Ch 14. Neuro Flashcards
Define Broca’s aphasia, Wernicke’s aphasia (2)
- Broca’s aphasia – inability to find words, speech halting and slow
2. Wernicke’s aphasia – comprehension is impaired (word salad)
Define the cranial nerves (12)
OOO TTAF VGV AH 1. Olfactory – smell 2. Optic – pupils and VA 3. Oculomotor – EOM *Third nerve palsy: down and out 4. Trochlear – EOM – can’t look up and away 5. Trigeminal – V1 (ophthalmic), V2 (maxillary), V3 (mandibular) face sensation 6. Abducens – can’t look out 7. Facial – facial movement 8. Vestibulocochlear - hearing 9. Glossopharyngeal – uvula and gag 10. Vagus – uvula and gag 11. Accessory – trapezius shrug 12. Hypoglossal – tongue movement
Bulbar palsy symptoms (5)
- dysphagia (difficulty in swallowing)
- difficulty in chewing
- Slurred speech
- difficulty in handling secretions
- choking on liquids
- dysphonia (defective use of the voice)
- dysarthria (difficulty in articulating words)
Bulbar palsy refers to a range of different signs and symptoms linked to impairment of function of the cranial nerves IX, X, XI and XII, which occurs due to a lower motor neuron lesion in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem.
Myasthenia gravis Sx (4)
- Cardinal feature is fatigueable weakness (gets worse during the day)
2. Ptosis
3. Diplopia - Bulbar Sx (dysphagia, dysarthria, facial weakness)
- Beware: myasthenic crisis (respiratory weakness)
Cholinergic toxidrome and Tm (8+2)
\: SLUDGE BB 1. Salivation 2. Lacrimation 3. Urination 4. Diarrhea 5. GI (NV) 6. Emesis 7. Bronchorrhea 8. Bronchospasm 9. Bradycardia 10. Tm=Atropine, 2-PAM
HINTS exam (3)
Specific for a central (ex CVA) cause of vertigo. *Performed by neuroopthomolagists, not ED docs.
1. Head impulse – normally, a functional vestibular system will identify head movement and position, and correct eye movement. This fails in peripheral vestibulocochlear nerve pathology.
A positive test (central) will have the head impulse with no corrective saccade.
A negative test (peripheral) will HAVE the corrective saccade.
2. Nystagmus – vertical is bad
3. Test of skew – cover uncover, skew is bad.
What is the dermatome to the: deltoid, arm, forearm, middle finger, small finger, nipple, umbilicus, thigh, knee, foot (10)
1. Deltoid – C4 2. Arm – C5 3. Forearm – C6 4. middle finger – C7 5. small finger – C8 6. Nipple – T4 7. Umbilicus – T10 8. Thigh – L2 9. Knee – L3 10. Foot – L4, L5, S1 (lateral)
Headache red flags (10)
- Thunderclap headache
- Focal neurological sign
- Exertional onset
4. Ataxia
5. History of cancer - Preceding trauma (with vomiting, neuro sign etc)
- On anticoagulants
- Fever/neck stiffness
- Vision change (temporal arteritis or AACG)
- Pregnancy
- Lupus, Vasculitis, Sarcoidosis, Behcet’s disease, HIV, immunocompromised
Clinical features of cluster headache (4)
- Severe
2. Unilateral - Circadian (pattern)
- Ipsilateral symptoms: lacrimation, conjunctival injection, rhinorrhea, ptosis, miosis, sweating
PRES symptoms (4)
Posterior Reversible Encephalopathy Syndrome
1. Headache
2. Visual acuity change
3. Encephalopathy
4. Seizure
5. High BP (HTN)
* Imaging with MRI shows symmetrical vasogenic edema of the occipital area of the brain *
Rx. BP control. Supportive.
Sensitivity of CT for SAH at 6-12 hours? At 24 hours? 1 week? (3)
- At 6-12 hours 98%
2. At 24 hours 90%
3. At 1 week 50%
What finding on LP (CSF analysis) indicates SAH? (1) How long does this take to develop? (1)
- Xanthochromia (yellow appearance of the CSF due to bilirubin breakdown)
2. It takes 12 hours to develop xanthochromia in CSF
What is your BP goal in SAH (1)?
In intracranial hemorrhage (1)?
Which agents can you use (2)?
