Lumbar Puncture and Antithrombotics

Guidelines from University of Colorado for prevention of spinal hematoma:


Anticoagulation Guidelines for Neuraxial Procedures (Univ of Colorado)



Dodd, Katherine Claire, Hedley C A Emsley, Michael J R Desborough, and Suresh K Chhetri. 2018. “Periprocedural Antithrombotic Management For Lumbar Puncture: Association Of British Neurologists Clinical Guideline”. Practical Neurology 18 (6): 436-446. doi:10.1136/practneurol-2017-001820.  <Accessed 12/31/2018>

VPS Position and Risk of Malfunction

VPS malfunction can be caused by obstruction, valve infection, cathether disconnection or most commonly, malpositioning of the ventricular / peritoneal catheter.

A recent study correlated shunt position with the risk of malfunction, and determined that catheter positioned in sites A (Foramen of Monroe), B (third ventricle) and C (body of lateral ventricle) resulted in lower risks of shunt malfunction. Bad positions include sites D (septum pellucidum) and E (walls of lateral ventricle).


Dobran, Mauro, Davide Nasi, Fabrizio Mancini, Maurizio Gladi, Gabriele Polonara, Alessandra Marini, Simona Lattanzi, and Massimo Scerrati. 2018. “Relationship Between The Location Of The Ventricular Catheter Tip And The Ventriculoperitoneal Shunt Malfunction”. Clinical Neurology And Neurosurgery 175: 50-53. doi:10.1016/j.clineuro.2018.10.006.

Ischemic Strokes CT / Imaging Parameters


  • ACÁ
  • MCA
  • PCA
  • Vertebrobasilar
  • Borderline
  • Multiple territories


  1. No attenuation
  2. Early tissue changes
  3. Late tissue changes

CT Grade

    Grade 0 (none) – no acute lesions visible
    Grade 1 (subtle) – GM attenuation equal to WM attenuation
    Grade 2 (severe) – GM and/or WM attenuation lower than normal WM

MRI Grade

  • Grade 0 – no lesion
  • Grade 1 (subtle) – hyperintensities on DWI
  • Grade 2 (severe) – hyperintesities on T2W imaging +/- DWI hyperintensities


(See separate blog post)

Degree of Swelling (PROGRESSION):

  • None
  • Sulcal effacement
  • Minor effacement of lateral ventricles
  • Complete effacement of lateral ventricles
  • Effacement of III ventricle
  • Midline shift
  • Effacement of basal cisterns

Also note these CT findings:

  • Leukoaraiosis
  • Atrophy
  • Old strokes

IST Ischemic Lesion Score

– point scale for MCA territory

  • 0 = no acute lesion
  • 1 = small (lacunae or small cortical)
  • 2 = medium (striatocapsular or superficial MCA)
  • 3 = large (complete MCA territory)
  • 4 = very large (complete MCA and ACÁ territories)


Mair, Grant, Rüdiger von Kummer, Zoe Morris, Anders von Heijne, Nick Bradey, Lesley Cala, and André Peeters et al. 2018. “Effect Of IV Alteplase On The Ischemic Brain Lesion At 24–48 Hours After Ischemic Stroke”. Neurology, 10.1212/WNL.0000000000006575. doi:10.1212/wnl.0000000000006575.