Amit Khera, MD, MSc

• Director, Preventive Cardiology
• Assistant Professor
• Department Inernal Medicine/Cardiology
• UT Southwestern Medical Center
• Dallas, Texas

It is typically a disease of adolescents who will be able to report a prodromal awareness of feeling cold blood pressure chart with age and gender order 12.5 mg microzide visa, clammy hypertension zoloft purchase microzide 12.5mg visa, and unwell ulterior motive synonym discount 25mg microzide otc. If the event is not terminated by lying down in the prodromal phase blood pressure bottom number buy discount microzide 12.5 mg, the child goes on to fall stiffly to the ground or slump, and may exhibit brief tonic or clonic movements, or urinary incontinence. Blue breath-holding spells are primarily hypoxic in origin due to disordered respiration. As a result, the child becomes predominantly blue, limp, and may briefly lose consciousness; again, this may result in subsequent jerking limb movements. The flavour is very different from absence or other seizure that actively interrupts and cuts across normal activity. Movements may include pelvic thrusting, rolling or reciprocating kicking or flailing movements. None of these occur as part of the repertoire of a generalized tonic­clonic seizure. Narcolepsy and cataplexy Narcolepsy is an under-recognized cause of excessive daytime sleepiness (see b p. Cataplexy is a sudden loss of muscle tone typically precipitated by laughter or startle that is a common feature of narcolepsy particularly by early adulthood (although there are other causes). Recognition and appropriate management of functional symptoms is an important skill for the child neurologist. There are some adult data suggesting that pre-existing brain disease increases the risk of functional symptoms, but little evidence that neurological presentations are more common than other presentations of functional disease. Terminology · this is a sensitive and important issue if a successful outcome is to be achieved. It is important to be aware that families may be accessing professional or patient support group material on the internet, and they need to understand that, although a variety of terms are in widespread use they are referring to essentially the same clinical problem. Although psychiatric diagnostic schemes emphasize distinctions between deliberate and subconscious intent, and possible motivations. Diagnostic pointers to functional basis include the following: Paralysis · Variable loss of function. Even if the movement is not performed there is usually an involuntary postural adjustment anticipating the lifting of the leg, felt as increased downward pressure of the held heel into the couch, which would not occur if legs were truly paralysed. Sensory Whole limb anaesthesia, hemisensory loss for all modalities to the midline. It is rare for a functional diagnosis to be subsequently revised to a somatic condition. Probably the most problematic areas relate to unwitnessed seizures (video footage or direct observation are often extremely helpful), and bizarre postures that may turn out to be dystonia. Such feelings are rapidly sensed by families and tend to exacerbate and perpetuate symptoms. In the case of functional seizures, keep open the possibility that a (small) proportion of events may be due to epilepsy. In some situations however it may be more appropriate to hand over ongoing management to other services. Be particularly careful to respect confidentiality in discussions with the school. Perceptions of the illness by other professionals involved with the child need to be addressed. A multidisciplinary physical-psychosocial-schooling rehabilitation approach as used in children with acquired brain injuries may be useful for complex situations. Many activists and patient groups resent any suggestion of psychological contributions to causation or prolongation of symptoms for whom an organic. The controversy amongst some support groups about graded exercise relates to understandable fear of over-exhaustion and setback. In practice these fears can be explictly addressed and review arrangements agreed. There are pointers that are suggestive, but none are intrinsically diagnostic and there is always a differential diagnosis. A spectrum of problems exists from fictitious (reporting something that is not occurring), through fabrication of documentation and charts, to direct induction of symptoms or signs in a child. Common neurological symptoms include reported