- In SAH, sBP less than 180
2. In ICH, sBP less than 160 - Labetalol or nicardipine (avoid nitroglycerin/nitroprusside because they increase ICP)
Treatment of SAH that improves patient outcome? (6)
Normoglycemia, normothermia, normo-BP, and no-eating 1. sBP <180 (MAP <140) 2. NPO 3. Head of bed to 30 degrees 4. Treat fever (goal temp <38) 5. Bed rails up 6. Normoglycemia 7. Seizure? Dilantin 1500mg 8. Admit to a stroke unit!
Where do hypertertensive intracranial bleeds occur (4)
- Putamen
- Thalamus
- Pons
- Cerebellum
Your patient is coning. How do you lower ICP? (4)
- Hyperventilate (CO2 to 35)
2. Mannitol (1g/kg) - Hypertonic saline (100mL of 3%)
How do you reverse ICH bleeding on warfarin? Heparin? ASA? Clopidogril? Xa inhibitor (Rivaroxaban, Apixaban, Edoxaban)? (5)
- Warfarin: vitamin K 10mg IV in 100mL NS over 10 minutes, and octaplex. Check INR in 15 minutes and again at 6 hours, redose octaplex if INR >1.5
- Heparin: protamine
- ASA, clopidogril: supportive care.
- Xa inhibitor: Andefanet alfa
What is the circulation to the brain (2)?
- Anterior (internal carotid system) – ACA, MCA, opthalmic
2. Posterior (vertebral system) – vertebral (brainstem), cerebellum, thalamus, occipital and auditory structures
Stroke types (2)
- Ischemic: thrombotic, embolic, hypoperfusion
2. Hemorrhagic: ICH, SAH
Symptoms of an ACA stroke? MCA stroke? Posterior stroke? (3)
- ACA stroke – contralateral sensory and motor to lower extremity
- MCA stroke – contralateral face, arm, leg. Often receptive and expressive aphasia. Gaze preference towards the side of the infarct.
- PCA stroke – ataxia, nystagmus, vertigo, vomiting, and altered LOC
* CT is not very good for posterior/cerebellar strokes. Consider MRI
Early neurosurgical intervention for cerebellar infarction. Cerebellar edema means that they herniate and deteriorate very quickly *
DDx of stroke (example: stroke Sx in a 45 year old male) (5)
- Cervical artery dissection, vertebral artery dissection
- Cardioembolic from mitral valve prolapse, rheumatic heart disease
- Complex migraine
- Hypoglycemia
- Substance abuse (cocaine, meth, heroin)
6. Seizure with Todd’s paralysis - Cerebral venous thrombosis
- Malingering
Symptoms of carotid and vertebral artery dissection? (3)
- Headache
2. Neck pain - Face pain
- Neurological Sx (cranial nerve palsy, VA change, stroke)
- Often have preceding minor neck trauma
*Treatment=consult neuro. Anti-platelets or anticoagulation or stent… nobody really knows!
Goal BP targets in ischemic stroke (2), and which agents can you use (2)
- BP less than 220/120
- BP less than 185/110 if using tPA
- Labetalol 10-20mg IV over 1-2 min. Repeat x1 PRN (beware asthma, COPD)
4. Nicardipine 5mg/hour infusion
tPA inclusion criteria (3) and exclusion criteria (10)
- Diagnosis of ischemic stroke (NIHSS score)
- Onset of symptoms less than 4.5 hours
- Age >18
tPA exclusion criteria: - Hemorrhagic stroke
- Recent intracranial bleeding
- Recent intracranial surgery
4. History of intracranial hemorrhage - Brain mass
- Recent major surgery or GI bleed (2 weeks)
- Platelets less than 100,000
- INR over 1.7
9. Patient anticoagulated (heparin, factor Xa) - Pregnancy
11. Aortic dissection
12. BP greater than 185/110
Dose of tPA: 0.9mg/kg IV, max 90mg. Give 10% over 1 minute, then remainder over 60 minutes.
Role of ASA in stroke? (1)
- Rx ASA within 24-48 hours of stroke onset, but NO ASA within 24 hours of tPA therapy
Definition of TIA (1)
- A transient episode of neurological dysfunction caused by brain ischemia, but without acute infarction. Symptoms typically last less than 1-2 hours.
* ** 10% 90-day stroke risk after a TIA !!! ***
Risk stratification score used in TIA? (4)
ABCD2 score
1. Age > 60
2. BP > 140/90
3. Clinical (speech +1, one-sided weakness +2)
4. Diabetes
5. Duration (<10 mins, 10-60mins, >60mins)
NOTE: Many recommend NOT using this score, and starting anti-platelet and urgent FU on every patient
Treatment of ischemic stroke in a sickle cell patient (1)?
