Chapter 8 - Neurologic Disorders

Question 1

Primary vs. secondary headaches

Answer 1

• Primary – not associated with other diseases
• Examples of primary – migraine, tension-type, cluster
• Secondary – associated with or caused by other conditions, generally won’t get better until specific cause is diagnosed and addressed
• Examples of secondary – tumor, intracranial bleeding, increased ICP, meningitis, giant cell arteritis, mass lesion, etc. Viremic or acute sinusitis headache is most commonly secondary type headache seen in primary care

Question 2

SNOOP Pneumonic for Headaches

Answer 2

• Consider diagnosis other than primary headache if headache “red flags” are present
• S – presence of systemic symptoms, secondary headache risk factors
• N – neurologic signs/symptoms
• O – onset (time)
• O – onset (age)
• P – prior headache history, positional, papilledema

Question 3

SNOOP Pneumonic for Headaches: S (systemic symptoms, secondary headache risk factors)

Answer 3

• Systemic symptoms including fever, unintended weight loss, others
• Secondary headache risk factors include HIV, malignancy, pregnancy, anticoagulation, marked BP elevation, others
• Possible clinical corrections – infection, inflammation, metastatic disease, intracerebral hemorrhage, others

Question 4

SNOOP Pneumonic for Headaches: N (neuro s/s)

Answer 4

• Newly-acquired neuro findings, including confusion, impaired alertness or consciousness, nuchal rigidity, papilledema, cranial nerve dysfunction, abnormal motor function, others
• CNS infection, encephalitis, mass lesion, stroke, AVM, collagen vascular disease, others

Question 5

SNOOP Pneumonic for Headache: O (onset – age)

Answer 5

• Older (> 50 years), younger (< 5 years)

* Temporal/giant cell arteritis (older), mass lesions (older or younger)

Question 6

SNOOP Pneumonic for Headaches: O (onset – time)

Answer 6

• Sudden, abrupt, or split-second (“thunderclap” headache)
• Onset with exertion, sexual activity, coughing and sneezing is suggestion of increased ICP
• Subarachnoid hemorrhage (esp. with “thunderclap”), mass lesion

Question 7

SNOOP Pneumonic for Headaches: P (prior headache history, positional, papilledema)

Answer 7

• Change in quality and/or frequency
• Change in upright vs. laying down, neck position
• Visual problems
• Medication overuse, mass lesion, subdural hematoma, intracranial hypotension, infection

Question 8

Primary Headaches: Tension-type

Answer 8

• Lasts 30 minutes to 7 days (usually 1-24 hours) with ≥ 2 of the following characteristics
• Pressing, non-pulsatile pain
• Mild to moderate intensity
• Usually bilateral location
• Notion of 0-1 of the following (> 1 suggests migraine):
o Nausea, photophobia, or phonophobia
• Female: male ratio = 5:4

Question 9

Primary Headaches: migraine without aura

Answer 9

• Lasts 4-72 hours with ≥ 2 of the following characteristics
• Usually unilateral location, though occasionally bilateral
• Pulsating quality, moderate to severe intensity
• Aggravation by normal activity such as walking, or causes avoidance of these activities
• During headache, notion of ≥ 1 of the following:
o Nausea and/or vomiting, photophobia, phonophobia
• Female: male ratio = 3:1
• Positive family history in 70-90%

Question 10

Primary Headaches: migraine with aura

Answer 10

• Same presentation as a migraine without aura, just with the presence of the aura
• Migraine-type headache occurs with or after an aura
• Focal dysfunction of the cerebral cortex or brain stem causes ≥ 1 aura symptoms to develop over 4 minutes, or ≥ 2 symptoms occur in succession
• Symptoms can include feelings of dread or anxiety, unusual fatigue, nervousness or excitement, GI upset, visual or olfactory alteration
• No aura symptoms should last > 1 hour. If this occurs, an alternate diagnosis should be considered (ex: focal seizure)

Question 11

Primary Headaches: cluster

Answer 11

• Tendency of headache to occur daily in groups or clusters
• Usually last several weeks to months and then disappear for months to years
• Usually occur at characteristic times of year such as vernal and autumnal equinox. Common time is ~ 1 hour into sleep, hence the term “alarm clock” headache, as the pain awakens the person
• Headache location is often behind 1 eye with a steady, intense (“hot poker in the eye” sensation), severe pain in a crescendo pattern lasting 15 minutes to 3 hours
• Most often with ipsilateral autonomic signs such as lacrimation, conjunctival injection, ptosis, and nasal stuffiness
• Female: male ratio = ~ 1:3
• Family history of cluster headache present in ~ 20%

Question 12

What are the general treatments for headache therapy?

