Monthly Archives: July 2020

Sophia Sundararajan, MD, PhD, and Shadi Yaghi, MD

Unlike many case presentations, the Illustrative Teaching Cases in Stroke are not designed to present zebras, but rather to review things typically seen in practice. The hope is that this series will create a body of work that presents common topics encountered in stroke patients with discussions that inform the management of similar conditions.

The primary audience for these discussions is residents and fellows. An actual case is presented and discussed, and bulleted teaching points are included at the end of the article. The case is presented succinctly, and the discussion is the bulk of the paper. The articles are short and easy to read, and they are a quick way to review clinical “pearls” in cerebrovascular disease.

The purpose of this series is not to focus on esoteric or unusual cases, but to review and stress points that trainees are likely to encounter during their training and beyond. The focus of each case varies. In some cases, the key feature is a review of neuroanatomy. Another may review types of testing for a specific condition or the differential diagnosis for a particular symptom. The focus should not be related to a technical advance or how to do a procedure.

Elena Zapata-Arriaza, MD, PhD
@ElenaZaps

Lee VH, Thakur G, Nimjee SM, Youssef PP, Lakhani S, Heaton S, Powers CJ. Early neurologic decline in acute ischemic stroke patients receiving thrombolysis with large vessel occlusion and mild deficits. J Neurointerv Surg. 2020.

Large vessel occlusion (LVO) with minor neurological deficit can occur in about 24% of patients with acute ischemic stroke (AIS). The lack of clinical trials addressing this type of patient generates different therapeutic approaches, which impact the natural history of the disease. Lee et al. aim to determine the likelihood of early neurologic deterioration (END) in patients with LVO and low NIHSS treated with rtPA.

The authors performed a retrospective analysis of AIS with low NIHSS (≤7) and LVO (M1, M2, terminal carotid artery -ICAT- and tandem lesions) treated with rtPA from 2014-2019 in a telestroke platform. Most of the included patients were transferred to a tertiary hospital with endovascular treatment availability, and they received CTA on arrival. END was defined as NIHSS worsening of ≥4 within 24 hrs of stroke onset that was not related to symptomatic hemorrhage.

Burton J. Tabaac, MD
@burtontabaac

Creutzfeldt CJ, Holloway RG, Curtis JR. Palliative Care: A Core Competency for Stroke Neurologists. Stroke. 2015;46:2714–2719.

As physicians and healthcare providers, we often focus on restorative care and efficacious treatments. It is paramount, and of high import, that we are competent and trained to provide high-quality end-of-life care as well. Essential in our role is the ability to offer comfort measures when consistent with a patient’s wishes, and to serve as a source of information and support for family members when loved ones are transitioning to comfort-guided care.

This article’s authors provide a contemporary review of the literature and offer recommendations on how providers may integrate palliative medicine into the care of their patients. Palliative care is an approach to medical care for patients with serious illness. It includes end-of-life and hospice care, but is much broader. Palliative care is not limited to those with a terminal prognosis, but rather is appropriate at any age and at any stage of a serious illness.(1) The article articulates, “Palliative care focuses on improving communication about goals of care and maximizing comfort and quality of life of patients and families through the identification, prevention, and relief of pain and suffering in body, mind, and spirit.”