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yourtwistedlies · 2 months

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❝ women’s hearts are lethal weapons ❞

val ! ✩ she/her ✩ minor ✩ jason grace’s gf (REAL) ✩ speak now obsessed ✩ gracie abrams lovebot ✩ summer baby ✩ certified procrastinator ✩ professional listener ✩ pathological people pleaser ✩ general amaya’s #1 fan ✩ fitz vacker defender ✩ honorary grammar police ✩ kpop stan (mostly ggs) ✩ my moots’ cheerleader ✩ under the illusion i can write ✩ somewhat smart ✩ cabin 13 girl ✩

dni: if you are racist, homophobic, xenophobic, support genocide and mass murder, sexist, 18+ only, religiophobic, creepy, toxic, or literally just a jerk, please leave!

byi: i swear sometimes!! i also adore using cute nicknames and pet names for my moots!! if you don’t feel comfortable w/ that or anything else, please let me know <33

moots - wattpad - ao3 - carrd - follower event (coming soon ⁉️) - 🇵🇸 | 🇺🇦 save the children!

•̩̩͙⁺ the basics ₊˚. ↴ ·˚༘

call me valerie/val or twisted!!

she/her, straight (heterosexual), minor (18+ only acc’s please do not follow), 18+ do not interact unless i interact first or we are moots (on my list or to be added- i am the judge of who is to be added), cancer (zodiac, but i don’t believe in them), Christian (i post about it sometimes), << summer baby, entp (mbti), 4w3 (enneagram), ambivert, slytherin, cabin 13, shade (guys i swear i wasn’t trying to be edgy or smth with the past two and this 😭😭 i took the official quizzes i promise lmao), swiftie, kpop fan, staying up writing until 4am gives me life, purple is the best color (this is not up to debate, only yellow even comes close), proud notes app writer, CATS > DOGS (occasionally my verdict changes), bunny lover, chronic platonic sofitzer, i’m either hyperactive or extremely tired (there is no in between), people say im smart, but sometimes i feel like the biggest idiot ever lmao, and ofc dex dizznee’s much needed publicist (my favorite role of mine ever)!!!

•̩̩͙⁺ music ₊˚. ↴ ·˚༘

taylor swift, olivia rodrigo, sza, conan gray, alicia keys, emei, gracie abrams, maisie peters, sabrina carpenter, laufey, queen riri (rihanna), adele, tiffany day, le sserafim, ive, newjeans, itzy, nmixx, stay-c, aespa, everglow, txt (baby fan), illit ＆ more kpop, lizzy mcalpine, pheobe bridgers, nessa barrett, pinkpantheress, claire rosinkranz, lyn lapid, alessia cara, reneé rapp, mckenna grace, and more!!

as i hope you can tell, i like a lot of music :)

•̩̩͙⁺ books ₊˚. ↴ ·˚༘

pjo, hoo, (never read toa, but yes, ik what happens in tbm), the rrverse, kotlc, city spies, ss (spy school), alex rider (not done with rr), the academy for the unbreakable arts,

and my many other fandoms i’ve forgotten about (dead magisterium fandom oop-)

i’ll add more fandoms as i remember them lol

•̩̩͙⁺ ships ₊˚. ↴ ·˚༘

rayllum, clauderry (stfu they’re adorable), percabeth (otp energy), sokeefe, dexiana, tiana (yes i know im the most indecisive bitch ever shut up you toad /jjjj i actually love u platonically), jason grace x ME (/j but i do love him lol), and more!!

•̩̩͙⁺ blogs ₊˚. ↴ ·˚༘

side blog: @yourtangledpromises

taylor blog: @iknowplxces

writing blog: @thejournalofvalerie (coming soon) (also, i won’t write anything 18+!! except curse words occasionally)

poetry blog: @yourwhisperedsecrets (coming soon)

moodboards/aesthetics blog: @yoursweetconfessions (coming soon)

and perhaps more?? (muahahaha)

•̩̩͙⁺ side note ₊˚. ↴ ·˚༘

if you’d like to be added to my moots list, or talk, please tell me (by wonder girls)!!

if we’re moots we’re actually bffs now (you just don’t notice it yet)

if i don’t respond to your ask/tag/rb/literally anything immediately i am not ignoring you!! i’m just lazy or busy and will do it later <33

im your biggest fan btw

1 Corinthians 16:14

with love,

valerie

#yayyyyy #pinned post time babyyyy #basically just me rambling abt myself lmao #pinned post #∿ 𖨌 {🧭} ₊˚.⋆☾ navigation ៸៸﹡.❤︎︎#ʋαʅ