seizures, collapse, drowsiness, and developmental delay. Verbal fabrications are much more common than induced physical signs of illness: this poses particular problems in the context of reported seizures, which by their nature are typically unobserved. The key is a story that does not hang together: symptoms not congruent with known diseases; symptoms, signs, and investigation results that do not correlate treatments that do not produce the expected results. Repeated presentations to multiple specialties, the reporting of new symptoms following resolution of the previous ones and particular reported symptoms (stopping breathing, loss of consciousness, seizures, choking, or collapse) are concerning. Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. Persisting concerns If concerns cannot be allayed, further assessment is mandatory. Procedures will vary by jurisdiction, and local policies should be followed, but it is clear that adequate assessment must involve other agencies able to evaluate concerns in the context of familiarity with the wider family background. Specific investigations Suspected hypoglycaemia · If hypoglycaemia is suspected or documented, measure true blood glucose (fluoride oxalate) and draw 2 mL of blood (in lithium heparin or serum) for C peptide and insulin. The preferred sample (blood, urine) and handling requirements depend on the substance of interest. Arrange for their accurate labelling and careful freezing and storage to enable retrospective analysis if concerns regarding a particular intoxicant arise. Seizures · Prolactin levels typically rise after significant tonic­clonic seizures but may not, so that the value of normal levels is limited. Sample needs to be collected within 15 min (which severely limits their usefulness) and compared with a control sample taken exactly 24 h later (to allow for the normal circadian rhythm in the levels). Migraine Epidemiology Getting at least one migraine per year: · 3% of all children 7­10 yrs. Previous vascular hypotheses of vasoconstriction and dilation have been discredited. Genetic factors 50­80% of children will have a parent with a migraine variant (which may have waned by the time a parent is interviewed, so a lack of a current headache history may be misleading). Migraine without aura probably multifactorial with genetic and environmental factors. These and other findings suggest a channelopathy may compromise neurotransmitter homeostasis causing aura and other neurological manifestations of childhood headache. The trigeminal innervation Large cerebral vessels, pial vessels, venous sinuses and dura mater are innervated by small diameter myelinated and unmyelinated neurons serving nociception. Cortical spreading depression may activate trigeminal neurons (especially ophthalmic division) to release substance P and calcitonin gene-related peptide, leading to sterile neurogenic inflammation, and plasma extravasation with mast cell degranulation and platelet aggregation. This causes trigeminal area allodynia (perceived pain from a normally non-painful stimulus), sensitization of thalamic neurons and a disordered central nervous system response. Involvement of the trigeminal nucleus with the dorsal horns of C1 and C2 (remember how long the nucleus is! In practice the common primary headache types are: · Tension-type headache: despite its name (and previous variations such as tension, and tension-like) there is no evidence of a primary psychological cause or any role for scalp muscle contraction, and it is now regarded as a type of primary headache. Episodes lasting minutes to days; the pain typically bilateral and mild/moderate intensity; no nausea but photo-/phonophobia may be present. Aura is usually visual, flashing, sparkling or shimmering lights; fortification spectra (zigzags); black dots, and/or scotomata (field defects). Clinically, these syndromes resemble transient ischaemic attacks: creating reversible focal neurological deficits lasting tens of minutes to a few hours. As such, migraine enters into the differential diagnosis of a wide range of episodic neurological symptoms and signs. Prominent autonomic signs (nausea, vomiting, sweating, vasomotor changes in skin) are also suggestive. Otherwise migraine becomes a diagnosis of exclusion of alternative, more serious pathologies: see sections concerning investigation of children with arterial ischaemic stroke (see b p. Triggers Migraine episodes may be triggered by a variety of factors including stress, relaxing after stress.

