Atlanta classification

Q: Which of the following pathologies goes under the Atlanta classification? (select one) 

 A) acute pancreatitis 

 B) Acute Kidney failure 

C) Acute GI bleed 

D) Acute stroke 

E) Acute intestinal ischemia

Answer: A 

 Atlanta classification divides acute pancreatitis into two broad categories: 

1.  Interstitial edematous acute pancreatitis - characterized by acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis. 
2.  Necrotizing acute pancreatitis - characterized by inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis. 

Though it sounds simple, the management line becomes different for each category. 

#GI 

 Reference: 

 Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.

Type-3c Diabetes Mellitus

Q: What is type 3C diabetes?

Answer: Pancreatogenic diabetes

Pancreatogenic diabetes is usually a complication of Chronic pancreatitis and sometimes pancreatic cancer.

Long-standing chronic pancreatitis causes a wide range of exocrine insufficiency, leading to metabolic consequences. These include osteopenia, osteoporosis, bone fractures, pancreatogenic diabetes, and opioid dependency due to frequently prescribed narcotics. It may also cause pseudocyst formation, bile duct or duodenal obstruction, pancreatic ascites, pancreatic pleural effusion, splenic vein thrombosis, arterial pseudoaneurysms, small intestinal bacterial overgrowth, gastroparesis, pancreatic ductal adenocarcinoma.

#GI

#endocrinology

References:

1. Hart PA, Bellin MD, Andersen DK, et al. Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer. Lancet Gastroenterol Hepatol 2016; 1:226.

2. Vonderau JS, Desai CS. Type 3c: Understanding pancreatogenic diabetes. JAAPA. 2022 Nov 1;35(11):20-24. doi: 10.1097/01.JAA.0000885140.47709.6f. PMID: 36219100.

3. Bhattamisra SK, Siang TC, Rong CY, Annan NC, Sean EHY, Xi LW, Lyn OS, Shan LH, Choudhury H, Pandey M, Gorain B. Type-3c Diabetes Mellitus, Diabetes of Exocrine Pancreas - An Update. Curr Diabetes Rev. 2019;15(5):382-394. doi: 10.2174/1573399815666190115145702. PMID: 30648511.

Lyme carditis

 Q: 44 years old male who was diagnosed with Lyme's disease 4 weeks ago is now admitted to ICU with syncope and Atrio-ventricular block (AV-block) on EKG. It would be prudent to insert a permanent pacemaker to avoid sudden cardiac death?

A) True

B) False

Answer: B

AV block due to Lyme carditis is usually short-lived and resolved in six weeks. A temporary pacemaker may be required, but a permanent pacemaker is rarely needed. While evaluating the EKG of a patient suspected of having Lyme carditis, it is important to pay attention to the PR interval. If the PR interval is more than 300 milliseconds, there is a high chance of the patient progressing to complete AV block, which may require a temporary pacemaker. 

Patients who fail to complete the antibiotic course appropriately for any early signs of Lyme disease, erythema migrans, are more prone to progress to Lyme carditis.

#cardiology

References:

1. Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med 1980; 93:8. 

2. Yeung C, Baranchuk A. Diagnosis and Treatment of Lyme Carditis: JACC Review Topic of the Week. J Am Coll Cardiol. 2019 Feb 19;73(6):717-726. doi: 10.1016/j.jacc.2018.11.035. Erratum in: J Am Coll Cardiol. 2019 Nov 26;74(21):2709-2711. PMID: 30765038. 

3. Sangha O, Phillips CB, Fleischmann KE, et al. Lack of cardiac manifestations among patients with previously treated Lyme disease. Ann Intern Med 1998; 128:346. 

4. van der Linde MR, Crijns HJ, Lie KI. Transient complete AV block in Lyme disease. Electrophysiologic observations. Chest 1989; 96:219.

LAA thrombi in AF

Q: What percentage of left atrial thrombi in atrial fibrillation (AF) originates from Left Atrial Appendage? (select one)

A) 50%

B) 70%

C) 90%

Answer: C

The objective of asking this question is to cover two concepts.

