digest healthy and free daily and last but not least weekly health and fitness Corner also check out nasty Boise see the truest story never told Fiction podcast for that real life on the go experience with the 27 year old Golden boy..." Learn more about your ad choices. Visit megaphone.fm/adchoices

Paul is back and it wouldn't be an episode of The DBP without some philosophical ideologies. We cover his recovery from a subarachnoid hemorrhage. What lead to such a horrific medical emergency & everything that comes with a near death experience. Beauty in relation to sadness. "Mother Nature is a chaotic bitch." AI (not Allen Iverson) is something I wanted to talk with Paul about and here it is. Artificial Intelligence and our relation to monetizing data, and the manipulation that comes with simply owning computers. Paul is the man, the myth, the legend that you wanna hear his opinion on these hot topics. Thank God for him, his health, and his unique point of view. Enjoy

Listen as Dr. London Smith (.com) and his producer Cameron discuss Subarachnoid Hemorrhage with Marleen Broussard (Marcelina Chavira). Not so boring! https://www.patreon.com/join/jockdocpodcast Hosts: London Smith, Cameron Clark. Guest: Marcelina Chavira. Produced by: Dylan Walker Created by: London Smith

Happy New Year! This month we've got a New in EM looking at the use of neutrophil-lymphocyte ratios in septic arthritis and a discussion on specificity vs. sensitivity. Becky and Chris look at the new NICE guidance on subarachnoid haemorrhage and Rob talks for too long about it, and then we return to New Online with some new articles for your CPD. If you'd like to email us, please feel free to do so here. here. (02:38) New in EM – Neutrophil:lymphocyte ratio in septic arthritis - Synovial Fluid and Serum Neutrophil-to-Lymphocyte Ratio Novel Biomarkers for the Diagnosis and Prognosis of Native Septic Arthritis in Adults (14:49) Guidelines for EM – NICE Guidance on the diagnosis and management of subarachnoid haemorrhage NICE NG228 - Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management An Observational Study of 2,248 Patients Presenting With Headache, Suggestive of Subarachnoid Hemorrhage, Who Received Lumbar Punctures Following Normal Computed Tomography of the Head - Sayer et al. (2015) Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule - Perry et al. (2020) An international study of emergency physicians' practice for acute headache management and the need for a clinical decision rule - Perry et al. (2009) The SHED Study - TERN (56:21) New Online – new articles on RCEMLearning for your CPD GAS, iGAS and Scarlet Fever – Nikki Abela Agents of Change – Public Health in ED – Ines Corcuera and Michelle Ryan

Dr. Bilal Butt, a neuro-critical care physician, joins us to discuss the diagnosis and management of aneurysmal subarachnoid hemorrhages. Learn common presenting features and complications that may arise during hospitalization. You can reach Dr. Butt by email at:  bilal.butt@som.umaryland.eduUniversity of Maryland Website: https://www.medschool.umaryland.edu/profiles/Butt-Bilal/Find me on Twitter @DrKentris or send me an email at theneurotransmitterspodcast@gmail.com-----------------------------------------------------The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

On this month's NCS Podcast Series episode, Holly Ledyard interviewed Dr. David Y. Chung and Dr. Bradford B. Thompson in their recent article, “Association of External Ventricular Drain Wean Strategy with Shunt Placement and Length of Stay in Subarachnoid Hemorrhage: A Prospective Multicenter Study." NCS offers free CE credits for the NCS Podcast Series episodes. Listen to any of the posted episodes, complete a five question survey, and claim your credits here! Credits are available for physicians, pharmacists, nurses, and non-physicians. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Bonnie Rossow. Our host is Fawaz Almufti, and our production staff includes Tareq Saad Almaghrabi, Andrew Bauerschmidt, Leonid Groysman, Atul Kalanuria, Lauren Koffman, Kassi Kronfeld, Holly Ledyard, Lindsay Marchetti, Alexandra Reynolds, Lucia Rivera Lara, Jon Rosenberg, Jason Siegel, Zachary Threlkeld, Teddy Youn, and Chris Zammit. Our administrative staff includes Bonnie Rossow. Music by Mohan Kottapally.

Dear listeners, in this episode (episode 3) of SLU Neurology Podcast, our PGY3 resident Ulviyya Gasimova and PGY4 resident Khurram Afzal discussed subarachnoid hemorrhage. If you have any comments or suggestions, feel free to reach us at sluneurologypodcast@gmail.com Our GDPR privacy policy was updated on August 8, 2022. Visit acast.com/privacy for more information.

