1. Andrew Levin, PGY3 Ronald Hamilton, MD
CPC -- 9/4/2015
Andrew Levin, PGY3
Ronald Hamilton, MD
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The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

2. 4/3/2019 3:41 AM
CC – Patient “PL”
64 y/o woman with a hx of HTN, DM1 and ESRD transferred urgently to PUH ED from local vascular outpatient surgery center
Per EMS: under twilight anesthesia, she suddenly stiffened on the table. There is also a report that she had some lip-smacking
Reportedly stopped answering questions
Possible weakness on her right side.
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

3. What's known about the outpt surgery
4/3/2019 3:41 AM
What's known about the outpt surgery
Minimal improvement in mentation w/ Narcan
Surgery terminated abruptly and sent urgently to PUH (surgical sheath still embedded in fistula)
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

4. What do you want to do? DDX?
4/3/2019 3:41 AM
What do you want to do? DDX?
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

5. Neurology is Consulted…
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Neurology is Consulted…
Arrives to ED at 3:40pm
NEURO: MS: Drowsy but arousable. Answers all questions with "ok" or "mmhmm"
CN: PERRL. Does not follow commands to assess cranial nerves.
MOTOR: Decreased bulk. Normal tone. Able to only lift left arm, which is antigravity. Left arm has a pronator drift. Unable to lift right arm or bilateral lower extremities off the bed.
REFLEXES: No ankle clonus
SENSORY: Unable to assess sensory fully. Does withdraw from pain.
COORDINATION: Unable to assess coordinateion
GAIT: deferred.
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

6. NIHSS… 1A. Level of Consciousness (0-3) = 1
4/3/2019 3:41 AM
1A. Level of Consciousness (0-3) = 1
1B. LOC Questions (0-2) = 2
1C. LOC Commands (0-2) = 2
2. Best Horizontal Gaze (0-2) = 1
3. Visual Fields (0-3) = 1
4. Facial Palsy (0-3) = 1
5. Motor Arm
Right (0-4) = 4
Left (0-4) = 3
6. Motor Leg
Left (0-4) = 4
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

7. Clinical Localization?
4/3/2019 3:41 AM
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The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

8. ED Course CTH: No acute process
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ED Course
CTH: No acute process
CTA: Occlusion of superior and inferior M2
CTP: Relatively matched defect pLMCA territory
What else would you do? What’s the mechanism?
Not given tPA or sent to IA
Admitted to NICU
vascular surgery and renal medicine consulted
Noncontrast head CT:
No acute intracranial hemorrhage or mass effect.
CTA neck:
1. No high-grade stenosis or arterial occlusion within the major
arteries of the neck.
2. Remote appearing compression deformity of the C4 vertebral body
with reversal of the normal cervical lordosis leading to at least
moderate canal stenosis at the C3-C4 level.
CTA head: Occlusion of the superior and inferior M2 branches of the
left middle cerebral artery, a left M3 branch, as well as a paucity
of distal left MCA branches.
CT perfusion: Relatively matched defect involving the posterior left
middle cerebral artery territory consistent with infarct.
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

9. NICU Course MRI following morning (next slide) 4/3/2019 3:41 AM
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

10. 4/3/2019 3:41 AM
MRI
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

11. NICU Course MRI following morning:
4/3/2019 3:41 AM
MRI following morning:
Acute L pMCA infarct, small infarcts: L occipital, b/l cerebellar
Innumerable microhemorrhages c/w amyloid angiopathy
Vascular surgery removed retained surgical sheath
Seen by renal medicine and underwent dialysis over night for K+ 8.6
NIHSS improved to 18 (from 27) on HD2
Sister, working with PL and palliative, changed code status from DNR/DNI to CMO on HD3
Passed away on HD4
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

12. PATHOLOGY Gross Pathology prediction Histology Prediction
4/3/2019 3:41 AM
PATHOLOGY
Gross Pathology prediction
Histology Prediction
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

13. Virtual Microscopy 2A H&E 2C H&E, LFB/PAS, GFAP, CD68, NeuN, NF
2H H&E, LFB/PAS, NeuN, NF, CD68, GFAP
2J H&E, NF, NeuN