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skybristle · 4 months

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more sparks please. girl what happened to you and do i have to kill anyone

rbs > likes

These two. dw shes already fucking them up. hashtag feminism! [they are also both women]

these two n what they do to her [i wont go fully into it but just elaborae since i already summarized it here in my post abt maw but]. yeah. When she was constructed she was a very ambitious iterator and very. jittery and eager to help her kind and very very radiant. probably the perfect iterator!

of course.... as ive probably heavily alluded to ash is a POS ! as her senior, and the only one in their group at the time, she looks to him for guidance and feels so terrible finding out how fucked up he is with his own colony and how he is struggling to bear it [he IS depressed and chronically ill however also just. has zero accoutnability or responsibility whatsoever and refuses to recongize his mistakes ever or consider his actions beyond what he receives from them] so of course as they fall for eachther and she helps him shoulder his burden he simply takes it for granted and does little to return the favor. its soo unbalanced and unhealthy but sparks is just trying and trying because god !! she wants to be good !! she wants to help people !!! so fucking bad!!!

but shes left bleeding alone, in an overextended structure as they operate on her while shes awake, overclocking her systems and sendinf electricity like lightning down her puppet, he basically messages maw Once to try and get her to knock it off before falling back into his patter nof laziness like welp! did what i can do ! and has the audacity to whine to sparks about feeling inadequate. and she really has no choice but to get back up and dust herself off and live with this reality, which persists quite literally forever, even if its less stressful when her colony eventually leaves. and she stays stuck in this delusion that ash couldnt have done any more and that it was just unfortunate and.. he still needs her help she cant leave him in the dust [what did he do to her again?].

especially as their local group slowly grows and he kind of refuses to accept the responsibility so sparks is also shouldering mentorship and taking care of them and etc. the only exception really is whispers who isnt allowed to speak to sparks because their colony is an asshole so they grow close to their designated senior and ash actually does take the kid kinda under his wing as much as he sucks, mainly at sparks concerns initially.

shes also. super badly traumatized by maw and a lot of that fear and paranoia echo especially later on when maw *actually hurts another iterator*. shes well aware how much maw resents her and maw is the only thing to really scare her. over time sparks loses her whimsy and just becomes very calcualted and dilligent. takes little pleasure in it anymore but if shes not working shes nothing, even as she makes her issues and overextension worse she hasnt rested in ages.

once mass ascension happens and ash bascialyl goes 'welp im done. see ya'll' now that nobody is literally there to make him do his job and goes into sleepmode completely disregarding all the work sparks has done for their group and for *him* not just to appease his colony on his behalf thats when she finally breaks this delusion she has and fucking snaps. she still is kidn of in the position where now shes FORCED To hold authority because hes gone but doesnt bother to try with those who dont answer to her. shes just so angry and frustrated and just workaholics it all away but its really. its not helpful long term and this anger is just building as things in their group get worse and worse as he sleeps in the distance none the wiser.

and, finally, when whisper's emergency broadcast rings true and all hell breaks loose- and he wakes up and the first thing he does is crawl back to sparks to make her do his shit again without even acknowledging his abandonment for many many kilocycles she just completely fucking loses it on him. dedicates herself to- rather than try to put ehr group back together and aid whispers, she just charges headfirst into hurting everyone whos ever hurt her. im still trying to figure out what goes on with maw but as for ash. she creates the brainiac to steal his seniority but also just hijack his structure in an incredibly painful manner. just so she can feel her pain. oh, and just like her, she wont have anyone to crawl to for sympathy [being needlessly cruel and ignoring others suffering? sounds a lot like maw. disregarding the needs of your group to chase a selfish goal as someone lay dying? sounds a lot like ash. lol. lmao even].

after she gets the seniority crown she starts having a guilt crisis. then whispers. uhm. Well. Escapes starlight's can and jumps in the void sea [ive been alluding to it this whole time but nobodies said anything so. ill just lay that here and let u guys react] she finally realizes how badly she fucked up [thats what makes her better than maw and ash] and what shes done and how much shes kind of fucked over her bridges with the people who actually cared about her [chimes and ochre especially] and. yeah. i need to piece out what happens after this still but i mean starlight and maw r still kicking around and sparks now has the responsibiltiy to do SOMETHING which would probably resul in violent retallion from at least maw and kick this bs and sparks hurt and anger up all over again. lol. lmao even.