On Episode 16 of the Stroke Alert Podcast, Dr. Negar Asdaghi highlights two articles from the May issue of Stroke: “Number of Affected Relatives, Age, Smoking, and Hypertension Prediction Score for Intracranial Aneurysms in Persons With a Family History for Subarachnoid Hemorrhage” and “Endovascular Treatment for Acute Ischemic Stroke With or Without General Anesthesia.” She also interviews Dr. Patrick Lyden on “The Stroke Preclinical Assessment Network: Rationale, Design, Feasibility, and Stage 1 Results.” Dr. Negar Asdaghi:         Let's start with some questions. 1) How is it that stroke can be cured in rodents but not in humans? 2) Are we wasting time or gaining time with general anesthesia before endovascular thrombectomy? 3) My father had an aneurysmal subarachnoid hemorrhage, Doctor. What is my risk of having an aneurysm, and how often should we check for one? We're back here with the Stroke Alert Podcast to tackle the toughest questions in the field because this is the best in Stroke. Stay with us. Dr. Negar Asdaghi:         Welcome back to the May 2022 issue of the Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine and your host for the monthly Stroke Alert Podcast. For the May 2022 issue of Stroke, we have a number of papers that I'd like to highlight. We have seven articles as part of our Focused Update on the topic of neuroimmunology and stroke, organized by our own Stroke editors, Drs. Johannes Boltze and Miguel Perez-Pinzon. We also have an interesting study by Dr. David Saadoun and colleagues from Sorbonne University in Paris, where we learn that in patients with Takayasu disease, how the delay in diagnosis, as defined by the time from symptom onset to the diagnosis being over one year, was significantly associated with development of ischemic cerebrovascular events. In the Comments and Opinions section, we have an interesting study by Dr. Goldenberg and colleagues from University of Toronto on the benefits of GLP-1 receptor agonists for stroke reduction in type 2 diabetes and why should stroke neurologists be familiar with this new class of diabetic medication. Dr. Negar Asdaghi:         Later, in the interview section of the podcast, I have the great honor of interviewing Dr. Patrick Lyden, one of the founding fathers of thrombolytic therapy in stroke, as he walks us through the Stroke Preclinical Assessment Network and what his hopes are for the future of stroke therapy. I also ask him for some advice, and he did tell us about the view from the top, as he truly stands on the shoulder of giants. But first with these two articles. Dr. Negar Asdaghi:         In a landmark population-based study out of Sweden that was published in Brain in 2008, we learned that the odds of development of aneurysmal subarachnoid hemorrhage for individuals with one first-degree relative with a prior history of aneurysmal subarachnoid hemorrhage was 2.15. For individuals with two affected first-degree relatives, the odds ratio was 51. So, it's not surprising that a great deal of anxiety is caused within a family when a relative has an aneurysmal subarachnoid hemorrhage, especially if that family member was young or another member of the family had the same condition before. This scenario is commonly followed by a number of inevitable questions: Should all family members of the affected individual be screened for presence of an intracranial aneurysm? If yes, how often should vascular imaging be performed, and should other aneurysmal risk factors, such as age, sex, smoking, and hypertension, be also considered in the screening decision-making? In this issue of the journal, as part of a derivation-validation study, a group of investigators, led by Dr. Charlotte Zuurbier from University Medical Center at Utrecht Brain Center in the Netherlands, studied the ability of a simple scoring system that was developed in their derivation cohort to predict the presence of an intracranial aneurysm on vascular imaging. Dr. Negar Asdaghi:         They then tested the scoring model in their validation cohort. So, for their development cohort, they used data on 660 persons who were screened at the University Medical Center for presence of an intracranial aneurysm because they had two or more affected first-degree relatives with a prior history of aneurysmal subarachnoid hemorrhage. The median age of participants at the time of first screening was 40, and 59% were female. Dr. Negar Asdaghi:         So, in this cohort, the investigators simply looked at factors that were independently associated with finding an aneurysm on vascular screening by their multivariate analysis. And they identified the following factors; the first factor was the number of affected relatives. Now, a reminder that all of these people in the cohort had at least two first-degree relatives with an aneurysmal subarachnoid hemorrhage. And they found that amongst these people, those that had three or more family members with aneurysmal subarachnoid hemorrhage were significantly more likely to have a positive screening test for intracranial aneurysm. The next factor was older age — the older that relative, the more likely their screening imaging was positive for an aneurysm — and the other independent factors were smoking and hypertension. So they created the NASH acronym; N for number of relatives, A for age, S for smoking, and H for hypertension. When assigning points for each of these factors, the NASH scoring system had a C statistics of 0.68 in predicting whether or not someone would have a positive test, which is an intracranial aneurysm. Dr. Negar Asdaghi:         And now a reminder for our listeners that C statistics gives us the probability that a person with a certain condition, in this case, a certain NASH score, will have the outcome of interest, in this case, an aneurysm found by vascular imaging. In general, for C statistics, the closer we get to 1, the more robust is our predictive model. Values over 0.7 indicate that we have a good model, but values over 0.8 indicate a very strong model. So the NASH score, at 0.68, has a reasonably good capability in predicting who will or will not have an intracranial aneurysm if we complete the vascular imaging. But it's not a very strong model, and this should be kept in mind. Let's look at some of their numbers. In their development cohort, the probability of finding an intracranial aneurysm for a person who scored low on NASH, that is a young person who never smoked and is not hypertensive, was only 5%, whereas the probability of finding an intracranial aneurysm in a person who scored high on NASH, that is an older person in their 60s or 70s, with three or more affected relatives, who is hypertensive and a smoker, was 36%. Dr. Negar Asdaghi:         So, then they tested this NASH score in their external validation cohort and found that the likelihood of identifying an aneurysm increased as expected along the range of predicted probabilities of NASH. That is, the higher the score, the more likely to find an aneurysm on screening with vascular imaging. And the C statistics in the validation cohort was slightly lower than the C statistics in the derivation cohort. So, the important lesson we learned from this study is that the risk of having an intracranial aneurysm in a person who has a first-degree family member with a prior history of aneurysmal subarachnoid hemorrhage is substantially different depending on their NASH score, and this should be taken into consideration when deciding on screening and counseling various family members of the affected patient or prioritizing who should be screened first in routine practice. Dr. Negar Asdaghi:         The ideal anesthetic management during endovascular therapy is still unknown. A number of studies have compared the different anesthetic options available during thrombectomy, which include general anesthesia, or GA, conscious sedation, use of local anesthesia, and no sedation at all. The main argument for doing endovascular therapy under general anesthesia is that although this procedure will take some precious pre-thrombectomy time, it does result in strict immobility. And that is really ideal in the sense that it improves catheter navigation and interpretation of angiography, in addition to obviously providing a secure airway and, of course, avoiding the need to have to do an emergency intubation in case of procedural complications. The argument against general anesthesia is not only the issue of time but also the risk of hypotension and hemodynamic compromise, especially during induction, and the loss of very valuable neurological examination in a completely sedated patient during the procedure. Dr. Negar Asdaghi:         The question is, does general anesthesia improve or worsen neurological and functional outcomes post-thrombectomy? Several smaller randomized trials have looked at this very question, mainly comparing GA to all other forms of sedation during thrombectomy, but they have yielded inconsistent findings regarding the three-month functional outcome. Dr. Negar Asdaghi:         Some of them showed that patients under GA ended up doing better. Some showed no difference in the overall outcomes. But overall, their pooled analysis suggested that GA might be superior to the competing counterpart, which is the conscious sedation, and associated with better functional outcome. But these centers had highly specialized anesthesia teams, and it's possible that their findings may not be generalizable to routine practice. So, in this issue of the journal, using the Swiss Stroke Registry, Dr. Benjamin Wagner from the Department of Neurology at the University Hospital in Basel and colleagues report on the outcomes of endovascularly treated patients in the Swiss Stroke Registry receiving thrombectomy for an anterior circulation stroke with or without general anesthesia. The primary outcome was disability on the modified Rankin Scale after three months. For this study, they excluded one out of the nine centers in the registry that had lots of missing data on their three-month follow-up. Dr. Negar Asdaghi:         And so, from 2014 to 2017, 1,284 patients across eight stroke centers in the registry were included in this study. Sixty-six percent received thrombectomy under general anesthesia. On baseline comparison, the patients in the GA group were older, had a higher NIH Stroke Scale on admission, had worse preclinical functional status, and more likely to have presented with multi-territorial ischemic stroke. So, many reasons as to why people who underwent general anesthesia would have a worse clinical outcome in this study. So, now let's look at their primary outcome. In the unadjusted model, the three-month modified Rankin Scale was significantly worse in the GA group as compared to the non-GA group, which is obviously expected given the differences in their baseline characteristics. Dr. Negar Asdaghi:         But what was surprising was that the odds of having a higher mRS score was significantly greater still in the adjusted models. They also did propensity score matching analysis, and they found that the NIH Stroke Scale after 24 hours, and the odds of dependency and death and mortality were all higher in the adjusted model in the GA group. They also looked at a number of secondary outcomes and found that door-to-puncture time was longer in the GA group. Dr. Negar Asdaghi:         And also these patients were more likely to be transferred to ICU after treatment as compared to the non-GA treated counterparts. The authors point out that these real-world data are in keeping with the findings from the HERMES meta-analysis, which included over 1,700 endovascularly treated patients, and two previously published large registry data, one from Italy, which included over 4,000 endovascularly treated patients, and one from Germany, including 5,808 patients, all of them showing a worse functional outcome in endovascular therapy if the treatment was performed under general anesthesia, as compared to all other forms of sedation or no sedation at all. Again, these findings are in contrast with the reassuring results of the randomized trials on this topic, specifically in contrast to the AnStroke, SIESTA, and GOLIATH randomized trials, which compare GA to conscious sedation, showing either neutral or positive results in favor of general anesthesia pre-thrombectomy. Dr. Negar Asdaghi:         So, in summary, what we learned from this real-world, observational study is that general anesthesia was associated with worse functional outcome post-endovascular thrombectomy, independent of other confounders, which means that the jury is still out on the ideal form of anesthesia for an individual patient prior to endovascular therapy, and we definitely need larger, multicenter studies on this topic. Dr. Negar Asdaghi:         There are over a thousand experimental treatments that have shown benefit in prevention of neurological disability in animal models of ischemic stroke but have failed to show the same efficacy in human randomized trials. In fact, to date, reperfusion therapies, either in the form of intravenous lytic therapies or endovascular treatments, are the only successful treatments available to improve clinical outcomes in patients who suffer from ischemic stroke, and stroke remains a leading cause of death and disability worldwide. How come stroke can be cured in rodents but not in humans? Are neuroprotective therapies, or as more correctly referred to, the cerebroprotective therapies, the epitome of bench-to-bedside translational research failure? And if this is true, what are the key contributors to the scientific conundrum, and how can this be averted in the future? This is the question that a remarkable group of neuroscientists, led by Dr. Patrick Lyden from University of Southern California, are hoping to answer. Dr. Negar Asdaghi:         In this issue of the journal, these investigators describe the rationale, design, feasibility, and stage 1 results of their multicenter SPAN collaboration, which stands for the Stroke Preclinical Assessment Network. I'm joined today by Professor Lyden himself to discuss this collaboration. Now, Professor Lyden absolutely needs no introduction to our stroke community, but as always, introductions are nice. So, here we go. Dr. Lyden is a Professor of Physiology, Neuroscience, and Neurology at Zilkha Neurogenetic Institute, Keck School of Medicine, at USC. He has truly been a leader in the field of preclinical and clinical vascular research with over 30 years of experience in conducting studies and randomized trials, including conducting the pivotal NINDS clinical trial that led to the approval of the first treatment for acute ischemic stroke in 1996. Throughout his exemplary career, he has accumulated many accolades and is the recipient of multiple awards and honors, including the prestigious 2019 American Stroke Association William Feinberg Award for Excellence in Clinical Stroke. Good morning, Pat, it's truly an honor to welcome you to our podcast today. Dr. Patrick Lyden:            Thanks, I'm glad to be here. Dr. Negar Asdaghi:         Well, in the era of successful reperfusion therapies, it seems that the new generation of stroke neurologists and interventionalists have their eyes, so to speak, on the clock and are interested in opening the blood vessels and opening them fast. In the age of reperfusion treatments, why do we still need to talk about the role of cerebroprotective treatments? Dr. Patrick Lyden:            Well, not to sound too glib about it, but not everybody gets better after a thrombectomy. So, thrombectomy is good, it's more effective than anything else that we've tried before, but there are a remaining number of patients with a residual disability. Not only that, and from a more scientific standpoint, thrombectomy offers us the opportunity now to combine cerebroprotective therapy with known reperfusion. Remember, before, we didn't know when the artery had opened, but now we do an embolectomy, we know there's reperfusion. It gives us the opportunity to know that we're combining our treatment with reperfusion. Dr. Negar Asdaghi:         So, in the paper, you discussed how hundreds of treatments have been studied and shown efficacy in reducing neurological disability in animal models of stroke, and yet failed in human studies. In your opinion, what were the top two most disappointing studies in terms of clinical failure despite pre-clinical encouraging data? Dr. Patrick Lyden:            Well, the first one I mentioned was personal because it was the first one that I led, and it was a molecule called clomethiazole that I had helped establish the rationale for in my very first grant. So, it was the first trial I led, it was multinational, and, of course, I firmly believed we were going to hit a home run, and we failed. But to the field, the real watershed moment in neuroprotective therapy was the so-called SAINT II Trial. SAINT II was a study of a drug called NXY-059, and it was the first drug that purportedly had satisfied all of the so-called STAIR criteria. The STAIR criteria came out of a roundtable between academics and industry on how to best qualify drugs preclinically before going to human trials. And the idea was, if you were a 10 out of 10 on the STAIR criteria, then you should win when you come to human clinical trials. And the SAINT II Trial, which I was a co-leader, a co-investigator, on, also failed. Dr. Patrick Lyden:            And so many, many, many drugs had failed by that point. Tens of millions, if not a hundred million dollars, had been spent by industry, and SAINT II really caused the field to stop. Industry stopped investing in stroke; academic investment in stroke dried up. NIH funding became more difficult to get after SAINT II, and that really was sort of the really historical low moment in the development of treatment for stroke. Dr. Negar Asdaghi:         I was a resident when SAINT II came out, and I remember that somber feeling. Dr. Patrick Lyden:            It was a sad day. Dr. Negar Asdaghi:         Yeah. So, in the paper, you outline a number of potential causes as to why this translational failure may have occurred. But you highlighted the absence of preclinical scientific rigor as the most responsible source. And you already alluded to this a little bit. Can you please tell us a bit more? Dr. Patrick Lyden:            Absolutely. And first, of course, we have to say that the ideal clinical trial design is not available. We really don't know the absolute best way to test the drugs in human clinical trials. But leave that for another day. Dr. Patrick Lyden:            On the preclinical side, what can we say we're doing wrong? We're not sure, but one thing that has been highlighted over and over is that we don't approach preclinical characterization with as much rigor as we should. What do I mean by that? Animal models recapitulate for us some of the biology of a stroke, but not all. For example, many, many times we test a drug in a young model, an animal that's quite young, corresponding to a late teenager in human terms. Well, that's ridiculous. Stroke occurs in elderly people, and so on. So, the NIH called in a landmark conference for additional rigor, enhanced rigor. And I should mention the STAIR criteria were a first attempt at this. STAIR put out guidelines that said animals should be elderly, the animals should be randomized, et cetera, et cetera. And so that didn't happen. Although the STAIR criteria were out there, very few laboratories really committed to full rigor. And so the NIH funded the Stroke Preclinical Assessment Network, SPAN, to implement every aspect that we could think of that would add the best possible scientific design, the utmost rigor. So, we implemented true blinded assessment, true randomization, complete case ascertainment where we follow every single subject in the study and account for dropouts and subjects that don't complete the treatment, and, most importantly, a proper statistical design with adequate power and very large numbers. And the hypothesis that we're testing is that additional rigor in SPAN will lead to a better positive predictive value when we think about drugs that should go forward for testing in human stroke trials. Dr. Negar Asdaghi:         So, I think you already answered my next question, which was basically, why do you think SPAN is going to achieve what all others have failed to achieve? But I wanted to simplify and repeat what you mentioned. So, in simple terms, what SPAN is trying to do is to bring all preclinical research to a level of scientific rigor that was not necessarily present and make it a multicenter effort. And can you a little bit tell us about the different stages, again, of SPAN? Dr. Patrick Lyden:            Well, I'm not arguing that all preclinical research needs to be done following a SPAN type of model. Where SPAN fits in is at the end of a development project. So, if you want to characterize the cellular and molecular mechanisms, you don't need to do all of this rigor that we're doing. Just study the drug in the lab and do the mechanistic studies that need to be done. If you want to do dose finding, it doesn't need to be done this way. But at the end of that, OK, first we establish the mechanism, that's the first stage. Then we establish the toxicity. Then we establish target engagement. At the end, we are looking for some evidence that the drug will have a beneficial effect on outcomes. And in previous animal models, the only outcome, generally, the most common outcome that was studied, was size of the stroke. But in humans, the FDA does not recognize stroke size as a valid outcome. Dr. Patrick Lyden:            We look at function, most often measured with the Rankin score and the NIH Stroke Scale. So, we had to create a functional outcome, and then we had to study it at multiple laboratories to make sure we could replicate the effect across multiple sites. And we chose what's called a multi-arm, multi-stage (MAMS) statistical design. All the drugs start out in the experiment at the end of the first interim analysis, which is 25% of the sample size. We cull any compounds or treatments that appear futile are removed. Any that appear effective move on. At the end of the second stage, there's more culling. There's a total of four stages, and we're about to enter stage four, by the way. That's starting next week. And in stage four, there will be, at most, two, maybe only one treatment that has appeared non-futile and possibly effective for final characterization. Dr. Negar Asdaghi:         So, really interesting. I just want to highlight two important comments that you mentioned for our listeners again. So this is multi-layer, as you mentioned, multi-arm, multi-stages. It's sort of filter by filter, just ensuring that what we're seeing, the efficacy we're seeing in preclinical studies, will potentially be replicated in clinical studies. And what you mentioned that's very important is outcomes that classically is measured in animal models are infarct volume that are obviously very important but not necessarily may translate to exactly what we look at in clinical studies, which is functional outcomes, modified Rankin score and NIH Stroke Scale. So, with that, I want to then come back to the treatments that are actually being studied as part of SPAN. You have six very different agents as part of SPAN, from tocilizumab to uric acid. Why do you think these therapies will work? Dr. Patrick Lyden:            Well, my job as the PI of the coordinating center is to remain completely agnostic to the treatments. So, everybody's equal, and they all come in on an equal playing field. We actually have a mechanical treatment called remote ischemic conditioning, as well, and then five drugs. And these were selected through a peer review process at NIH. And then we were informed at the coordinating center what drugs we would be studying. Five drugs and one treatment. And then, of course, the challenge to us was to somehow create a blinded, randomized situation. Now, this turned out to be a fascinating, it's more mechanical, but how do you blind when some of the drugs are given orally, some are given intraperitoneally, some are given intravenously, some are given once, some are given multiple times? So, we had to work with the manufacturers and inventors of these drugs and figure out a way to package them, and in the paper, actually, there's a photograph in the appendix that shows we had to find these bottles that were amber-colored and how to load them and lyophilize the drug. Dr. Patrick Lyden:            And it's actually pretty fascinating how we were able to get all of these different, wildly different therapies, as you say, into a paradigm where they could be tested one against another in a truly blinded, truly randomized way. Dr. Negar Asdaghi:         Do you think you can go on record and say which one is your favorite? Dr. Patrick Lyden:            My favorite drug's not even in SPAN. I am truly agnostic because where my heart is, is with a drug that I've been studying in my laboratory completely separately and not part of SPAN. Dr. Negar Asdaghi:         All right, so we don't have a favorite. So, in a recent review article in Stroke, you commented on treatments used by ancient Persians, Greeks, and Romans to remedy the brain affected by stroke and how the future generation of physicians will look back at our current practices of stroke with the same, how you said, awe and bemusement we hold for Galen, Aristotle, and Avicenna. How do you think stroke will be treated in the year 2222? Dr. Patrick Lyden:            Well, first of all, and to be serious for just one moment, 200 years from now, I worry more about the climate than about medicine. And I really believe our biggest efforts need to be spent on saving the planet. But assuming we make it that long, obviously diagnostic methods will be completely different. Using ionizing radiation to scan the body will be laughed at by physicians in the future. There'll be detection technologies that aren't even on our radar yet today. And then treatments will be cellular focused and regionally focused. We give a drug through a vein and it circulates throughout the entire body, and I'm sure physicians in the future will find a way to somehow get treatment into the part of the body that's injured, not the whole body. And then, who knows? All we can say is they will laugh at us in the same way that we laugh at Theodoric the Barber of York. Dr. Negar Asdaghi:         Let's move on from the future to the past. You're arguably one of the founding fathers of reperfusion therapies. You were instrumental in getting intravenous lytic therapy approved in 1996. It literally took the field 20 years for the next treatment to be approved, that's endovascular treatment. If you could go back in time and give your young self an advice on the subject of research, of course, design and execution, what advice would you give yourself? Dr. Patrick Lyden:            Don't listen to old guys. We got a lot of advice from gray-bearded folks back when we were putting together the tPA trial, and fortunately we ignored some very bad advice and did what we imagined was the right thing to do as young, headstrong up-and-comers do. The other thing is, we really believed that by publishing our science very objectively, without editorial comment, we would be listened to. And that was dead wrong. So, the data was printed in the New England Journal in a very neutral tone, and we felt people would read that data and they would start using tPA the day after the publication. And, as you say, it took 20 years for tPA to really gain widespread acceptance, thrombolytic therapy. Today, people view it as standard, but it wasn't that way at the beginning. And I would say to myself and my colleagues at that time, "Don't be afraid to promote a positive result." Yes, it has to be done with the utmost rigor, but once you have a positive result, there will be plenty of people around pretending they know more than you and telling the world why you are wrong. And it's very important to stand up for your science and stand up for your results and say, no, no, no, no, that interpretation is wrong. The data says what we said it says, and this is an effective treatment and should be used, as an example. Dr. Negar Asdaghi:         What a great advice. Just be bold and say it loud and stand up for your science. Pat, it's been a pleasure interviewing you and having you on the podcast. We really look forward to watching your research. Bring, let me say it again, 2222 closer to now. Dr. Patrick Lyden:            Thank you. Glad to be here. Dr. Negar Asdaghi:         Thank you. Dr. Negar Asdaghi:         And this concludes our podcast for the May 2022 issue of Stroke. Please be sure to check out this month's table of contents for the full list of publications, including two articles on quality improvement in stroke and neurohospitalist—inpatient teleneurology, which comes as part of our Advances in Stroke series prepared by our section editors. And as we close our podcast today, let's take a moment and ask ourselves the same question that I asked Dr. Lyden earlier. What is the next frontier in stroke treatment? Past reperfusion therapies, we have to find ways to preserve the neurons and not just the neurons, all components of the brain. So, is the future of stroke therapy cerebroprotection? Ever since the dawn of history, humanity has lived alongside of death with the conscious apprehension that as we age, we lose the very gift of life. But unlike our ancestors, the search for immortality isn't the quest to find a fountain of youth anymore. We learned that death is inevitable, but with medicine, we can reduce illness and suffering to prolong a life worth living, one with a healthy brain. And today we're closer than ever to this modern immortality with cerebroprotection in stroke, as we stay alert with Stroke Alert. Dr. Negar Asdaghi:         This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit AHAjournals.org.  