Answer 12

• Lifestyle modification
• Analgesics
• Rescue therapy
• Migraine-specific meds
• Prophylactic (controller) meds

Question 13

Headache Therapy: Lifestyle modification

Answer 13

• Recognize and avoid triggers – chocolate, etoh, MSG, perfume, too much or too little sleep, hunger, altered routines
• Encourage regular exercise, attend to posture, use tinted lenses
• Keeping a headache diary can help identify triggers

Question 14

Headache Therapy: analgesics

Answer 14

• NSAIDs, acetaminophen, others

* Limit use to 2 treatment-days per week to avoid analgesic rebound headache

Question 15

Headache Therapy: rescue therapy

Answer 15

• Opioids, antiemetics, short course of systemic corticosteroids
• Use when standard therapy is ineffective or with severe or specific symptoms

Question 16

Headache Therapy: migraines-specific meds

Answer 16

• Triptans (selective serotonin receptor agonists), select ergot derivatives
• Ex: sumatriptan (Imitrex)
• Caution use in pregnancy, cardiovascular disease, uncontrolled HTN d/t potential vascular effect
• Helpful in tension-type headaches that don’t respond to analgesic therapy

Question 17

Headache Therapy: prophylactic (controller) meds

Answer 17

• Beta blockers (propranolol)
• TCAs (nortriptyline, amitriptyline, others)
• Antiepileptic drugs (gabapentin, valproate, topiramate)
• Lithium (specific to cluster headaches)
• Plant-based and nutritional supplements – butterbur, feverfew, CoQ-10, magnesium are effective and recommended
• Indication for prophylaxis – use of any product more than 3x/week, ≥ 2 migraines/month that produce disabling symptoms ≥ 3 days, poor symptom relief from various abortive therapies, presence of concomitant medical condition (including HTN, hemiplegic or basilar migraine)
• Goal of prophylaxis – reduce headache frequency and severity, allow headache mediations to be more effective in controlling symptoms

Question 18

Pre-hospital care for an ischemic stroke

Answer 18

• EMS template for key history components: vascular events, trauma, surgery, bleeding, HTN, DM, and anticoagulant or antihypertensive use
• Most important historical component is time of symptom onset

Question 19

Hospital-based care in ischemic stroke

Answer 19

• Stabilization
• History to rule out conditions that mimic stroke (ex: hypoglycemia, OD, infection, etc.)
• Neuro exam and stroke scale scores (NIHSS)
• All patients should have: head CT or MRI, ECG, CMP, CBC, cardiac markers, PT/INR, PTT
• Other studies depend on presentation and history

Question 20

Management of HTN in stroke

Answer 20

• Most patients with HTN will demonstrate a decline after first few hours without intervention
• If patient is candidate for tPA, acute BP reduction should be instituted if SBP > 220 or DBP < 110
• If patient is not candidate for tPA, withhold drugs unless BP SBP > 220 or DBP > 110
• Caution: acute BP reduction – lower BP by 15-25% in the first 24 hours

Question 21

Reperfusion with tPA in ischemic strokes

Answer 21

• Begin within 4.5 hours of symptom onset
• Incidence of bleed approximately 6%
• Careful selection of patients is critical in minimizing adverse bleeding events

Question 22

NIHSS Stroke Scale Scores

Answer 22

• < 4 = good prognosis, no TPA
• 4-20 = mild to moderate stroke, ideal TPA candidate
• > 20 = severe deficit, no TPA

Question 23

Absolute contraindications to TPA for acute ischemic stroke

Answer 23

• Current intracranial hemorrhage
• Subarachnoid hemorrhage
• Active internal bleeding
• Recent (within 3 months) intracranial or intra-spinal surgery or serious head trauma
• Presence of intracranial conditions that may increase the risk of bleeding (ex: malignancy)
• Bleeding diathesis
• Current severe uncontrolled HTN

Question 24

Intracranial bleeding: subarachnoid hemorrhage

Answer 24

• Cause – bleeding into subarachnoid space secondary to cerebral aneurysm or head injury, rapid accumulation of blood, ARTERIAL
• Signs/symptoms – thunderclap headache, “worst headache of my life”, vomiting, confusion/LOC, seizure
• Treatment – surgery, BP control
• Other – most common causes are uncontrolled HTN or vascular malformations

Question 25

Intracranial bleeding: epidural hematoma

Answer 25

• Cause – bleeding between dura mater and skull, fractures to temporal or parietal skull, rapid accumulation of blood, ARTERIAL
• Signs/symptoms – headache, transient LOC, unilateral or fixed pupil, n/v, dizziness
• Treatment – surgery if significant, BP control