An advantage these methods share is that they emphasise the importance of exploring the data blood pressure food order microzide 12.5mg with visa, and they can help uncover patterns that might otherwise be missed arteria3d viking pack 25 mg microzide mastercard. For example blood pressure chart app order microzide 12.5mg on-line, the split {{gorilla hypertension medicines cheap microzide 25mg free shipping, orang, gibbon}, {human, chimp}} can be written as 00011. If we treat this string as a binary number then each split can be assigned a unique number (Hendy & Penny, 1993). Below are the 16 splits for the five hominoid species and their corresponding numbers: Human Chimp Gorilla Orang Gibbon Number 0 1 0 1 0 1 0 0 0 1 1 0 0 1 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 3 4 5 6 1 1 1 0 0 7 0 0 0 1 0 8 1 0 0 1 0 9 0 1 0 1 0 10 1 1 0 1 0 11 0 0 1 1 0 12 1 0 1 1 0 13 0 1 1 1 0 14 1 1 1 1 0 15 By convention, the split numbers are in the range 0 to 2(n 1), so the split {,{human, chimp, gorilla, orang}} is written as 01111 = 15 rather than 10000 = 16. The advantage of this numbering scheme is that we can refer to any split by a single number rather than listing all the species in that split. Only splits that divide < previous page page 201 next page > < previous page page 202 next page > Page 202 the sequences into two sets that both have more than one sequence can tell us about phylogenetic relationships. However, any given unrooted tree for n sequences contains only (2n 3) such splits. For the hominoids this means that only two of the 11 non-trivial splits can be in the tree for these sequences. Ideally, our data would contain evidence for just mutually compatible splits, but this is rarely, if ever, the case. Spectral analysis provides a means for visualising the support for all the splits in a data set. In its simplest form, spectral analysis consists of plotting the frequencies of each split in the data set. This is straightforward if there is a maximum of two character states per character, because then each character can be directly translated into a split. To illustrate, the first informative sites in the hominoid data set each have only two states: Human Chimp Gorilla Orang-utan Gibbon G A G A A T T T C C C T T C C A A G A G T C T C C C C T T C A A A C C T T T C C C T T C C C C A A A so we can substitute 0 and 1 for the two states: Human Chimp Gorilla Orang-utan Gibbon Split 1 0 1 0 0 5 1 1 1 0 0 7 0 1 1 0 0 6 1 1 0 1 0 11 1 0 1 0 0 5 0 0 1 1 0 12 1 1 1 0 0 7 1 1 1 0 0 7 0 1 1 0 0 6 1 1 0 0 0 3 Each split is numbered according to the scheme described in Box 6. Applying this procedure to the remaining sites, we obtain the spectrum for this data set. Note that every split has at least some support, hence we need some grounds for choosing which splits will be used to construct a tree (not all splits can coexist in the same tree). The five trivial splits labelled , , , and will of course be in any tree, but which of the non-trivial splits should we choose? One possible solution for this data set is to choose the two mutually compatible splits that have the most support. Note that the data contains almost equal support for the {human, chimp} and {gorilla, chimp} splits. When we analysed this data using maximum likelihood as our optimality criterion the best tree contained the {human, chimp} split, but was not significantly better than a tree containing the {chimp, gorilla} < previous page page 202 next page > < previous page page 203 next page > Page 203. The inability to chose between these two is understandable given the almost equal support for these two conflicting splits in the data. The expected spectrum for this tree is shown below, where the vertical axis is the probability of observing each split: Note that while the split {{a, b}, {c, d}} has the most support of any nontrivial split, the two competing splits {{a, c}, {b, d}} and {{a, d}, {b, c}} also have some support. An attractive property of the Hadamard transformation is that it is reversible: given the spectrum above we can exactly recover the original edge lengths of the tree we used to generate the spectrum. Hence, one method for constructing a tree from a spectrum is to find the tree that would have generated a spectrum most like the actual spectrum we observed. Although spectral analysis is a potentially powerful technique, it has some limitations which stem from the rapid increase in the number of possible splits with increasing numbers of sequences; for 20 sequences there are over half a million splits in the spectrum. Furthermore, for discrete data the method is effectively restricted to two-state characters. Nucleotide sites may have up to four states, which have to be converted in some way into two-state characters, such as purines and pyrimidines. However, spectra can also be obtained from distance matrices which circumvents this difficulty to some extent. However, this fact is lost as soon as we < previous page page 204 next page > < previous page page 205 next page > Page 205. The two largest non-trivial splits, {gibbon, orang-utan} and {human, chimp}, are compatible with each other and form the best tree. The human, chimp split is in the best tree but is only fractionally better supported than the {chimp, gorilla} split. The branch lengths correspond to the amount of support for each split, and are in units of expected nucleotide substitutions. Looking at the spectrum we can see that the split {chimp, gorilla} has almost as much support as the {human, chimp} split. Split decomposition is a method that seeks to represent more of the information contained in the spectrum. For example, site 1 corresponds to the split {human, chimp} {gorilla, orang, gibbon}. Taking each split in turn, we can attempt to construct a tree by combining the splits. The first site partitions the five hominoids into those with T (human, chimp, and gorilla) and those with C (orang and gibbon). These two splits are compatible, so we now have the tree ((human, (chimp, gorilla)), (orang, gibbon)). The split {human, chimp} {gorilla, orang, gibbon} cannot be combined with the split supported by site 2. If we were to continue to build a tree we would have to decide which of these splits to accept. In this example, we can depict both splits 2 and 3 by introducing a parallelogram to indicate that there are two alternative splits. Site 4 supports the same split as site 3, hence adding that to the network does not change the network topology. The remaining sites (59) are all trivial splits that each partition a single sequence from all the other sequences. The length of each link in the graph is proportional to the number of sites supporting each split. By collapsing the parallelogram linking human, chimp and gorilla, we could obtain either the tree ((human, chimp), gorilla) or (human, (chimp, gorilla)). Hence, in a sense the network represents a set of possible trees in a single diagram. Applying this method to the complete hominoid data set, we obtain the diagrams shown in. Although split decomposition diagrams can be difficult to interpret at first, they do offer a way of representing more of the information in a data set, and promise to be a useful tool for exploring phylogenetic spectra. In the discussion of split decomposition above, we have assumed that the sequences are related by a tree, even though there may be conflicts among different sites. Hence the split decomposition network depicts the conflicting signals rather than an actual picture of how the sequences are related. However, the assumption that a tree is an appropriate representation of relationships among the sequences may be incorrect. If competing splits have significant support, then perhaps the relationships among the sequences are better represented by a network. In the top diagram the lengths of each line are proportional to the support for the corresponding split; in the bottom diagram each split is drawn at the same size. When thinking of trees, accuracy is proximity to the true tree; precision is how many alternative trees are excluded. A method that finds only one tree is very precise, but if that tree is wildly different from the true tree, then the method is inaccurate. The difference may be clearer if you consider two thermometers, A and B, that are both used to measure the temperature of water at boiling point (100°C). The temperature according to thermometer A is 101°C, whereas according to B it is 98. A method that assigns an integer score to each tree (such as parsimony is more likely to assign the same length to different trees simply because there are a finite number of integer tree lengths for a given data set, but an infinite number of real numbers Hence, tree criteria that use real numbers may give a false sense of precision simply because it is almost impossible to obtain more than one tree with exactly the same value of the criterion. Given the range of possible methods for inferring phylogeny, we naturally want to know if they work, that is, do they recover the actual evolutionary relationships among nucleotide sequences? Several approaches have been developed to answer this question: analysis, simulation, known phylogenies, and congruence. This condition can be expressed more formally in terms of branch lengths for a three-taxon tree.

So blood pressure chart height discount microzide 12.5 mg online, when I post a picture with Elvis and Penny hypertension quiz questions effective 12.5mg microzide, tagging #dogsofinsta is an easy way to reach more viewers and gain more likes blood pressure kits for sale generic microzide 25 mg amex. Get started by taking these simple steps: (1) Download the latest version of the app to avoid bugs and ensure you have the best version possible at your disposal arrhythmia icd 9 2013 discount microzide 12.5mg free shipping. Your handle is your social media short name and should contain the keywords of your veterinary practice name. Switch your account to a business profile by following these simple steps. This is important because it will unlock a full range of advertising and analytics options that are otherwise unavailable. Look at Instagram as your opportunity to share exclusive behind the scenes access to your veterinary practice. Finishing touches on a great post can include hashtags that appropriately describe your local area, theme or mood. People share photos of their pets and themselves not because they must, but because of the incredible joy that these pets bring and the fun of it all! We now see that two generations consist of a large volume of pet owners and foot traffic at your veterinary practice. As of 2016, Millennials (those whose age range between 18 ­ 34) have surpassed the Baby Boomer generation (whose age range between 51 ­ 69) for the very first time. However, these two demographics can differ greatly with the way that they operate on a daily basis and what they consider to be effective methods of both conducting business and going about daily communication. This makes it all that much more important to understand and respect both demographics, while learning to run your veterinary practice in a way that will benefit them both! Baby Boomers typically have a more traditional approach and tend to be later adopters of technology. As a result, Baby Boomers tend to enjoy in-person communication, reviewing paperwork with hard copies and other nuances that align more with their habits, traditions and background. They do research online, they Skype with friends, and they may be much more comfortable with online bookings and open to remote consults instead of in-office ones. For example, if you offer appointment bookings through an app, this may absolutely delight a young millennial who uses their iPhone for everything. After all, they book hotels with their Expedia app and they sign paperwork with DocuSign, all without printing a single piece of paper! This same app however, might not thrill a Baby Boomer who uses an iPhone, but mainly for calls, and otherwise prefers hard copies of appointment reminders and telephone calls. They may have booked their