Unruptured Intracranial Aneurysm Treatment Score

UIATS = Unruptured Intracranial Aneurysm Treatment Score

  • quantifies 29 key factors related to patient, aneurysm and treatment characteristics involved in clinical decision-making in management of unruptured aneurysm
  • 2 scores generated – 1 favoring repair and the other favoring conservative management.
  • For a score difference with >3 points, higher score suggests the type of treatment
  • For a score difference with <=2 points, no definitive recommendations can be made

 

 

Reference:

Mayer, T., Etminan, N., Morita, A., & Juvela, S. (2016). The unruptured intracranial aneurysm treatment score: A multidisciplinary consensusAuthor Response. Neurology86(8), 792.2-793. doi: 10.1212/01.wnl.0000481228.68055.71

 

 

 

 

Risk Score to Predict QTc Prolongation in Hospitalized Patients

For patients with COVID-19, we are using drugs that prolong QT-interval.  The risk of life-threatening arrhythmias from QT prolongation may be higher.  This article reports a scoring system to identify patients that are at risk for QT prolongation.

The study found that the following factors predicted QTc prolongation:  female, sepsi, LV dysfunction, administration of QT-prolong drug, >= 2 QT prolonging drugs, loop-diuretic, age >68, serum K <3.5, admitting ATc >450ms.

A risk score was developed.  Risk was classified as low (score of 0-6), moderate (7-10) and high (11-21).

 

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A high risk score >11 was associated with 74% Sn and 77% Sp (PPV 79% NPV 76) for predicting QTc prolongation.  Incidence of QTc prolongation 15% in low risk, 37% in moderate risk and 73% in high risk.

 

 

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Reference:

Tisdale, J., Jaynes, H., Kingery, J., Mourad, N., Trujillo, T., Overholser, B., & Kovacs, R. (2013). Development and Validation of a Risk Score to Predict QT Interval Prolongation in Hospitalized Patients. Circulation: Cardiovascular Quality And Outcomes, 6(4), 479-487. doi: 10.1161/circoutcomes.113.000152

Arteriovenous Malformation Scores

Table.  Predictive grading systems for procedural risk in the endovascular treatment of brain AVMs.Capture

 

Buffalo score best predicts procedural risks, although predictive value is modest (AUC ~0.7).

 

Reference:

Pulli, B., Stapleton, C., Walcott, B., Koch, M., Raymond, S., & Leslie-Mazwi, T. et al. (2019). Comparison of predictive grading systems for procedural risk in endovascular treatment of brain arteriovenous malformations: analysis of 104 consecutive patients. Journal Of Neurosurgery, 1-9. doi: 10.3171/2019.4.jns19266

 

IVH Score

This score is used for patients with intracerebral hemorrhages with intraventricular extension, and is not appropriate for pure intraventricular hemorrhages.

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In this score, each lateral ventricle is graded as:

  • 0 = no blood or small amount of layering
  • 1 = up to 1/3 filled with blood
  • 2 = 1/3 to 2/3 filled with blood
  • 3 = mostly or completely filled with blood

3rd and 4th ventricles receive a score of:

  • 0 = for no blood
  • 1 = partially or completely filled with blood

Hydrocephalus was coded as

  • 0 = absent
  • 1 = present

 

The formula for calculating the IVH score is as follows:

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Or simplified:  3(RV+LV) + III + IV + 3(H)

 

Once the IVH score has been computed, the IVH volume can be calculated using the following formula:

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To make things simpler, here is a table showing the calculated IVH volume based on the IVH score.

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Here are two examples of IVH scores calculated for you:

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How to use the IVH Score?

With the IVH score, cutoff of 40 mL indicates poor outcome and 60 mL, mortality.

With the ICH score, cutoff is 25 mL and 30 mL respectively.

The total volume of hemorrhage can be calculated by adding the ICH volume (using the ABC/2 formula) and the IVH volume (using the ICH score).   Total volume predicts outcome better than ICH volume alone.

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NOTE:  Be wary of using ICH score and IVH score to withdraw care.  Early limitation of care in ICH / IVH is a self-fulfilling prophecy which is, of course, associated with mortality.

 

Reference:

Hallevi, H., Dar, N., Barreto, A., Morales, M., Martin-Schild, S., Abraham, A., Walker, K., Gonzales, N., Illoh, K., Grotta, J. and Savitz, S. (2009). The IVH Score: A novel tool for estimating intraventricular hemorrhage volume: Clinical and research implications*. Critical Care Medicine, 37(3), pp.969-e1.

