Chapter 59: Chronic Neurological Problems Flashcards
Probably the most common type of pain. Primary are not caused by a disease or another medical condition. Secondary are caused by another condition or disorder, such as sinus infection, neck injury, and stroke.
Headache
Also called a stress headache. Most common type. Bilateral location and pressing or tightening quality. Usually of mild or moderate intensity and can last from minutes to days. Believed to be associated with neuromuscular factors similar to those involved in migraine headaches. Bilateral frontal-occipital headache- constant, dull pressure, or sandlike headache associated with neck pain and increased tone in the cervical and neck muscles. May involve sensitivity to light (photophobia), but does not involve n/v. No prodrome (early manifestation of impending disease), and physical activity does not aggravate sx. Careful hx taking for dx. May have increased resistance to passive movement of the head and tenderness of the head and neck. EMG may reveal sustained contraction of the neck, scalp, or facial muscles.
Tension-type headache
Recurring headache characterized by unilateral (sometimes bilateral) throbbing pain, a triggering event or factor, and manifestations associated with neurologic and autonomic NS dysfunction. Most common age for onset is 20-30 years. More common in women than men. Risk factors include family hx, low level of education, low socio-economic status, high workload, and frequent tension-type headaches. Complex series of neuromuscular events may initiate it. May have specific factors that trigger it (foods, menstruation, head trauma, physical exaggeration, fatigue, stress, missed meals, weather, and drugs. Chocolate, cheese, oranges, tomatoes, onions, MSG, aspartame, and alcohol- particularly red wine). A prodrome (may include neurologic [eg photophobia], psychologic [eg hyperactivity, irritability] and other [eg food craving] manifestation) and an aura (complex of neurologic sx characterized by visual [eg bright lights, scotomas-patchy blindness, visual distortions, sensory, and/or motor phenomena) may precede the headache phase. Presentation varies in severity. Dx usually based on hx. No specific lab or radiologic tests.
Migrane headache
Rare form of headache. Involve repeated headaches that can occur for weeks to months at a time, followed by periods of remission. Trigeminal nerve has a role in the production of pain, but they also involve dysfunction of intracranial blood vessels, the SNS, and pain modulation systems. Alcohol is a dietary trigger, along with strong odors, weather changes, and napping. One of the most severe forms of headache, with intense pain lasting from a few minutes to 3 hours. The pain is sharp and stabbing, which is in contrast to the pulsing pain of the migraine headache. The pain is generally located around the ye, radiating to the temple, forehead, cheek, or gums. Other manifestations include swelling around the eye, lacrimation, facial flushing or pallor, nasal congestion, and constriction of the pupil. The pt is often agitated and restless, unable to sit still or relax. They can occur every other day and as often as 8 times/day. The attacks occur in clusters. The clusters occur with regularity, usually at the same time each day, during the same seasons of the year. A cluster typically lasts 2 weeks to 3 months, and then the pt goes into remission for months to years.
Dx based on hx. CT, MRI, MRA may rule out an aneurysm, tumor, or infection.
Cluster headaches
Other types of headaches
Although tension, migraine, and cluster headaches are by far the most common types of headaches, other types can occur. These headaches may be the first sx of a more serious illness. HA can accompany subarachnoid hemorrhage; brain tumors; other intracranial masses; vascular abnormalities; trigeminal neuralgia; disease of the eyes, nose and teeth; and systemic illness (e.g. bacteremia, CO poisoning, mountain sickness, polycythemia vera). The sx vary greatly. B/c of the variety of causes, clinical evaluation must be thorough. It should include an evaluation of personality, life adjustment, environment, and family situation, as well as a comprehensive eval of neuro and physical status
Tx for tension-type headache
ASA, Tylenol, or NSAIDs. Nonopioid analgesics.
Tx for migrane headache
The aim of drug tx of an acute migraine attack is terminating or decreasing the sx. Many people with mild to moderate sx can obtain relief with NSAIDs, ASA, or caffeine-containing combination of analgesics. For moderate to severe headaches, the triptans have become the first line of therapy (e.g. sumatriptan [Imitrex]. affect selected serotonin receptors, thus reducing neurogenic inflammation of the cerebral blood vessels and producing vasoconstriction. most effective when taken at the onset or during the aura. Pts with heart disease or stroke should avoid).
Prevention is important. Topiramate [Topamax], an anti seizure drug, taken daily, is effective in prevention (S/Es- hypoglycemia, paresthesia, weight loss, cognitive changes. Must be used for 2-3 months to determine effectiveness).
