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Reposted by Richard Choi, DO, FNCS

josh farkas 💊 @pulmcrit.bsky.social · 4d

Updated the IBCC DKA chapter 🍭

Biggest changes were organizational, there is now a pretty clear & streamlined 8-step guide

Biggest content change was a rewrite of the definition of DKA (but - spoiler alert - the definition remains unclear & controversial)…

emcrit.org/ibcc/dka/#top #EMIMCC

a woman in a checkered shirt says way too much sugar in a kitchen

ALT: a woman in a checkered shirt says way too much sugar in a kitchen

media.tenor.com

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

End/ Patient did well and went to rehab on #DAPT. Thanks for following til the end. Please make sure to let me know your thoughts, any feedback is welcome!
@aartisarwal @caseyalbin @CajalButterfly @PulmCrit @drdangayach @namorrismd @nirmalregency @mettermd @OGdukeneurosurg @AvrahamCooperMD

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

End/ Take 🏡 messages:

✅ Recurrent stroke in same vessel = need to keep 🔍 for cause

✅ #CarotidWeb is an intimal flap that can cause stroke

✅ When identified, consult vascular surgery / neuroendovascular for definitive management

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

18/ With regards to 💊💉:

⏩ Single or Dual antiplt considered 1st line by many

⏩ unclear if SAPT, DAPT or anticoag superior though all with high recurrence

⏩ Stent vs. Endarterectomy reasonable, no clear superiority in trials

⏩ Intervention likely better than SAPT, DAPT or AC

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

17/ #CarotidWebs also:

⏩ best seen on oblique CT views (need recons), unclear if MRA superior

⏩ can be seen on longitudinal B mode on #ultrasound

⏩ gold standard = #DSA

⏩ optical coherence tomography (OCT) may be the future! 😎

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

16/ #CarotidWebs:

⏩ tend to occur in younger people

⏩pathogenesis incompletely understood (? Developmental, acquired, hormonal related)

⏩ high risk of stroke recurrence (~11% anually) - bigger web = ⏫ risk of stroke

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

15/ #CarotidWeb is a shelf-like intimal flap that projects into the lumen and is a known stroke risk factor! See more here:

jnis.bmj.com/content...

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

14/ Pt had recurrent stroke on #anticoagulation! Pt requires an intervention. Given stent and endarterectomy have similar efficacy (no head-to-head data available), pt undergoes stent placement and goes to rehab!

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

13/ This is a carotid web! What do you do?

Continue anticoag

Endarterectomy

Stent

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

12/ Pt again undergoes thrombectomy successfully, but this time, an astute #neuroendovascular genius notes this:.

What do you see?

Dissection

Atherosclerosis

Carotid web

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

11/ What is going on here?? What could it be?

Cardiac myxoma

Carotid web

Hypercoag of malignancy

Other zebra

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

10/ Despite anticoagulation, pt presents several months later with left sided weakness, neglect, gaze deviation again 😩! #CT 🐱scan again with no acute stroke, evidence of prior stroke, but CTA again with right M1 occlusion!!!

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

9/ However, given low EF, reasonable to start anticoagulation and so patient is discharged on anticoagulation!
See: www.ahajournals.org/...

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

8/ #ESUS = suspected cardioembolic stroke but w/o afib. #Anticoagulation in this patient population has not definitively demonstrated to be superior to #antiplatelet

A recent meta analysis of the available trials showed no superiority:

Anticoagulation vs Antiplatelets Across Subgroups of Embolic Stroke of Undetermined Source | Neurology

Background and ObjectivesThe term “embolic stroke of undetermined source” (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In ...

www.neurology.org

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

7/ Work up unremarkable, no afib findings, echo without shunt but low EF (35%), carotid on CTA without stenosis. Do you anticoagulate?

Yes

No

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

6/ What do you think is the etiology?

Can't tell

Cardioembolic

Large vessel

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

5/ Patient receives TNK and undergoes thrombectomy with great outcome! (pre/post angio, MRI DWI)

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

4/ 🐱 #CT head done with #ASPECTS 10, but #CTA reveals this:

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

3/ Remember 🚐:

V – visual – field cut or gaze deviation

A – aphasia

N – neglect

This is the easiest way to identify #LVO or Large Vessel Occlusion! Given the neglect and gaze deviation, certainly worried for LVO!

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

2/Middle aged person comes in with left sided deficits and is evaluated for #stroke. On exam, left hemiparesis, left hemineglect, right gaze deviation. What is the etiology?

LVO

Small vessel

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 7d

1/ Hello #medtwitter #neurotwitter #neurocritcare #FOAMEd have another brief case that I wanted to discuss with you and see if maybe you can learn something new or reinforce old knowledge!

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 15d

True concern: how many of our #ich patients will benefit from #MIS?

www.ahajournals.org/...

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 20d

Hi #neurocritcare @neurocritical don’t forget to participate in the #SoMe contest if you’re going to #NCS2025!

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 21d

@HopkinsNCCU

@PulmCrit

@drdangayach

@neurochristiana

@nirmalregency

@interneurona

@MicieliA_MD

@mettermd

@oneDRwoman_

@OGdukeneurosurg

@AvrahamCooperMD

@LorenzoPinelli

@daniel_gewolb

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Richard Choi, DO, FNCS @rkchoi.bsky.social · 21d

@a_charidimou

@EricLawson90

@CajalButterfly

@Capt_Ammonia

@DrAtulRamesh1

@RamaniBalu1

@DSandsmarkMDPhD

@PennNeurology

@TJUHNeuroCrit

@namorrismd

@ShadiYaghi2

@MDNeurocritcare

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