First, as 90% of thrombi in AF originate in the LAA, it is a good practice in cardiac surgery to ligate, amputate, or occlude the LAA if the patient already has an open sternum for other indications, particularly in those patients who cannot take oral anticoagulation. Other patients who are not undergoing cardiac surgery may get such ablation/occlusion via procedures such as the WATCHMAN device.

Second, clinicians should be mindful that 10% of thrombi are NOT coming from the LAA and should evaluate the caveats. It may be left atrial structural or functional abnormalities or a hypercoagulable state. Also, if the LAA is not properly amputated, residual communication between the LAA and Left Atrium (LA)—known as residual jet—can lead to stroke. A residual jet >5 mm may predispose to thrombus formation. 

#cardiology

#cardiac-surgery

References:

1. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61:755.

2. Saraf K, Morris GM. Left Atrial Appendage Closure: What the Evidence Does and Does Not Reveal-A View from the Outside. Interv Cardiol Clin. 2022 Apr;11(2):171-183. doi: 10.1016/j.iccl.2021.11.009. Epub 2022 Mar 11. PMID: 35361462.

3. Dudziñska-Szczerba K, Kułakowski P, Michałowska I, Baran J. Association Between Left Atrial Appendage Morphology and Function and the Risk of Ischaemic Stroke in Patients with Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2022 Apr;11:e09. doi: 10.15420/aer.2022.08. PMID: 35846423; PMCID: PMC9272406.

ICP in cryptococcal meningitis

Q: 42 years old male with known history of AIDS and previous cryptococcal meningoencephalitis is brought to ED by his roommate with clouding of sensorium and ataxia. On exam patient is found to have visual and hearing loss, and papilledema. Lumbar puncture (LP) was planned. What is considered to be the increased Intra Cranial Pressure (ICP) in cm of H2O? - select one

A) >10 

B) >20 

C) >30

D) >40 

Answer: B

One of the essential procedures required in patients with AIDS and suspected cryptococcal meningoencephalitis is LP to measure ICP.

High ICP is one of the hallmark of cryptococcal meningoencephalitis. It is probably due to increased vascular permeability secondary to cytokine-induced inflammation. Also, clogging of arachnoid villi with fungal antigen and/or yeasts, plays role by impairment of CSF resorptive function.

Pressure above >20 cm of H2O is considered as high ICP.

#procedures

#ID

References:

1. Chang CC, Harrison TS, Bicanic TA, et al. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. Lancet Infect Dis 2024.

2. The World Health Organization. Guidelines for the diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents, and children. http://apps.who.int/iris/bitstream/handle/10665/260399/9789241550277-eng.pdf;jsessionid=7A37044AC579D4A69EBBBF0B47BC60AF?sequence=1 (Accessed on May 19, 2024).

3. Claus JJ, Portegies P. Reversible blindness in AIDS-related cryptococcal meningitis. Clin Neurol Neurosurg 1998; 100:51.

4. Pappas PG. Managing cryptococcal meningitis is about handling the pressure. Clin Infect Dis 2005; 40:480.

Fibrinogen in DIC

Q: Normal fibrinogen level in DIC is a good prognostic feature. 

A) True 

B) False 

Answer: B 

Disseminated intravascular coagulation (DIC) is a symptom of the underlying disease, and severity usually correlates with the underlying disease's severity. It is marked by abnormalities such as 

• prolonged PT and aPTT 
• low fibrinogen
• increased D-dimer 
• low platelet count 
• microangiopathic hemolytic anemia (MAHA) on blood smear. 

Fibrinogen is an acute-phase reactant. In sepsis, malignancy, and other inflammatory conditions may have markedly increased fibrinogen production; thus, a plasma fibrinogen level within the normal range may represent a severe underlying process.

 #hematology 

References:

1. Papageorgiou C, Jourdi G, Adjambri E, Walborn A, Patel P, Fareed J, Elalamy I, Hoppensteadt D, Gerotziafas GT. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost. 2018 Dec;24(9_suppl):8S-28S. doi: 10.1177/1076029618806424. Epub 2018 Oct 8. PMID: 30296833; PMCID: PMC6710154. 