appointment through the app, and they may be flipping through Instagram in the waiting room, but the feedback you can get from them during their visit is still invaluable, and they crave information about the care of their pet. But be sure to also offer more traditional methods of client engagement which are tried and true, and are likely to remain important fixtures of the industry long into the future. This includes in-office visits, hard copies of paperwork and other established methods of doing business. When you customize your approach to benefit each client individually, you make sure that everyone feels welcome at your veterinary practice and avoid the pitfalls that can come when you make an assumption about preferences. Valuing them both in the ways that you choose to communicate and conduct business is the only surefire way to make sure that every pet owner who comes to your veterinary practice leaves delighted. We look for narrative when attributing meaning, simply because it resonates more deeply with us than an isolated statistic. Garcia founded our veterinary practice on the core belief that by enriching the lives of pets, we enrich the world around us. The staff and veterinarians at Simply Done Tech Clinic take immense pride in this philosophy, bringing this belief to action by implementing passionate, compassionate veterinary care. The joy and wonder of a happy pet immediately inspired Eric to pursue a career in veterinary medicine after completing his undergraduate degree. There are a variety of reasons that go into this recommendation, but the predominant reason is because two-way text messages open you up to non-stop communication, a whole host of follow-up expectations and perhaps most importantly, potential legal repercussions. Instead, one-way text messages allow you to dictate the content and tone of communication, insulating you from additional liability while still giving you the benefits of instantaneous communication. I recommend sending pet owners simple and concisely constructed text messages whenever a pet is dropped off for surgery, a procedure or appointment, as well as boarding or grooming services. Even just a simple text message can help you to alleviate any potential worry from a pet owner, and demonstrates your accountability and care in one fell swoop. Thanks to rapidly accelerating forms of technology, text messages can be sent to any type of mobile device, and even the new Apple Watch (or any wearable technology)! Not only are you adapting to new technology, but you are going above and beyond to stay in touch and alleviate any possible concerns that could crop up along the way. Yes, new technology does open up new avenues of liability, most of which are covered by opting into the one-way text message feature instead of the two-way. Still, you will need a consent form from your clients before sending them text messages. You can easily capture this consent by adding a brief, additional section to any new client registration form, or a drop off procedure/authorization form. These services seamlessly integrate with your existing practice management software, and will send text messages to clients automatically. Automation is absolutely imperative for this level of communication, and some services like Vetstreet and Petly will offer two-way texting for confirmations. A simple, "Y" or "N", will allow clients to confirm or dissolve appointments, and a list will automatically generate to display who has confirmed their appointments and who has yet to do so. You can then make follow-ups as necessary, leveraging the convenience and quick communication that these services have to offer. These features are an outstanding way to increase compliance and reduce missed appointments that cost your veterinary practice a significant amount of money over time. Calling your clients regularly remains important, but is in fact complimented by the extra effort of text-message communication. Tips to Get Started Sending One-on-One Text Messages (1) Find the platform that works best for you and your veterinary practice. I really like ZipWhip and is popular in veterinary practices or perhaps adding an additional cell-phone line? Depending on your existing structure, you may find that some approaches work better than others. Assign these team members to begin sending out test text-messages before rolling out the service to pet owners in real-time. Gear up and get going; start rolling out your new text message service and have fun! Despite this, a useful working definition can sometimes feel a little hard to pin down in practical terms. This morning, as I was doing my daily journaling exercise to start the day the following flowed forth. I thought it might be worth sharing as I travel on my own messy journey as a leader. Leadership is: the daily ritual of positively influencing those around you such that they can achieve their latent potential over the course of each day, week, month, year and lifetime. Applying good judgement - having the serenity to know what you can fix, the courage to know what you cannot and the wisdom to know one from the other. Starting now and seeing every occurrence as a chance to develop better outcomes by practicing the first two things. This will take: A lifetime of practice and dedication - kings are born, managers are appointed, good leaders work at it every second. Your reward: the fulfilment and serenity that comes from seeing your world change positively as result of reciprocity when you positively change the world of others. A Revealing Conversation About Leadership One of the group members asked the following question. So when I saw this on the Vets: Stay, Go or Diversify Facebook group I simply could not help but jump in. I am curious about how we can be better vets so that we increase our value to the practice? Plus either be a good role model or be there to support and facilitate us vets to achieve the desired outcome. Have good systems in place to make everything run smoothly and efficiently and listen when we give feedback.