Welcome to Episode 16 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 16 of “The 2 View” – SAH: revisited, pediatric hepatitis outbreak, medical errors, and AHA/ACC heart failure guidelines. SAH - Revisited Headache. American College of Emergency Physicians. Acep.org. Published June 2019. Accessed April 27, 2022. https://www.acep.org/patient-care/clinical-policies/headache/ Ibrahim YA, Mironov O, Deif A, Mangla R, Almast J. Idiopathic Intracranial Hypertension: Diagnostic Accuracy of the Transverse Dural Venous Sinus Attenuation on CT scans. Neuroradiol J. PubMed Central. National Library of Medicine: National Center for Biotechnology Information. Published December 2014. Accessed April 27, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291803/ Spadaro A, Scott KR, Koyfman A, Long B. Reversible cerebral vasoconstriction syndrome: A narrative review for emergency clinicians. Am J Emerg Med. PubMed.gov. National Library of Medicine: National Center for Biotechnology Information. Published October 4, 2021. Accessed April 27, 2022. https://pubmed.ncbi.nlm.nih.gov/34879501/ Pediatric Hepatitis Outbreak Jetelina K. Severe hepatitis outbreak among children. Your Local Epidemiologist. Published April 26, 2022. Accessed April 27, 2022. https://yourlocalepidemiologist.substack.com/p/severe-hepatitis-outbreak-among-children Multi-Country – Acute, severe hepatitis of unknown origin in children. Who.int. Published April 23, 2022. Accessed April 27, 2022. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON376 Recommendations for Adenovirus Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology. HAN archive - 00462. Cdc.gov. Published April 21, 2022. Accessed April 27, 2022. https://emergency.cdc.gov/han/2022/han00462.asp Medical Errors Dihydroergotamine (DHE) for Migraine Treatment. American Migraine Foundation. Published January 28, 2021. Accessed April 27, 2022. https://americanmigrainefoundation.org/resource-library/dhe-for-migraine/ Kelman B. Former nurse found guilty in accidental injection death of 75-year-old patient. NPR. Published March 25, 2022. Accessed April 27, 2022. https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injection-death-of-75-year-old-patient. Khan A. Medical Errors in the Emergency Department. SAJEM Editorial. Researchgate.net. Accessed April 27, 2022. https://www.researchgate.net/profile/Abdus-Khan/publication/336838935MedicalErrorsintheEmergencyDepartment/links/5dbae7df4585151435d6e97f/Medical-Errors-in-the-Emergency-Department.pdf Pasquini S. Healthcare Experience Required for PA School: The Ultimate Guide. The Physician Assistant Life. Published February 2, 2015. Accessed April 27, 2022. https://www.thepalife.com/hce-paschool/ AHA/ACC Heart Failure Guidelines Emergency Heart Failure Mortality Risk Grade (EHMRG). MDCalc. Accessed April 27, 2022. https://www.mdcalc.com/emergency-heart-failure-mortality-risk-grade-ehmrg Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published April 1, 2022. Accessed April 27, 2022. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 Ottawa Heart Failure Risk Scale (OHFRS). MDCalc. Accessed April 27, 2022. https://www.mdcalc.com/ottawa-heart-failure-risk-scale-ohfrs Rider I. Evidence Based Disposition in Heart Failure – Who needs to be admitted and who can be discharged? emDOCs.net - Emergency Medicine Education. Published October 5, 2020. Accessed April 27, 2022. http://www.emdocs.net/evidence-based-disposition-in-heart-failure-who-needs-to-be-admitted-and-who-can-be-discharged/ SGEM#170: Don't Go Breaking My Heart – Ottawa Heart Failure Risk Scale. The Skeptics Guide to Emergency Medicine. Published March 5, 2017. Accessed April 27, 2022. https://thesgem.com/2017/03/sgem170-dont-go-breaking-my-heart-ottawa-heart-failure-risk-scale/ Thibodeau J, Turer A, Gualano S, et al. Characterization of a Novel Symptom of Advanced Heart Failure: Bendopnea. ScienceDirect. Sciencedirect.com. Presented November 3, 2012. Accessed April 27, 2022. https://www.sciencedirect.com/science/article/pii/S2213177913004125?via%3Dihub Something Sweet O'Connell A, Greco S, Zhan T, et al. Analyzing the effect of interview time and day on emergency medicine residency interview scores. BMC Med Educ. Published April 26, 2022. Accessed April 27, 2022. https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-022-03388-6 Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Show notes at pharmacyjoe.com/episode698. In this episode, I'll discuss whether tranexamic acid has a role in the treatment of aneurysmal subarachnoid hemorrhage. The post 698: Does Tranexamic Acid Have a Role In Aneurysmal Subarachnoid Hemorrhage? appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode698. In this episode, I ll discuss whether tranexamic acid has a role in the treatment of aneurysmal subarachnoid hemorrhage. The post 698: Does Tranexamic Acid Have a Role In Aneurysmal Subarachnoid Hemorrhage? appeared first on Pharmacy Joe.

