Carotid Sinus Massage: Why and How is it done?

Carotid sinus massage (CSM) is commonly used in a variety of settings, most commonly in the evaluation of paroxysmal supraventricular tachycardias (SVTs) as well as the evaluation of patients with suspected reflex syncope or carotid sinus hypersensitivity, which may be manifested as dizziness or syncope. Carotid sinus massage is also used in emergency settings to diagnose or treat paroxysmal supraventricular tachycardia.

Indications
Carotid sinus massage is also recommended for the initial treatment of hemodynamically stable paroxysmal supraventricular tachycardia. In addition, carotid sinus massage may help to clarify the type and origin of narrow-complex tachycardia.

Physiology
The carotid sinus senses changes in arterial blood pressure by means of baroreceptors — interwoven nerve endings of sensory neurons that extend throughout the adventitia along the first segment of the internal carotid artery, just above the carotid bifurcation. Baroreceptors are stimulated by the stretching of the blood-vessel wall. In response to high blood pressure, the firing rate of the nerve fibers increases, inhibiting the sympathetic nervous system and stimulating the parasympathetic nervous system through a centrally acting mechanism; the result is a decrease in blood pressure and heart rate.

Procedure

•  The patient is placed in the supine position with the neck extended (ie, raising the chin away from the chest) to maximize access to the carotid artery. The carotid sinus is usually located inferior to the angle of the mandible at the level of the thyroid cartilage near the arterial impulse, at the upper border of the thyroid cartilage, medial to the sternocleidomastoid muscle. 
• Hold your index and middle fingers together and slide them from the thyroid cartilage posteriorly, toward the patient’s spine, until you feel the carotid pulse.(figure above).
• Pressure is applied to one carotid sinus for 5 to 10 seconds. Although pulsatile pressure via vigorous circular motion may be more effective, steady pressure is recommended because it may be more reproducible.
• If the expected response is not obtained, the procedure is repeated on the other side after a one- to two-minute delay.

Response

• The expected responses vary somewhat depending upon the indication (ie, paroxysmal SVT versus carotid sinus hypersensitivity).

• For a patient with paroxysmal supraventricular tachycardia in whom carotid sinus massage is performed for both diagnostic and/or therapeutic purposes, the potential heart rate and rhythm responses are similar to those that can be seen following any vagal maneuver or the administration of adenosine. Potential outcomes include slowing of sinoatrial nodal activity, block at the atrioventricular node "unmasking" atrial activity, termination of the SVT, or no response (generally indicating inadequate performance of the technique). The typical blood-pressure response to carotid sinus massage may be mild. 

• For a patient with suspected carotid sinus hypersensitivity in whom carotid sinus massage is performed, a positive response is defined as asystole for 3 or more seconds or a >50 mmHg drop in systolic blood pressure.

Contraindications

• Carotid sinus massage is contraindicated in patients who are at risk for stroke due to carotid artery disease. 

• It is also contraindicated in patients who have had a transient ischemic attack or stroke within the preceding 3 months or who have clinically significant ipsilateral carotid stenosis or bruit.

• In patients who are at high risk for stroke, such as those with peripheral artery disease or coronary heart disease, it may be helpful for an experienced clinician to perform carotid Doppler ultrasonography before carotid massage is attempted. 

• Complications from previous massage, myocardial infarction in the preceding 3 months, or any history of ventricular arrhythmia are also contraindications.

Complications

• Minor complications of carotid sinus massage include local discomfort or pain. Light-headedness or syncope may also occur. Serious complications, such as stroke or transient ischemic attack, are rare and have been estimated to occur at a rate of less than 0.5%.

• The risk of stroke or transient ischemic attack can be minimized by observing the contraindications to carotid sinus massage. In very rare instances, atrial fibrillation and ventricular tachyarrhythmia may be induced as a result of extreme bradycardia. The consequences of these complications can be minimized by making sure that all materials required for resuscitation are at hand.

Lumbar puncture (spinal tap)

A lumbar puncture (spinal tap) as the name indicate is performed in the lumbar region.

During a lumbar puncture, a needle is inserted between two lumbar bones (usually between vertebrae L3-L4 ; L4-L5) to remove a sample of cerebrospinal fluid. This is the fluid that surrounds your brain and spinal cord to protect them from injury.

A lumbar puncture can help diagnose serious infections, such as meningitis; other disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis; or cancers of the brain or spinal cord.

A lumbar puncture may be done to:

.Collect cerebrospinal fluid for laboratory analysis

.Measure the pressure of your cerebrospinal fluid

.Inject spinal anesthetics, chemotherapy drugs or other medications

.Inject dye (myelography) or radioactive substances (cisternography) into cerebrospinal fluid to make diagnostic images of the fluid's flow.

