Tag Archives: algorithm

Algorithm for Treatment of Cerebral Venous Thrombosis (CVT)

An algorithm for the diagnosis and management of CVT:

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CTV, CT venography; CVT, cerebral venous thrombosis; ICH, intracerebral
hemorrhage; LMWH, low molecular weight heparin; MRV, magnetic resonance venography; PRES, posterior reversible encephalopathy syndrome; UHF,
unfractionated heparin.

 

Table 1 Major risk factors and conditions associated with CVT
Infection

  • INFECTION:
    • Paranasal sinusitis
    • Intracranial infections: abscess, meningitis
    • Trauma Head trauma, neurosurgical operations
    • Internal jugular catheter
  • MEDICAL / SURGICAL CONDITIONS
    • Dehydration
    • Pregnancy and puerperium
    • Coagulation disorders: factor V Leiden, protein C / S deficiency, antithrombin III deficiency, hyperhomocysteinemia, APAS
    • Hematologic disorders: polycythemia, sickle cell disease, TTP, polycythemia, PNH
    • Malignancies, inflammatory bowel disease, nephrotic syndrome, liver cirrhosis, collagen vascular disease including SLE, Wegener’s granulomatosis and Behçet syndrome
    • Previous surgical procedures
  • MEDICATION
    • Oral contraceptives, hormone replacement therapy,  L-asparagenase, corticosteroid

 

Table 3 Clinical presentations of CVT:

  • Symptoms
    • Headache
    • Double or blurred vision
    • Altered consciousness
    • Seizure
    • Behavioral symptoms (delirium, amnesia, mutism)
  • Signs
    • Papilledema
    • Focal neurologic deficit
    • Cranial nerve palsy
    • Nystagmus

 

Society of Neurointerventional Surgery (SNIS) Recommendations:

Imaging
► A combination of MRI/MRV or CT/CTV studies should be performed in patients with suspected CVT (class I; level of evidence C).
► DSA as a diagnostic modality is indicated in cases of suspected CVT when the diagnosis of CVT cannot be reliabl established with non-invasive imaging alone (class IIa; level of evidence C).

Medical and surgical treatment
► Anticoagulation with unfractionated heparin or low molecular weight heparin is reasonable in patients with CVT (class IIa; level of evidence C).
► Decompressive craniectomy may be considered in patients with large parenchymal lesions causing herniation or intractable intracranial hypertension (class IIb; level of evidence C).

Endovascular therapy
► Endovascular therapy may be considered in patients with clinical deterioration despite anticoagulation, or with severe neurological deficits or coma (class IIb; level of evidence C). The duration of anticoagulation therapy before declaring it to be a ‘failure’ and proceeding with endovascular therapy is unknown.
► There is insufficient evidence to determine which endovascular approach and device provides the optimal restoration of venous outflow in CVT. In many cases, a variety of treatment approaches is required to establish sinus patency.

 

Radiologic Findings in CVT:

  1.  noncontrast CT – hyperdensity of occluded sinuses + cerebral edema +/- ICH
  2. contrast CT – empty delta sign, HU>70% highly specific for acute CVT
  3. MRI – T2 hypointensity in acute CVT, T1 and T2 hyperintensity in subacute CVT

 

 

References

Lee, S., Mokin, M., Hetts, S., Fifi, J., Bousser, M. and Fraser, J. (2018). Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. Journal of NeuroInterventional Surgery, 10(8), pp.803-810.

 

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Carotid Stenosis Algorithm

NASCET (North American Symptomatic CEA Trial) – CEA vs medical reduced risk of stroke (17%) and death (7%) at 2 years for stenosis >70%.

ACAS (Asymptomatic Carotid Artery Stenosis Trial) – CEA vs medical reduced risk of stroke or death (6%) at 5 years for stenosis >60%.

CREST (Carotid Revascularization Endarterectomy vs Stenting Trial) – CEA vs CAS in both symptomatic and asymptomatic – comparable rates of primary outcome measures (death, stroke, MI, stroke at 4 years).  Periop stroke more in stenting, periop MI more in CEA.  **NB Periopr stroke more disabling (based on 1 year in QOL assessment).

 

ICA Stenosis Algorithm

 

References:

Experiences with carotid endarterectomy at Sree Chitra Tirunal Institute.  Unnikrishnan M, Siddappa S, Anto R, Babu V, Paul B, Kapilamoorthy TR, Sivasankaran S, Sandhyamani S, Sreedhar R, Radhakrishnan K – Ann Indian Acad Neurol (2008)

 

Lee, Kiwon. The Neuroicu Book. 1st ed. Print.

Algorithm: Management of GBM in Older Adult

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Reference:

“Initial Treatment Of Malignant Glioma In Older Adults”. Uptodate.com. 2017. Accessed 8 Mar. 2017.

Stepwise Treatment of DCI

Management of DCI is presented here as a three-stage algorithm.  Tier One therapy should be initiated for new DCI which can manifest as neurological deterioration, characteristic imaging findings or MMM abnormalities indicating ischemia.  Tier Two therapy hsould be started in cases of refractory DCI(inadequate reversal of ischemia after first-line therapy.)

 

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Reference:

Francoeur, Charles L. and Stephan A. Mayer. “Management Of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage”. Critical Care 20.1 (2016).

 

Timing of Tracheostomy in Neurologic Disease

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REFERENCE:

Yaakov Friedman and Sabine Sobek. Critical Care Medicine: Principles of Diagnosis and Management in the Adult, 14, 202-212.e5.  Tracheostomy.

Algorithm to Identify MRI Sequences

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<click here for MS Powerpoint file>

Reference:

“Introduction To Imaging: What Am I Looking At?”. YouTube. N.p., 2016. Web. 19 Dec. 2016.

 

 

Hyponatremia Protocol

Na <133 mEq/L or a decrease of 6 mEq/L in 24 to 48 hours:

  1. NaCl tabs 3 g PO/NGT q6h
  2. Start 3%NaCl at 20 mL/h
  3. BMP q6h

Na <130:
Increase rate by 20 mL/h (max rate = 80 mL/h)
If on hold at present, initiate 3 percent NaCl infusion at 20 mL/h IV

Na = 130-135:
Increase rate by 10 mL/h (max rate = 80 mL/h)
If on hold at present, initiate 3 percent NaCl infusion at 10 mL/h IV

Na = 136-140:
No change

Na ≥140:
Hold infusion

 

Reference:

Woo, Carolyn H. et al. “Performance Characteristics Of A Sliding-Scale Hypertonic Saline Infusion Protocol For The Treatment Of Acute Neurologic Hyponatremia”. Neurocritical Care 11.2 (2009): 228-234. Web.