okay so when we are planning this
conference I just come to our planning
committee meeting and dr. Mayer looks at
me and was like snella what do you think
about talking about weird causes of
stroke so I'm like smile and I'm like
sure and inside I'm like what the heck
am I going to talk about and so my
current stroke fellow helped me out and
tagged me on a Facebook page women
neurology and all of a sudden I get a
lot of different ideas of different
causes of stroke they're just coming
left and right and as you can see there
unless there's so many and I this can
take about two days to go through
different causes so two of the most
interesting causes they came up on that
facebook chat was fat emboli from
liposuction and a patient always having
a stroke every time IV fluids we were
being run into them because the PICC
line was put into the carotid artery
however here we have different MRIs
these are just different strokes that
we've seen here at Henry Ford some of
them look like your typical Ambala
comparing strokes small vessel disease
and then some are quite weird different
ages different locations some little
random little dots so we had to
investigate them thoroughly so I'm gonna
we had to pick three things that we
learned so I divided it into three
topics vasculitis vets allopathy or
actual physical changes of the blood
vessels Kolia up with these or things
that cause the blood clots to form and
then our systemic diseases are inherited
disorders dissection so my residents are
going to be like dr. Malik this is not
uncommon we see it all the time however
it is uncommon in the general population
and in the community hospitals it's seen
in middle-aged young folks less than 40
years old men get in the about fourth
decade
but the fifth decade there are the
causes of dissection are very strange so
you can have trauma it doesn't have to
be a blunt trauma it can be a simple
thing like shoveling snow or going to
the salon or someone falling asleep on
the airplane and wake up and they had a
dissection you have pre-existing
arterial disease or fibromuscular
dysplasia recent viral illnesses and
then structural abnormalities does such
as styloid process elongation or it's
called the Eagle syndrome so here we had
a 32 year old gentleman come to our
stroke unit who is the vice president of
a major company in the Metro Detroit
area completely healthy very athletic no
medical problems ever woke up and had a
left MCA stroke and we see that he has a
dissection of the left ICA and he's been
going back and forth for business to
Europe and had multiple airplane rides
and all we could speculate was the cause
of his stroke being falling asleep and
somehow kinking the carotid and causing
the dissection so carotid dissections
they present with a one third of them
have Horner's syndrome about 10% have
cranial nerve palsy and then you can
have migraine light symptoms
vertebral dissections have majority have
a headache mainly in the occipital
region and they also have neck pain and
the most common clinical feature is
wallenberg syndrome so what's the
treatment there's always been the debate
aspirin coumadin what do we do so you
can use coumadin or antiplatelet therapy
and extracranial dissections but a few
years ago the caddis study came out and
basically they showed no difference
between the two of them however you
would not do anticoagulation
inter-cranial ii because of the higher
risk of subarachnoid hemorrhage and
that's due to the fact there's only two
layers of blood vessels intracranial ii
the prognosis of dissections is very
good about three-fourths have complete
or excellent recovery and the recurrence
within the first month is less than 2%
so in Africa we have a lot of Zebras in
America North America we rarely ever
seen them just like moyamoya disease is
very common in
come more common in Asia and is becoming
more recognizable in the North America
so what exactly is moyamoya disease you
can have ischemic or hemorrhagic strokes
there it's an artery apathy in children
and young adults that result in
progressive narrowing of the distal ICA
MCN AC arteries you develop collateral
logical Australia collaterals and so on
an angiogram you'll see a group of blood
vessels that look like a puff of smoke
and hence moyamoya so common
associations with moyamoya syndrome Down
syndrome sickle cell disease and
autoimmune disorders that graves Luke
lupus or Sjogren's so this was a 26 year
old female that came when I was a
resident she came in cephalo Pathak not
knowing anything what's going on
couldn't really non-focal exam but she
had multiple strokes in multiple
territories different ages and as you
can see on the MRA the Circle of Willis
basically does not exist so what's the
treatment you can start with the
antiplatelet therapy x' and didn't treat
the underlying disorder if there's any
present such as Graves disease if you
have recurring strokes you want to do a
CT perfusion scan with Diamox
and if it shows poor perfusion then the
patient should undergo revascularisation
so the ECIC bypass or a dice or a dams
are the two procedure two or three
procedures that neurosurgeons do so we
live in detroit so five million people
in the world and the United States use
cocaine is very common in the united
detroit they cause a skim extra core ice
ages and it's due to vasospasm
hypertension and abnormal platelet
aggregation and heroin is also a cause
of stroke because of the injections can
cause infectious endocarditis and septa
emboli sanphet amines is another cause
so we have to always look at the drugs
people are on they also cause ice eh
subarachnoid hemorrhage or ischemic
stroke and you get vascular take like
changes so here we had a 30 year old kid
and my mind kid came in and had this
hemorrhage
and the residents look at me and say
Jojo Malik is because of hypertension
well this is not another typical region
for hypertension plus the patient's not
hypertensive he has no history of
hypertension his blood vessels were
normal on the angiogram there was no
evidence of aneurysm AVM nothing in
further evaluation and questioning of
the patient he finally admits that he
takes five to ten and energy drinks a
day and that has become a very common
cause of stroke and young folks it's so
it's always important to ask people what
extra things they're doing and energy
drinks cause strokes because the
vasoconstriction just like cocaine and
there's actually over a hundred lawsuits
currently for the monster company
because of strokes related to their
product other types of drugs that can
cause vasoconstriction sumatriptan SSRIs
and in my review for this talk I found
that hypercalcemia can cause