A man with parenchymal bleeding, biparietal displaced fracture and Coronal-Sagittal sutures diastases

 A 61-year-old man presented with sudden onset of excessive agitation. While walking home late in the evening, he lost his balance, fell and hit his head on the ground. He had a history of diabetes melitus, hypercholesterolemia, hypertension and coronary artery disease with a pacemaker placed a year ago. 2 years ago he had an episode of transient ischemic attack which led to a right sided hemiparesis. He was taking metformin for his diabetes melitus; metoprolol, spironolactone, ramipril for his hypertension; atorvastatin for his hypercholesterolemia; aspirin and coumadin for anticoagulation. His vitals on presentation were temperature 36,4, blood pressure 150/90, respiratory rate 18/min, pulse 78/min.CT scan on admission (see above: LEFT: brain window RIGHT: bone window) showed parenchymal bleeding, biparietal displaced fracture and Coronal-Sagittal sutures diastases.

He was considered a high-risk candidate for emergent surgery by the anesthesia team and send to the ICU for follow-up. The neurosurgery team declared the patient inoperable due to the high risk of mortality intra-operatively. He died a couple of weeks later as his health deteriorated. 

10 QUICK FACTS ABOUT THE NOBEL PRIZE IN MEDICINE

I. It has been awarded 109 times to 216 Nobel laureates between 1901 and 2018.

II. 39 prizes were awarded to one laureate

III. 33 prizes  were shared by 2 two laureates

IV. 37 prizes  were shared by 3 laureate

V. The nobel prize amount for 2018 was set at 9 million SEK about $986K Per full Nobel Prize.

VI. The youngest Nobel prize laureate in medicine is Frederick Banting (Age: 32/Nationality: Canadian/ year of award:1923)"for the discovery of insulin."

VII. The oldest Nobel prize laureate in medicine is Peyton Rous (Age: 87 /Nationality: American/ Year of award:1966)"for his discovery of tumour-inducing viruses."

VIII. The Nobel Prize and Prize in Medicine have been awarded to women 12 times between 1901 and 2018

USA:7

Germany:1
Italy: 1 

France:1

Norway:1
China:1

  1947: Gerty Theresa Cori, née Radnitz( American)
“for their discovery of the course of the catalytic conversion of glycogen”
  1977: Rosalyn Yalow (American)
“for the development of radioimmunoassays of peptide hormones”
  1983: Barbara McClintock (American) the only one who has received an unshared Nobel Prize.
  1986: Rita Levi-Montalcini (Italian)
“for their discoveries of growth factors”
  1988: Gertrude B. Elion(American)
“for their discoveries of important principles for drug treatment”
  1995: Christiane Nüsslein-Volhard(German)
“for their discoveries concerning the genetic control of early embryonic development”
 2004: Linda B. Buck(American)
“for their discoveries of odorant receptors and the organization of the olfactory system”
 2008: Françoise Barré-Sinoussi(French)
“for their discovery of human immunodeficiency virus”
 2009: Carol W. Greider(American) & Elizabeth H. Blackburn(American)
“for the discovery of how chromosomes are protected by telomeres and the enzyme telomerase”
 2014: May-Britt Moser(Norwegian)
“for their discoveries of cells that constitute a positioning system in the brain”
 2015: Tu Youyou(Chinese)
“for her discoveries concerning a novel therapy against Malaria”

9. Top 10 nationalities with the most Nobel Laureates In Medicine:

USA(~100)
UK(39)
Germany(16)
France(11)
Sweden(8)
Switzerland (7)
Australia(6)
Austria(5)
Denmark(5)
Japan(5)

10. Top 8 institutions with the most Nobel laureates in medicine:

 Havard (University and Medical School combined ; :12 ‍:0)
 Rockefeller University(:10‍:0)
 Pasteur institute(:6 ‍:1)
 Massachusetts Institute of Technology ( :5 ‍:0)
 California Institute of Technology( :5 ‍:0)
 University College London(:5 ‍:0)
Oxford University(:5 ‍: 0)
Max Plank Institute( :4 ‍:1)

Source: data.nobelprize.org

Russian Government Scholarships for International Students

Russia is one of the few countries in the world that offers foreign citizens the opportunity to pursue their studies without paying tuition fees.

• This country is well known for its high academic standards, especially in the field of mathematics, natural sciences, and physics.
• Russia is recognized worldwide for training mathematicians, chemists, physicists, engineers, geologists, physicians, programmers, and specialists in natural sciences.

