brain ct / hemolytic anemia
TRANSCRIPT
L E A R N I N G P O I N T S
MORNING REPORT 06/09
WHAT IS THE DIAGNOSIS?
CAROTID ARTERY STENOSIS
• Causes approximately 10 to 20% of strokes.• Occurs most frequently at its bifurcation.• Atherosclerotic plaques cause symptoms most
often through distal embolism to branches of the retinal or cerebral arteries (MCA).• 50% patients with symptomatic carotid disease
report TIA symptoms preceding the stroke.
Grotta JC. Carotid stenosis. N Engl J Med 2013;369:1143-1150
TREATMENT
• In patients with symptomatic disease, carotid endarterectomy should be considered within 2 weeks if there is stenosis of more than 70% of the diameter of the ipsilateral carotid artery• Less benefit in patients with stenosis of 50 to 69% and in
asymptomatic patients, and there is no benefit in patients with stenosis of less than 50%.
• Carotid stenting is an alternative to carotid endarterectomy, particularly in patients at high surgical risk and in younger patients (<70 years of age).
Grotta JC. Carotid stenosis. N Engl J Med 2013;369:1143-1150
LEARNING POINTS
AUTOIMMUNE HEMOLYTIC ANEMIA
Lechner K, Jäger U (2010) How I treat autoimmune hemolytic anemias in adults. Blood 116(11):1831–8.
AUTOIMMUNE HEMOLYTIC ANEMIA
Warm Ab
IgGReacts against protein Ag on
the RBC surface
Cold Ab
90% IgMReacts against polysaccharide
Ag
Mixed Ab
Swiecicki PL, Hegerova LT, Gertz MA. Cold agglutinin disease. Blood 2013;122:1114–21.
COLD AGGLUTININ DISEASE
• 15% of patients with autoimmune hemolytic anemia. • Cold agglutinin IgM can be:• Monoclonal: underlying lymphoproliferative disorder• Polyclonal: post-infectious setting (mycoplasma, EBV,
legionella)
• The diagnosis is establish with hemolytic anemia, reticulocytosis, hyperbilirubinemia, ↑ LD, and + Coombs test for anti-C3 and classically negative anti-IgG.• After test findings suggest CAD, the antibody titer and thermal
activity should be determinedSwiecicki PL, Hegerova LT, Gertz MA. Cold agglutinin disease. Blood 2013;122:1114–21.
TREATMENT
• Nonpharmacologic measures are the cornerstone of management of CAD: avoiding cold exposure.
• Supportive transfusions may be used in patients with severe anemia. An in-line blood warmer should be considered to minimize cold agglutinin binding to transfused red cells.
• The most appropriate pharmacotherapy for CAD has remained an area of research. • 35% of patients treated with single-agent prednisone had a response, and most
responders needed further therapy. • Alkylating agent–containing regimens had a 44% response rate, but a similar low
proportion of patients achieved independence from further therapy compared with those being given corticosteroid-containing regimens.
• Response rate of 50% with purine analogs, with 40% of treated patients achieving independence from further therapy.
• Rituximab response rates were 83% in single-agent therapy and 79% in combination therapy with 51% patients achieving independence from further therapy.
Swiecicki PL, Hegerova LT, Gertz MA. Cold agglutinin disease. Blood 2013;122:1114–21.