Carlos Martinez

Neurologo
Hospital J.M Cullen
Santa Fe-Argentina

[sikandar adwani @SikandarAdwani]

Cardioembolic stroke is a SOURCE-CONTROL diagnosis.

The approach is simple:

PATTERN → SOURCE → PREVENTION → TIMING

PATTERN
Suspect embolism when you see:
• sudden maximal deficit
• cortical signs
• LVO
• abrupt vessel cut-off
• multiple vascular territories
• bilateral infarcts
• anterior + posterior circulation lesions
• hemorrhagic transformation
• recurrent events despite antiplatelet therapy

But remember:
An embolic MRI pattern is a clue.
Not a prescription.

SOURCE
Now interrogate the heart.
Common suspects:
• AF / atrial flutter
• left atrial appendage thrombus
• LV thrombus after MI
• mechanical valve
• rheumatic mitral stenosis
• infective endocarditis
• NBTE / cancer / APS
• PFO with paradoxical embolism
• aortic arch plaque

Each source changes treatment.

TESTS
Minimum source hunt:
• ECG
• telemetry
• CTA/MRA head-neck
• TTE ± contrast
• TEE when LAA, valve, PFO, vegetation, or aortic arch source is suspected
• prolonged rhythm monitoring if no cause is found
• blood cultures if fever, murmur, prosthetic valve, or sepsis clue
• DVT/PFO workup in selected young strokes
A normal ECG does not clear the heart.

PREVENTION
Source selects treatment.

AF → DOAC usually
Mechanical valve → warfarin
Rheumatic MS + AF → warfarin
LV thrombus → anticoagulate + repeat imaging
IE → antibiotics/source control
NBTE/cancer → anticoagulation + treat driver
Selected PFO → closure discussion
ESUS → no empirical DOAC
This is the biggest trap:

ESUS is not hidden AF until proven otherwise.
Atrial cardiopathy is not AF.
PFO is not always causal.
AF does not mean stop looking.

TIMING
Do not anticoagulate the anxiety.

Use the brain scan.

TIA → day 0–1

Small infarct → day 1–3

Moderate infarct → day 3–6

Large infarct / hemorrhagic transformation → day 6–14+ and reimage

Modern trials support earlier DOACs in selected AF-related strokes.

But routine early anticoagulation for every AIS is still not the rule.

Final rule:
Pattern suggests embolus.
Proof names the source.
Source selects prevention.
Infarct size sets the clock.
Anticoagulate the source, not the vibe.

#Neurotwitter #MedX #Stroke #Cardioembolic

[Jamir Pitton Rissardo @theneurolander]

DOACs vs VKAs in Cerebral Venous Thrombosis

What Does the Evidence Really Say?

@SageJournals
https://t.co/YXpN74QOAv

#MustRead #HotTopic #DidYouKnow, #NewsUpdate, #Update

[Mica Schachter, MD @neurona_critica]

Epidemiology, pathogenesis, and emerging concepts in unruptured intracranial aneurysms

https://t.co/oYVMwaECd8 @TheLancetNeuro

[Practical Neurology @PracticalNeurol]

🧠Read the updated ABN guidelines for autoimmune myasthenia gravis - summarised in the infographic below.
Highlights include👇
• Daily (not alternate-day) steroids
• Early thymectomy for AChR+ MG (<50 yrs; consider ≤65 yrs)
• Evidence for early rituximab
• New targeted options — complement & FcRn inhibitors

📖 Open access: https://t.co/i7izaUKb7C
🎧 Listen to the podcast discussion: https://t.co/lWc3J2PNf7
#neurology #myastheniagravis #neuroeducation #openaccess #MedEd #NeuroX #openaccess
@theABN_Info @ABNTrainees

[Michael Okun @MichaelOkun]