- Exchange transfusion, goal to reduce HGB S less than 30% * Sickle cell is not a contraindication to tPA
Delirium versus dementia (3)
- Delirium acute (days)
- Delirium is fluctuating (normal to abnormal to agitated very quickly)
- Delirium has reduced alertness/attention
- Delirium has decreased orientation/task focus
Dementia is insidious (months-years), constant over 24hours, alert consciousness/alertness
DDx of delirium or altered LOC (4)
DIMS
- Drugs (Intoxication or withdrawal: EtOH, anticholinergic, narcotics, polypharmacy, carbon monoxide, NMS/SS, )
- Infection (Encephalitis, Meningitis, Pneumonia, Cystitis, Cellulitis, Prostatitis)
- Metabolic (NCSE, CHF, renal failure, hepatic encephalopathy, hypothyroid, electrolytes, B12, Wernicke’s encephalopathy (thiamine))
- Structural (SDH, SAH, mass lesion)
Urinary incontinence, dementia, abnormal gait equals (1)
- Normal pressure hydrocephalus
What is the Cushing reflex in high ICP? (3)
- Hypertension
2. Bradycardia
3. Abnormal respirations
Patient has a seizure, and does not awaken after 30 minutes. What to do? (2)
- Consider metabolic and non-convulsive status epilepticus. Full workup, CThead, and EEG.
Vertigo DDx (10)
- BPPV
- Labyrinthitis (viral, bacterial)
- Vestibular neuronitis
- Meniere disease
- Migraine
6. Light-headedness: hypotension, orthostatic hypotension - Cerebellar or posterior stroke
- Cerebellar or posterior mass lesion
- MS
10. Infections (neurosyphilis, TB) - Anemia
12. Alcohol intoxication or Wernicke’s
Vertigo red flags (6)
- Sudden onset
- Ataxia
- Vertigo at rest
- Headache or neck pain
- Vertical nystagmus
- Focal neurological finding
- Positive HINTS test
- Fever
- ++ Cardiovascular risk factors
- Anticoagulation (warfarin)
How to Dx (1) and treat BPPV ()
- Diagnosis: Dix Hallpike
2. Treatment: Epley maneuvre
What is the diagnosis: (4)
1. Constant vertigo, lasts hours, with tinnitus:
2. Constant vertigo with tinnitus and recent URTI/otitis media:
3. Constant vertigo with hearing loss:
4. Lasted 10 minutes, severe vertigo with vomiting, resolved:
- Constant vertigo, lasts hours, with tinnitus: meniere’s disease (CT)
- Constant vertigo with tinnitus and recent URTI/otitis media: bacterial labyrinthitis (CT/antibiotics)
- Constant vertigo with hearing loss: acoustic neuroma
- Lasted 10 minutes, severe vertigo with vomiting, resolved: embolic or TIA
Symptomatic treatment options for vertigo (3)
- Antihistamines (dimenhydrinate, diphenhydramine)
- Metoclopramide
- Ondansetron
Definition: status epilepticus (1)
- Seizure lasts more than 5 mins, or two or more seizures without regaining consciousness
Classification of seizures (2)
- Generalized
2. Partial
Types of seizures (4)
- Generalized (impaired consciousness)
- Tonic clonic (AKA grand mal)
- Absence seizure
- Myoclonic, tonic, clonic, atonic
- Partial (simply partial, partial with secondary generalization)
A transient or focal deficit that occurs after a seizure (1)
- Todd’s paralysis (should resolve in 48hours)
Seizure DDx (5)
1. Syncope 2. Psychogenic seizure 3. Hyperventilation syndrome 4. Migraine headache 5. Movement disorders 6. Hypoglycemia
Lab values elevated after a seizure (2)
- Prolactin (15-60mins)
2. Lactate (30mins)
Most common cause of provoked (secondary seizure) in the developing world (1)
- Neurocysticercosis (Taenia solium)
Treatment of seizure associated with pre-eclampsia (gestation >20weeks, HTN, edema, proteinuria) (1)
- Magnesium sulfate 4g over 20 minutes
Treatment options (meds) for status epilepticus, receptor? (5)
- Lorazepam/benzo 0.1mg/kg (2-4mg IV) and repeat x1 - GABA
- Fosphenytoin 20 PE at 150mg/min or Phenytoin 20mg/kg at 50mg/min – Sodium channel blocker
- Levitiracetam 2g IV - GABA
- Propofol 1mg/kg IV bolus - GABA
5. Ketamine 5mg/kg/h – anti NMDA - Phenobarb 20mg/kg at 50-75 mg/min
Serious side-effects of phenytoin (3)
- Related to the diluent (propylene glycol)
1. Hypotension
2. Cardiac arrhythmia
3. AVBlocks
4. Very irritating to the vein
Serious side-effects of valproic acid (3)
- Hepatic failure
2. Pancreatitis - Teratogenicity
How does it present? (10) 1. Guillain-Barre syndrome 2. Bell’s Palsy 3. Ramsay Hunt Syndrome 4. Lyme disease 5. Botulism 6. Tick paralysis 7. Amyotrophic lateral sclerosis (ALS), AKA Lou Gehrig’s disease 8. Myasthenia gravis 9. Multiple sclerosis 10. Parkinson disease
- Guillain-Barre syndrome: viral illness, then ascending symmetric weakneass and areflexia. Paralysis may go to the diaphragm. Rx IVIG
- Bell’s Palsy – unilateral facial paralysis (CN VII). Rx. Pred 50mg 7days. Eye drops and lubrication. 15% will have permanent paralysis.
