(1_3) Neurology in 1 week Flashcards

1
Q

Types of Stroke

A

“Types of Stroke

Stroke ““H-I-T”” you!

H-Hemorrhagic
I-Ischemic
T-TIA (Transient Ischemia Attack)

T.I.A (Transient Ischemic attack)

Patients often describe it as a shade being pulled over their eyes: S-H-A-D-E-D

S-Sensory loss; TIA may herald a stroke
H-Hypertension, Hyperlipidemia
A-Amaurosis fugax (transient monocular blindness)
D-DDx: seizures, neoplasms, migraine, vertigo
E-Extrinsic factor is monitored for warfarin administration; E-Endarterectomy
D-Diabetes”

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2
Q

Neurology Overview Map

A


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3
Q

CCS: Stroke

A

Imaging:

  • CT w/o contrast (MRI/MRA later if etiology not known)
  • EKG (Holter monitor if the EKG is normal: Warfarin, dabigatran, or rivaroxaban for atrial fibrillation)
  • TEE: Anticoagulation for clots, possible surgery for valve vegetations
  • Carotid Dopplers/Duplex: Endarterectomy for stenosis > 70%, but not if it is 100%

Labs:
glucose stat, Hb-A1C, fasting lipids
CBC, BMP
PT/PTT/INR

if <50 y/o
-ESR, VDRL/RPR ANA/DS-DNA Protein C, protein S, factor V Leiden mutation, antiphospholipid syndromes

Control HTN (if pt has DM <140/90), DM, HLD (LDL<100, statin for nonhemorrhagic stroke)

TX:
Ischemic: tPA (if w/in 3 hr), ASA, Statin
Hemohhragic: ASA, NPO, elevate the head of the bed, Tx incr ICP (hyperventilation, mannitol, steroids) ICU admit, cardiac/BP monitor, BP:

Hemorrhagic: keep BP <160
Ischemic getting TPA: BP < 185/110
Ischemic no TPA: BP > 160/80
Acute ischemic: ASA, if already on ASA add dipyridamole or change to clopidogrel

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4
Q

What is TIA?

A

1) Transient ischemic attack.
2) last <24 hours; it can never be hemorrhagic

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5
Q

What is stroke?

A

1) >24h with permanent deficit
2) 80% is ischemic (emboli vs thrombosis) and 20% is hemorrhagic

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6
Q

CCS: Transient Ischemic Attack

A

Physical Exam:
General, Skin, HEENT, Chest, Heart, Abdomen, Extremities, Neuro

Orders:
Imaging:
Head CT, ECG, Carotid Doppler
Neuro checks every 2 hours

Labs:
CBC, BMP, PT/PTT, Troponin, Lipid profile

Clock Advance clock to results.
Location Change to the inpatient unit.

Orders
Meds: Aspirin/Clopidogrel/Dipyridamole
Procedure: Carotid angiography

Clock Advance to results.

Orders
Carotid endarterectomy (if >70% stenosis), Consult neurology
Consult vascular surgery

Clock Advance to additional results and case end.

End Orders None

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7
Q

Lab Tests to Consider for CCS cases

A

Lab Tests to Consider for CCS cases

*CBC, BMP, and UA is warranted for all patients

*BOUPI

  1. Blood: CBC, BMP, LFT, Lipid Panel, PT/INR, PTT, Cultures (for fevers/infection); Type and Screen, Crossmatch
  2. Other: EKG, PEFR, Pulse Ox
  3. Urine: UA/UC, Urine Tox
  4. Pregnancy: urine BHCG
  5. Imaging
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8
Q

What are the main features of anterior cerebral artery stroke?

A

“1) profound lower extremity weakness (upper is mild)

2) urinary incontinence
3) Personality changes

ACA=(LIP)

Anterior cerebral artery (A*C*A) occlusion:

*C*-Contralateral Crural (leg) monoplegia
*C*-Crest of Cerebral hemispheres and medial hemispheric walls represent the leg area of the motor strip


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9
Q

What are the main features of middle cerebral artery stroke?

A

“1) Aphasia, Apraxia (neglect), profound Arm impairment
2) Eyes deviate towards the lesion

MCA= AE

Middle cerebral artery (MCA) occlusion: ““Difficulty with A-B-Cs in M-C-A””

A-Apraxia
B-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia)
C-Contralateral Clumsiness of arm, face. – Leg is somewhat spared.

M-Memorization difficulties
C-Calculation difficulties
A-Aphasia with language-dominant hemispheral involvement.


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10
Q

What are the main features of posterior cerebral artery stroke?

A

“1) Prosopagnosia (can’t recognize faces)
2) Contralateral homonymous hemianopia with macular sparing

PCA=PC

Posterior cerebral artery (PCA) occlusion: P-O-S-T

P-Proximal fling movements
O-Occipital lobe infarction results in contralateral homonymous hemianopsia which may be complete
S-Speech and Spelling maintained, but unable to read fluently
T-Thalamic syndrome


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11
Q

What are the main features of vertebrobasilar artery system stroke?