To shunt or not to shunt, that is the (NPH) question? The first large randomized trial of shunting for normal pressure hydrocephalus (NPH) just dropped in NEJM, and there was clear benefit for walking, and it favored the group receiving shunts. Spoiler alert: Walking improved, however thinking (cognition) and bladder function did not.
Key Points:
- NPH is a condition usually presenting in older adults where fluid builds up in the brain and it associated w/ trouble walking, memory and thinking challenges as well as bladder incontinence.
- Shunting significantly improved walking speed and balance compared w/ placebo.
- No meaningful change in cognition or bladder control observed at 3 months.
- Risks included subdural bleeding and headaches, underscoring the need for careful follow up.
My take: NPH has always been a tricky area for clinicians when trying to decidr 'to shunt or not to shunt.' Here are 5 points that resonated w/ me: 1- Shunting in well selected persons can restore some walking ability in NPH. 2- Thinking did not improve at 3 months. 3- Incontinence showed no clear benefit. 4- Risks to always discuss w/ people considering shunts should include bleeding and headaches (as not uncommon). 5- Walking gains may possibly reduce falls and boost independence, however we must be careful as sometimes improved walking w/o improved balance, can actually trigger falls.
https://t.co/yCnSCpclPL @FixelInstitute @ParkinsonDotOrg @alzassociation @SfNtweets @SfNtweets @NEJM

[Nature Reviews Disease Primers @DiseasePrimers]

Learn more about #AutoimmuneEncephalitis with our NEW Primer by Titulaer and colleagues. Check it out here: https://t.co/waeSSDq5PU

[World Stroke Academy @WorldStrokeEd]

#MondayTip
Imaging Techniques in AIS
📸Essential for diagnosis, guiding treatment &amp; prognosis
⏱️Excessive imaging can delay treatment👉time is brain
🎯Targeted imaging is often sufficient for safe, effective decisions

From @bijoymenon @johanna_ospel https://t.co/Q9YO4I9eTb

[Continuum: Lifelong Learning in Neurology @ContinuumAAN]

Key Point 2 from the article Multiple System Atrophy Dr. Tao Xie from the August #MovementDisorders issue, which is available to subscribers at https://t.co/uMxlrXNllP.
#Neurology #NeuroTwitter #MedEd

[Lisa Burrows @lisbteamdizzy.bsky.social @LisBteamdizzy]

https://t.co/v1JNITtQgW

[Carlos Martinez @c18mart]

@WorldStrokeEd @opontesnetoMD @a_charidimou @sheilambrasil @J_Rosales_MD @FishingNeurons @ShadiYaghi2 @interneurona @DrAsyraf @American_Stroke @ALATACV This was incorporated into the STANDING protocol (SponTAneous Nystagmus, Direction, head Impulse test, standiNG).

[Carlos Martinez @c18mart]

@WorldStrokeEd @opontesnetoMD @a_charidimou @sheilambrasil @J_Rosales_MD @FishingNeurons @ShadiYaghi2 @interneurona @DrAsyraf @American_Stroke @ALATACV 3/ This means that the usefulness of HINTS strongly depends on the examiner’s experience.

4/ To overcome this, an additional semiological sign was introduced: evaluation of truncal ataxia.

[Carlos Martinez @c18mart]

@WorldStrokeEd @opontesnetoMD @a_charidimou @sheilambrasil @J_Rosales_MD @FishingNeurons @ShadiYaghi2 @interneurona @DrAsyraf @American_Stroke @ALATACV Limitations of HINTS and the role of STANDING

1/ Although HINTS has been around for over 10 years, it has practical limitations.

2/ Many emergency physicians struggle with the interpretation of eye movements and tend to rely on neuroimaging instead.

[Carlos Martinez @c18mart]

@WorldStrokeEd @opontesnetoMD @a_charidimou @sheilambrasil @J_Rosales_MD @FishingNeurons @ShadiYaghi2 @interneurona @DrAsyraf @American_Stroke @ALATACV 5/ This clinical entity has been termed acute truncal ataxia (ATA) or acute imbalance syndrome.
https://t.co/s3Dc2TS4Lh

[Carlos Martinez @c18mart]

@WorldStrokeEd @opontesnetoMD @a_charidimou @sheilambrasil @J_Rosales_MD @FishingNeurons @ShadiYaghi2 @interneurona @DrAsyraf @American_Stroke @ALATACV 3/ Therefore, the systematic evaluation of truncal ataxia and its grading classification becomes a key diagnostic tool.