July 2021 Treatment of Subarachnoid Hemorrhage-Associated Delayed Cerebral Ischemia With Milrinone: A Review and Proposal Narrator: Jacqueline Marie Morano, MD

Today's episode journeys into the neuroscience behind magic mushrooms! Psilocybin, the psychoactive ingredient, is known for making its users feel like their senses are mixing, their brains are dissociating, and the walls are melting? Does it all come down to cortical deactivation in the brain region responsible for encoding our sense of self? Come and listen to learn a little bit more about magic mushrooms effects, their huge potential as therapies for mental health disorders, and the potential consequences of their use. If you have any comments, questions, concerns, queries, or complaints, please email me at NeuroscienceAmateurHour@gmail.com or DM me at @NeuroscienceAmateurHour on Instagram. Citations below: Hartney E. What to Know About Magic Mushroom Use. Verywell Mind. Published February 26, 2012.Psilocybin (Magic Mushrooms) Uses, Effects & Hazards. Drugs.com. https://www.drugs.com/illicit/psilocybin.html.Lowe H, Toyang N, Steele B, et al. The Therapeutic Potential of Psilocybin. Molecules. 2021;26(10):2948. doi:10.3390/molecules26102948‌Aronson JK, ed. Psilocybin. ScienceDirect. Published January 1, 2016. Accessed January 26, 2022. https://www.sciencedirect.com/science/article/pii/B978044453717100158XDrug Scheduling. www.dea.gov. https://www.dea.gov/drug-information/drug-scheduling#:~:text=Schedule%20I%20drugs%2C%20substances%2C%20orCarhart-Harris RL, Erritzoe D, Williams T, et al. Neural correlates of the psychedelic state as determined by fMRI studies with psilocybin. Proceedings of the National Academy of Sciences. 2012;109(6):2138-2143. doi:10.1073/pnas.1119598109Bhagwagar Z, Hinz R, Taylor M, Fancy S, Cowen P, Grasby P. Increased 5-HT(2A) receptor binding in euthymic, medication-free patients recovered from depression: a positron emission study with [(11)C]MDL 100,907. The American Journal of Psychiatry. 2006;163(9):1580-1587. doi:10.1176/ajp.2006.163.9.1580Psychedelic Treatment with Psilocybin Relieves Major Depression, Study Shows. Johns Hopkins Medicine Newsroom. Published November 4, 2020. ‌More promise for psilocybin in depression but safety remains a concern. Clinical Trials Arena. Published November 15, 2021.Vollenweider FX, Vollenweider-Scherpenhuyzen MFI, Bäbler A, Vogel H, Hell D. Psilocybin induces schizophrenia-like psychosis in humans via a serotonin-2 agonist action. NeuroReport. 1998;9(17):3897-3902. Mozhdehipanah H, Gorji R. Subarachnoid Hemorrhage as a Manifestation of Magic Mushroom Abuse: A Case Report and Review Literature. Journal of Vessels and Circulation. 2020;1(3):40-42. doi:10.52547/jvesselcirc.1.3.40‌Hendricks PS, Johnson MW, Griffiths RR. Psilocybin, psychological distress, and suicidality. Journal of Psychopharmacology. 2015;29(9):1041-1043. doi:10.1177/0269881115598338Substance Abuse and Mental Health Services Administration: SAMHSA's National Helpline800-662-HELP (4357)TTY: 800-487-4889Support the show (https://www.patreon.com/neuroscienceamateurhour)

Animateurs/invités : Dre Emma Glaser, médecin famille au GMF-U Bordeaux Cartierville et animatrice de la série de balados Première ligne du Réseau-1 Québec, et Dr Hughes De Lachevrotière, médecin de famille au GMF-U Sud de Lanaudière et professeur adjoint de clinique au Département de médecine de famille et de médecine d'urgence de l'Université de Montréal.Objectifs :Être en mesure d'interpréter et d'évaluer la qualité de l'information recueillie des différentes sources webDévelopper un esprit critique face aux baladodiffusions, sites web, vidéos et médias sociauxMessages clés :Faites preuve de rigueur et d'analyse critique dans l'évaluation des sources d'information sur le webUtiliser la grille d'analyse de sources d'information web afin d'être familier avec les différents éléments à vérifier; le tout deviendra rapidement intuitifCet épisode a été enregistré dans le cadre des modules critiques pour les résidents en médecine familiale à l'Université de Montréal.Références : GT lecture critique MF UdeM. (2021). Grille d'analyse de sources d'information web. Traduction libre et adaptation de l'outil “The rMETRIQ Score – The revised Medical Educational Translational Resources : Impact and Quality Score” de Colmers-Gray I. et al, “The Revised METRIQ Score: A Quality Evaluation Tool for Online Educational Resources” AEM Educ Train. (2019). Chopra, A, Yiu, S, Helman, A. (2011) Part 1: Migraine Headache and Subarachnoid Hemorrhage. Emergency Medicine Cases.

Dr. Marc Simard is interviewed by Dr. Jon Rosenburg on his recent article titled, “Low-dose intravenous heparin infusion in patients with aneurysmal subarachnoid hemorrhage: a preliminary assessment.” NCS offers free CE credits for the NCS Podcast Series episodes. Listen to any of the posted episodes, complete a five question survey, and claim your credits here! Credits are available for physicians, pharmacists, nurses, and non-physicians. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Bonnie Rossow. Our host is Fawaz Almufti, and our production staff includes Tareq Saad Almaghrabi, Andrew Bauerschmidt, Leonid Groysman, Atul Kalanuria, Lauren Koffman, Kassi Kronfeld, Holly Ledyard, Lindsay Marchetti, Alexandra Reynolds, Lucia Rivera Lara, Jon Rosenberg, Jason Siegel, Zachary Threlkeld, Teddy Youn, and Chris Zammit. Our administrative staff includes Bonnie Rossow. Music by Mohan Kottapally.

Dr. Andrew Bauerschmidt interviews Dr. H. Alex Choi about his presentation, "SAHRANG: Subarachnoid Hemorrhage Recovery and Galantamine- A pilot multicenter randomized placebo controlled trial" from the NCS Annual Meeting. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Bonnie Rossow. Our host is Fawaz Almufti, and our production staff includes Tareq Saad Almaghrabi, Andrew Bauerschmidt, Leonid Groysman, Atul Kalanuria, Lauren Koffman, Kassi Kronfeld, Holly Ledyard, Lindsay Marchetti, Alexandra Reynolds, Lucia Rivera Lara, Jon Rosenberg, Jason Siegel, Zachary Threlkeld, Teddy Youn, and Chris Zammit. Our administrative staff includes Bonnie Rossow. Music by Mohan Kottapally.

Welcome to the emDOCs.net podcast! Join us as we review our high-yield posts from our website emDOCs.net.Today on the emDOCs cast with Brit Long, MD (@long_brit),  we cover Thunderclap Headache. To continue to make this a worthwhile podcast for you to listen to, we appreciate any feedback and comments you may have for us. Please let us know!Subscribe to the podcast on one of the many platforms below:Apple iTunesSpotifyGoogle Play

Dr. Lucia Rivera is joined by Drs. Aravind Ramesh and Matt Thomas to discuss their recent article, "Beta-Blockade in Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-Analysis." NCS offers free CE credits for the NCS Podcast Series episodes. Listen to any of the posted episodes, complete a five question survey, and claim your credits here! Credits are available for physicians, pharmacists, nurses, and non-physicians. NCS offers free CE credits for the NCS Podcast Series episodes. Listen to any of the posted episodes, complete a five question survey, and claim your credits here! Credits are available for physicians, pharmacists, nurses, and non-physicians. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Bonnie Rossow. Our host is Fawaz Almufti, and our production staff includes Tareq Saad Almaghrabi, Andrew Bauerschmidt, Leonid Groysman, Atul Kalanuria, Lauren Koffman, Kassi Kronfeld, Holly Ledyard, Lindsay Marchetti, Alexandra Reynolds, Lucia Rivera Lara, Jon Rosenberg, Jason Siegel, Zachary Threlkeld, Teddy Youn, and Chris Zammit. Our administrative staff includes Bonnie Rossow. Music by Mohan Kottapally.