vasoconstriction don't ask me I just put
it down there's something called
spontaneous reversible vasoconstriction
or call alcohol forming syndrome so the
MRI on the bottom is a young lady who
just gave birth to twin girls and three
weeks later she started having numbness
and headaches
she went to her local hospital they
found on flu imaging that she had all
these strokes in the posterior
circulation her MRA at that time didn't
look like anything majorly abnormal
except she was found to have a few
little aneurysms she was transferred to
our institution and she became having
more neurological symptoms and she found
to have an acute stroke about three days
later and if you look at her repeat MRA
you can see that her both her MCAS are
very narrowed and basically non-existent
she was an active vasospasm she
underwent cerebral angiogram and we gave
local Nemoto pain with some minimal
relief of that vasospasm so these
patients actually have sudden headache
they can have seizures neurological
deficits you do a lumbar puncture there
it's normal normal the neuro deficits
can start a few days after the headaches
it's something that's very difficult to
diagnose just like it's difficult to
find the Lions in the jungle when
they're looking for their prey that you
can see up there so you need to rule out
subarachnoid hemorrhage and primary
vasculitis and the treatments of Col
Fleming syndrome is steroids or calcium
channel blockers so we're gonna switch
gears we're gonna I'm going to very
briefly talk about disorders of
coagulation you have to search for these
just like you have to look twice to see
the crocodile in this water you have to
search hard for these abnormalities and
do a lot of blood work so
antiphospholipid antibody syndrome is
one of the common syndromes we see here
protein CN s deficiency antithrombin
deficiency
polycythemia essential thrombocythemia
sickle-cell disease and some genetic
factors like factor v leiden & MTHFR
reductase those typically present with
venous clots more than arterial clots so
we had a young 25 year old who's on who
has lupus who is under alysus who came
in as with this hemorrhage she was on
anticoagulation because of having DVTs
and we stopped the anticoagulation and
we just had a whole discussion about
anticoagulation but two months later
despite not being on anticoagulation she
came back with another hemorrhage so she
actually has antiphospholipid antibody
syndrome she needs to have long-term
anticoagulation so i just briefly just
put the different blood works that you
should order on patients when you're
looking up hyper credible state and
young folks with no other explained
cause of stroke so I'll switch gears to
systemic diseases so primary systemic
angina so they can be split into four k
three four categories necrotizing giant
cell and granule
I'm not going to go through all of that
you have it on your flash drive so
there's a lot of autoimmune diseases
inherited diseases just like there's a
lot of wilderbeest in Africa so I am NOT
going to talk about all of them but I'm
presenting two cases that we saw here on
our service there's a 62 year old female
she just came to our emergency room just
with swelling of the leg a common
problem that Leedy staff always see they
did a routine CBC and the diligent IDI
resident noted that the out there was
elevated WBC count low pro kleh platelet
counts and a lot of yo sinha fills in
the blood she also had this strange rash
on her so they had dermatology do a skin
biopsy and she had your fennel fills on
on the specimen she was being treated
with prednisone thinking she has a
because of some autoimmune issue four
months later we found that she had
slurred speech and generalized weakness
she comes back and she's got this crazy
MRI dots everywhere like what what the
heck is going on is some vast political
very good healthy blood vessels so this
is hyper viscosity secondary hyper
youths an affiliate syndrome I never
heard of it until I saw this patient so
we can learn everyday from the patients
that we see these patients have to be
treated with hydroxyurea unfortunately
she did pass because they couldn't get
her autoimmune under under control and
she had multiple other comorbidities so
I had to put this case in because the
chapter and the book was written by
someone from Henry Ford Hospital so this
is a 50 year old male he presented with
diplopia and he was found to have this
pontine stroke so my residents would
probably say dr. malik small vessel
disease send them home put them on
aspirin right so this is actually
fibrous disease so it's a rare ex
excellent disorder accumulation of
glycol I pour proteins initially can
have episodic print pain crises and they
start having strokes in their fourth
staff if decade of life and typically
they will have small vessel disease
strokes
and they normally involve the vertebral
basilar system so the treatment is very
difficult we do treat them still with
the underlying antiplatelet therapy
however it is not linked to just smoking
and blood pressure but linked to their
underlying autoimmune disease so I what
I just wanted to put on a few disorders
associated problems of vision
so there's ills retinopathy acute
posterior multifocal plaque white
pigment at the epithelia P never heard
of it I put it on there Marfan syndrome
su sex and Hearns so and then there's
there's things that you have skin
disorders like bishops
suite syndrome there's only about four
or five cases and published ensuite
syndrome Sneden syndrome so basically i
put these on saying that we have to look
at the patient at home we have to look
at them on everything on their skin get
a good history what else are they taking
in order to diagnose why they're
actually having strokes so the last case
is a twenty seven-year-old 14 week
pregnant woman who came in with a QT
physio she had a stroke at the age of 19
and 20 after giving birth she had her
hypo crag workup done and everything
came back negative even genetic testing
um tae was normal but she came in with
this left MCA stroke and a clot and the
left MCA artery one month later she came
in with worsening right-side weakness we
admitted her we got an MRI and she has a
stroke on the other side and a clot on
the other side this time the blood work
showed everything negative except beta 2
glycoprotein came back a little bit
elevated she was then diagnosed with the
antiphospholipid antibody syndrome and
is on lifelong anticoagulation
so bottom line we have to keep searching
for the cause of stroke because we never
know what we may miss we may even find
something as where as the Rhino and the
Serengeti National Park
[Applause]
[Music]