ABPN Vascular Neurology common mistakes
ABPN Vascular Neurology · Understand the traps and how to avoid them.
Calculates the thrombolysis window from the time a family member first noticed deficits in a patient who woke up with them, rather than from last known well.
Conflates symptom discovery with biological onset and forgets that wake-up strokes are treatable under imaging-selected protocols.
What to do instead
Anchor every timeline to last known well; for unknown onset, use DWI-FLAIR mismatch or perfusion imaging per DAWN/DEFUSE-3 and document the qualifying criteria.
Labels a pure motor or sensory syndrome 'lacunar' even when the exam shows aphasia, neglect, or homonymous hemianopia.
Remembers 'small deep infarct = lacunar' but not the syndrome definition requiring absence of cortical signs.
What to do instead
Apply the classic lacunar criteria: any cortical sign (aphasia, neglect, hemianopia, agnosia) excludes lacunar and points to cortical or embolic etiology.
Discharges a patient with acute vertigo, diplopia, and ataxia after a normal non-contrast CT, without vascular imaging.
Anchors on peripheral vestibular disease and overestimates CT sensitivity in the posterior fossa.
What to do instead
Perform HINTS in acute vestibular syndrome, obtain MRI DWI and CTA, and keep a low threshold to image the basilar artery.
Gives vitamin K alone for warfarin-associated ICH and delays factor replacement; or fails to reverse a direct oral anticoagulant.
Uncertain about agent-specific reversal and the urgency of INR correction.
What to do instead
Give IV vitamin K plus 4F-PCC for warfarin; idarucizumab for dabigatran; andexanet alfa or 4F-PCC for factor Xa inhibitors; do not wait for INR.
Calls a hyperdense middle cerebral artery on non-contrast CT an acute hemorrhage and withholds reperfusion therapy.
Misreads the hyperdense vessel sign, which reflects thrombus, as parenchymal blood.
What to do instead
Distinguish hyperdense artery from blood by location and shape; confirm occlusion with CTA and treat as ischemic stroke.
Omits enteral nimodipine or stops it after aneurysm securing in aneurysmal subarachnoid hemorrhage.
Believes nimodipine prevents angiographic vasospasm and is unnecessary after clipping/coiling.
What to do instead
Prescribe 60 mg every 4 hours for 21 days; it improves functional outcome independent of vasospasm; monitor and manage hypotension.
Starts dual antiplatelet therapy after a moderate or large ischemic stroke, or continues it beyond 90 days.
Overgeneralizes CHANCE/POINT results and forgets the minor-stroke/high-risk TIA eligibility criteria.
What to do instead
Use DAPT only for NIHSS ≤3 or high-risk TIA, start within 24 hours, continue 21–90 days, then switch to single antiplatelet.
Treats progressive headache with a normal non-contrast CT as migraine and never obtains venous imaging.
Underestimates cerebral venous sinus thrombosis and relies on CT, which is often normal.
What to do instead
Obtain MRI/MRV when risk factors, thunderclap onset, or progressive headache are present; anticoagulate even with hemorrhagic venous infarction.
Rapidly lowers blood pressure to 'normal' in acute ischemic stroke or below 130 mm Hg systolic in intracerebral hemorrhage.
Applies chronic hypertension targets and fears hemorrhagic transformation without knowing permissive windows.
What to do instead
Permit hypertension in ischemic stroke unless tPA (keep <185/110); in ICH target systolic 130–150, avoid rapid or excessive reduction.
Starts long-term immunosuppression for reversible cerebral vasoconstriction syndrome or misses primary angiitis because angiography overlaps.
Confuses the two vasculopathies and does not repeat imaging or examine CSF.
What to do instead
RCVS: thunderclap headache, reversible constriction on follow-up, treat with nimodipine; PACNS: inflammatory CSF, biopsy confirmation before immunosuppression.