4/ Approximately 15% of stroke patients with AVS show grade 2 or 3 truncal ataxia without nystagmus as their main presentation.

[Carlos Martinez @c18mart]

@WorldStrokeEd @opontesnetoMD @a_charidimou @sheilambrasil @J_Rosales_MD @FishingNeurons @ShadiYaghi2 @interneurona @DrAsyraf @American_Stroke @ALATACV 1/ Some patients with stroke in the context of acute vestibular syndrome (AVS) may present with acute truncal ataxia without nystagmus.

2/ In these cases, the HINTS protocol is not applicable, limiting diagnostic sensitivity when relying only on eye movement examination.

[INTERNEURONA @interneurona]

Por si no han visto un foramen oval permeable y aneurisma del septum

#FOP #Stroke #ACV
👇

[Lisa Burrows @lisbteamdizzy.bsky.social @LisBteamdizzy]

Diagnostic accuracy of the STANDING algorithm in patients with isolated vertigo: a multicentre prospective study (STANDING-M) | Emergency Medicine Journal https://t.co/TyR3pUDgHx

[Claudio Alejandro 🕎 🇮🇱 @CAlejandroneuro]

¿Cuando Iniciar DOAC en ACVi?

🎯 Objetivo principal:
Estimar los efectos de iniciarDOAC en ≤4 días VS ≥5 días después de un ACVi en personas con FA

💊 Inicio temprano de DOAC📉 riesgo de ACVi recurrente, HIC sintomática o ACV no clasificado a los 30 días (OR 0.70, IC 95% 0.50-0.98, p=0.039).

🧠🩸No hubo evidencia de un 📈 en HIC Sintomática con inicio temprano de DOAC (10 [0.4%] de 2683 versus 10 [0.4%] de 2746; OR 1.02, IC 95% 0.43-2.46, p=0.96).

[Luciano Sposato 🇦🇷🇨🇦 @SposatoL]

🧠 PFO Closure in Ischemic Stroke & TIA Patients ≥60y
🔗 https://t.co/cvzHk1BjUY

📌 Single-center cohort, n=239
👴 120 patients ≥60y
⏱ 3.1y mean follow-up

🎯 Recurrent stroke rates
▪️PFO closure (≥60y): 6.1% (3/49)
▪️No closure (≥60y): 25.4% (18/71)
📉 aHR = 0.11 (95% CI: 0.03–0.49)

▪️PFO closure (<60y): 2.6% (2/78)
▪️No closure (<60y): 19.5% (8/41)
📉 aHR = 0.10 (95% CI: 0.02–0.50)

🛡 Safety
▪️Procedure-related events: 6.1% (≥60y) vs 5.1% (<60y)
▪️Periprocedural AF: 6.1% (≥60y) vs 3.8% (<60y)
✅ No significant differences

🤔 Thoughts
⚠️ No benefit seen in TIA subgroup (aHR = 0.43; 95% CI: 0.03–5.82) → underpowered?
⚠️ High recurrence in non-closure groups → Competing mechanisms? Selection bias?

👉 Are you closing PFOs in patients ≥60y with ischemic stroke?

[Instituto Nacional de Neurología y Neurocirugía @INNNMVS]

🚨#EducaciónContinua Invitamos al Curso Virtual "NeuroECHO Vascular, Actualidades en Infarto y Hemorragia Cerebral".🧠
👩‍💻👨‍💻 5 Sesiones en linea del 17 de julio al 14 de agosto
🔍🖊Consulta el programa y regístrate escaneando el código QR.
✅Actividad de carácter gratuita.🥼