In this episode, we review the high-yield topic of Subarachnoid Hemorrhage from the Neurology section. Follow Medbullets on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets

Welcome to Episode 007 (cue the James Bond music please) of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 7 of “The 2 View” A Wolf in Sheep's Clothing Birnbaumer, Diane MD. A Wolf in Sheep's Clothing: Serious Causes of Common Complaints. Advanced Emergency Medicine Boot Camp. September 2019. Las Vegas. Accessed June 29, 2021. Subarachnoid Hemorrhage Carpenter CR, Hussain AM, Ward MJ, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture with an Exploration of Test Thresholds. Acad Emerg Med. PubMed.gov. Published September 6, 2016. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/27306497/ Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. Published 2012. Accessed June 29, 2021. https://www.ahajournals.org/doi/full/10.1161/str.0b013e3182587839 Headache. Acep.org. Published June 2019. Accessed June 29, 2021. https://www.acep.org/patient-care/clinical-policies/headache/ Hine, J MD, Marcolini, E MD. Aneurysmal Subarachnoid Hemorrhage. EM:RAP CorePendium. Emrap.org. Published September 17, 2020. Accessed June 29, 2021. https://www.emrap.org/corependium/chapter/recTI59VW0TPBpesx/Aneurysmal-Subarachnoid-Hemorrhage Kim YW, Neal D, Hoh BL. Cerebral aneurysms in pregnancy and delivery: pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery. PubMed.gov. Published February 2013. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/23147786/ Marcolini E, Hine J. Approach to the Diagnosis and Management of Subarachnoid Hemorrhage. West J Emerg Med. NCBI. Published February 28, 2019. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404699/ Ogilvy, C MD, Rordorf, G MD, Singer, R MD. Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis. UpToDate. Uptodate.com. Updated February 25, 2020. Accessed June 29, 2021. https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-clinical-manifestations-and-diagnosis?search=subarachnoid%20hemorrhage&source=searchresult&selectedTitle=1~150&usagetype=default&display_rank=1 Ottawa Subarachnoid Hemorrhage (SAH) Rule for Headache Evaluation. Mdcalc.com. Accessed June 29, 2021. https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation Subarachnoid Hemorrhage, no LP. EM:RAP. Emrap.org. Published May 2020. Accessed June 29, 2021. https://www.emrap.org/episode/emrap2020may/subarachnoid Gonococcal Arthritis Klausner, J MD, MPH. Disseminated gonococcal infection. UpToDate. Uptodate.com. Updated January 7, 2021. Accessed June 29, 2021. https://www.uptodate.com/contents/disseminated-gonococcal-infection Li R, Hatcher JD. Gonococcal Arthritis. In: StatPearls. StatPearls Publishing. Published July 26, 2020. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK470439/ Milne, Wm. MD. SGEM#335: Sisters Are Doin' It for Themselves…Self-Obtained Vaginal Swabs for STIs. Thesgem.com. Published June 26, 2021. Accessed June 29, 2021. https://www.thesgem.com/2021/06/sgem335-all-by-myselfself-obtained-vaginal-swabs-for-stis/ Ventura, Y MD, Waseem, M MD, MS. Disseminated Gonococcal Infection: Emergency Department Evaluation and Treatment. Emdocs.net. Published May 17, 2021. Accessed June 29, 2021. http://www.emdocs.net/disseminated-gonococcal-infection-emergency-department-evaluation-and-treatment/ Epiglottitis Abdallah C. Acute epiglottitis: Trends, diagnosis and management. Saudi J Anaesth. Published July-September 2012. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498669/ Ames WA, Ward VM, Tranter RM, Street M. Adult epiglottitis: an under-recognized, life-threatening condition. Br J Anaesth. Oxford Academic. Published November 1, 2000. Accessed June 29, 2021. https://academic.oup.com/bja/article/85/5/795/273886 Dowdy RAE, Cornelius BW. Medical Management of Epiglottitis. Anesth Prog. Published July 6, 2020. Accessed June 29, 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342809/ Farkas, J. Epiglottitis. Emcrit.org. Published December 18, 2016. Accessed June 29, 2021. https://emcrit.org/ibcc/epiglottitis/ Mayo-Smith M. Fatal respiratory arrest in adult epiglottitis in the intensive care unit. Implications for airway management. Chest. PubMed.gov. Published September 1993. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/8365325/ Roberts, J MD, Roberts, M ACNP, PNP. Nasal Endoscopy for Urgent and Complex ED Cases. Lww.com. Published October 28, 2020. Accessed June 29, 2021. https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=110 Wolf M, Strauss B, Kronenberg J, Leventon G. Conservative management of adult epiglottitis. Laryngoscope. PubMed.gov. Published February 1990. Accessed June 29, 2021. https://pubmed.ncbi.nlm.nih.gov/2299960/ Wellens Syndrome Wellens Syndrom EKG Sign: See full show notes here: https://bit.ly/3eSyzp0 Cadogan M, Buttner R. Wellens Syndrome. Life in the Fastlane. Litfl.com. Published June 4, 2021. Accessed June 29, 2021. https://litfl.com/wellens-syndrome-ecg-library/ Smith S. Wellens' missed. Then returns with Wellens' with dynamic T-wave inversion. Dr. Smith's ECG Blog. Blogspot.com. Published May 4, 2011. Accessed June 29, 2021. http://hqmeded-ecg.blogspot.com/2011/05/wellens-missed-then-returns-with.html?m=1 Wellens Syndrome ECG Recommended Book Resources for the Month Merck. The Merck Manual of Patient Symptoms. (Porter RS, ed.). Merck; 2008. Schaider JJ, Barkin RM, Hayden SR, et al., eds. Rosen and Barkin's 5-Minute Emergency Medicine Consult. 4th ed. Lippincott Williams and Wilkins; 2010. Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Last month we asked you a trivia question regarding the very first NP program – who was the duo that began the program and what was the first NP specialty program? The correct answer was Dr. Loretta Ford and Dr. Henry Silver. The first NP specialty program was pediatrics. We'll be sending Lindsey Harvey, MSN, FNP-BC to the November Original EM Boot Camp Gratis for providing that answer! We can't wait to see you and all of the other registrants in November in Las Vegas! Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to.

Narrator: Jacqueline Marie Morano, MD

We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage. Hosts: Mark Iscoe, MD Brian Gilberti, MD Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/SAH.mp3 Download One Comment Tags: Critical Care, Neurology, Subarachnoid Hemorrhage Show Notes Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)   Hunt-Hess grade and mortality (from Lantigua et al.

We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage. Hosts: Mark Iscoe, MD Brian Gilberti, MD Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/SAH.mp3 Download Leave a Comment Tags: Critical Care, Neurology, Subarachnoid Hemorrhage Show Notes Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)   Hunt-Hess grade and mortality (from Lantigua et al. 2015.)

Conversation between Drs. Safa Abdelhakim and Jennifer Kim about subarachnoid hemorrhage.Note: This podcast is intended solely as an educational tool for learners, especially neurology residents. The contents should not be interpreted as medical advice.

Initial approach, supportive care, risk stratification, and management of the troublesome complications for ruptured subarachnoid aneurysm, with Thomas Lawson (@TomLawsonNP), nurse practitioner in the neurocritical care unit at OSU Wexner Medical Center. Takeaway lessons SAH + shock or hypoxemia = suspect neurogenic pulmonary edema and/or Takotsubo cardiomyopathy. Aneurysmal SAH is much different from traumatic and … Continue reading "Episode 22: Aneurysmal subarachnoid hemorrhage with Thomas Lawson"

Subarachnoid hemorrhage. It's a mouthful and it sounds terrifying. Join host Eryn Martin as she talks about the subarachnoid hemorrhage that she experienced in  May of 2020 in the midst of the US Covid quarantine. Out of nowhere, Eryn was struck by an uncontrollable headache and vomiting after completing an at-home workout. After being rushed to the hospital, she was told by neurologists that she had suffered from a perimesencephalic subarachnoid hemorrhage, meaning that she had experienced a spontaneous venous rupture in her brain. Eryn was rushed from her local hospital in New Hampshire to the neurological intensive care unit at Massachusetts General Hospital in Boston, where she spent seven days recovering. Eryn talks about her time in the hospital, her return home, what her recovery journey has been like, and the hurdles and surprises along the way. HELP US SPREAD THE WORD!   If you dug this episode head on over to Apple Podcasts and kindlyhttps://podcasts.apple.com/us/podcast/making-headway/id1534964037 ( leave us a rating, a review and subscribe!) Ways to subscribe to the Making Headway Podcast: https://podcasts.apple.com/us/podcast/making-headway/id1534964037 (Click here to subscribe via Apple Podcasts) https://open.spotify.com/show/4Ishnxgh8xbJfV8BtbCtZw (Click here to subscribe via Spotify) https://making-headway.captivate.fm/listen (Click here to subscribe via RSS) https://www.stitcher.com/podcast/making-headway (You can also subscribe via Stitcher)   https://www.makingheadwaypodcast.com/ (Visit the Making Headway Podcast website) to learn more about Eryn and Mariah and our journey to podcasting. Follow us onhttps://www.instagram.com/makingheadwaypodcast/ ( Instagram) orhttps://www.facebook.com/makingheadwaypodcast ( Facebook).