 2. Kim HK, Lee DS, Kang SH, Kim JQ, Park S, Cho HI. Utility of the fibrinogen/C-reactive protein ratio for the diagnosis of disseminated intravascular coagulation. Acta Haematol. 2007;117(1):34-9. doi: 10.1159/000096786. Epub 2006 Nov 8. PMID: 17095857.

BT in asthma

Q: A 24-year-old male is admitted to ICU with a fourth exacerbation of Asthma within the last 6 months. The patient continued to fail all therapies despite full compliance. The patient has now registered for a Bronchial Thermoplasty (BT) trial. Which of the lobes is usually NOT treated during this procedure? - select one

A) Right upper lobe

B) Righe middle lobe

C) Right lower lobe

D) Left upper lobe

E) Left lower lobe

Answer: B

BT is a measure of extreme for patients who continued to fail all conventional medical therapy for Asthma. The procedure involves applying heat via localized controlled radiofrequency waves with a bronchoscope. It aims to reduce the increased mass of airway smooth muscle associated with asthma. 

The procedure is usually completed with three consecutive bronchoscopies three weeks apart. The target tissue temperature is kept at 65˚C for the airway walls. All accessible airways distal to the mainstem bronchus that are 3 to 10 mm in diameter are treated once, except those in the right middle lobe, which are left untreated due to difficulty with access.

#procedures

#pulmonary

References:

1. Wahidi MM, Kraft M. Bronchial thermoplasty for severe asthma. Am J Respir Crit Care Med 2012; 185:709.

2. Langton D, Wang W, Sha J, et al. Predicting the Response to Bronchial Thermoplasty. J Allergy Clin Immunol Pract 2020; 8:1253.

3. Torrego A, Solà I, Munoz AM, et al. Bronchial thermoplasty for moderate or severe persistent asthma in adults. Cochrane Database Syst Rev 2014; :CD009910.

4. Chupp G, Kline JN, Khatri SB, et al. Bronchial Thermoplasty in Patients With Severe Asthma at 5 Years: The Post-FDA Approval Clinical Trial Evaluating Bronchial Thermoplasty in Severe Persistent Asthma Study. Chest 2022; 161:614.

Type B - LA - types

Q: What is Type B1, Type B2 and Type B3 Lactic acidosis?

Answer; Basically, there are 2 major types of Lactic acidosis: A and B (let's forget about type D for a while!!)

Type A lactic acidosis occurs in the setting of poor tissue perfusion or oxygenation. It is due to either overproduction or underutilization.

Overproduction: Circulatory, pulmonary, or hemoglobin transfer disorders are commonly responsible.

Underutilization: Liver disease, gluconeogenesis inhibition, thiamine deficiency, and uncoupled oxidative phosphorylation

Type B lactic acidosis is when there is no evidence of poor tissue perfusion. Type B is divided into 3 subtypes.

• Type B1 is associated with systemic diseases such as renal and hepatic failure, diabetes, and malignancy.
• Type B2 is caused by drugs and toxins, including biguanides, alcohols, iron, isoniazid, and salicylates. HIV drugs have been described, too.
• Type B3 is due to inborn errors of metabolism.

#metabolism

References:

1. Seheult J, Fitzpatrick G, Boran G. Lactic acidosis: an update. Clin Chem Lab Med. 2017 Mar 1;55(3):322-333. doi: 10.1515/cclm-2016-0438. PMID: 27522622.

2. Claudino WM, Dias A, Tse W, Sharma VR. Type B lactic acidosis: a rare but life threatening hematologic emergency. A case illustration and brief review. Am J Blood Res. 2015 Jun 15;5(1):25-9. PMID: 26171281; PMCID: PMC4497494.

cholestyramine and thyrotoxicosis

Q:  46 years old female is admitted to ICU with symptoms consistent with exacerbation of her hyperthyroidism symptoms. The endocrinology service started the patient on methimazole. Patient's home list of medications shows Cholestyramine in it. Cholestyramine will make affect of methimazole? (select one)

A) better

B) worse

Answer: A

For patients who require rapid amelioration of hyperthyroid symptoms, Cholestyramine is a good adjunctive therapy to add with methimazole. It lowers serum T4 and T3 concentrations more rapidly than methimazole alone and resolves hyperthyroid symptoms rapidly.

