Now, most commonly this phenomenon develops secondary to lumbar puncture, myelography, spinal anesthesia, cranio spinal surgeries et cetera. In other mechanical events, it's simple as a valsalva maneuver, coughing and sneezing have been on the record as inducing it. The first reference to this relative to chiropractic care came in 1997 with a proceeding by Mokri out of Mayo. He didn't assert a causal relationship. He just simply said that one of the patients in his study had a previous finding on having visited a chiropractor. Relative to diagnosis, if the patient has a history of an invasive procedure, say, lumbar puncture for example, if the headache is relieved by lying down, you want to get an MRI of the brain. They're going to be looking for changes in the meninges and the thickening of the pachymeninges, the presence of subdural fluids, subdural hematomas and a downward displacement of the cerebellar tonsils. In its most extreme form this produces rupture and herniation of the brain stem and can be fatal in that environment. That'll lead us to an extremely rare situation. It does exist. It can also be misdiagnosed as a Chiari malformation number 1. CT myelography, it's helpful to find the site, radionuclide cisternography hence we're not going to be involved in, just for your background, will again help us site the location and lower cervical spinal fluid pressure is potentially diagnosed. What's the takeaway today? The Heart Association folks had given ourselves stuffs to work with. The other researches along the way have helped us along. There's one area we want to keep in mind in, when a patient presents with a positional headache, they lay down its better, they stand up its worse, be cautious. Hear these words in the back of your head. Send them out for a referral for a neurosurgical consult and go from them. Dr. Hoffman, Dr. Weinstein, thank you so much for the opportunity. I hope this helpful to you and to your colleagues. Thank you, gentlemen. Thanks, Dr. Clum. I know that the people that are participating on this even will get lots of great information to utilize going forward. The reality is that most of our colleagues will never encounter a situation involving a stroke, which makes it hard to make real to people. At the same time, there are a certain percentage of our doctors that will encounter a patient that winds up with stroke and/or stroke claim. The simple fact is that we get to deal with it as much as the information that was presented today is terrific and helps us feel good about what we
Dr. Stu Hoffman:
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