Most general practitioners and pediatricians are not familiar with the notion that prominent autonomic symptoms and signs may occur as epileptic seizure manifestations of occipital origin blood pressure medication iv order 12.5mg microzide with visa. As a consequence hypertension treatment guidelines 2013 buy 12.5mg microzide visa, this diagnosis can be easily missed and have potentially lifethreatening sequelae arteria lingualis purchase microzide 12.5mg. Ictal bradycardia is seen primarily in association with focal seizures heart attack cover by sam tsui and chrissy costanza of atc discount microzide 12.5 mg, particularly involving the temporal and limbic lobes. In our case, an intrarectal dose of diazepam was rapidly effective in normalizing heart rate, possibly preventing a cardiorespiratory arrest, with all its consequences. Our case illustrates the efficacy of an intrarectal dose of diazepam in case of ictal bradycardia, possibly preventing a cardiorespiratory arrest. Although more studies are needed on the subject, supportive family management should also include specific education about autonomic status epilepticus symptoms. Autonomic seizures and autonomic status epilepticus peculiar to childhood: diagnosis and management. Panayiotopoulos syndrome: epidemiological and clinical characteristics and outcome. Benign childhood focal epilepsies: assessment of established and newly recognized syndromes. Panayiotopoulos syndrome: a benign childhood autonomic epilepsy frequently imitating encephalitis, syncope, migraine, sleep disorder, or gastroenteritis. Neurology 72 April 14, 2009 207 e71 Management dilemmas Despite the ever-increasing number of randomized controlled trials for treatment of neurologic diseases, individual patients present unique clinical dilemmas, and it can be challenging to determine how best to apply the findings from large studies in individual cases. In the field of vascular neurology, for example, clinical trial data are perhaps more extensive than in any other neurologic subspecialty, yet significant controversy persists over how to interpret these data. In the cases in this section, the authors describe the management of patients with cerebrovascular disease, exploring both how existing data can be used to guide complex clinical reasoning and the limitations of existing data when applied to individual patients. In the emergency room, it was noted that visual blurring resolved with right eye closure, but his ophthalmologic examination was otherwise normal. He reported no headache, neck pain, prior trauma, prior transient neurologic deficit, or palpitations. There was no history to suggest seizure, and the monocular visual deficit and lack of headache would be atypical (albeit not impossible) for complex migraine. Extraocular muscle weakness causing ocular misalignment can cause the phenomenon of blurred vision resolving with closure of one eye, but no extraocular muscle weakness was detected on examination. Abrupt onset of unilateral blurred vision with contralateral face and arm weakness suggests simultaneous retinal and ipsilateral frontal hemispheric ischemia. Potential etiologies include embolism or hypoperfusion due to pathology of the internal carotid artery, aortic arch, or heart. In a series of 1,008 patients age 15­49 with first stroke, cardioembolism and cervical artery dissection were the 2 most common causes of stroke, causing 19. On further questioning, there were no identifiable inciting events for the dissection. The most recent meta-analysis of nonrandomized data included 1,636 patients from 39 studies in which 1,137 patients were anticoagulated (with unfractionated heparin, low-molecular-weight heparin, or warfarin) and 499 received antiplatelet agents (with aspirin, clopidogrel, or dual therapy with aspirin and clopidogrel or aspirin and dipyridamole). There were no statistically significant differences in rates of stroke or mortality between the 2 treatment strategies. However, it has been noted that most studies of carotid dissection failed to capture patients during the acute period when stroke risk is highest. Approximately 24 hours after his presentation and 12 hours after initiation of anticoagulation, he developed worsening right arm weakness and aphasia. While borderzone infarction is classically attributed to hypotension, there is evidence that embolism may also play a role. The end-arterial territories are potential sites for the smallest emboli, and patients with borderzone infarction due to carotid disease have been noted to have evidence of ongoing embolization on transcranial Doppler high-intensity transient signal studies. In our patient, radiologic evidence of carotid occlusion and a blood pressure of 100/60 mm Hg suggested hypoperfusion as the mechanism of his new strokes. The largest prospective