It is given in a dose of 4 g four times daily with methimazole.

Mechanism of Action: Thyroid hormones are metabolized in the liver and are conjugated with glucuronide and sulfate. The conjugation products are excreted in the bile. Free thyroid hormones are released and reabsorbed in the intestine. Bile acid sequestrants like cholestyramine interfere with this enterohepatic circulation and recycling of thyroid hormone.

Caution: Since cholestyramine can interfere with the absorption of oral medications, other drugs given orally should be given two hours before or two hours after cholestyramine administration. Cholestyramine may be discontinued when clinical status improves.

#endocrinology

#pharmacology

References:

1. Solomon BL, Wartofsky L, Burman KD. Adjunctive cholestyramine therapy for thyrotoxicosis. Clin Endocrinol (Oxf) 1993; 38:39.

2. Kaykhaei MA, Shams M, Sadegholvad A, et al. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine 2008; 34:52.

Visual functions and adverse ocular effects in patients with amiodarone

Q: What could be the ocular side effects of Amiodarone?

Answer: Most side effects are due to Amiodarone intracytoplasmic lamellar deposits in the cornea, lens, retina, and optic nerve.

• Colored rings around lights.
• Corneal epithelial opacities resembling a cat's whiskers
• Lens opacity
• Retinopathy (rare)
• Optic neuropathy

#pharmacology

References:

1. Mäntyjärvi M, Tuppurainen K, Ikäheimo K. Ocular side effects of amiodarone. Surv Ophthalmol. 1998 Jan-Feb;42(4):360-6. doi: 10.1016/s0039-6257(97)00118-5. PMID: 9493278.

2. Ikäheimo K, Kettunen R, Mäntyjärvi M. Visual functions and adverse ocular effects in patients with amiodarone medication. Acta Ophthalmol Scand. 2002 Feb;80(1):59-63. doi: 10.1034/j.1600-0420.2002.800112.x. PMID: 11906306.

A case of unusual choking

Q; 65-year-old female was admitted to ICU 9 days ago with small bowel obstruction. Pt. is now stable and about to get transferred out of the unit. The patient suddenly starts complaining of a choking sensation with two hands on the neck. The monitor shows oxygen desaturation. The patient was intubated emergently. No laryngeal or vocal edema was seen on the laryngoscope, but vocal cord paralysis was noted.

Answer; Nasogastric tube syndrome

Nasogastric tube syndrome was described about 25 years ago by Sofferman and Coll. It is a life-threatening complication of an indwelling (more than a week) nasogastric tube. The syndrome may present as complete vocal cord abductor paralysis. The syndrome is thought to result from perforation of the NG tube-induced esophageal ulcer and infection of the posterior cricoid region (postcricoid chondritis) with subsequent dysfunction of vocal cord abduction. Unilateral paralysis of the cord is also described. Treatment includes the protection of the airway, removal of NG tubes, and the use of antibiotics. Some advocate antireflux therapy, too. Another variant is described as having no esophageal ulcer but possibly because of ischemia of the laryngeal abductor muscle secondary to physical compression of the postcricoid blood vessels by NG tube.

The bigger the size, the higher the chances of NGT syndrome.

#procedures

#ENT

References: 

1. Apostolakis LW, Funk GF, Urdaneta LF, McCulloch TM, Jeyapalan MM. The nasogastric tube syndrome: two case reports and review of the literature. Head Neck. 2001 Jan;23(1):59-63. doi: 10.1002/1097-0347(200101)23:1<59::aid-hed9>3.0.co;2-a. PMID: 11190859.

