9. Neurology Flashcards
Descrire diagnosis criterias : Cluster headaches (aka suicide headaches) (6)
At least 5 headaches with the following characteristics :
* severe unilat orbital, supraorbital +/- temporal pain lasting 15-180 mins untreated
* Attach associated with >/= 1 of the following autonomic sx (usually unilat and ipsilat) : conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis, ptosis, eyelid edema, agitation (unable to lie down)
* Frequency from 8/d to q2d
* r/o organic cause
Unmistakble circadian + circannual periodicity (pts suffer daily/nightly over weeks/months) : episodic vs chronic
50% of pts will have migraine like sx (photophobia, phonophobia, no/vo)
Describe episodic and chronic cluster headaches
- Episodic (85-90%) : headaches occur in series lasting weeks to months (6-12 wks) w/remission lasting months (at least 3 months) to years. Most attacks are usually in the spring or fall
- Chronic (10-15%): attacks lasting 21 yr or w/ remission $1 mo (definitely <3 months)
Describe physical : Cluster headache (4)
- Vitals (BP + Hr)
- Neuro exam
- Meningeal irritation
- Carotid arteries, sinus, scalp arteries, neck muscles
Describe investigations : Cluster headache (3)
- Cluster headaches are a primary headache disorder so typically do NOT require imaging / investigations
- MRI if any red flags, atypical symptoms, atypical response to treatment
- Also consider ordering TSH, prolaclin, pituitary function screening,
Name redflags : Cluster headache (6)
SNOOPS
* Systemic - fever, HTN, myalgias, |wt, scaip tenderness
* Neuro symptoms - confusion, LOC, papilledema, visual field defect, CN asymmetry, extremity drift / weakness, reflex asymmetry, seizure
* Onset - sudden / abrupt / split second
* Older patients - new onset or progressive >50y/0
* Previous Hx - New / Different, Change in severity, progressing
* Secondary risk factors - HIV, CA, Precipitated by Valsalva maneuver (cough, sneeze)
Name triggers : Cluster headache (4)
- Alcohol
- Food containing nitrates
- Nitroglycerin
- Strong odours such as petroleum, paint and nail varnish
Describe ACUTE management : Cluster headache (8)
- Inhaled 02 through non-breathing mask at beginning of attack. (A) 100% at a rate of 6-12 L / min x15 min
Also consider one of the following medications
* Sumatriptan 6mg subcut (A)
* zolmitriptan 5mg intranasally (A)
* zolmitriptan 10mg po (B)
* Sumatriptan 20mg intranasal (B)
* Lidocaine 4% - 10% nasal (C)
* Octreotide (C)
Start prophylactic medications + Bridging medication
Are triptans effective before culester headaches?
Nol effective when used before attack (prophylactic)
Name C-I : Triptans (2)
cardio disorders, cerebrovascular disorders
Describe bridging treatment : Cluster headaches (3)
Started simultaneously with maintenance therapy (assists until maintenance can suppress h/a - taper once remission occurs), respecially if >/= 2 attacks / day
* unilateral greater occipital nerve block 80mg methy/prednisolone w/
2mL of 2% lidocaine (preferred over steroid to I cumulative effect)
* Corticosteroids - prednisone 60mg x5 d then I by 10mg q2d unfil discontinued, OR methylprednisolone 100mg po then taper
* Ergotamine
Describe prophylaxis/maintenance medication : Cluster headache (8)
Windraw treatment as soon as bout resolves (4w after last episode), and restart at therapeutic dose when new bout occurs.
- Verapamil initial dose 80mg TID (A) (20% will get an arrhythmia, so get a baseline ECG, repeat 10d after dose adjustments and then q6mo while
stable).
