Constructing Case Based Learning: Intracranial Dissections

This video is intended for residents and attendings to understand an approach to case based learning, and illustrate that approach by intentionally applying it to a complicated rare disease -- intracranial dissection. As a bonus, we review the diagnostic studies, treatments, and outcomes of intracranial dissections. Given the challenging topic, medical students require accompanying resident or attending guardian :)
Created by:
Igor Rybinnik MD
Produced and narrated by:
Igor Rybinnik MD
Neurology Clerkship Director
Rutgers Robert Wood Johnson Medical School
Images adapted from, and redrawn whenever possible:
Hurst RW, Rosenwasser RH. Neurointerventional Management: Diagnosis and Treatment, 2nd Edition. CRC Press, 2012.
Dale E. Audio-visual Methods in Teaching. The Dryden Press (1947)
Martin JH. Neuroanatomy Text And Atlas, 4th Edition. McGraw Hill , 2012
Sound effects:
Who Wants to Be a Millionaire. ABC, 2015-2019
Disclaimer: Please note that this material was simplified for educational purposes. For patient management, please review your clinical society's guidelines and engage expert consultation where appropriate. Also, the opinions of the presenters do not necessarily reflect those of Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, or Rutgers University as a whole.

[@gunduzosmanli1685]

I am beginner in Neurology, first year resident in Germany and you help me incredibly. Thank you for all of your effort and stuff of the highest quality. Love you from Baku

[@TheMickey1812]

Mr. Rybinnik, I also wanted to say, that your content is amazing! I just finished my medical school and I find it very refreshing to see and listen to your presentations as a reminder and repetition. But I always learn something new. I hope you continue your great teaching despite the few viewers. Keep going and thank you!

[@theneurophile]

Thank you. I’ll keep making videos as time allows.

[@yashwanthrao98055]

Dude you gotta be the best in constructing clinical scenarios ! I mean I would just love 1000 hypothetical clinical scenarios with varying degrees of toughness in case presentations ! I hope you find time to create such scenarios more and more !

[@theneurophile]

Awesome idea. I will think about structuring this.

[@yashwanthrao98055]

@@theneurophile maybe an app as well in near future ⚡️

[@baybars_0]

amazing, thank you so much from a neuroradiologist

[@christinek2235]

Thank you for these amazing videos!

[@RamPMonyPers]

I have absolutely nothing to do with neurology. I'm not even a doctor. I was looking for scientific videos on disorders of consciousness, preparing for entering in psychology school next year, when KZbin's algorithm sent me here. Well, Dr. Rybinnik, your presentations are so well-made that even a non-med chap like me gets it. Wow!

[@theneurophile]

Thank you so much! Good luck with psychology - it's a fascinating field!

[@RamPMonyPers]

@@theneurophile Thank you so much for the encouragement! For the present though, I am thoroughly enjoying myself watching your spectacularly well-made videos.

[@milalcr2006]

Dr. Rybinnik your lectures are amazing, very helpful and this kind of interactive clinical case presentation is perfect for helping us learn and retain information. I'm a Neurology resident and after this video I feel more sure of myself the next time I encounter a SAH. I clearly know what to do, I'll be way faster and more efficient. Please keep making these videos, I will share them with my colleagues. You need to get a lot more views on this channel.

[@niceyesplease]

Your content is by far the most creative, most professional and fun I have ever experienced. Thank you, from a radiologist.

[@theneurophile]

Thank you for the kind words!

[@pablomadridmartinez7707]

I really love all of the content you’ve uploaded, please keep it up!

[@jaelake9393]

Awesome talks

[@lindalee8793]

I would definitely recommend your videos to my med students. Looking forward to more of your videos.

[@thales5999]

Love you. You are wonderful.

[@sukruoguzdr]

I've never seen such a gorgeous presentation like this, so cool. I've never seen such a gorgeous presentation like this, so cool. On the other hand, for the 3rd case I didn't feel that was as you mentioned "In case #3, it was felt that risk of rupture/SAH is higher than the risk of stroke post endovascular procedure." This sentence includes some validities. Stroke may have low risk following the endovascular coil embolization of the parent vessel in this patient. But the already occluded the VA V4 segment should give rise the thought that stroke is higher risk more than rupture/SAH. And there is not dissected aneursym/SAH, anyway. In may opinion, aspirin would be the best approach for this patient. Thank you, Sir Igor Rybinnik. All my best regards.

[@gonzalomenz3998]

Congrats!

[@giedjwu1028]

So grateful to have stumbled in your videos dr... more power and god bless you for your generosity

[@sanjeevkook]

Great learning sir

[@mpatholog]

Great job 👍 Thank you very much !

[@eduardohita6523]

Dude, you are amazing, please do not stop making these videos! They are gold! Thanks

[@theneurophile]

Thank you. I am almost done with the next one.

[@JJA222]

Such a great instructor!

[@mohamedtarek3832]

Amazing videos from an amazing professor... Thanks alot my dear professor for these amazing lectures 👏👏👏

[@ashrafmohammedabdelwahabmo4950]

Fantastic, it is really amazing

[@apurvasharma4367]

You are the best

[@doctormsigwa8578]

Thank you!

[@henamamoni6407]

Thanks a lot.👌

[@samuelguiza8714]

Thank you for the content doctor is amazing, What program do you use to make presentation?

[@theneurophile]

I use PowerPoint.