trial of induced hypertension included only 13 patients,7 and the largest retrospective study only 46 treated patients. Patients with acute ischemic stroke most likely to benefit from induced hypertension are those with large-vessel occlusion or stenosis. There appears to be no increased incidence of hemorrhagic complications or other adverse outcomes in patients undergoing induced hypertension after acute ischemic stroke, even in patients who have been simultaneously anticoagulated. While larger controlled trials are necessary, preliminary data suggest that induced hypertension may be both safe and beneficial in selected patients. It is unclear whether any of the patients in studies of induced hypertension reported as having large-vessel stenosis or carotid stenosis/occlusion may have had carotid artery dissection as the etiology. However, because our patient had new strokes while receiving anticoagulation in the setting of flow-limiting carotid dissection and a low blood pressure, phenylephrine was initiated. At systolic blood pressures of 130 mm Hg and above, he was able to maintain his right arm against gravity, but below this threshold, he could not lift this arm from the bed. This blood pressure threshold for his right arm strength persisted for several days, and oral midodrine and fludrocortisone were initiated in order to wean him from phenylephrine. At followup 1 month later, he had full right arm strength, and his aphasia had begun to improve. Some practitioners recommend repeat vascular imaging as early as 6 weeks following initiation of anticoagulation, with discontinuation of anticoagulation if the artery remains occluded, and continuation of anticoagulation if arterial patency has returned but with persistent significant stenosis. Although our decision to discontinue anticoagulation and initiate an antiplatelet agent at 6 months is not influenced by findings on vascular imaging, this imaging establishes a new radiologic baseline for the patient, should a subsequent new ischemic event occur. Six months following his initial presentation, our patient had made substantial progress in his speech with speech therapy. Up to 43% of patients with cervical artery dissection presenting with local symptoms alone may ultimately have strokes,4 so discovery of dissection warrants stroke preventative therapy, even if initial symptoms are nonischemic in nature. There are no data from randomized controlled trials to guide therapeutic decision-making. Therefore decisions about the use of antiplatelet agents or anticoagulants, optimal duration of therapy, and when or if to repeat cervical arterial imaging must be individualized for each patient. This will hopefully yield answers to long-controversial questions in the management of cervical artery dissection. Berkowitz conceived of, wrote, and revised the manuscript; created the figure; and cared for the patient. Berkowitz reports no relevant disclosures, but receives royalties from Clinical Pathophysiology Made Ridiculously Simple (Medmaster, Inc. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki young stroke registry. Time course of symptoms in extracranial artery dissections: a series of 80 patients. She had a history of developmental delay, attention-deficit disorder, and remote seizures. On presentation, she was afebrile, somnolent but arousable, groaning incoherently, and unable to follow commands. Gaze was midline and deviated downward with restricted spontaneous upward gaze but full lateral gaze. Decreased spontaneous movement of the right side could point to a left-sided lesion, although localization can be challenging in the setting of herniation. There was no history of trauma suggestive of intracranial injury, progressive localizing neurologic deficits indicating an expanding mass lesion, fever implicating intracranial infection, or prior infection suggestive of postinfectious demyelinating syndrome. There was no evidence of infarct, hemorrhage, vascular malformation, or structural abnormality. Three new hemorrhages occurred in the control group, while none occurred in the heparin group. Secondary analyses showed trends toward decreased death and improved outcome in the treatment group at 3 and 12 weeks. After 6 days of treatment, the patient was interactive and able to follow commands, but she was blind and had decreased strength on the right side. Repeat neuroimaging showed new left temporoparietal hemorrhagic infarction and unchanged extensive venous sinus thrombosis. In catheter-directed thrombolysis, a catheter is guided to the occluded sinus for direct infusion of thrombolytics. Headache is present in 89% of patients, accompanied by a wide spectrum of signs including paresis (37%), seizures (39%), and depressed level of consciousness (14%).

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