- Verapamil initial dose 80mg TID (A) (20% will get an arrhythmia, so get a baseline ECG, repeat 10d after dose adjustments and then q6mo while
- Lithium 300mg00 then increase by 300mg qweeky (B) - more commonly used in chronic than episodic. Monitor trough levels q1-2mo
- Topiramate 100mg/d(B) (contraindication: nephrolithiasis)
- Ergotamine (B)
- Valproic Acid 5-20mg/kg (C)
- 3 Melatonin 10mg QHS (C)
- Baclofen 15-30mg (C)
- Neuromodulators
avoid medication overuse (ex. NSAID ≤ 15d/mo, opioid ≤ 10d/mo)
Any concussion, name clinical signs immediately following the injury include any below (5)
- Loss or I consciousness less than 30 min
- Lack of memory for events immediately before or after injury <24 hrs
- alteration in mental state at the time of the injury (ex. slow thinking)
- Physical symptoms (ex. vestibular, headache, weakness, vision)
- NOTE: No evidence of intracranial lesion on imaging (if present suggestive of more severe brain injury)
Describe history and physical of concussion
History + Physical
* Headache
* Loss of consciousness
* Nausea / Vomiting
* Amnesia
* Dizziness
* Loss of balance/poor coordination
* Visual disturbances
* Tinnitus
* Photophobia
* Vertigo
* Phonophobia
* Decreased playing ability
* Examine head / scalp for swelling / ecchymosis / tenderness / numbness / step offs
* Look for battle sign / racoon eyes / rhinorrhea / otorrhea/hemotympanum
* Examine cervical spine for ROM + tenderness
* Examine TMJ for ROM, tenderness, dislocation
* Full neuro examine (cranial, motor, sensory, coordination)
Emotional / behavioural
* Irritability
* Emotional lability
* Sadness / Depression
* Anxiety
* Inappropriate emotions
* Fatigue / Lethargy / Drowsiness
Cognitive
* Slowed reaction times
* Difficulty concentrating
* Difficulty remembering
* Confusion
* Feeling in a fog
* Feeling dazed
Sleep
* Drowsiness
* Trouble falling asleep
* Sleeping more than usual
* Sleeping less than usual
Name complications : Concussion (3)
- Poor attention, concentration
- ⬇️ speed processing, impaired memory and learning
- Diffuse cerebral swelling / malignant brain edema syndrome
In concussions, consider what if the child/adolescent plays high-risk sports?
Consider baseline neuro-cognitive testing if the child / adolescent plays high-risk sport (not as a general rule) (B)
For concussion, describe Immediate Management (at the time / location of injury) (3)
- ABC, c-spine protocol
- Remove individual from game / activity, NEVER return to game if suspected concussion (⬇️response, ⬇️ attention causes ⬆️ risk) “if in doubt, sit them out. Do NOT leave alone. Do serial monitoring for a few hrs
- Assessment by medical professional (neuro + mental status). After addressing first aid issues, use SCAT5 as sideline assessment tool
Key Features of mild traumatic brain injury (mTBI) assessment in ER or doctor’s office
Medical History
* symptoms
* mechanism
* severity / duration of altered level of consciousness, co-occurring injuries
* PMHx
* psychosocial
Exam
* mental status
* cognition
* physical status
* cranial nerves
* extremit tone / strength / reflexes, gait + balance, coordination, scalp / skull for fracture
* TMJ
Clinical status including improvements / deterioration (delayed presentation should be considered as failure to clinically improve during observation - consider symptoms and have a low threshold to image)
Determine need for urgent neuroimaging
* Most uncomplicated mTBI clinical symptoms start to improve by 2 hours post-injury and are returning to normal by 4hrs post-injury
* Clinical symptoms that are deteriorating or not improving by 4 hours post-injury on serial observation (Ex. alertness / behaviour/ cognition, PTA, vomiting, severe headache) are very concerning
In concussions, name criterias for discharge home from ER
Normal mental status w/ clinically improving post-concussive symptoms after observation until at least 4 hrs post-injury
No clinical risk factors indicating CT or pt has a normal CT
No clinical indicators for prolonged observation such as:
* Clinical deterioration
* Persistent abnormal GCS or focal neurological deficit
* Persistent abnormal mental status
* Vomiting / severe headache
* Presence of known coagulopathy
* Persistent drug / alcohol intoxication
* Multi-system injury
* Presence of concurrent medical problems
* Age >65
For concussion, name discharge considerations + planning (6)
- if symptomatic, NO driving for 24hrs. Even asymptomatic pts may exhibit poorer vehicle control for 48 hrs
- Needs to be with a responsible person to take pt home and observe
- Needs to be able to return if pt deteriorates
- Summary prepared for primary care physician
