(1_3) Neurology in 1 week Flashcards
Types of Stroke
“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”
Neurology Overview Map
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CCS: Stroke
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
What is TIA?
1) Transient ischemic attack.
2) last <24 hours; it can never be hemorrhagic
What is stroke?
1) >24h with permanent deficit
2) 80% is ischemic (emboli vs thrombosis) and 20% is hemorrhagic
CCS: Transient Ischemic Attack
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
Lab Tests to Consider for CCS cases
Lab Tests to Consider for CCS cases
*CBC, BMP, and UA is warranted for all patients
*BOUPI
- Blood: CBC, BMP, LFT, Lipid Panel, PT/INR, PTT, Cultures (for fevers/infection); Type and Screen, Crossmatch
- Other: EKG, PEFR, Pulse Ox
- Urine: UA/UC, Urine Tox
- Pregnancy: urine BHCG
- Imaging
What are the main features of anterior cerebral artery stroke?
“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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What are the main features of middle cerebral artery stroke?
“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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What are the main features of posterior cerebral artery stroke?
“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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What are the main features of vertebrobasilar artery system stroke?
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
What are the main features of lacunar infarct?
“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”
What are the differences between MRI and CT in stroke?
1) MRI >95% accurate in 24h,
2) CT >95% accurate in 3-5 days
What is the window period for tPA in stroke?
3 hours
What are the contraindications for tPA?
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
Types of Neuro-Vascular diseases
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
What test should be ordered for stroke?
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
Describe Antiphospholipid syndrome
- 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)
Tx for Antiphospholipid syndrome
- 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
What is the further management of stroke?
Control HTN, Diabetes and HLD
- Hypertension (<140/90 in DM)
- Diabetes same as general population
- Hyperlipidemia LDL<100 Add statin in nonhemorhhagic stroke
The younger the patient, the more likely the cause of the stroke is due to what?
vasculitis or hypercoagulable state.
When is endartrectomy indicated?
Systolic less than 130,
diastolic less than 80,
LDL less than 100, tight glycemic control
How do you treat status epilepticus?
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.
Neurology Map
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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.
What further test do you order for seizure?
EEG
Can potassium disorders cause seizure?
Never
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
Types of Seizures
“Seizures
1) Partial (2)
- Simple
- Complex
2) Generalized (4)
- Absence (““petit mal)””
- Tonic-Clinic (grand-mal)
- Atonic
- Myoclonic
3) Status Epilepticus”
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
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.
What are the first line antiepileptics?
1) Phenytoin
2) Valproate
3) Levetriacetam (Keppra)
4) Carbamazepine
What are the second line antiepileptics?
Gabapentin or phenobarbital
What is the best treatment for absence seizure?
Ethosuximide
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
Types of Neuro-degenerative disorders
Degenerative disorders (3)
1) ALS
2) MS
3) Parkinson’s
What cognitive changes do you see in Parkinson’s disease?
Normal cognition and memory
What is the treatment for mild Parkinson’s?
1) <60 anticholinergics e.g. benztropine (Cogentin) or trihexylphenidate
2) >60 amantadine
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
What is the treatment for severe Parkinson’s?
1) Bromocriptine
2) pramipaxole/cabergoline/ropinerole
3) selegiline
How do you treat tremor?
Parkinson’s or resting tremor:Amantadine
Intention tremor: treat the underlying disease
Essential tremor: Propranolol
Types of tremors
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Neurology Map
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How do you Dx multiple sclerosis?
“1) VDRL, B12
2) TSH
3) CT scan
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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
Multiple sclerosis ddx
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CCS Case Presentation
CCS Case Presentation
After noting chief complaint assess the following:
- Setting (Office, ED, Ward, ICU)
- Demographics: Age, Ethnicity, Gender
- Abnormal Vitals: Is patient stable or unstable?
- Change location as appropriate
- IVF/access for hypotension
- Pulse ox and Oxygen for dyspnea/tachypnea - DM?
- Allergies
- Social Hx: Drugs, ETOH, Tobacco
CCS: Dementia DDX
“alzheimers
B12 deficiency
hypothyroid
depression
increased ICP
mass
chronic subdural
neurosyphilis
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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