- Ramsay Hunt Syndrome – herpes zoster infection of geniculate ganglion. Unilateral facial nerve palsy, pain, and vesicular eruption on the face. Rx Pred 50mg 7 days and valacyclovir.
- Lyme disease – look for erythema migrans rash. Can come with cardiac involvement and neuropathies. Rx Doxy 21 days.
5. Botulism – infants or injection drug users with wounds. Descending, symmetric paralysis. Bulbar muscles: diplopia, dysarthria, dysphagia. N+V+abdo cramps. Infantile botulism = poor feeding, constipation, lethargy, “floppy infant”
- Tick paralysis – tick bite, then ascending paralysis
- Amyotrophic lateral sclerosis (ALS) – UMN and LMN atrophy. Spasticity, hyperreflexia, limb weakness, emotional liability. Beware respiratory muscle weakness.
- Myasthenia gravis – anti Ach receptor AB’s, gives you progressive muscle weakness throughout the day, especially proximal or bulbar muscles. Myasthenia crisis is when the weakness involves the respiratory muscles. Avoid Sux.
- Multiple sclerosis – loss of myelin leads to UMN and LMN lesions, often on/off pattern, consider in optic neuritis (pain and VA loss over days).
- Parkinson disease – loss of dopamine in substantia nigra. TRAP: tremor, rigidity, akinesia, posture
Bacterial meningitis bugs (3)
- Strep pneumo
- H flu
- N meningitides
- Listeria monocytogenes (alcoholics)
5. Staph aureus (after neurosurgery or shunt procedure)
Meningitis signs/symptoms (4)
- Headache
- Fever
- Stiff neck
- Altered mental status >95% meningitis will have HA and fever
CSF findings in bacterial meningitis (4)
- Gram stain positive (70% before AB’s, 25% after AB’s)
- WBC>1000
- Low glucose
- High protein
Emperic treatment of meningitis (2 +/- 3 others)
- Ceftriaxone 2g IV
- Vancomycin 15mg/kg IV (for resistant Strep pneumo)
- Ampicillin 2g IV (if immunocompromised – for Listeria)
- Dexamethasone 10g IV (only beneficial in Strep pneumo)
- Acyclovir 10mg/kg IV q8H (if suspicious of HSV encephalitis – behaviour, altered LOC, seizures)
The most worrisome cause of viral encephalitis, treatment (2)
- HSV encephalitis
2. Acyclovir 10mg/kg IV q8H
CSF shunt malfunction symptoms (5)
Essentially Sx of increased ICP. Do a shunt study (Xrays of the shunt), +/- CT head. 1. Nausea and vomiting 2. Irritable / mental status change 3. Bulging fontanelle 4. Lethargy 5. Ataxia 6. CN palsy 7. Headache
What do you do if you suspect a shunt infection? (3)
- Do NOT do an LP
- They need a shunt tap
- Antibiotics (Ceftriax + Vanco)
- Call neurosurgery
Diagnosis and treatment of complications with intrathecal baclofen (2)
- This can be life threatening! Sudden increases in spasticity can lead to rhabdo or infection
- Rx IV benzo’s (PO baclofen doesn’t penetrate CSF well)
- Consult neurosurgery
DDx of diplopia (3)
- Internuclear opthalmoplegia (MS) – you can’t abduct the affected eye past midline, but gazing laterally is OK
- Brainstem stroke
3. Dislocated lens
Evidence-based treatment options for migraine headache (6)
- Ibuprofen 600mg or Ketorolac 10mg if vomiting
- Tylenol 1000mg
- Maxeran 10mg IV
- Prochloperezine or Haloperidol
- Dexamethasone 10mg PO or IV
- Triptan’s (causes vasoconstriction – avoid in CAD, CVD, ++HTN, pregnancy)
- Greater occipital nerve block – occipital protuberance, 1.5cm down and lateral
- Ketamine 20mg IV over 20 minutes
* No IV fluids – only if significant dehydration/vomiting. If the headache is refractory after one hour repeat maxeran 10mg IV with Benadryl 50mg. Consider magnesium 2g IV.
