Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you always pursue stroke work up in patients diagnosed with transient global amnesia?
I do not routinely recommend imaging or EEG for clinically straight-forward patients with Transient Global Amnesia (TGA), although I suspect I am in the minority. When the diagnosis is in question, or when the symptoms have not resolved, then yes, I would do additional workup, including MRI and EEG....
For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention?
The practical answer to the question would be when the patient is alert enough to be able to swallow safely so an actual number of days cannot be given. It will be different for each patient.
How do you approach a mildly positive finding on an autoimmune encephalitis panel when there is no other evidence of encephalitis (such as elevated CSF protein, abnormal imaging, or EEG findings)?
In general, low positive Abs by ELISA or radioimmunoprecipitation assays have low predictive value for neurological disease and cancer outside of specific clinical contexts (e.g. a PQ of 0.03 nmol/L in a patient with myasthenic syndrome).For encephalitis, GAD65 < 20 nmol/L, and PQ type calcium chann...
In patients in the ICU who are on the inter-ictal continuum, how do you decide whether or not to treat for potential non-convulsive status epilepticus?
In those situations, you will have to take into account the whole clinical picture - what the etiology is (are we dealing with a structural injury and those periodic patterns may not resolve, and in those situations, your goal is not resolution of the EEG); if the concern is for an autoimmune etiolo...
How do you manage autonomic storming in patients with increased intracranial pressure?
In many respects, the treatment of paroxysmal sympathetic hyperactivity (PSH), or storming, is similar whether or not there is elevated ICP. The goal is to limit stimuli that provoke the episodes of storming and reduce sympathetic outflow or block its downstream effects. The difference is in those p...
For patients with generalized tonic-clonic seizures lasting > 2 minutes without IV access, what alternative medications can be used?
You can use intranasal midazolam (Nayzilam), intranasal diazepam (Valtoco) or rectal diazepam (Diastat). Other options are buccal or intramuscular midazolam using the IV solution.
How do you acutely manage a free-floating thrombus in a major artery in a patient with a stroke as a result of it?
There is no clear guidance from trials. My own practice has been to anticoagulate for 72 hours, then repeat the CTA. If the thrombus is no longer visible, I switch to dual anti-platelet Rx; if still there switch to DOAC for 30 days and reimage.
How do you approach the management of a large vessel stroke if you anticipate the development of malignant cerebral edema?
In ischemic strokes with anticipated malignant cerebral edema, I would base some initial management decisions for prevention of edema on the labs obtained at admission. If the sodium is less than 130, I would start hyperosmolar therapy to bring levels into a normal range. If less than 135, normal sa...
What is your decision process on decreasing the sodium goal for patients with cerebral edema?
In my practice, when treating an adult patient with cerebral edema, we avoid hyponatremia but do not set a specific sodium goal. Rather, we titrate therapies (e.g., mannitol, hypertonic saline) to achieve a specific ICP goal (e.g., ICP < 22 mmHg). We stop administering mannitol if the osmolar gap > ...
How do you approach management of cerebral venous sinus thrombosis in a patient with severe thrombocytopenia?
Many patients with thrombocytopenia have abnormally functioning platelets, and as such still benefit from anticoagulation treatment. In patients with cerebral venous sinus thrombosis and counts <50K, I recommend involving hematology to help determine the appropriate regimen, which may involve a hepa...