- Written and verbal advice covering (1) s+s of deterioration, (2) lifestyle
advice to assist recovery (3) typical post-concussive symptoms - Follow-up with primary care physician if they are not back to normal within 2 days
Describe investigations for concussions (6)
- plain skull ×-ray only recommended if no indication for CT but concern for skill fracture (not routinely done)
- CT Scan (NOT MRI) (note 1 lifetime risk of cancer w/ radiation exposure)
- PEDS: PECARN (has been validated, more sensitive than CATCH has not been compared to CATCH2)
- PEDS = CATCH2 (Canadian study) sensitivity: 100% for neurosurgical intervention & 99.5% for brain injury
- ADULTS = Canadian CT Head Rules
- Neuropsychological testing (best if pre-concussion baseline at the beginning of the sports season) if symptoms >4w
In investigations for concussions in peds, describe PECARN (4)
Age < 2 y/o (sensitivity 100%)
* GCS ≤ 14 or acute encephalopathy / altered mental status (agitation, somnolence, slow response) or palpable skull # > CT
* (1) Occipital / parietal / temporal skull hematoma or (2) history of
LOC 25 sec or (3) severe mechanism or (4) not acting normally per
parent > observation vs. CT based on experience, worsening parental preference
Age ≥ 2 yo (sensitivity 99%)
* GCS ≤ 14 or acute encephalopathy / altered mental status (agitation, somnolence, slow response) or palpable skull # > CI
* (1) History of LOC or (2) history of vomiting or (3) severe
mechanism or (4) severe headache > observation vs. CT based
on experience, worsening parental preference
In investigations for concussions in peds, describe CATCH2 (8)
CT head is required for children with minor head injury [in past 24hr,
witnessed LOC / disorientation, definite amnesia, persistent vomiting
(>1 episode) or irritability (<2 y/o) & GCS 13-15] & 21 of these findings
- GCS score <15 2 hours after injury
- Suspected open or depressed skull fracture
- History of worsening headache
- Irritability on exam
- Any sign of basal skull fracture (hemotympanum, racoon eyes, otorrhea, rhinorrhea of cerebrospinal fluid, battle sign)
- Large, boggy hematoma of the scalp
- Dangerous mechanism of injury (ex.MVA, fall from ≥ 3 feet or 5 stairs, fall from bicycle with no helmet)
- 4 ore more episodes of vomiting
Describe : Canadian CT Head Rules
Does NOT apply to: Non-trauma, GCS<13, Age <16, on Coumadin
Minor head injury with any one of the following
High Risk symptoms: (CT for neuro intervention)
* GCS <15 after 2 hours from injury
* Suspected open or depressed skull fracture
* Any sign of basal skull fracture (hemotympanum,racoon eyes, CSF otorrhea/rhinorrhea, Battle’s sign)
* ≥2 episodes of vomiting
* ≥ 65 years of age
Medium Risk Symptoms (CT for brain injury on CT scan)
* Amnesia before impact of ≥ 30 min
* Dangerous mechanism (pedestrian, occupant ejection (MVA, horse,
cycle), fall from elevation > own height or 5 stairs)
Describe general approach/things to consider/observations : Conccusion (8)
- NO driving for 24hrs. Even asymptomatic pts may exhibit poorer vehicle control for 48 hrs
- Supervision (not alone) for 24-48hours
- Monitor for worsening symptoms - severe H/A, persistent vomiting, seizure, abnormal breathing, poor memory, unsteady, I vision
- Do NOT awaken throughout the night but check every 4 hrs
- Use CRT5 to recognize symptoms + SCAT5 to monitor symptoms
- Acute (0-4w) : educate (symptoms), reassure (most recover in 3mo), sub symptom threshold training / return to play/work, nonpharmacologic interventions, stress management techniques, screen for depression /anxiety in the first few weeks. If asymptomatic by the time they seek help but did have symptoms of concussion, presume concussion & counsel / educate appropriately
- Post-Acute (4-12w) : refer to interdisciplinary team if symptomatic
- Persistent (+3mo) : same as post-acute
Descrbe Pharmacotherapy for concussions
- No evidence, but consider acetaminophen or NSAIDs
Descrbe Management of Persistent (>4weeks) symptoms in concussions (6)
- Refer to interdisciplinary TBI treatment clinic (earlier referral if complicated health-related or contextual factors)
- Reassess symptoms / function severity (support system, mental health history, co-occurring conditions, unemployment) and compliance
- begin biweekly re-assessment for worsening / new symptoms
- Encourage supervised exercise and activity as tolerated
- Manage pain, comorbid mental health
- Consider vocational therapy and community integration program
When to return to play/work/school in the first 2 days after concussion? (5)
physical and cognitive rest. Goal is activity as
tolerated that does not cause significant / prolonged symptom exacerbatio.