#sky rambles #rain world #rain world oc #oc tag: countless swirling sparks #oc tag: plunging flows of ash #oc tag: erupting maw #story tag: bending horizons #<- just realized i should have a tag like that ill go back and add it to my other posts

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frostbite-the-bat · 2 years

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Okay, my brain is still a little scrampled eg :tm: and foggy and I'll have to go to sleep again soon but I want to ramble about this as I think writing it down may help others but also help to ram it in my own head a little bit - so this may not be worded the way id like it to but hopefully the message will still come across

This is about fanwork/headcanons/aus and such - since I am working on quite a big Deltarune AU myself and I constantly worry about it not being "canon" enough, since it is meant to be canon-esk and develop things that the player doesn't see in the game.

But... That is kind of the magic of aus! You can do so much cool stuff with an existing media, potray things your own way, change things to suit your needs or change problematic things, add cool ocs, add cool headcanons and make them canon in the au and create things to support them even more, and other things!!! literally go ham and have fun!!!!!! i am thinking abt that one post that i rbd a while ago that i rbs bc of the last addition abt aus and how people should make oc worlds at that point (and how that is how twilight was created)

And I suppose, if you change canon characters too much and claim them as your ocs (like the fucking mass amount of spamton ex ocs, and we know how i feel about those /neg) but still!! literally just have fun its not harming anyone, only absolutely butthurt negative assholes!!! ive been worrying about changing stuff in **MY** au because one or two people out there may not like it.

if you were in the early bugsnax fandom you may remember the drama about people giving them tails. yes!! people argued abt giving grumpuses tails!! and like !!who cares!! change the designs however the fuck you want! go ham!! make them fluffy! give them cute ears and tails! give them paw pads! give them cool markings! make them in your design and make your version of them truly yours and make it fun to draw! im sure all those designs are lovely and fun and if you wanna do it nothing should fucking stop you

and same goes for me and other ppls hcs!! currently i was worrying about making everything kinda furry-esk in my dpau and all that, and the MASSIVE changes ive done to plugboys and yesmen especially (literally making yesmen snake people for several reasons)

and like!! who cares its not canon!! its MY interpretation!! its MY au!! my au that changes so much stuff and allows me to create an amazing oc story and world within an pre-existing media AND letting those characters interact with canon characters!! and add new stories with canon characters and expand canon species!! literally dont hold yourself back unless it stresses you out and shit! (i need to learn that lol..i add TOO much stuff) its not even canon and i fully know the difference!!!

but literally! its also an outlet for creativity and i think you should be allowed to go ham if you want. if someone tells you to not do something like give grumpuses tails or make the addisons fluffy theyre an asshole.

literally like as long as ur not making the media harmful like add gross shit like p//dophilia, z//philia and whitewash characters or do any other racist digusting shit then i think u should be allowed to have fun! wanna make smthn a furry? go on ahead have fun literally fuck ppl!! who is it harming????????? like! you can also dislike these things! just scroll look away, maybe block which is all fine and healthy you can and should do that! if a hc doesnt match yours and may make you uncomfy literally just ignore it. dont start shit thats pointless. spend ur time better, draw cute puppies instead or smthn!! or speak about it privately bc i think being a bit bitchy with friends is okay to have an outlet but if you go directly after someone literally fuck off. (i personally can confirm theres some things i bitch about a lot but guess what i also do!! i also block those things and look away!! and im actively tryna get better than be hurt over pointless stuff online bc its not smthn im proud of)

but like srsly.. let ppl have fun n shit!!! srsly theres no harm in it fjgirhgotr yall 2 serious

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lickorice · 3 years

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i think we should all sleep with our windows open a tiny bit otherwise how would the sleep bats and women in wet nightgowns get in

#ok to rb lol #currently inebriated but i can finally finally finally have my window open for the first time since summer and for me it means that summer #is over and I can finally behave myself. summer is my worstest enemy i wish her the worst #and it was raining so hard a few hours ago but now its just that wonderful little rhythm that she does with her crinkle crinkle andpitpitpt #truly would not be able to express my content in this moment #the turmoil of spending a summer in new york all my ones self has nearly passed and thought i must brave the wilderness of senior year with #no friends @ the university #i can do so with the solace that i may open may window at night to sleep under the sweet cool night breeze #no pleasure more privately comforting #have 2 stop talking about having no friends it is no help. i do have lots of lovely wonderful inspiring beautiful friendships #they are all just so far away:(#i miss them so much i am foing to mass soon to see them #massachusetts. not church. although i genuinely have been considering that i do not believe in god i just wish for the voice of a person #who feels they know the turn of the earth and such #also churches r so beautiful #or might start going to temple #been a hot minute since ive done any of that stuff i miss being jewish