Dr. Leonie Müller-Jensen discusses her paper, "Cerebrospinal Fluid Cytology in Subacute Subarachnoid Hemorrhage". Show references: https://n.neurology.org/content/95/15/699

Episode 22 Salty and Sweet: Hypertension and DiabetesThe sun rises over the San Joaquin Valley, California, today is August 7, 2020.Have you heard any news about COVID-19? You surely have, who hasn’t? But above all the negativity surrounding this disease, including political issues, there is hope for the future. Have you heard of, for example, mRNA 1273?(1) Could this be the vaccine we have been waiting for? We don’t know yet, but there are more than 21 vaccines being tested right now around the world. If an effective vaccine is found, you’ll certainly hear about it in this podcast.Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”― Viktor E. Frankl Part I: Primary Aldosteronism with Roberto Velazquez Amador, MD, Rio Bravo Family Medicine Residency Program Who are you?I am Dr Velazquez Amador, I am originally from Jalisco, Mexico where I was born and race. I completed my medical studies at the Universidad of Guadalajara, and now I on the third year of FM residency.What did you learn this week?I learned about a patient whom had an incomplete work up for adrenal insufficiency but still treated. He ended up showing signs of Cushing’s syndrome and resistant hypertension. I want to talk about secondary hypertension and Primary Aldosteronism.Why that knowledge important for you and your patients?It is important because it reminds me that secondary causes of hypertension are often under diagnosed. How did you get that knowledge?Reading upon new cases, specially from the inpatient population, it often leads me to find new differentials and new testing modalities.  Where did that knowledge come from?First line review data place for me is Uptodate now that I am in residency. But the initial knowledge came while on Medical school. Reading physiology and physiopathology books. The book that I like to consult a lot is Kelly’s Essentials for Internal Medicine, this book chapters encompass anatomy, physiology and the pathology aspect beside diagnoses and treatment. It is very complete. While in residency, also my reference is the AAFM articles.  DisorderSuggestive clinical featuresGeneralSevere or resistant hypertension An acute rise in blood pressure over a previously stable value Proven age of onset before puberty Age less than 30 years with no family history of hypertension and no obesity Renovascular diseaseUnexplained creatinine elevation and/or acute and persistent elevation in serum creatinine of at least 50% after administration of ACE inhibitor, ARB, or renin inhibitor Moderate to severe hypertension in a patient with diffuse atherosclerosis, a unilateral small kidney, or asymmetry in kidney size of more than 1.5 cm that cannot be explained by another reason Moderate to severe hypertension in patients with recurrent episodes of flash pulmonary edema Onset of hypertension with blood pressure >160/100 mmHg after age 55 years Systolic or diastolic abdominal bruit (not very sensitive) Primary kidney diseaseElevated serum creatinine concentration Abnormal urinalysis Drug-induced hypertension:  Oral contraceptives Anabolic steroids NSAIDs Chemotherapeutic agents (eg, tyrosine kinase inhibitors/VEGF blockade) Stimulants (eg, cocaine, methylphenidate) Calcineurin inhibitors (eg, cyclosporine) Antidepressants (eg, venlafaxine) New elevation or progression in blood pressure temporally related to exposure PheochromocytomaParoxysmal elevations in blood pressure Triad of headache (usually pounding), palpitations, and sweating Primary aldosteronismUnexplained hypokalemia with urinary potassium wasting; however, more than one-half of patients are normokalemic Cushing's syndromeCushingoid facies, central obesity, proximal muscle weakness, and ecchymoses May have a history of glucocorticoid use Sleep apnea syndromeCommon in patients with resistant hypertension, particularly if overweight or obese Loud snoring or witnessed apneic episodes Daytime somnolence, fatigue, and morning confusion Coarctation of the aortaHypertension in the arms with diminished or delayed femoral pulses and low or unobtainable blood pressures in the legs Left brachial pulse is diminished and equal to the femoral pulse if origin of the left subclavian artery is distal to the coarct HypothyroidismSymptoms of hypothyroidism Elevated serum thyroid stimulating hormone Primary hyperparathyroidismElevated serum calcium  Primary AldosteronismThe evaluation of a patient with hypertension depends upon the likely cause and the degree of difficulty in achieving acceptable blood pressure control since many forms of secondary hypertension lead to "treatment-resistant" hypertension. Because it is not cost effective to perform a complete evaluation for secondary hypertension in every hypertensive patient, it is important to be aware of the clinical clues that suggest secondary hypertension. There are a number of general clinical clues that, in isolation or in combination, are suggestive of secondary hypertension. Primary aldosteronism is  a hormonal disorder that leads to high blood pressure. It occurs when your adrenal glands produce too much of a hormone called aldosterone. The classic presenting signs of primary aldosteronism are hypertension and hypokalemia, but potassium levels are frequently normal in modern-day series of primary aldosteronism. The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. However, most patients with primary mineralocorticoid excess are normokalemic and, rarely, some are hypokalemic but normotensive (primarily in young adult females).The most common subtypes of primary aldosteronism are:Aldosterone-producing adenomas (APA)Bilateral idiopathic hyperaldosteronism (IHA; bilateral adrenal hyperplasia)The presence of primary mineralocorticoid excess should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. In patients diagnosed with primary aldosteronism, treatment of the mineralocorticoid excess results in reversal or improvement of the hypertension and resolution of the increased cardiovascular risk.Who should be tested?Test for primary aldosteronism in the following patients: ●Hypertension and spontaneous or low-dose, diuretic-induced hypokalemiaThe following patients should undergo testing even if they are normokalemic:●Severe hypertension (>150 mmHg systolic or >100 mmHg diastolic) or drug-resistant hypertension (defined as suboptimally controlled hypertension on a three-drug program that includes an adrenergic inhibitor, vasodilator, and diuretic)●Hypertension with adrenal incidentaloma●Hypertension with sleep apnea●Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (15 ng/dL (416 pmol/L), but may be as low as 10 ng/dL (277 pmol/L).Some clinicians calculate a PAC/PRA ratio as part of the case detection strategy, but we prefer to use the paired random PAC and PRA (or PRC). The mean value for the PAC/PRA ratio in normal subjects and patients with primary hypertension (formerly called "essential" hypertension) is 4 to 10, compared with more than 30 to 50 in most patients with primary aldosteronism In general, a PAC/PRA ratio greater than 20 (depending upon the laboratory normals) is considered suspicious for primary aldosteronism, although others use a cutoff criterion of 30.              Part II: Continuous Glucose Monitoring with Denise Le DeWhitt, MS3, Ross University School of Medicine  What is a CGM?A continuous glucose monitor is a special type of device that allows for continuous measurement of glucose levels from the interstitial fluid rather than the blood. Depending upon the device, glucose levels are measured every 5-15 minutes. CGM allows for a measurement of a trend in a patient’s glucose levels as compared to a measurement of a glucose level at a single point in time, commonly known as traditional finger prick testing. How is it used?A CGM works by placing a small sensor under the patient’s skin, commonly located on the abdomen or under the arm. The glucose readings are sent to a monitor via a transmitter. Depending upon which CGM brand is used, the monitor maybe attached to an insulin pump, which can be easily placed in a patient’s pocket or purse for convenience. Alternatively, some CGM devices may even send the glucose readings directly to a smartphone, or other smart device, if the patient has the app. Why should we prescribe CGM instead of traditional glucometer?Allows patients to take active control of their Diabetes.It gives patients a better idea on how their sugar levels can fluctuate in a day (visually can see hypoglycemic and hyperglycemic level trends).Decreased incidence of having hypoglycemic emergencies.Some devices come with an alarm that can alert the patient when their glucose levels are too high or too low.Reduced finger stick pricks. Most popular brand names, or just focus on Free Style Libre (cheapest)Free Style Libre (APPROVED by Medicare lowest cost and widest inaccuracy in low glucose range)It is a CGM system that automatically measures the blood glucose levels of the person wearing it.Apply the sensor with the provided applicator, and a glucose sensing filament is inserted just below the skin.  The sensor measures glucose in the interstitial fluid.By waving the digital reader above the sensor, it records the amount of glucose in the wearer’s system at the moment and stores the data in the digital reader.It allows for immediate access to glucose levels and to trend hypoglycemia and hyperglycemia. It allows for ease of checking glucose in public discreetly. The system makes it easy for health care providers to have access to the stored glucose logs by connecting the reader to a computer.Dexcom G6: (Medicare approved, costly sensors and transmitters)Senseonics Eversense CGM (NOT approved by Medicare)Medtronic Guardian 3: Impacted by Acetaminophen use, provides real time alerts for highs and lows Medi-Cal and Medicare Coverage Medicare covers therapeutic continuous glucose monitors (CGMs) and related supplies instead of blood sugar monitors for making diabetes treatment decisions, like changes in diet and insulin dosage. For these individuals, coverage of diabetes drugs and technology dramatically increases their chances of living a life free of complications. Despite this, however, continuous glucose monitors (CGM) are not covered by Medi-Cal. CGMs are covered under California Children’s Services (CCS), a state program for children with certain diseases or health problems, this is limited only to children with multiple co-morbidities and children who are disabled.Not currently covered under Medi-cal insurance. How to set up for patient and for our officeFalls under the category of Durable Medical Equipment covered under MedicareIn order to be eligible these are the conditions that must be met:Physician must prescribe the equipment for home use, and it must be medically necessary.Physician prescribing the monitoring system, as well as the supplier, must be enrolled in Medicare and accept Medicare assignment.Medicare recipient must have diabetes and must be using a blood glucose monitor to test levels 4 or more times daily. They must also be taking 3 or more daily insulin injections.With Medicare Part B, Medicare covers 80 percent of the approved amount. Medicare recipients are responsible for paying 20 percent of the final, approved cost, and the Part B deductible will apply.   ______________________________Speaking Medical: Xanthochromiaby Isabelo Bustamante, MS3Have you seen the word xanthochromia in a Cerebrospinal Fluid (CSF) study result? Xanthochromia has a Greek origin combining “yellow” (xantho) and “color” (chromia). Xanthochromia basically meansyellowish-colored CSF that can be seen with the naked eye. CSF is normally crystal clear. Xanthochromia can be found after several hours of bleeding into the subarachnoid space. This is because of the degradation of red blood cells after Subarachnoid Hemorrhage or SAH. Now you know the medical word of the week, xathochromia. Have a nice week.    ____________________________Espanish Por Favor: Azúcarby Dr Claudia CarranzaHi this is Dr Carranza on our section Espanish Por Favor. This week’s word is azúcar.  The word azúcar  was made popular by the famous Cuban singer Celia Cruz; she used it as an expression of happiness and joy “AZÚCAR!” Azúcar is a sweet crystalline substance derived from many plants such as sugar cane and sugar beet. You guessed it! Azúcar means sugar in Spanish. Azúcar is a substance that is part of us as humans and it literally runs through our veins.  Azúcar comes from the Hispanic Arabic assúkkar. Azúcar is a vital word to use when talking to patients with diabetes and obesity. Most people will understand blood glucose if you say just azúcar, but if you see a weird look in your patient you may be more specific with the phrase azúcar en la sangre.  Azúcar alta means high sugar (hyperglycemia), and azúcar baja means low sugar (hypoglycemia).  Now you know the Espanish word of the week, “AZÚCAR”, I hope you have a sweet day full of joy and happiness! Until next time! ____________________________Now we conclude our episode number 22 “Salty and Sweet: Hypertension and Diabetes”. We covered the basics on Primary Aldosteronism with Dr Velazquez, the salty part: sodium and potassium; and Continuous Glucose Monitoring with Denise, the sweet part: sugar. Isabello explained xanthochromia, which is yellowish cerebrospinal fluid, and, to put the cherry on this salty and sweet cake, Dr Carranza taught that sugar in Spanish is azúcar.This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Gina Cha, Claudia Carranza, Roberto Velazquez, and the special participation of our medical students Isabelo Lucho Bustamante and Denise Le DeWhitt. Audio edition: Suraj Amrutia. See you soon! _____________________References:mRNA-1273 Approval Status, Reviewed by Judith Stewart, BPharm. Last updated on Jul 27, 2020. https://www.drugs.com/history/mrna-1273.htmlUniversity of Southern California - Health Sciences. “Significantly less addictive opioid may slow progression of osteoarthritis while easing pain.” ScienceDaily, 13 July 2020. www.sciencedaily.com/releases/2020/07/200713120014.htm, accessed on Jul 30, 2020.