Dark, quiet area. Sleep.
Botox- prophylactic. Additional anti seizure drugs (divalproex [Depakote], gabapentin [Neurontin]), tricyclic antidepressants (e.g. amitriptyline [Elavil]), SSRIs (eg fluoxetine [Prozac]).
Tx for cluster headaches
Because cluster headaches occur suddenly, often at night, and do not last long, drug therapy is not as useful as it is for other types of headaches. Acute tx is inhalation of 100% O2 delivers at a rate of 6-8 L/min for 10 min, which may relieve HA by causing vasoconstriction and increasing synthesis of serotonin in the CNS. This can be repeated after a 5 minute rest. A drawback to this tx is that the pt must have continuous access to the O2 supply.
Triptans (e.g. sumatriptan [Imitrex]) are also effective.
Prophylactic drugs- verapamil, lithium, ergotamine, divalproex, melatonin, anti seizure meds.
Other headache interventions
Thorough assessment; daily exercise; relaxation techniques; quiet, dimly lit environment; massage; moist hot packs; dietary counseling (wine can trigger migraines); medications)
Paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. May accompany a variety of disorders, or may occur spontaneously without any apparent cause.
Seizures
Metabolic disturbances that cause seizures:
acidosis, electrolyte imbalances, hypoglycemia, hypoxia, alcohol and barbiturate withdrawal, water intoxication or dehydration. Not considered epilepsy if cease when underlying condition is treated.
Extra cranial disorders associated with seizures
Heart, lung, liver or kidney disease; systemic lupus erythematosus; DM; HTN; and septicemia.
A condition in which a person has spontaneous recurring seizures c/b a chronic underlying condition. Incidence is increasing in older adults. Males are more likely to develop it than females. People at high risk: those with Alzheimer’s disease or those who have had a stroke.
Epilepsy
Etiology and pathophys of seizures
Have many possible causes, with the most common causes varying by age.
First 6 months of lief: severe birth injury, congenital defects involving the CNS, infections, and inborn errors of metabolism
2-20 y/o: birth injury, infection, trauma, and genetic factors
20-30 y/o: usually occurs as the result of structural lesions, such as trauma, brain tumors, or vascular disease
50+ y/o: stroke and metastatic brain tumors.
Nearly 30% (70% according to Bonnie’s lecture) are idiopathic (idiopathic generalized epilepsy [IGE]), meaning they are not attributable to a specific cause.
Abnormal neurons undergo spontaneous firing. This firing spreads by physiologic pathways to involve adjacent or distant areas of the brain. If it speaks to involve the whole brain, a generalized seizure occurs. Factor that causes this is unclear. Any stim that causes the cell membrane of the neuron to depolarize induces a tendency for spontaneous firing.
Genetic link of IGE
Genetic abnormalities may be the most important factor contributing to IGE. The role of genetics has been difficult to determine because of the problem of separating genetic from environmental or acquired influences.
Clinical manifestations of seizures
Determined by the site of the electrical disturbance. Divided into two major classes: generalized and focal. Depending on the type, a seizure may progress through several phases: 1) prodromal phase (signs or activity that precede seizure); 2) aural phase (sensory warning); 3) ictal phase (full seizure); 4) postictal phase (period of recovery after).
Involve both sides of the brain and are characterized by bilateral synchronous epileptic discharges in the brain from the onset of the seizure. In most cases pt loses consciousness for a few seconds to several minutes
generalized seizures
Most common generalized seizure. Formerly known as gran mal. Characterized by losing consciousness and falling to the ground if the pt is upright, followed by stiffening of the body (tonic phase) for 10 to 20 seconds and subsequent jerking of the extremities (clonic phase) for another 30 to 40 seconds. Cyanosis, excessive salivation, tongue or cheek biting, and incontinence may accompany the seizure. The postictal phase- pt usually has muscle soreness, is tired, and may sleep for several hours. Some pts may not feel normal for several hours or days after. Pt has no memory of the seizure.
Tonic-clonic seizure
Usually occurs only in children and rarely continues beyond adolescence. May cease altogether as the child matures, or it may evolve into another type of seizure. Brief staring spell resembling “day dreaming” that lasts only a few seconds, so it goes unnoticed. When left untreated, the seizures may occur up to 100X/day. EEG demonstrates a spike-and-wave pattern that is unique to this type of seizure. Hyperventilation and flashing lights can precipitate these seizures.
Absence seizures
Characterized by a staring spell accompanied by other s/s, including brief warning signs, peculiar behavior during the seizure, or confusion after the seizure. It is longer lasting than a typical absence seizure and may be associated with loss of postural tone. EEG demonstrates atypical spike-and-wave patterns.