A

Vertical nystagmus, Vertigo, vomiting,
Drop attacks, dysarthria
Walking problems (ataxia)
Sensory changes of the face

VBAS=VDAS

A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D

  • Dizziness
  • Diplopia
  • Dysarthria
  • Dysphagia
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12
Q

What are the main features of lacunar infarct?

A

“Sensory deficit and hemiparesis
Absence of cortical deficit
Ataxia
Basal ganglia signs e.g. Parkinsonism

Lacunar infarct=SAAB

Lacunar infarct: ““Lacunar”” from the Latin for G-A-P or- D-I-S-P-A-R-I-T-Y

G-deep Gray matter: basal ganglia
A-Atherosclerosis
P-hyPertension

D-Dysarthria and a contralateral clumsy hand or arm due to infarction in the base of the pons or in the genu
of the internal capsule. (20%)
I-Internal Capsule: Lacunae in the posterior limb of the Internal capsule may cause pure motor hemiplegia
involving the face, arm, leg, foot. (60%)
S-Subcortical, capsular, or thalamic lacunae
P-Pontine lesions
A-Ataxic hemiparesis due to an infarct in the base of the pons
R-Rare: Lacunae in the anterior limb of the Internal capsule may cause severe dysarthria with facial weakness.
I-Ipsilateral ataxia (arm/leg) with leg weakness: Pontine lesion (rare)
T-Thalamus: Lacunae in the Thalamus may cause pure sensory stroke (10%)
y-V-Ventrolateral Thalamic lacunae”

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13
Q

What are the differences between MRI and CT in stroke?

A

1) MRI >95% accurate in 24h,
2) CT >95% accurate in 3-5 days

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14
Q

What is the window period for tPA in stroke?

A

3 hours

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15
Q

What are the contraindications for tPA?

A

1)
Previous hemorrhagic stroke
Stroke within one year
Bleeding disorders
Suspicious aortic dissection

2)
3 weeks: Traumatic CPR in the last 3 weeks
6 weeks: surgery or active bleeding in the last 6 weeks
6 months: cerebral trauma in the last 6 months

3)
cerebral mass or neoplasm

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16
Q

Types of Neuro-Vascular diseases

A

Vascular (3)
1) Stroke (Ischemic VS Hemorrhagic) & TIA

2) Arterial lesions
- ACA, MCA, PCA
- Lacunar infarct, Vertebrobasilar artery syndrome
- Ophthalmic artery (Amarousis Fugax)

3) Head trauma & Intracranial Hemorrhage
- Concussion VS Contusion
- Hematoma (Epidural VS Subdural)
- Stress Ulcer Prophylaxis
- Subarachnoid hemorrhage

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17
Q

What test should be ordered for stroke?

A

1) EKG, Holter’s monitor if EKG is normal
2) Echocardiography
3) Carotid artery Doppler

4) if <50 do:
- ESR
- VDRL, RPR
- ANA, anti- DS DNA, antiphospholipid antibody
- Protein C,S, factor V Leiden

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18
Q

Describe Antiphospholipid syndrome

A
  • Autoimmune, hypercoagulable state caused by antiphospholipid antibodies.
  • APS provokes blood clots (thrombosis) in both arteries and veins as well as pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, and severe preeclampsia.
  • The diagnostic criteria require one clinical event, i.e. thrombosis or pregnancy complication, and two antibody blood tests spaced at least three months apart that confirm the presence of either lupus anticoagulant, or anti-β2-glycoprotein-I (β2-glycoprotein-I antibodies are a subset of anti-cardiolipin Ab)
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19
Q

Tx for Antiphospholipid syndrome

A
  • treated by giving aspirin to inhibit platelet activation, and/or warfarin as an anticoagulant.
  • The goal of the prophylactic treatment with warfarin is to maintain the patient’s INR between 2.0 and 3.0. It is not usually done in patients who have had no thrombotic symptoms.
  • Anticoagulation appears to prevent miscarriage in pregnant women. In pregnancy, low molecular weight heparin and low-dose aspirin are used instead of warfarin because of warfarin’s teratogenicity. Women with recurrent miscarriage are often advised to take aspirin and to start low molecular weight heparin treatment after missing a menstrual cycle. In refractory cases plasmapheresis may be used
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20
Q

What is the further management of stroke?

A

Control HTN, Diabetes and HLD

  • Hypertension (<140/90 in DM)
  • Diabetes same as general population
  • Hyperlipidemia LDL<100 Add statin in nonhemorhhagic stroke
21
Q

The younger the patient, the more likely the cause of the stroke is due to what?

A

vasculitis or hypercoagulable state.

22
Q

When is endartrectomy indicated?

