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QUICK DESIGN GUIDE (--THIS SECTION DOES NOT PRINT--) This PowerPoint 2007 template produces a 48”x96” professional poster. It will save you valuable time placing titles, subtitles, text, and graphics. Use it to create your presentation. Then send it to PosterPresentations.com for premium quality, same day affordable printing. We provide a series of online tutorials that will guide you through the poster design process and answer your poster production questions. View our online tutorials at: http://bit.ly/Poster_creation_help (copy and paste the link into your web browser). For assistance and to order your printed poster call PosterPresentations.com at 1.866.649.3004 Object Placeholders Use the placeholders provided below to add new elements to your poster: Drag a placeholder onto the poster area, size it, and click it to edit. Section Header placeholder Use section headers to separate topics or concepts within your presentation. Text placeholder Move this preformatted text placeholder to the poster to add a new body of text. Picture placeholder Move this graphic placeholder onto your poster, size it first, and then click it to add a picture to the poster. QUICK TIPS (--THIS SECTION DOES NOT PRINT--) This PowerPoint template requires basic PowerPoint (version 2007 or newer) skills. Below is a list of commonly asked questions specific to this template. If you are using an older version of PowerPoint some template features may not work properly. Using the template Verifying the quality of your graphics Go to the VIEW menu and click on ZOOM to set your preferred magnification. This template is at 50% the size of the final poster. All text and graphics will be printed at 200% their size. To see what your poster will look like when printed, set the zoom to 200% and evaluate the quality of all your graphics before you submit your poster for printing. Using the placeholders To add text to this template click inside a placeholder and type in or paste your text. To move a placeholder, click on it once (to select it), place your cursor on its frame and your cursor will change to this symbol: Then, click once and drag it to its new location where you can resize it as needed. Additional placeholders can be found on the left side of this template. Modifying the layout This template has four different column layouts. Right-click your Mouse on the background and click on “Layout” to see the layout options. The columns in the provided layouts are fixed and cannot be moved but advanced users can modify any layout by going to VIEW and then SLIDE MASTER. Importing text and graphics from external sources TEXT: Paste or type your text into a pre-existing placeholder or drag in a new placeholder from the left side of the template. Move it anywhere as needed. PHOTOS: Drag in a picture placeholder, size it first, click in it and insert a photo from the menu. TABLES: You can copy and paste a table from an external document onto this poster template. To make the text fit better in the cells of an imported table, right-click on the table, click FORMAT SHAPE then click on TEXT BOX and change the INTERNAL MARGIN values to 0.25 Modifying the color scheme To change the color scheme of this template go to the “Design” menu and click on “Colors”. You can choose from the provide color combinations or you can create your own. © 2012 PosterPresentations.com 2117 Fourth Street, Unit C Berkeley CA 94710 firstname.lastname@example.org Student discounts are available on our Facebook page. Go to PosterPresentations.com and click on the FB icon Background Workup and clinical outcome Initial presentation MRI showed a high-grade temporoparietal GBM (Images 1 and 2). fMRI imaging was performed to plan safe tumor removal. fMRI during reading aloud (Image 3) shows close tumor proximity to the eloquent cortex. Tongue tapping (Image 4) and left finger tapping (Image 5) images indicate surgical resection was possible without significant postoperative deficit. Diffusion tensor imaging (Image 6) shows a displaced right optic radiation without tumor interruption. Contrast head CT (Image 7) shows poor tumor visualization compared to MRI. Tumor histopathology (Image 8) showed typical GBM with heterogeneous mixtures of poorly-differentiated neoplastic astrocytes. Imaging Teaching points While state-of-the art technology and cutting- edge diagnostic tools aid in diagnosis, thorough history (persistent “dizzy spells” in this case) and physical exam still reign supreme in patient care The search for secondary – or even tertiary – causes must be considered in diagnosis; in this case the secondary cause was seizures leading to asystole, and the tertiary cause being tumor MRI may be performed with traditional pacemakers, utilizing low-energy protocol sequences and close cardiac monitoring fMRI has markedly changed and improved neurosurgical resection of malignancy, specifically improving outcomes by avoiding critical speech, motor, and vision pathways DTI can identify specific neuronal tracts by imaging water molecule diffusion The general public should be trained in BLS/CPR, as immediate and effective resuscitation likely saved this patient’s life References 1. Seeck, M., et al. Symptomatic postictal cardiac asystole in a young patient with partial seizures. Europace 2001 Jul;3(3):247. 