Atypical absence seizures
Characterized by a sudden, excessive jerk of the body or extremities. Jerk may be forceful enough to hurl the person to the ground. These seizures are brief and may occur in clusters.
Myoclonic seizure
“Drop attack.” Involves either a tonic episode or a paroxysmal loss of muscle tone and begins suddenly with the person falling to the ground. Consciousness returns by the time the person hits the ground, and normal activity can be resumed immediately. Pts with this type of seizure are at a great risk of head injury and often have to wear protective helmets.
Atonic seizure
Involves a sudden onset of maintained increased tone in the extensor muscles. These pts often fall.
Tonic seizures
Beings with loss of consciousness and sudden loss of muscle tone, followed by limb jerking that may or may not be symmetric.
Clonic seizures
Also called partial or partial ____ seizures. Are the other major class of seizures. Being in one hemisphere of the brain in a specific region of the cortex. Produce s/s r/t the function of the area of the brain involved. Divided according to their clinical expressions.
Focal seizures
Pts remain conscious but experience unusual feelings or sensations that can take many forms. They may experience sudden and unexplainable feelings of joy, anger, sadness, or nausea. They also may hear, smell, taste, see, or feel things that are not real.
Simple focal seizure
Pts have loss of consciousness or an alteration in their consciousness, producing a dream-like experience. They display strange behavior such as lip smacking and automatisms (repetitive movements that may not be appropriate). Pts may continue an activity started before the seizure, but after the seizure they do not remember the activity performed during the seizure. Other automatisms are less organized, such as picking at clothing, fumbling with objects (real or imaginary), or simply walking away. These seizures usually last just a few seconds.
Complex focal seizure
May be confined to one side of the brain and remain focal (partial) in nature, or they may spread to involve the entire brain, culminating in a generalized tonic-clonic seizure. Any tonic-clonic seizure that is preceded by an aura or warning sign is a ____ seizure that generalizes secondarily. Many tonic-clonic seizures appear to be generalized from the outset but may actually be 2* generalized seizures, but the preceding partial component may be so brief that is is undetected by the pt. Unlike the 1* generalized tonic-clonic seizure, the 2* generalized seizure may result in a transient residual neurologic deficit postictally. This is called Todd’s paralysis (focal weakness), which resolves after varying lengths of time.
Focal seizures.
Also called pseudo seizures. Psychiatric in origin. Closely resemble epileptic seizures (often misdiagnosed as epilepsy). Proper dx requires video-EEG monitoring to capture a typical episode. Pts frequently have a hx of emotional abuse, physical neglect, or a specific traumatic episode
Psychogenic seizure
A state of continuous seizure activity in which seizures recur in rapid succession without return to consciousness between seizures. The most serious cx of epilepsy and is a neurologic emergency. Can occur with any type of seizure. During repeated seizures, the brain uses more energy than can be supplied. Neurons become exhausted and cease to function. Permanent brain damage may result. Tonic-clonic ____ ____ is the most dangerous because it can cause ventilatory insufficiency, hypoxemia, cardiac dysrhythmias, hyperthermia, and systemic acidosis, all of which can be fatal.
Status epilepticus
Cx of seizures
Severe injury and even death from trauma suffered during a seizure. Pts who lose consciousness during a seizure are at greatest risk. Persons with epilepsy have a mortality rate 2-3x the rate of the general population.
Most common cx of seizure disorder is the effect it has on a pt’s lifestyle. The pt may develop ineffective coping methods b/c of the psychosocial problems r/t having a seizure disorder. Pt with epilepsy may experience discrimination in employment and educational opportunity. Transportation may be difficult because of legal sanctions against driving.
Diagnosis of seizure disorders
Has many socioeconomic, physical, and psychologic consequences for the pt. Most useful diagnostic tools are an accurate and comprehensive description of the seizures and the pt’s health hx. EEG is helpful but only if it shows abnormalities. Abnormal findings help determine the type of seizure and help pinpoint the seizure focus. Not a definitive test b/c some pts who do not have seizure disorders have abnormal patterns on their EEGs, whereas many pts with seizure disorders have normal EEGs bw seizures. CBC, serum chemistries, studies of liver and kidney function, and a urinalysis should be done to rule out metabolic disorders. A CT scan or MRI should be done in any new-onset seizure to rule out a structural lesion. Cerebral angiography, SPECT, MRS, MRA, and PET may be used in select clinical situations.