Aneurysmal Subarachnoid HemorrhageSpecial Guest: Casey May, PharmD, BCCCP Show Notes: https://pharmacytodose.files.wordpress.com/2020/06/asah-show-notes.pdf Reference List: https://pharmacytodose.files.wordpress.com/2020/06/asah-references.pdf 02:51 – Types of intracerebral bleeds; 06:19 – Types of subarachnoid hemorrhage; 08:25 – Pathophysiology of aSAH; 10:45 – Risk factors; 12:48 – Classic aSAH presentation; 16:36 – Classificiation systems; 22:25 – Prioritizating acute management of aSAH; 25:15 – Blood pressure goals; 26:21 – Preferred anti-HTN agent?; 28:25 – Biggest concerns with anti-HTN agents; 31:08 – ICP management; 35:40 – Surgical clipping v. Endovascular coiling; 42:51 – Cerebral vasospasms and delayed cerebral ischemia; 55:07 – Nimodipine in aSAH; 68:20 – DVT prophylaxis; 73:48 – Seizure prophylaxis; 76:30 – Augmented renal clearance; 83:56 – Take-home points  PharmacyToDose.Com@PharmacyToDose on Twitter/InstagramPharmacyToDose@Gmail.com

A deadly cause of headache... We talk some serious movie references here while dropping bombs about SAH, its causes, diagnosis, and management. What about BP in SAH? No one knows, but we'll try... "Come with us if you want to live, er, pass boards." Website: www.emboardbombs.com Copyright Terminator 1984, Terminator Salvation 2009

Each month, EMedHome.com presents EMCast, the 90-minute podcast hosted by Dr. Amal Mattu, the premier educator in Emergency Medicine. Subscribe to EMedHome.com for an array of clinical content that will impact every shift. This month's EMCast covers:(1) Coronary Artery Bypass Graft (CABG) Complications(2) In-flight Medical Emergencies(3) Subarachnoid Hemorrhage

How do you manage a ruptured aneurysm? What do you do with their BP? With the EVD? Let’s talk through a case… The post Aneurysmal Subarachnoid Hemorrhage appeared first on NeuroTutorials.

In this installment of the NCS Podcast, Dr. Starane Shepherd interviews Dr. Michael Reznik on their investigation as to the clinical impact of agitation and fluctuations in consciousness following subarachnoid hemorrhage. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Jim Siegler. Our host is Fawaz Almufti, and our production staff includes Ramani Balu, Michael Brogan, Joshua Levine, Sarah Stern-Nezer, Benjamin Miller, Starane Shepherd, and Chris Zammit. Our administrative staff include Becca Stickney, Sara Memmen, and Angel Gindele. Music by Lee Roosevere. Reznik ME, Mahta A, Schmidt JM, Frey HP, Park S, Roh DJ, Agarwal S and Claassen J. Duration of Agitation, Fluctuations of Consciousness, and Associations with Outcome in Patients with Subarachnoid Hemorrhage. Neurocritical care. 2018;29:33-39.

Välkommen till juniavsnittet av AKUTBOKEN podcast. Här är ämnena och artiklarna i detta avsnitt: Diagnostik av subarachnoidalblödning Marcolini et al. (2019) Approach to the Diagnosis and Management of Subarachnoid Hemorrhage. West J Emerg Med. 20:203-211. PMID: 30881537 Diagnostik av nekrotiserande fasciit Fernando et al. (2019) Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, […]

This month on the NCS Podcast, Dr. Sara Stern-Nezer interviews Dr. Baxter Allen about his recently published investigation exploring the risk of seizures following clipping or endovascular coiling of ruptured intracranial aneurysms. The NCS Podcast is the official podcast of the Neurocritical Care Society. Our senior producer is Jim Siegler. Our host is Fawaz Almufti, and our production staff includes Michael Brogan, Starane Shepherd, Benjamin Miller, Chris Zammit, and Ramani Balu. Our administrative staff include Becca Stickney, Sara Memmen, and Angel Gindele. Music by Lee Roosevere. Allen BB, Forgacs PB, Fakhar MA, Wu X, Gerber LM, Boddu S, et al. Association of seizure occurrence with aneurysm treatment modality in aneurysmal subarachnoid hemorrhage patients. Neurocritical care. 2018;29:62-68

Case Study: A woman presents to the hospital with a Subarachnoid Hemorrhage. Simply put a vessel in her head started leaking blood, likely from a ruptured aneurysm. This lady is rushed to interventional radiology (IR) to have a procedure known as a coiling performed that will stop the bleeding in her head. In order to perform the procedure a neurosurgeon must go in through the artery in her groin in order to reach the aneurysm in her brain. Once the procedure is successfully complete a nurse in the IR must hold pressure at the groin site up to 10 minutes so the patient does not "bleed out" and die. Once the patient is transferred to the intensive care unit (ICU) and the patient is alone with her new nurse, she discloses that while the nurse in IR was holding pressure, he sexually assaulted her. David, a Neurological Intensive Care Unit nurse joins the show to express the routes that should be taken and helps expose common mentalities throughout coworkers and what to do with the doubt that arises when others blow off the patient's recollection of the assault. Ultimately, what would you do if this woman was your mother, sister, or wife? What would you do if you overheard the staff calling your loved one a liar and crazy? If after the investigation they determined the nurse was innocent? --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/jami-fregeau/message Support this podcast: https://anchor.fm/jami-fregeau/support

History Sudden and maximal in onset Compared to previous headaches Family history of aneurysm Associated Symptoms Photophobia Visual Changes Neck Stiffness Exam Full neuro examination Cranial nerves Visual fields Speech Cerebellar (finger-nose) Motor Sensation Gait Testing Plan Non-contrast head CT Excellent sensitivity 100 RBCs in tube 4 Can be […]

Subarachnoid hemorrhage is the king of life-threatening headaches and is on my differential every time. This episode will cover how to take the history, exam, testing and treatment of this devastating diagnosis.

This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_142_0_Final_Cut.m4a Download Leave a Comment Tags: APE, Cardiology, Caustic Ingestions, CHF, SAH, SCAPE, Subarachnoid Hemorrhage, Toxicology Show Notes Take Home Points In patients with APE, give high-dose nitro to decrease after load and preload quickly. 400-500 mcg/min for the first 4-5 minutes is my standard approach Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here A NCHCT performed within 6 hours of symptom onset is extremely sensitive for ruling out SAH but, nothing is 100%. If you've got a high-risk patient, you should still consider LP Patients with caustic ingestions can have rapidly deteriorating airways. Prepare early and be ready to take over the airway at a moments notice Read More Core EM: Acute Pulmonary Edema EMCrit:

This week we discuss more pearls from our morning report conference on APE, SAH and caustic ingestions. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_142_0_Final_Cut.m4a Download Leave a Comment Tags: APE, Cardiology, Caustic Ingestions, CHF, SAH, SCAPE, Subarachnoid Hemorrhage, Toxicology Show Notes Take Home Points In patients with APE, give high-dose nitro to decrease after load and preload quickly. 400-500 mcg/min for the first 4-5 minutes is my standard approach Consider DSI to facilitate pre-oxygenation. Ketamine is your go to drug here A NCHCT performed within 6 hours of symptom onset is extremely sensitive for ruling out SAH but, nothing is 100%. If you’ve got a high-risk patient, you should still consider LP Patients with caustic ingestions can have rapidly deteriorating airways. Prepare early and be ready to take over the airway at a moments notice Read More Core EM: Acute Pulmonary Edema EMCrit: Sympathetic Crashing Acute Pulmonary Ed...

Participants: • Master of Ceremonies and CNS Resident Committee Chair: Martina Stippler, MD • Author/Presenter: Fawaz Al-Mufti, MD • CNS Faculty: Brian Jankowitz, MD • Discussants and CNS Resident Fellows: Rimal Dossani, MD and Kumar Vasudevan, MD

Dr. Jason Hine- Subarachnoid Hemorrhage: evidence based approach from presentation to work up   Reproduced from EMsandbox Website Subarachnoid Hemorrhage

Today Amanda Chats to Neurosurgeon Dr. Mitch Hansen about Subarachnoid Haemorrhage. The after hours call to see neurosurgical patients is one that often instils dread, so we hope that these handy tips, and a good approach will help you approach this daunting condition! 