  

2. Isozaki E, Tobisawa S, Naito R, Mizutani T, Hayashi H. A variant form of nasogastric tube syndrome. Intern Med. 2005 Dec;44(12):1286-90. doi: 10.2169/internalmedicine.44.1286. PMID: 16415551.

  .

3. Taira K, Koyama S, Morisaki T, Fukuhara T, Donishi R, Fujiwara K. Nasogastric Tube Syndrome: A Severe Complication of Nasointestinal Ileus Tube. Case Rep Gastroenterol. 2023 Apr 13;17(1):191-196. doi: 10.1159/000526715. PMID: 37261032; PMCID: PMC10228247.

  

4. Sano N, Yamamoto M, Nagai K, Yamada K, Ohkohchi N. Nasogastric tube syndrome induced by an indwelling long intestinal tube. World J Gastroenterol. 2016 Apr 21;22(15):4057-61. doi: 10.3748/wjg.v22.i15.4057. PMID: 27099450; PMCID: PMC4823257.

5. Sofferman, R.A. and Hubbell, R.N., "Laryngeal Complications of Nasogastric Tubes," ANNALS OTOLOGY, RHINOLOGY, AND LARYNGOLOGY, 90:465-468, 1981.

Ketamine and liver

Case: 77-year-old patient has been in ICU intubated due to severe community-acquired pneumonia for the last 2 weeks. The patient was unable to tolerate propofol, dexmedetomidine, or benzodiazepine infusions either due to exaggerated response or reports of allergy. Finally, ketamine infusion appears to work well with the patient. On the 12th day of infusion, it is noted that the patient has progressively rising alkaline phosphatase and other liver enzymes. What should be your concern?

Answer: Sclerosing cholangitis 

Sclerosing cholangitis due to prolonged continuous infusion of Ketamine in the ICU is less recognized. Thanks to the COVID pandemic where ketamine infusion was used liberally and numerous cases were reported highlighting the said issue.

Signs of sclerosing cholangitis during ketamine infusion include jaundice, decompensated cirrhosis, hepatic failure, and liver enzymes consistent with cholangiopathy.

#pharmacology

#hepatology

#toxicology

References:

1. Keta-Cov research group. Electronic address: vincent.mallet@aphp.fr, Keta-Cov research group. Intravenous ketamine and progressive cholangiopathy in COVID-19 patients. J Hepatol 2021; 74:1243.

2. de Tymowski C, Dépret F, Dudoignon E, et al. Ketamine-induced cholangiopathy in ARDS patients. Intensive Care Med 2021; 47:1173.

Drug overdose and SOB

Case: The Rapid Response Team (RRT) has been called for a 32-year-old male with a history of IV drug abuse (IVDA) who is now in inpatient rehab  - for an acute episode of shortness of breath. CXR showed bilateral pulmonary edema. The patient failed a noninvasive ventilation mask and required intubation. Echocardiography is reported to be normal, with good right and left ventricular funtions. Critical Care fellow floated the swan with normal wedge pressure. 

Answer: Noncardiogenic pulmonary edema of opioid overdose 

Well known for the last 150 years but often undiagnosed is the independent noncardiogenic pulmonary edema due to opioid overdose. Any of the opioids or related agents can be responsible, including fentanyl, morphine, or heroin.

In the above question, the patient may have developed noncardiogenic pulmonary edema from methadone OVERDOSE while in the treatment!

Although the exact mechanism is unknown, the probability is the combination of two factors: the drug's direct toxicity and hypoventilation-induced respiratory acidosis, which causes cerebral and pulmonary edema. Naloxone can be tried, but pulmonary edema is usually resolved once the hypoventilation is managed. Usually, the response is very rapid. 

#pulmonary

#toxicity

References:

1. Osler W. Oedema of the left lung—morphia poisoning. Montreal General Hospital Reports Clinical and Pathological, vol 1, Dawson Bros Publishers, Montreal 1880. p.291.

2. Dezfulian C, Orkin AM, Maron BA, et al. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836.

3. Farkas A, Lynch MJ, Westover R, et al. Pulmonary Complications of Opioid Overdose Treated With Naloxone. Ann Emerg Med 2020; 75:39.