- 24-48hrs of rest (cognitive and physical) no reading, texting, TV, computer, electronic games, consider no school (see below)
- Insufficient evidence that complete rest beyond 48hr is beneficial to recovery and evidence that complete rest > 48hrs may slow recovery
- After 24-48hr rest, encourage gradual / progressive 1 in activity while no increasing symptoms (do NOT want symptoms to worsen)
- Sub symptom threshold aerobic exercise in 1st w speeds recovery
When to return to play after concussion? (3)
- Typically no high risk activities for 7-10d. Most athletes return in 1-4w
- Follow below approach: If player has NO recurrence of symptoms in 24 hrs (while off meds), they progress to the next level (therefore it takes ~1w to fully rehab once asymptomatic at rest).
- Any worsening of
symptoms, pt rests for 24 hrs then moves back one Level (i.e. if at Level 4 & symptoms worsen / recur, rest for 24hrs then go back to Level 3)
When to return to school after concussion? (3)
- Within 24-48 hr: If asymptomatic: return to school as tolerated (NO tests or consider accommodation). If symptomatic: no school / sports
- 2 days to 2 weeks: if asymptomatic, return to school as tolerated. If symptomatic refrain from school, monitor symptoms, with permission notify disability services that accommodations / reintegration needed
- > 2 weeks: attend school w/ accommodations even if symptomatic. If poor reintegration after 4w, refer for neuropsych assessment and move courses to audit status / review accommodations
When to return to work after concussion? (1)
gradual return to work after 72hrs ‡ accommodation
Describe : Management of Sleep-Wake Disturbance of concussions (3)
50% of patients w/ concussion (usually insomnia). Impacts mood, mental capacities, communication, social / leisure activity, occupation
Management CBT (sleep hygiene, maladaptive habits, autonomic /cognitive arousal, dysfunctional belief / attitude)
* Caution w/ sleep meds if neurological impairment. Can consider Trazodone, mirtazapine, TCA, prazosin, zopiclone. AVOID benzos
* Consider melatonin, magnesium + zinc, acupuncture (all grade C)
Referral: to sleep specialist if concern of sleep-related breathing disorder, seizure, periodic limb movements, narcolepsy
Describe : Management of Post-Traumatic Headache of concussions (7)
- 30-90% of pts w/ concussion
- Post-traumatic headache is a secondary type of headache (i.e. categorize as migraine or tension etc. which are primary types of H/A)
- Physical: neuro + MSK including cervical spine + vestibular exam
- Investigations: brain CT / MRI if neurological s+s suggestive of intracranial pathology, progressive symptoms without cause
- Confirm no analgesic overuse headache (i.e. > 10d per mo of analgesic, narcotic, ergotamine, triptan, diclofenac). Consider 6-8w washout period
- Use headache diary (frequency, duration, location, intensity, associated symptoms, provoking / alleviating factors, treatment)
- Management: LSM (ex. quiet, lie down, cold / hot pack, breathing exercises, sleep, regular meals, hydration, exercise, control caffeine / tobacco / EtOH) & Rx for primary H/A (including prophylaxis)
Describe : Management of Mental Health Disorder of concussions (3)
- Consider impact of isolation, functional limitations, occupation status
- Management: treat the same as mental health disorder without mTBI- consider seizure risk, balance, dizziness, fatigue, H/A prophylaxis
- Some evidence for citalopram, sertraline, venlafaxine, mirtazapine
Describe : Management of Cognitive Difficulties of concussions (3)
- 15-33% experience cognitive symptoms beyond 4 weeks