We are back with a quick dose of high quality, high yield emergency medicine board review. Episode 4 touches on Ascending cholangitis, NEXUS, SSS, Subarachnoid hemorrhage, Anticholinergic syndrome, Lead poisoning...and many mnemonics. The post Podcast Ep 4: Mnemonics, SSS, Subarachnoid Hemorrhage, & More appeared first on RoshReview.com.

Dr. Michael Epter, Program Director, discusses subarachnoid hemorrhage evaluation & management. This talk was recorded on 7/27/2016.

A discussion a rare, but morbid sub-type of stroke seen in the emergency room.

Podcast summary of articles from June 2016 edition of Journal of Emergency Medicine from the American Academy of Emergency Medicine.  Topics include Central vs Peripheral SvO2 and Lactate, Subarachnoid Hemorrhage, Hepatitis C, Pelvic Trauma, DeWinter ECG, and board review on Sepsis.

Tom Bleck - Subarachnoid haemorrhage: what matters? Tom Bleck gives an overview of the pertinent facts regarding the complications and management of aneurysmal subarachnoid haemorrhage (SAH). The complications of aneurysmal SAH can be divided into immediate, early and late. The risk of re-bleeding is maximal on the first day, it is fatal in 75% of patients and the best management is to secure the aneurysm by coiling or clipping. Blood pressure control is utilised widely but parameters are arbitrary and the data is scarce. Early complications (days 1 - 3) include early brain injury in its various forms, stress cardiomyopathy, neurogenic pulmonary oedema and cerebral salt wasting. The most important late complication (day 4 onwards) is vasospasm. Tom briefly discusses the mechanisms and manifestations of SAH-associated brain injury including ischaemia, blood brain barrier breakdown, sustained depolarisation, hydrocephalus, vasospasm, seizures, hyperglycaemia and fever. He goes on to discuss in more detail the management of vasospasm, the associated evidence and the importance of distinguishing between clinically detectable and subclinical vasospasm.

Interview with R. Loch Macdonald, MD, PhD, author of Loss of Consciousness at Onset of Subarachnoid Hemorrhage as an Important Marker of Early Brain Injury, and Stephan A. Mayer, MD, author of Subarachnoid Hemorrhage and Loss of Consciousness

In this episode on Hypertensive Emergencies, Dr. Joel Yaphe, EM residency program director at the University of Toronto & Dr. Clare Atzema, one of Canada's leading cardiovascular EM researchers will discuss the controversies of how to manage patients who present to the ED with high blood pressure and evidence of end organ damage related to the high blood pressure. Hypertensive emergencies are a grab bag of diagnoses that all need to be treated differently. Hypertensive Encephalopathy, Aortic Dissection, Acute Pulmonary Edema, Pre-eclampsia & Eclampsia, Acute Renal Failure, Subarachnoid Hemorrhage and Intracranial Hemorrhage all need individualized blood pressure management. The post Episode 41: Hypertensive Emergencies appeared first on Emergency Medicine Cases.

In this episode on Hypertensive Emergencies, Dr. Joel Yaphe, EM residency program director at the University of Toronto & Dr. Clare Atzema, one of Canada's leading cardiovascular EM researchers will discuss the controversies of how to manage patients who present to the ED with high blood pressure and evidence of end organ damage related to the high blood pressure. Hypertensive emergencies are a grab bag of diagnoses that all need to be treated differently. Hypertensive Encephalopathy, Aortic Dissection, Acute Pulmonary Edema, Pre-eclampsia & Eclampsia, Acute Renal Failure, Subarachnoid Hemorrhage and Intracranial Hemorrhage all need individualized blood pressure management. The post Episode 41: Hypertensive Emergencies appeared first on Emergency Medicine Cases.

Background. Cerebral vasospasm is one of the leading courses for disability in aneurysmal subarachnoid hemorrhage. Effective treatment of vasospasm is therefore one of the main priorities for these patients. We report about a case series of continuous intra-arterial infusion of the calcium channel antagonist nimodipine for 1-5 days on the intensive care unit. Methods. In thirty patients with aneurysmal subarachnoid hemorrhage and refractory vasospasm continuous infusion of nimodipine was started on the neurosurgical intensive care unit. The effect of nimodipine on brain perfusion, cerebral blood flow, brain tissue oxygenation, and blood flow velocity in cerebral arteries was monitored. Results. Based on Hunt & Hess grades on admission, 83% survived in a good clinical condition and 23% recovered without an apparent neurological deficit. Persistent ischemic areas were seen in 100% of patients with GOS 1-3 and in 69% of GOS 4-5 patients. Regional cerebral blood flow and computed tomography perfusion scanning showed adequate correlation with nimodipine application and angiographic vasospasm. Transcranial Doppler turned out to be unreliable with interexaminer variance and failure of detecting vasospasm or missing the improvement. Conclusion. Local continuous intra-arterial nimodipine treatment for refractory cerebral vasospasm after aSAH can be recommended as a low-risk treatment in addition to established endovascular therapies.

Editor's Audio Summary by Howard Bauchner, MD, Editor in Chief of JAMA, the Journal of the American Medical Association, for the September 25, 2013 issue

Rob Tarr, JNIS editor, talks to Jennifer Frontera, Neurosurgery, Mount Sinai School of Medicine, about her study showing aneurysm coiling followed by ICH evacuation is a viable alternative to clipping and ICH evacuation, for subarachnoid hemorrhage with intracerebral hematoma.See also:Management of subarachnoid hemorrhage with intracerebral hematoma: clipping and clot evacuation versus coil embolization followed by clot evacuation http://bit.ly/XnJABz

This is an article published in the last year in the British Medical Journal that looked at the sensitivity of modern CT scanners in detecting subarachnoid hemorrhage. This article made a lot of waves because it suggested that a head CT within 6 hours of headache onset is 100% sensitive for subarachnoid hemorrhage.  Some have called it a practice changer that allows us to avoid doing a lumbar puncture so its important to read it for yourself and decide if it should change your practice.

The New AHA/ASA SAH Guidelines

In Part 1 of this episode on Headache Pearls & Pitfalls - Migraine Headache & Subarachnoid Hemorrhage, Dr. Anil Chopra and Dr. Stella Yiu discuss the best evidenced-based management of migraine headache in the ED including the use of dexamethasone, dopamine antagonists, the problems with narcotics and the efficacy of 'triptans'. An easy way to remember the worrisome symptoms of headache indicating a serious cause is reviewed followed by a detailed discussion of the pearls, pitfalls and controversies around the work-up of Subarachnoid Hemorrhage (SAH) in light of some exciting recent literature, including the basis for a new Canadian decision rule for SAH.

In Part 1 of this episode on Headache Pearls & Pitfalls - Migraine Headache & Subarachnoid Hemorrhage, Dr. Anil Chopra and Dr. Stella Yiu discuss the best evidenced-based management of migraine headache in the ED including the use of dexamethasone, dopamine antagonists, the problems with narcotics and the efficacy of 'triptans'. An easy way to remember the worrisome symptoms of headache indicating a serious cause is reviewed followed by a detailed discussion of the pearls, pitfalls and controversies around the work-up of Subarachnoid Hemorrhage (SAH) in light of some exciting recent literature, including the basis for a new Canadian decision rule for SAH. The post Episode 14 Part 1: Migraine Headache and Subarachnoid Hemorrhage appeared first on Emergency Medicine Cases.

In this episode, Dr Cian O'Kelly discusses subarachnoid hemorrhage. After listening to this podcast, learners will be able to: list the risk factors for subarachnoid hemorrhage and describe the mortality and morbidity of the condition describe the classical presentation of the patient with a subarachnoid hemorrhage list the tests required to make the diagnosis outline the treatment of the patient with a subarachnoid hemorrhage due to intra-cranial aneurysm list the complications associated with subarachnoid hemorrhage   Running time 13:21

Background: Cerebral edema is an important risk factor for death and poor outcome following subarachnoid hemorrhage (SAH). However, underlying mechanisms are still poorly understood. Matrix metalloproteinase (MMP)-9 is held responsible for the degradation of microvascular basal lamina proteins leading to blood-brain barrier dysfunction and, thus, formation of vasogenic cerebral edema. The current study was conducted to clarify the role of MMP-9 for the development of cerebral edema and for functional outcome after SAH. Methods: SAH was induced in FVB/N wild-type (WT) or MMP-9 knockout (MMP-9(-/-)) mice by endovascular puncture. Intracranial pressure (ICP), regional cerebral blood flow (rCBF), and mean arterial blood pressure (MABP) were continuously monitored up to 30 min after SAH. Mortality was quantified for 7 days after SAH. In an additional series neurological function and body weight were assessed for 3 days after SAH. Subsequently, ICP and brain water content were quantified. Results: Acute ICP, rCBF, and MABP did not differ between WT and MMP-9(-/-) mice, while 7 days' mortality was lower in MMP-9(-/-) mice (p = 0.03; 20 vs. 60%). MMP-9(-/-) mice also exhibited better neurological recovery, less brain edema formation, and lower chronic ICP. Conclusions: The results of the current study suggest that MMP-9 contributes to the development of early brain damage after SAH by promoting cerebral edema formation. Hence, MMP-9 may represent a novel molecular target for the treatment of SAH. Copyright (C) 2011 S. Karger AG, Basel

Michael Diringer, MD, FCCM, discusses his article published in Critical Care Medicine about the management of acute aneurysmal subarachnoid hemorrhage. Diringer is professor of neurology, neurosurgery, anesthesiology and occupational therapy at Washington University School of Medicine in St. Louis, Missouri. He is also section chief of neurological critical care. Diringer discusses the anticipation, prevention, and management of secondary complications related to aneurysmal subarachnoid hemorrhage.

Sat, 1 Jan 2005 12:00:00 +0100 https://epub.ub.uni-muenchen.de/16968/1/10_1159_000084372.pdf Hamann, Gerhard F.; Dichgans, Martin; Pellkofer, Hannah L.; Brüning, Roland; Opherk, Christian ddc

Wed, 1 Jan 2003 12:00:00 +0100 https://epub.ub.uni-muenchen.de/16807/1/10_1159_000070198.pdf Hamann, Gerhard F.; Seelos, Klaus; Winkler, F.; Milz, P.; Velden, J.