Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you give TNK or IVT to a patient with proximal occlusion and an NIHSS of 0-3 (non-disabling)?
For non-disabling stroke symptoms with an NIHSS 0-5, current AHA Guidelines recommend against IV thrombolysis. (Technically, TNK has not yet made it into the AHA Guidelines, but that's not the topic here). Of course, what is considered disabling is always a debate, but the PRISMS trial defined it as...
Would you give IV thrombolysis to a patient presenting with acute disabling stroke symptoms after a TAVI procedure?
Maybe. If a stroke occurs after a TAVR, it is usually embolic. Theoretically, these patients might be candidates for intravenous thrombolysis, but there are two important reservations. First, patients usually receive full dose of heparin during the procedure, and are loaded with dual antiplatelets i...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
How do you approach treatment of myoclonic status epilepticus from anoxic brain injury?
Personal experience - I would treat with lorazepam if the myclonus makes the patient acidotic, else I would not treat it.
How do you approach ictal-interictal continuum in patients with presumed toxic/metabolic etiology?
This is a common conundrum in the EEG reading room. If during the routine EEG I get a sense that the GPDs are clearly state-dependent (i.e., more frequent in the alert state, taper off in the quiet state) and they have clear triphasic morphology, I may not do anything further aside from the recommen...
How do you approach the management of EBV Meningoencephalitis (CSF pleocytosis and CSF PCR positive for EBV)?
You have to be extremely careful before making this diagnosis. It is known that positive CSF PCR for EBV can be a "bystander" when there is actually another cause of encephalitis that shouldn't be missed. Therefore, one has to make sure that extensive PCR and/or antibody testing in the CSF has been ...
When are steroids indicated in the treatment of strep pneumo meningitis?
Yes, I recommend a four-day regimen of dexamethasone 0.4-0.6 mg per kilogram daily given before or with the first dose of antibiotics. Delaying the administration of corticosteroids would reduce the desired anti-inflammatory effects. van de Beek et al., PMID 14998499 Brouwer et al., PMID 26362566...
What blood pressure goals do you typically target for patients in the immediate post thrombectomy period?
There aren't excellent data to guide this decision. In general, I make a patient-specific decision. For all patients (both tPA treated and otherwise), I target <180/100. If they're TICI 0-1, I usually keep to that. With TICI 2a, I usually lower to <160 and with 2b/3 I usually lower to <140. The guid...
What antithrombotic regimen do you recommend prior to and in anticipation of CEA for patients with symptomatic carotid stenosis?
Dual antiplatelet therapy with aspirin and clopidogrel
Do you typically recommend platelet transfusions in patients with spontaneous ICH?
Enthusiasm for platelet transfusion for spontaneous intracerebral hemorrhage among patients on antiplatelet therapy has been dampened by the results of the PATCH study. The small 190-patient randomized study demonstrated worse outcomes for those assigned to platelet transfusion. While the serious ad...