- Investigations: use focused clinical interview and validated questionnaire (Ex. SCAT5) to assess and track symptoms. Consider referral (ex. neuropsych assessment) if symptoms >4w
- Management: if symptoms persisting, consider work / school accomodation / modification (ex. paced activities, schedules)
Describe : Management of Vestibular Dysfunction of concussions (4)
- Most common BPPV but also post-concussive migraines, autonomic dysregulation, meds
- Investigations: BPPV diagnosed w/ Dix-Hallpike (clear c-spine first)
- Management: canalith / particle repositioning maneuver (ex. Epley maneuver), vestibular rehabilitation
- Referral: refer to specialist before 3 month post-injury
Describe : Management of Fatigue of concussions (4)
- Weariness / tiredness after physical / mental exertion
- 27% have persistent fatigue at 3 months post-injury
- Investigations: hx / px, consider CBC, TSH, lytes
- Management: r/o mood, sleep, metabolic, ⬇️ Na, ⬇️ Ca2+, polypharmacy, med s/e. encourage increasing activity, sleep hygiene, pacing
When to refer for concussions (2)
If pt has 1 ore more moderate / severe in any of the below categories, then refer to
a TBI specialist
Refer to interdisciplinary TB treatment clinic if persistent symptoms
Name DSM V Criteria/history : Dementia - Major Neurocognitive Disorder
Decline from previous level of function in 1 or more cognitive domain (complex attention, learning + memory, language, perceptual-motor, social cognition, executive function [SOAP: sequencing, organizing, abstract, planning]). NOTE this is NOT a decline in alertness / attention (?delirium)
Significant impairment on patient’s life (i.e. IADL, social, occupation)
* Hx: DDx, function, meds, fam hx, questionnaires, sleep hx (?OSA)
* Basic Activities of Daily Living (BADLs) > DEATH (Dressing, Eating, Ambulation, Toileting, Hygiene).
* Instrumental Activities of Daily Living (lADLs) > SHAFT-M (Shopping /social, Housework / hobbies, Accounting, Food prep, Telephone / tools / transportation, managing Medication)
Talk to caregivers about concerns + burn out
* Assess function w/ Pfeffer Functional Activities Questionnaire, or Disability Assessment for Dementia
Describe : Mild Cognitive Impairment (MCI) (3)
- modest cognitive decline that
- doesn’t impact IADLs.
- Affects 10-20% of pts >65 y/o (follow q3-6 mo, 5-15% / yr develop dementia › 2/3 eventually progress)
Describe : Alzheimer’s (AD) (temporal / hippocampus) (4)
- 50%-80%
- gradual onset
- progression, normal neuro exam, initial short-term memory loss
- initial + most prominent deficit = amnestic
Describe : Frontotemporal dementia (4)
- 12%-25%
Behavioural problems (disinhibition, apathy, inertia, perseveration, hyper-orality) - ⬇️executive function
- interpersonal skills with loss of social awareness
Describe : Vascular Dementia (2)
- 10%-20% use VAS-COG, DSM5 or AHA criteria to diagnose
- abrupt, stepwise decline, cardiovascular risks
Describe physical exam : Dementia - Major Neurocognitive Disorder
- Gait: ataxic (cerebellar atrophy), parkinsonian w/ flexed posture, narrow base, slow gait w/ short shuffling steps + diminished arm swing (parkinson’s or Lewy body), hemiplegic (vascular dementia)
- Signs of stroke focal / lateralizing signs (vascular dementia)
- Parkinsonism: resting tremor, bradykinesia, rigidity, gait(LB, Parkinson)
Describe investigations : Dementia - Major Neurocognitive Disorder (4)
- R/O organic -> CBC, TSH, lytes, Cr, Vit B12, Ca2+, Albumin, FBG, lipids
- ECG prior to treatment (avoid AChEl if LBBB, 2nd/3rd degree block, sick sinus syndrome, bradycardia <50)