 

 

 

 

 

ABCD2 Score

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Table: ABCD2 Score

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TIA Prognosis and Key Mx Considerations by National Stroke Association

ABCD2 Score:

  • Discharge low risk scores (ABCD 0-3)
    • outpatient work-up within 1-2 days (alternate option: admit for work-up)
    • DIAGNOSTICS:
      • carotid imaging (US, CTA, MRA)
      • Consider TTE; if high suspicion for cardioembolic source / bilateral infarcts, obtain TEE
      • Consider 30-d ambulatory cardiac monitor to detect cryptogenic Afib
    • smoking cessation
    • THERAPEUTICS:
      • Start antiplatelet therapy:
        • ASA 81mg/day or
        • Clopidogrel 75mg/day or
        • ASA 25mg/ER dipyridamole 200mg BID
      • start high-intensity statins
        • Atorvastatin 40-80mg/d or
        • Rosuvastatin 20-40mg/day
      • *consider moderate intensity statins if >75y/o
        • Atorvastatin 10-20mg/d or
        • Rosuvastatin 5-10mg/d or
        • Simvastatin 20-40mg/d or
        • Pravastatin 40-80mg/d
      • Consider OAC or LMWH if rhythm shows atrial fibrillation – calculate CHADSVASC and HAS BLED score to guide therapy

    Admit high risk TIAs (ABCD2 scores >3)

    • Admit to hospital
    • Permissive hypertension (up to 220/120mm Hg) and gradually lower over 24-48h

Reference:

Stroke.org. (2017). [online] Available at: http://www.stroke.org/sites/default/files/resources/tia-abcd2-tool.pdf?docID [Accessed 31 Jul. 2017].

Gross, Hartmut, and Noah Grose. 2017. “Emergency Neurological Life Support: Acute Ischemic Stroke”. Neurocritical Care 27 (S1): 102-115. doi:10.1007/s12028-017-0449-9.

Spinal Cord Injury – ASIA Scale

 

 

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Key sensory points:

  • C2 At least one cm lateral to the occipital protuberance at the base of the skull. Alternately, it can be located at least 3 cm behind the ear.
  • C3 In the supraclavicular fossa, at the midclavicular line.
  • C4 Over the acromioclavicular joint.
  • C5 On the lateral (radial) side of the antecubital fossa just proximal to the elbow (see image below).
  • C6 On the dorsal surface of the proximal phalanx of the thumb.
  • C7 On the dorsal surface of the proximal phalanx of the middle finger.
  • C8 On the dorsal surface of the proximal phalanx of the little finger.
  • T1 On the medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus.
  • T2 At the apex of the axilla. T2 T1 C5 International Standards for the Classification of Spinal Cord Injury Key Sensory Points June 2008
  • T3 At the midclavicular line and the third intercostal space, found by palpating the anterior chest to locate the third rib and the corresponding third intercostal space below it.
  • T4 At the midclavicular line and the fourth intercostal space, located at the level of the nipples.
  • T5 At the midclavicular line and the fifth intercostal space, located midway between the level of the nipples and the level of the xiphisternum.
  • T6 At the midclavicular line, located at the level of the xiphisternum.
  • T7 At the midclavicular line, one quarter the distance between the level of the xiphisternum and the level of the umbilicus.
  • T8 At the midclavicular line, one half the distance between the level of the xiphisternum and the level of the umbilicus.
  • T9 At the midclavicular line, three quarters of the distance between the level of the xiphisternum and the level of the umbilicus.
  • T10 At the midclavicular line, located at the level of the umbilicus.
  • T11 At the midclavicular line, midway between the level of the umbilicus and the inguinal ligament.
  • T12 At the midclavicular line, over the midpoint of the inguinal ligament.
  • L1 Midway between the key sensory points for T12 and L2.
  • L2 On the anterior-medial thigh, at the midpoint drawn on an imaginary line connecting the midpoint of the inguinal ligament and the medial femoral condyle.
  • L3 At the medial femoral condyle above the knee.
  • L4 Over the medial malleolus.
  • L5 On the dorsum of the foot at the third metatarsal phalangeal joint.
  • T12 L1 L2 L3 L4 L5 International Standards for the Classification of Spinal Cord Injury Key Sensory Points June 2008
  • S1 On the lateral aspect of the calcaneus.
  • S2 At the midpoint of the popliteal fossa.
  • S3 Over the ischial tuberosity or infragluteal fold (depending on the patient their skin can move up, down or laterally over the ischii).
  • S4/5 In the perianal area, less than one cm. lateral to the mucocutaneous junction.

 

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ASIA WORKSHEET <pdf>

Auto_Stan_Worksheet <pdf>

 

Reference:

“ASIA Learning Center”. Asia-spinalinjury.org. N.p., 2017. Web. 23 Mar. 2017.