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lupine-publishers-rrhoaj · 4 years

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Lupinepublishers|arly Decompressive Craniectomy for Post- Thrombolysis Symptomatic Intracranial Haemorrhage

Key Message

Intravenous thrombolysis for acute ischemic stroke can be complicated by intracranial haemorrhage. Early decompressive craniectomy in such patients can be life saving but is associated with high risk of peri operative bleeding. We managed such a patient with decompressive craniectomy within 24hrs of thrombolysis by correcting coagulation with the help of thromboelastograhpy.

Keywords: Decompressive craniectomy; Intravenous thrombolysis; Symptomatic intracranial haemorrhage; Thromboelastography

Introduction

Acute ischemic stroke is one of the leading causes of death and permanent disability in the world. Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) has been the recommended treatment modality in acute ischemic stroke [1]. but the most dreadful complication of thrombolysis is intracerebral haemorrhage in about 7% cases. The clinicians are faced with difficult decision of how to best treat these patients as there are no evidence based guidelines regarding the management of such complications. The American Heart Association has suggested only empirical therapies to replace clotting factors and platelets to reverse coagulopathy [2]. Decompressive craniectomy (DC) is a life-saving procedure for malignant middle cerebral artery stroke associated with cerebral oedema, enough to cause herniation and death [3]. The decision of decompressive craniectomy following intracerebral haemorrhage after intravenous thrombolysis is not without the risk of peri operative haemorrhage. We report the first case where decompressive surgery was uneventfully performed as a life-saving procedure within 24hours of developing symptomatic intracerebral haemorrhage after intravenous thrombolysis. The timing for decompressive craniectomy was guided by thromboelastography (TEG).

Case report

A 63-year old hypertensive, diabetic man presented with left hemiplegia within 140 minutes of onset. On examination, he was alert, GCS 15, left hemiplegia, right gaze palsy and dysarthria, NIHSS (National Institute of Health Stroke Scale) of 17. Magnetic resonance imaging of the brain revealed infarct in the superior division of right middle cerebral artery (MCA) (Figure 1a). His blood biochemistry was unremarkable (Hb-13.8, Plt-145, PT-12.2, and RBS-174). After written consent, thrombolysis was started at 22:10hrs on 11.1.2015 with rt-PA, 5.8mg as bolus followed by 52.7mg infusion over one hour. At 5:30hrs on 12.1.2015, he had upper gastrointestinal bleed followed by impairment in consciousness and his NIHSS score increased to 28. Immediate repeat CT scan of the brain revealed extensive infarction of MCA with haemorrhage in the infarct, extensive oedema and midline shift with uncal herniation (Figure 1b). As he had been recently thrombolysed, his repeat coagulation profile was performed (Hb-10.4, Plt-160, PT-15.2, APTT-27.8, FDP- 256mg/dL) including thromboelastography which was classical of fibrinolysis. Eight units of cryoprecipitate and four units of fresh frozen plasma were transfused in the next six hours and repeat thromboelastography was normal. Then the decision was to proceed with decompressive craniectomy (15:30hr on 12.1.15). A bone window of 12cm in the antero posterior direction in the fronto parieto temporal region was created and duroplasty was performed. The procedure was uneventful. He did not receive any blood products in the peri operative period. Brain CT scan was again performed on the following day and it showed resolution of midline shift with no new hematoma (Figure 1c). He was managed in the intensive care unit with gradual weaning of sedation and ventilation. He was discharged in the sixth week on tracheotomy and NIHSS score of 12. Three months later he was admitted for cranioplasty (Figure 1d) and tracheostomy closure with Mrs Score of 3 (Figure 2a & 2b).

Figure 1: (a) Magnetic resonance imaging of the brain (diffusion weighted image) done at presentation shows acute infarction of the right superior middle cerebral artery. (b) Non contrast CT of the brain done 8 hours after thrombolysis showed haemorrhage in the infarct resulting in mid line shift and mass effect. (c) Non Contrast CT of the brain done on the next day after decompressive craniectomy and hematoma evacuation revealed no new bleed and resolving mass effect.(d) Non Contrast CT of the brain following cranioplasty.