Radke JB, Owen KP, Sutter ME, et al. The effects of opioids on the lung. Clin Rev Allergy Immunol 2014; 46:54.

4. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest 2001; 120:1628.

Sodium in Legionnaires' disease

Q: Legionnaires' Disease (Legionella Pneumonia) tend to cause?- select one 

A) Hypernatremia

B) Hyponatremia

Answer: B

LEGIONELLA PNEUMONIA is also called LEGIONNAIRES' DISEASE because it may carry some clinical symptoms that may raise suspicion of it from other forms of pneumonia. However, no clinical features can reliably distinguish Legionnaires' disease from other types of pneumonia.

Associated symptoms that should lead a clinician to think of it are:

• Gastrointestinal symptoms such as nausea, vomiting, and diarrhea
• Hyponatremia (see reference # 3)
• Elevated hepatic transaminases
• C-reactive protein levels >100 mg/L
• Failure to respond to treatment for pneumonia with beta-lactam monotherapy

The index of suspicion should also stay high where contamination of water supplies in large facilities such as hospitals, hotels, or apartment buildings is reported or when a patient reports a history of travel in an endemic area with exposure to hot tubs or fountains.

These patients tend to get sicker. Almost one out of five patients needs ICU care, and in present days, an ECMO call may be needed. Interestingly, despite their potential for severity, local complications such as empyema and lung abscesses are not common. Extrapulmonary infections such as cellulitis, abscesses, endocarditis, or meningitis are uncommon.

#pulmonary

#ID

#electrolytes

References:

1. Sopena N, Sabrià-Leal M, Pedro-Botet ML, et al. Comparative study of the clinical presentation of Legionella pneumonia and other community-acquired pneumonias. Chest 1998; 113:1195.

2. Roig J, Aguilar X, Ruiz J, et al. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. Chest 1991; 99:344.

3. Schuetz P, Haubitz S, Christ-Crain M, Albrich WC, Zimmerli W, Mueller B; ProHOSP Study Group. Hyponatremia and anti-diuretic hormone in Legionnaires' disease. BMC Infect Dis. 2013 Dec 11;13:585. doi: 10.1186/1471-2334-13-585. PMID: 24330484; PMCID: PMC3880094.

IVT and its success

Q: A 72-year-old male, with past medical history of only hypertension (HTN) found to have a  witnessed stroke in a restaurant. He is promptly brought to the hospital within 60 minutes of the stroke. Intravenous thrombolysis (IVT) was given. Thrombus in which of the following vessels may be more resistant to 'bust'? (select one) 

A) internal carotid artery 

B) middle cerebral artery 

Answer: A

The success of IVT depends not only on early treatment but also on clot size and site. More proximal clots are more resistant to thrombolysis. 

This is for the two major reasons. First, a clot in the internal carotid artery will probably be larger (the larger the diameter, the larger the clot). Second, the chances of developing extended clots in the adjacent arteries are higher (a long thrombus). 

Another major factor that affects the success of IVT is the burden of atherosclerotic lesions in the vessel, which may prevent the full recanalization of the vessel. Moreover, thrombus permeability, i.e., residual flow, also counts. The higher the thrombus permeability, the higher the chances of successful IVT

#neurology 

References: 

 1. Menon BK, Al-Ajlan FS, Najm M, et al. Association of Clinical, Imaging, and Thrombus Characteristics With Recanalization of Visible Intracranial Occlusion in Patients With Acute Ischemic Stroke. JAMA 2018; 320:1017. 

 2. Linfante I, Llinas RH, Selim M, et al. Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 2002; 33:2066. 

 3. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 2007; 38:948. 

 4. Yoo J, Baek JH, Park H, et al. Thrombus Volume as a Predictor of Nonrecanalization After Intravenous Thrombolysis in Acute Stroke. Stroke 2018; 49:2108. 

 5. Seners P, Turc G, Maïer B, et al. Incidence and Predictors of Early Recanalization After Intravenous Thrombolysis: A Systematic Review and Meta-Analysis. Stroke 2016; 47:2409.