[@anjelinejoegi422]

Amazing-what system do you use to present your cases? Its clearly not powerpoint

[@MichaelTeitcher]

Thank you for posting these fantastic resources! These videos are models of what case-based learning and slide presentations should be. Question on the third case: I understand that he was symptomatic, but in the absence of hemorrhage, why not manage with antiplatelet therapy alone and forgo an endovascular procedure?

[@theneurophile]

That is an excellent question. The management of dissections that extend intracranially is always a very challenging topic due to rarity of cases and lack of high quality evidence. The major concern of not intervening is the fact that intracranial dissections carry increased risk of SAH due to vessel rupture (that risk is estimated on a case-by-case basis mainly by looking for aneurysmal dilatation in the vert). Unless the risk of SAH is deemed to be high, we would treat with antiplatelet therapy. Each case is usually managed in a multidisciplinary fashion with Stroke Neuro and Neuro-endovascular. In case #3, it was felt that risk of rupture/SAH is higher than the risk of stroke post endovascular procedure. Thus, intervention was offered.

[@MichaelTeitcher]

@@theneurophile Thank you for the insightful explanation. These are tough cases to manage.

[@danilo7300]

I didn't really get how the stent manages to preserve flow in PICA, may someone help?. Anyway, GREAT content, I'm loving you channel (just started my neurology residency) and I think we need much more innovators in educations which actually try to convey relevant knowledge effectifly, as you try and manage to do, instead of just listing stuff the learner could easily read on his own. Please keep on with the videos!

[@theneurophile]

The problem is not the low flow, but rather embolization of a piece of unstable plaque/clot to the PICA from the proximal vertebral artery. A stent flattens the plaque against the walls of the artery, preventing further embolization. A stent of course also improves the vessel diameter, but that is secondary in this case.

[@Q-Bits8]

Can you use TOF-imaging for dissection diagnosis?

[@theneurophile]

TOF may show tapeing stenosis (a sign of dissection). But T1 FatSat is the confirmatory study.

[@linsen3209]

anterolateral system damage will result in contralateral loss of pain /temperature/ crude touch, in this case significant right side hemisensory loss, no? why then this patient has significant left side hemisensory loss (ipsilateral to the cord lesion site)? This patient might have complete anesthesia at level of spinal cord lesion which is on the left. but should not be more extensive than right side. Patient may have significant loss of sensation of fine touch/ proprioception/ vibration/ 2point discrimination/ stereognosis on the left (ipsilateral to the cord lesion) . So the clinical examination findings or at least the summary of the clinical exam is quite confusing. . I agree that the left side posterior spinal artery was probably knocked out (probably coil is very high up, block the retrograde flow from right side), which explained the left side cord infarct and cerebellar infarct. I don't think anterior spinal artery is significantly affected, as it is supplied by the right vertebral artery. What I don't understand is, after embolization, patient developed not only cord and cerebellar infarct, but also medullary infarct. So there is likely to be an embolic event as well

[@theneurophile]

Are you talking about the last case with distal VA dissection? PICA comes off of the V4 segment of vertebral artery, and PICA supplies the lateral medulla. So if coils accidentally occlude PICA flow, patients develop medullary strokes. With medullary strokes, facial sensory loss will be ipsilateral (CN5 nucleus lesion) and body loss would be contralateral (spinothalamic lesion). Cord is typically supplied by the anterior spinal artery (which is fed by both vertebral arteries) and two posterior spinal artery (each from the corresponding vertebral artery), although there is significant variability to that. This patient likely had anterior spinal artery mainly supplied by single vertebral artery, so infarction extended from the medulla into the cord. Posterior spinal artery was also affected ipsilaterally, so dorsal columns were also affected. Dorsal columns supply gross ipsilateral sensation (aside from proprioception and vibration) and anterolateral system supplies contralateral sensation (pain/temperature). So this is fairly rare example of a patient developing lateral medulla and lateral anterior/posterior cord stroke from a terminal vertebral artery occlusion.

[@linsen3209]

@@theneurophile thank you for taking time to reply. Clarified some of my questions I had earlier. . I still have some questions 1. I don't think Dorsal column supply gross ipsilateral sensation, it supply fine touch sensation. Anterolateral system supply crude touch/ pain/ temperature sensation. 2. If anterior spinal artery is mainly supplied by a single vertebral artery, and presumably by the one that was coiled, why occlusion of anterior spinal artery resulting in hemi-cord infarct instead of knocking out entire anterior 2/3 of spinal cord bilaterally? Yes there are 2 posterior spinal artery, occlusion of single vert will result in unilateral posterior 1/3 of spinal cord infarct correlating some of symptoms patient has.

[@theneurophile]

@@linsen3209 1. Sure. Patients with either dorsal column or spinothalamic tract damage may complain of sensory loss (we did not examine the patient carefully to identify what type of sensory loss was present on what side because we didn't have time during emergency care). 2. It is well reported that anterior spinal arteries do not necessarily supply the entire anterior cord. They may mostly supply left or right side of the cord at various segments. So it is possible to infarct half the cord by taking out anterior spinal artery. I want to stress two points: 1. Intracranial vertebral artery dissections are rare, but this type of stroke (infracting medulla and extending to the spinal cord) is even rarer. At our institution, we have small case series at most. 2. Spinal cord lesions rarely present like in the books. Because the spinal cord itself is a small structure and there is variability in vascular supply, I myself often see exceptions rather than the rules that we all learned in med school.

[@linsen3209]

@@theneurophile thank you for the reply. much appreciated. enjoyed your lecture👍

[@sanjeevkook]

No