A

Systolic less than 130,
diastolic less than 80,
LDL less than 100, tight glycemic control

23
Q

How do you treat status epilepticus?

A

1) Lorazepam (Ativan)
2) after 10-20 minutes fosphenytoin
3) after 10-20 minutes phenobarbital
4) after 10-20 minutes add general anesthesia, such as pentobarbital, thiopental, midazolam, or propofol.

24
Q

Neurology Map

25
What are the initial diagnostic orders for seizure?
1) Electrolytes: Sodium, calcium, glucose, oxygen, creatinine, and magnesium levels 2) Chemistry 3) if CT normal do MRI 4) Urine toxicology 5) Liver and renal function (Both liver failure and renal failure cause seizures.) 6. Neurology consultation should be ordered in any patient with a seizure after initial testing is done.
26
What further test do you order for seizure?
EEG
27
Can potassium disorders cause seizure?
Never
28
When do you treat even one seizure as epilepsy?
1) Strong family history 2) EEG abnormal 3) Status epilepticus requiring benzodiazepines for treatment 4) Non-correctable precipitating cause, e.g., brain tumor
29
Types of Seizures
"Seizures 1) Partial (2) - Simple - Complex 2) Generalized (4) - Absence (""petit mal)"" - Tonic-Clinic (grand-mal) - Atonic - Myoclonic 3) Status Epilepticus"
30
CCS: Syncope VS Seizure event work-up
1) CBC, CMP, Mg, phos 2) ABG 3) serum prolactin 4) ECG 5) EEG 6) CT head, eventually MRI 7) UA and urine toxicology
31
Work-up for Syncope
Diagnostic Testing On the initial screen, order the following: Cardiac and neurological examination EKG Chemistries (glucose) Oximeter CBC Cardiac enzymes (CK-MB, troponin) CCS Tip: Treat special circumstances as follows: - If a murmur is present, order an echocardiogram. - If the neurological exam is focal or there is a history of head trauma due to syncope, order head CT. - If a headache is described, order head CT. - If a seizure is described or suspected, order head CT and EEG. 
32
What are the first line antiepileptics?
1) Phenytoin 2) Valproate 3) Levetriacetam (Keppra) 4) Carbamazepine
33
What are the second line antiepileptics?
Gabapentin or phenobarbital
34
What is the best treatment for absence seizure?
Ethosuximide
35
When do you use lamotrigine and what is the most dangerous side effect?
Equal to first line but be careful of Steven Johnson's syndrome
36
Types of Neuro-degenerative disorders
Degenerative disorders (3) 1) ALS 2) MS 3) Parkinson's
37
What cognitive changes do you see in Parkinson's disease?
Normal cognition and memory
38
What is the treatment for mild Parkinson's?
1) \<60 anticholinergics e.g. benztropine (Cogentin) or trihexylphenidate 2) \>60 amantadine
39
What is the treatment for moderate Parkinson's?
1) L-DOPA plus carbidopa 2) selegiline and one of dopamine receptor agonists: pramipaxole, cabergoline or ropinerole
40
What is the treatment for severe Parkinson's?
1) Bromocriptine 2) pramipaxole/cabergoline/ropinerole 3) selegiline
41
How do you treat tremor?
Parkinson's or resting tremor:Amantadine Intention tremor: treat the underlying disease Essential tremor: Propranolol
42
Types of tremors
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43
Neurology Map
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44
How do you Dx multiple sclerosis?
"1) VDRL, B12 2) TSH 3) CT scan ![]() "
45
Multiple Sclerosis CCS
Exam Complete Orders Brain MRI, CSF immunoelectrophoresis, Visual evoked potentials, CBC, BMP, TSH, LFT, vitamin B12 serum, ANA serum Clock Advance clock to reschedule patient when all results are reported. Orders Interferon, Counsel patient, Reassure patient, Consult neurology Clock Advance to additional patient updates and case end. End Orders CBC, LFT in 1 month
46
Multiple sclerosis ddx
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47
CCS Case Presentation
CCS Case Presentation After noting chief complaint assess the following: 1. Setting (Office, ED, Ward, ICU) 2. Demographics: Age, Ethnicity, Gender 3. Abnormal Vitals: Is patient stable or unstable? - Change location as appropriate - IVF/access for hypotension - Pulse ox and Oxygen for dyspnea/tachypnea 4. DM? 5. Allergies 6. Social Hx: Drugs, ETOH, Tobacco
48
CCS: Dementia DDX
"alzheimers B12 deficiency hypothyroid depression increased ICP mass chronic subdural neurosyphilis ![]() "
49
CCS: Dementia workup
cbc with diff cmp tsh, t4 b12 folic acid ct head vdrl/rpr MMSE, neuropsych testing, CBC, BMP, B12, TSH, VDRL, HIV, UTOX, CT/MRI brain