@a_charidimou
@EricLawson90
@CajalButterfly
@Capt_Ammonia
@DrAtulRamesh1
@RamaniBalu1
@DSandsmarkMDPhD
@PennNeurology
@TJUHNeuroCrit
@namorrismd
@ShadiYaghi2
@MDNeurocritcare
End/ What are your thoughts on this #neurocritcare? Does this change your opinion on #DDAVP?
@neurocritcarej
@swarnarmd
@aartisarwal
@alyssafloseldes
@caseyalbin
@JimmySuhMD
@JimSiegler
@kMeierNSICU
@medinariojaMD
11/ And yet somehow, it does provide me with some relief to know that this initial #DDAVP dose does not appear to affect your ability to attain hypernatremia when needed! 😅
10/ Now multiple things to raise about the study:
👉 DDAVP dosing was low (0.3mcg/kg)
👉 Na at 48 hours was similar, but DDAVP half life is short, so may need to focus on shorter half-life
👉 single center, retrospective
👉 traumatic and non traumatic included
9b/ Hemostasis and thromboembolic rates were similar between both groups
New thrombotic events 5.8 vs. 6.4%, p = 0.8964
Hemostasis on repeat CTH 73.9 vs. 63.8%, p = 0.2454
9/ They included 127 pts, 75 🚫 #DDAVP and 52 who did. What did they find?
👉 DDAVP group more commonly traumatic ICH, on antiplatelet
👉 if DDAVP given, higher starting 3% rate
👉 🚫 difference in ability to get to goal Na
👉 higher volume of 3% in non-DDAVP group 🤔
8/ They then looked at how successfully the pts reached the goal w/in 48 hours, examining the time if took to get there and the volume of 3% required while also looking at:
👉 hematoma expansion
👉 thrombotic events
7/ Just how much does the Na ⬇️? That is a ❓ the authors were trying to answer!
👉 Single center retrospective study of #ICH patients ➡️ 0.3mcg/kg (max 20mcg) #DDAVP
👉 💊 with 3% #HypertonicSaline 💧to goal 150-155
🚫 hyponatremic pts
🚫 not on 💧 or different Na goal
6/ So while we may not for now resolve the issue of whether #DDAVP is effective, a cause of major concern is the ⬇️ Na, especially when so many #ICH patients will have #ICP and 🧠 edema issues!
5/ Any side effects?
🚫 vasopressor effect
👉 flushing
👉 edema
👉 hypervolemia
👉 ⬇️ Na
4/ So what is #DDAVP anyway?
✅ vasopressin analog
✅ ⬆️ vWF release
✅ ⬆️ plt function
3b/ The guidelines state:
👉 @StrokeAHA_ASA 2022 guidelines state insufficient evidence www.ahajournals.org/...
👉 @neurocritical “We suggest consideration of a single dose of DDAVP in ICH (0.4 mcg/kg IV) assoc/ w/ ASA or ADP R inh.” www.neurocriticalcar...
3/ The ❓ of iwhether #DDAVP is helpful is less clear, with some studies showing benefit while others did not
2/ When you have a pt with a hypertensive #ICH who is on ASA or clopidogrel/ticagrelor, do you typically give any #DDAVP or #platelets?
I think the question of platelets was answered by a randomized trial:
pubmed.ncbi.nlm.nih....
1/ 👋 there #neurotwitter #neurosky #neurocritcare, as part of my @neurocritcarej #SoMeAmbassador role, today we will be breaking down the following article:
link.springer.com/ar...
about #DDAVP and Sodium in #ICH
@OGdukeneurosurg Avraham Cooper @LorenzoPinelli @daniel_gewolb @medinariojaMD @alyssafloseldes
@namorrismd @ShadiYaghi2 @MDNeurocritcare @PennNeurology @TJUHNeuroCrit @DrAtulRamesh1 @JimSiegler @HopkinsNCCU @PulmCrit @drdangayach @neurochristiana @nirmalregency @interneurona @MicieliA_MD @mettermd @oneDRwoman_ @swarnaRMD @nirmalregency
End/ Thanks for following til the end. Please make sure to let me know your thoughts, any feedback is welcome!
@aanmember @continuumAAN @lyellj @aartisarwal @caseyalbin @JimmySuhMD @a_charidimou @EricLawson90 @CajalButterfly @Capt_Ammonia @RamaniBalu1 @DSandsmarkMDPhD
15/ Take 🏡 messages:
👉Vasculitis can still respond to IA Verapamil
👉HHV6 can cause devastating 🧠 vasculitis with resultant stroke
👉Don't dismiss weird Biofire results
👉Encephalitis can present without typical CSF findings concerning for infection
14/ Now if most of her stroke burden was on the right, why were the seizures on the left?
This continues to bother me. Repeat MRI did not show any focal acute process on the left, so if anyone has any ideas, let me know!
13/ Pt is transitioned to oral valacyclovir for a total 21 days & nimodipine -> verapamil. Seizures are managed with levetiracetam and lacosamide and eventually pt -> rehab with what clinically looks like a right MCA syndrome.
Unfortunately not evidence driven...
12/ While HHV6 encephalitis related vasculitis is rare, there are case reports that describe this, and so we presume this to be the case here!
11/ Unfortunately, findings are initially non-specific but #biofire is + for HHV6, so acyclovir switched to gancyclovir. RPR + but VDRL was non-reactive.
Confirmatory HHV6 PCR = >13K!!!
10/ What is your diagnosis?
a. Vasculitis, infection driven
b. Drug induced vasculopathy
c. RCVS
9/ Pt undergoes #LP which demonstrates:
✅3->4WBC
✅231->14 RBC
✅106 protein
✅ 80 glucose
8/ #EEG demonstrates focal status epilepticus, emanating from the left
7/ As you can see, IA verapamil seems to work well!
#MRI unfortunately demonstrates completed stroke and diffuse pachymeningeal enhancement (FLAIR, T1 post, DWI)
6/Empiric meningitis/encephalitis 💊 important. Perfusion map does not demonstrate either completed core nor TMax >6s, #angiogram can be helpful to help to dx this patient
#Angiogram demonstrates severe diffuse spasm (Right ICA, Left ICA, Right ICA post IA verapamil 💉)
5/ It is unclear what the etiology of this is. Differential includes:
👉RCVS
👉Vasculitis (primary vs. Secondary)
👉Drug induced vasculopathy
4/ There is patchy right MCA infarct with diffuse vasospasm. How do you treat?
a. Nimodipine
b. Angioplasty
c. Watch and wait
d. Antibiotics/virals