Figure 2: (a) Thromboelastograph trace obtained after 8hr of thrombolysis with R-1.7min, α-66.80, MA-19.6mm, LY30-97.4%, EPL%-100%. These features are characteristic features of fibrinolysis with normal R time, decreased maximum amplitude (MA), raised LY30 (percentage decrease in maximum amplitude or lysis after 30 minutes) and raised EPL. EPL represents the computer prediction of 30mins clot lysis based on interrogation of actual rate of diminution of the trace commencing 30sec post MA with a normal value of <15%. It is the earliest indicator of abnormal lysis. (b) Thromboelastographic trace obtained after infusion of cryoprecipitate and fresh frozen plasma with R-6min, K-1.5min, α-67.50, MA-49.6mm, LY30-0%, EPL%-0%.

Discussion

Thrombolysis remains the treatment of choice in acute ischemic stroke but with increased risk of symptomatic intracranial haemorrhage (ICH).The mortality in these patients is reported to be as high as 45% [4]. There are a few case reports in literature that state DC might be beneficial in the context of post IVT in patients with refractory cerebral oedema [5]. But the most important void is the optimal time to perform DC following thrombolysis. To the best of our knowledge there is only one prior case report where decompressive craniectomy was performed for intracranial haemorrhage following unsuccessful IVT after 48 hour of thrombolysis [6]. Here we report the index case where symptomatic intracranial haemorrhage followed thrombolysis, and was managed by DC and hematoma evacuation within 24 hours of IVT. This early life saving surgery was possible only after rapid correction of coagulation profile with the help of thromboelastography. As, a large series is difficult to be conducted in such cases, it is of interest to report small experiences as ours where the clinical dilemma of performing a surgery following thrombolysis with rt-PA was guided by thromboelastography.

Recombinant t-PA is an exogenous stimulator of the fibrinolytic system that enhances local fibrinolysis by converting plasminogen to plasmin. Our concern was the increased risk of peri operative haemorrhage associated with high mortality due to the persistent effect of TPA. With regard to the pharmacokinetics, half-life of rt- PA is <5 min, with clearance rate of 380-570mL/min [7]. Hence, 80% of rt-PA is cleared from the plasma within 10 minutes of administration. Despite short half-life of rt-PA fibrinolytic effects peak at 4hours and can persist up to 24-48hours [7]. The clinical dilemma in such a scenario was to wait for the disappearance of the fibrinolytic effects to avoid peri operative bleeding at the cost of outweighing the benefits of early DC in reducing the raised ICP. The other option was to efficiently detect and correct the coagulation abnormality by transfusing specific blood products to minimize the risk of bleeding. We had the benefit of thromboelastography at our institute to guide.com with the correction of the deranged coagulation profile before proceeding for DC. S Takeuchi et al. retrospectively reviewed 20 patients who underwent DC for malignant hemispheric infarction after IV TPA administration, with another 20 patients undergoing DC without prior IV TPA administration [8]. They observed intracranial bleeding or worsening of pre existing ICH in two patients (10%) in each group, but tPA was not thought to be contributory to the hemorrhagic events because of the long intervals between the IV tPA and DC(185 and 136h, respectively). However, fibrinolytic markers, such as fibrinogen or fibrin degradation products were unfortunately not measured in the above series.

Thrombelastography or TEG measures the physical properties of the clot via a pin suspended in a cup from a torsion wire connected with a mechanical-electrical transducer. TEG is different from other coagulation tests as it provides global information on the dynamics of clot development, stabilization and dissolution [9]. It assesses both thrombosis and fibrinolysis. Its role is established in cardiac and liver transplant surgery and is being increasingly explored to study role of fibrinolysis in early trauma coagulopathy [10]. Although routinely tested coagulation parameters (BT, CT, PTI, and APTT) were also normal in our case but TEG was characteristic of enhanced fibrinolysis. Hence, we transfused cryoprecipitate and fresh frozen plasma after which the TEG was normal, and we could proceed with surgery.

Conclusion

Decompressive hemicraniectomy with hematoma evacuation following thrombolysis represents an aggressive life saving treatment approach, especially for the patients who develop hemorrhagic complications of intravenous thrombolysis. TEG is one modality which can guide the reversal of deranged coagulation parameter so that major surgery can be undertaken with minimal risk. The decision to proceed with major surgical intervention requires a competent multi disciplinary team as well as an open discussion with relatives as DC may preserve both life and functional ability in well selected patients. More research is needed in this field to elucidate the potential for both modalities in appropriate patients.

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