2. Devinsky, O. Bradycardia/asystole induced by partial seizures: a case report and review. Neurology 1997 Jun;48(6):1712-4. 3. Van der Sluijs B.M., et al. Brain tumor as a rare cause of cardiac syncope. J of Neurooncology 2004 Mar-Apr;67(1-2):241-4. Contact information Jonathan Schwartz, M.D. University of Colorado Denver Internal Medicine Residency Program email@example.com Although brain MRI was indicated, it could not be performed because of the recent pacemaker implant. Contrast head CT was substituted, and suggested a vague temporoparietal lesion. MRI was now mandated, and a low-energy MRI protocol was used with temporary pacemaker reprogramming. A cardiologist was present throughout the scan. MRI showed a high-grade glioblastoma multiforme (GBM, Images 1 and 2), which raised concern for temporal lobe seizures as a cause of the lightheaded amnestic episodes. Furthermore, temporal lobe seizures became a possible explanation of his asystole. Consultation with an epileptologist and subsequent EEG confirmed temporal lobe seizures. The patient was initiated on antiepileptic drug therapy. The implanted pacemaker was removed and functional MRI (fMRI) was performed to determine if the tumor could be removed without impacting key vision, speech, and motor control centers. The tumor was successfully removed and GBM pathologically confirmed. An investigational, MRI- compatible pacemaker was implanted since the patient would need multiple follow-up MRI scans. GBM is the most common and most malignant glial tumor, 60% of all primary brain cancers Median survival is 14 months after diagnosis One study reported 5/1244 (0.4%) of patients with epilepsy suffered ictal asystole While seizures are common in patients with brain tumors, they are less common with high- grade compared to low-grade gliomas Patients with brain tumors in the motor cortex are at higher risk of having seizures GBM is a relatively rare cause of temporal lobe seizures; 12% of cases in one series Bradycardia, SA node dysfunction, and asystole only rarely present as the first sign of cerebral malignancy Ictal asystole is a rare but often fatal seizure complication, and is an important cause of sudden unexplained death in epilepsy (SUDEP) Ictal asystole is most commonly associated with temporal lobe seizures but has also been documented with frontal lobe seizures New data suggest treating the underlying cause of epilepsy may eliminate the need for pacemaker implantation Literature Review Jonathan G. Schwartz, M.D. 1, Robert S. Schwartz, M.D. 2, Joel A. Garcia, M.D. 1,3 1 Department of Medicine, University of Colorado Denver, Aurora, CO; 2 Minneapolis Heart Institute, Minneapolis, MN; 3 Division of Cardiology, University of Colorado Denver, Aurora, CO The cause of a pause is not always cardiac Syncope is a frequent cause of hospital admission, and cardiac causes must be considered and ruled out. Cardiogenic syncope results from sinoatrial or atrioventricular node disease, conduction system disease, or ventricular arrhythmias. Rarely, however, cardiogenic syncope has secondary or even tertiary causes, as this case illustrates. A previously-healthy 49 year old male was referred for follow-up after a dual chamber pacemaker was implanted one week prior. He was on vacation and was crossing the street when he suddenly lost consciousness. His wife, a critical care nurse, could find no pulse and immediately began CPR. The patient developed a pulse and regained consciousness. EMS arrived, placed him on continuous monitoring, and he again lost pulses and suffered a generalized seizure. He again regained pulses and was taken to a nearby ED for evaluation. Initial ECG revealed extreme bradycardia (see rhythm strip above) followed by sinus arrest, and he again lost consciousness. He was revived and again regained consciousness. Head CT, echocardiography, and metabolic panel were unremarkable. A temporary pacemaker was inserted, followed by permanent pacemaker implant. He was discharged home, but had persistent “lightheaded” and “dizzy” episodes for which he presented to our emergency department. He was referred to our clinic for pacemaker interrogation, which showed normal function. A careful history revealed these lightheadedness episodes were frequent, and associated with amnesia. This was concerning, especially since they persisted despite normal cardiac and pacemaker function. This warranted further workup, with particular focus on neurologic evaluation. ECG rhythm strip obtained upon EMS arrival Image 1: Transverse MRI with temporoparietal lesion Image 2: Sagittal MRI with temporoparietal lesion Image 3: Transverse fMRI, story reading Image 4: Transverse fMRI, tongue tapping Image 5: Transverse fMRI, left finger tapping Image 6: Diffusion Tensor Imaging with optic radiations Visual cortex Motor areas Motor Activity Tumor Visual tracts Image 7: Contrast CT showing poor discrimination of tumor Image 8: Histopathology of glioblastoma multiforme Tumor
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QUICK DESIGN GUIDE (--THIS SECTION DOES NOT PRINT--) This PowerPoint 2007 template produces a 36”x56” professional poster. It will save you valuable time.
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QUICK DESIGN GUIDE (--THIS SECTION DOES NOT PRINT--) This PowerPoint 2007 template produces a 36”x60” professional poster. It will save you valuable time.
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