 Scholarship Overview

• The Russian Government awards several thousand scholarships or quotas to international students every year.
• These scholarships were established with the sole purpose of strengthening ties between Russia and international students.
• In 2018, Russian universities were allocated 18,000 quotas.

 Host School(s)

• Russian Universities

 Fields of Study

• Scholarships are available for all fields offered at the universities, at all levels.
• Courses available include Medicine, Pharmacy, Agriculture, IT, Forestry, Fishing, Management, Applied Geology, Economics, Mining, etc...

What does the scholarship cover?

Recipients of this scholarship are entitled to:

• Free tuition for the duration of the study program
• A maintenance allowance of approximately 1630 rubles per month for the entire study period
• Dormitory accommodation, if available

 How many scholarships are given?

• 18,000 scholarships were granted in 2018

 Which countries are targeted?

• International students

Am I Eligible to Apply?

 To qualify for this scholarship, you must:

• Be an international student and a foreign citizen
• Possess the necessary English language requirements for the chosen course. Applicants opting for study in French or English will have an interview to assess their language proficiency. Results for any language tests taken must be presented.
• Have finished secondary school or vocational school (technical school, lyceum, high school, etc.) if applying for a Bachelor’s program. Your educational level on completion of secondary/vocational education should match that of a secondary school graduate in Russia.
• Have completed a Bachelor’s degree if applying for a Master’s program
• Have passed any competitive selection for the scholarship in your home country
• Have documentation proving completion of secondary education if applying for a Bachelor’s degree
• Have documentation proving completion of a minimum of a Bachelor’s degree or its equivalent if applying for a master’s program

 NB: Depending on the course selected, a Russian language course may be a compulsory part of the study program.

 How Do I Apply – Next Steps

1. Look for information on the selection of international applicants on the Study in Russia website. The scholarship announcement is also published on the Rossotrudnichestvo representation website and the website of the Russian embassy in your country.

2. Contact the Russian embassy nearest to you, preferably in your home country for information on the available scholarships and the fields of study.

3. Register on the Study in Russia website, fill in the electronic form and submit your application. You can choose up to 6 universities, in order of preference, from those listed on the quota. The following documents should be attached to the application.

• A copy of your passport, valid for at least 18 months from the date of your planned arrival in Russia, or a copy of your birth certificate
• Copies of your certificates or documents indicating your current level of education and qualifications received
• These documents can be submitted as hard copies to the Russian Embassy.

4. Wait for an invitation to participate in the selection process – interviews, tests, and examinations. The schedule may be posted on the embassy website, or you may get a direct email.

5. Look for your name in the list of successful candidates (based on the results of the selection process)

6. If you appear on the list of successful candidates, prepare the following additional documents.

• A medical/doctor’s certificate confirming that there are no medical reasons that will prevent your admission into a Russian university, including the results of an HIV test.
• Copies of documents (including a birth certificate and one colored passport size photo) listed on the Rossotrudnichestvo website. These documents must be notarized and translated into Russian.
• You can attach these documents to your electronic form and submit them online or deliver the hard copies to the Russian Embassy.

7. Wait for a notification/letter that confirms your enrolment in the university and contains information on the next steps.

NOTE:

• Allocation of state-funded spots is carried out by Rossotrudnichestvo (The Federal Agency for the Commonwealth of Independent States, Compatriots Living Abroad, and International Humanitarian Cooperation) through its international network of offices, as well as through embassies of Russia abroad.
• Applicants who do not know enough Russian for study in their chosen subject are enrolled in a preparatory department where they spend a year studying Russian and other general education disciplines relating to the field of study.
• Any applicant who is interested in enrolment in Arts and Humanities must take part in creative contests (additional exams) at the universities. The applicant will, therefore, need to enter Russia on a tourist visa for this purpose. Acceptance into the program is pegged on the outcome of this creative contest.

 Deadline

• 30 March 2019

 How do I get more information?

• Website: https://studyinrussia.ru/en/study-in-russia/scholarships/

CASE OF THE DAY

A 35-year-old man presented to the neurology clinic complaining of persistent  headache for the past 5 years. No other associated disease was found. Neurologic examination was intact. Serum biochemistry panel revealed no abnormality. Contrast enhanced MRI Imaging was ordered and the mass above was seen.

The neurosurgery and Radiation Oncology departments were consulted and a decision was made to excize the mass followed by radiotherapy depending on the pathology result. 

Surgery was done and intraoperative sample was sent to pathology. 

Pathology result will most likely reveal a:

A. Glioblastoma

B. Ependymoma

C. Cordoma

D. Menengioma

E. Craniopharyngioma

Answer is: D pathology revealed a grade 1 menengioma

What is schwannoma?