How do you treat akathisia (1)
- Diphenhydramine (Benadryl) 25-50mg IV
Screening test for delirium (1)
- Ottawa 3DY (day of the week, the date, the year, and WORLD backwards)
Treatment of choice for hyper-active delirium (1)
- Haloperidol IV/IM
Circulation to the brain (3)
- Anterior cerebral artery - leg
- Middle cerebral artery – arm, face
- Posterior cerebral artery – cerebellum, vision
* Right posterior cerebral artery stroke gives left homonymous hemianopsia
Treatment of stroke that improves patient outcome? (6)
Normoglycemia, normothermia, normo-BP, and no-eating
1. Airway management
2. Head of bed to 30 degrees
3. NPO (aspiration #1 killer of strokes!)
4. Bed rails up
5. Gentle BP control over 24-48 hours (<220, or <185 if giving tPA, <160 if hemorrhagic)
6. Control fever, blood glucose
7. ASA 160mg PO
8. Admit to a stroke unit
9. tPA…
tPA inclusion criteria (3) and exclusion criteria (10)
- Diagnosis of ischemic stroke (NIHSS score)
- Onset of symptoms less than 4.5 hours
3. Age >18 tPA exclusion criteria: - Hemorrhagic stroke
- Recent intracranial bleeding
- Recent intracranial surgery
- History of intracranial hemorrhage
- Brain mass
- Recent major surgery or GI bleed (2 weeks)
- Platelets less than 100,000
- INR over 1.7
- Patient anticoagulated (heparin, factor Xa)
- Pregnancy
11. Aortic dissection, carotid dissection
12. BP greater than 185/110 Dose of tPA: 0.9mg/kg IV, max 90mg.
Give 10% over 1 minute, then remainder over 60 minutes.
What is a lacunar infarct (1)
- Small infarct, stuttering course, pure small motor or sensory.
Dystonia treatment (1), Parkinson’s treatment (1)
- Dystonia means stuck. Too much acetylcholine. Rx anti-cholinergics. Can happen with eyes, and laryngospasm. Side-effect from neuroleptics (Haldol, anti-psychotics).
- Parkinson’s is death of dopamine cells in the basal ganglia. Rx L-Dopa.
Hemorrhagic stroke locations (4)
- Basal ganglia (near the lateral horn of 3rd ventricle) – from HTN
- Thalamus (around the 3rd ventricle) – from HTN
- Pons – PONS = Pinpoint Pupils
- Cerebellum
Hemorrhagic stroke BP goal (1)
- <160
(2) types of SAH
- Ruptured aneurysm – most common is from the AICA in circle of Willis
- AVM
When is CT highly sensitive for SAH (1)?
- Within 6 hours. If over 6 hours get the LP. RBC incompletely clearing, or + xanthochromia = SAH. 100 RBC
Workup of TIA (5)
- Labs CBC, lytes, Cr, urea, glucose, INR, PTT
- EKG (AFib, ischemia)
- 24h Holter (AFib)
- CT + CT angio (ischemia, carotid stenosis) OR carotid Doppler if no CT-A
- ECHO
Treatment of TIA (3)
- ASA 160mg PO then 81mg PO daily OR clopidogrel 75mg daily
- Atorvastatin 80mg daily
- If AFib (cardio-embolic) = anticoagulation (warfarin or DOAC)
- If >70% carotid stenosis: carotid endarterectomy within 2 weeks
- If carotid dissection: antiplatelet 6-12months
Types of nystagmus associated with central stroke (3)
- Vertical
- Torsional
- Direction changing