- MRI (preferred) or non contrast CT Head IF: onset < 2yr, unexpected decline in known dementia, focal / unexplained neurologic symptoms, previous malignancy / trauma / bleeding disorder, use of anticoagulants, unexplained neuro symptom, atypical presentation, S+s normal pressure hydrocephalus, significant vascular RF (Level IV)
- FDG-PET scan if diagnosis is unclear
Describe investigations : Dementia - Major Neurocognitive Disorder (4)
- R/O organic -> CBC, TSH, lytes, Cr, Vit B12, Ca2+, Albumin, FBG, lipids
- ECG prior to treatment (avoid AChEl if LBBB, 2nd/3rd degree block, sick sinus syndrome, bradycardia <50)
- MRI (preferred) or non contrast CT Head IF: onset < 2yr, unexpected decline in known dementia, focal / unexplained neurologic symptoms, previous malignancy / trauma / bleeding disorder, use of anticoagulants, unexplained neuro symptom, atypical presentation, S+s normal pressure hydrocephalus, significant vascular RF (Level IV)
- FDG-PET scan if diagnosis is unclear
Describe Lifestyle considerations : Dementia - Major Neurocognitive Disorder (11)
- Refer to Alzheimer Society (good evidence)
- Discuss advanced care planning (will, power of attorney, directives)
- safety issues ($, driving, stove, smoke detector, wandering, abuse)
- home care services
- keep routine, orient (calendars, family photos), encourage independence, respect space, don’t focus on memory gaps
- healthy diet (Mediterranean diet), smoking cessation
- individualized exercise program (aerobic / resistance / Tai Chi)
- eliminate narcotics, anticholinergics, benzodiazepines
- use blister packs / compliance packs if adherence is a concern
- encourage social interaction + cognitive stimulation
- adequate sleep and personal hygiene
Describe general considerations for pharmacotherapy : Dementia - Major Neurocognitive Disorder (3)
- ECG prior to treatment (avoid AChEl if LBBB, 2nd/3rd degree block, sick sinus syndrome, bradycardia <50)
- No pharmacotherapy for mild cognitive impairment
- Taper & d/c AChEl if & benefit or significant decline despite meds
Describe pharmacotherapy : Alzheimer’s Dementia (5)
- (1) Donepezil (Aricept) : 5 mg OD x 6w, then ⬆️ to 10mg OD qAM (Level 1)
- (1) Rivastigmine (Exelon) : 1.5 mg BID x 2w, ⬆️ by 1.5 mg BID q2w, max 6mg BID
- (1) Galantamine (Reminyl) : 8mg OD x 4w, then ⬆️ to 16mg OD, max 24mg OD
- (2) Consider Memantine (Ebixa) : 5mg OD x 1w then ⬆️ to 5mg BID, ⬆️ by 5mg/d q1w max10mg BID. Give with AChEl (different mechanism)
- aducanumab new medication available in the USA not in Cnd
Describe pharmacotherapy : Frontal Temporal Dementia (3)
- Emphasis on nonpharmacologic
- Can use SSRI for compulsions, agitations, impulsivity
- Consider atypical antipsychotics in severe agitation/aggression
Describe pharmacotherapy : Vascular Dementia (2)
- Manage HTN (BP ≥ 140/90), DM, smoking, lipids, sedentary LSM
- Consider cholinesterase inhibitor & NDMA (memantine) in select pt
Describe : Lewy Bodies / Parkinson’s Dementia (2)
- RCT - Rivastigmine (Exelon) : 1.5mg - 6mg BID
- Avoid neuroleptics (haloperidol, loxapine, risperidone)
Describe : Atypical Depression (dementia) (1)
Trial citalopram (Celexa) not to exceed 40mg/d
Describe pharmacotherapy : Parkinson’s / Cerebrovascular Disease (1)
AChEl is an option (typically rivastigmine)
Describe Severe Agitation and Aggression in dementia (8)
do NOT use Valproic acid
ONLY if severe (in order of efficacy)
* Risperidone
* Aripiprazole
* Olanzapine
* Gabapentin
* Carbamazepine
* Citalopram
* Prazosin
Which patients to refer in dementia? (3)
- Frontotemporal, Lewy Body, Parkinson’s Dementia
- Young patients (<65 y/o)
- Rapid progression (progression to dementia within 12 months of the appearance of first cognitive symptoms)