Question 26

Intracranial bleeding – subdural hematoma

Answer 26

• Cause – damage to VEINS causing blood to accumulate under dura mater, acute or chronic
• Signs/symptoms – headache, gradual LOC/change in mental status, seizures
• Treatment – surgery if significant, watch and wait, anti-seizure prophylaxis for 7 days
• Other – common in elderly and those with etoh abuse, most patients fall into the “watch and wait” category

Question 27

Early and late signs of increased ICP

Answer 27

• Early – headaches, n/v, change in mental status/LOC, change in behavior
• Late – unresponsiveness, dilated or nonreactive pupils, posturing, Cushing’s triad (bradycardia, widened pulse pressure, and apnea)

Question 28

Pathophysiology of meningitis

Answer 28

• Infection of the pia mater and the arachnoid mater of the brain
• May be infectious, chronic, or aseptic
• Infectious – usually bacterial but can be viral
• Chronic – usually d/t chronic inflammation
• Aseptic – more so d/t chronic inflammation but can also be viral

Question 29

Signs and symptoms of meningitis

Answer 29

• Severe headache
• Nuchal rigidity
• High fever
• Altered mental status
• Kerning’s sign – patient is lying supine, pain is elicited by passive extension of the knee
• Brudzinski sign – flexion of the neck causes involuntary flexion of the hip and knee

Question 30

Diagnostic testing for meningitis

Answer 30

• LP as soon as diagnosis is suspected but need a CT first to rule out space-occupying lesion if:
• Papilledema, coma, seizures, focal neuro findings
• Do not perform an LP in the presence of increased ICP

Question 31

Treatment for meningitis

Answer 31

• High-dose parenteral antibiotics if purulent suspected (bacterial)
• May need dexamethasone (can help with inflammation)

Question 32

Spinal fluid characteristics in bacterial vs. viral meningitis

Answer 32

• Bacterial (purulent): 200-200,000 cells, < 45 glucose, > 50 protein (usually very high), markedly high opening pressure
• Viral: 100-1,000 cells, normal glucose (50-80), > 50 protein (but < purulent), normal/slightly elevated opening pressure

Question 33

Spinal cord syndromes: autonomic dysreflexia

Answer 33

• Location: injury above T6
• Cause: traumatic injury
• Symptoms: exaggerated autonomic responses – diaphoresis and flushing (above level of injury) and chills and vasoconstriction (below level of injury), HTN, bradycardia, headache, nausea
• Treatment: remove stimulus/treat injury, manage autonomic manifestations

Question 34

Spinal cord syndromes: Brown-Sequard syndrome

Answer 34

• Location: injury anywhere along the cord
• Cause: penetrating trauma (“cut” halfway through cord)
• Symptoms: ipsilateral (same side) motor disturbance and proprioception, contralateral loss of pain and temperature
• Treatment: immobilization, transfer to trauma, steroids

Question 35

Spinal cord syndromes: central cord syndrome

Answer 35

• Location: injury to cervical spinal cord
• Cause: hyperextension injury
• Symptoms: upper and lower extremity motor weakness (more in upper); varying degree of sensory loss, impaired pain, temperature, light touch, and position sense below level of injury
• Treatment: ICU monitoring x24 hours; monitor for autonomic dysreflexia, HTN, and bradycardia; usually resolves in their own; most are mild and self-limiting

Question 36

Neuroimaging of the head: when to get an MRI?

Answer 36

• Infection
• Concussion/TBI
• Lesion/mass
• Acute stroke/TIA
• Dementia evaluation
• Seizure
• Used if you need a more thorough picture/investigation
• Contraindicated in patients with pacemakers and mental implants

Question 37

Neuroimaging of the head: when to get a CT without contrast

Answer 37

• When MRI is contraindicated
• “Red flag” headaches
• Trauma/skull fracture
• Structural abnormalities (ex: hydrocephalus)
• Intracranial hemorrhage
• Acute neuro changes
• Mass
• Seizure (when patient is unstable)
• Most CTs can be done without contrast
• Contraindication to CT with contrast – allergy, kidney or liver dysfunction, metformin use

Question 38

Neuroimaging of the head: CT with contrast

Answer 38

• When MRI is contraindicated
• Seizure (if patient is unstable)
• Mass

Question 39

Quick and dirty on myasthenia gravis

Answer 39

• Autoimmune destruction of acetylcholinesterase
• Signs and symptoms – muscle weakness, typically descending
• Treatment – acetylcholinesterase inhibitors, prednisone, plasmapheresis, IVIG

Question 40

Cranial Nerves

Answer 40

• 1. Olfactory – smell
• 2. Optic – vision
• 3. Oculomotor – most eye movement
• 4. Trochlear – moves eye
• 5. Trigeminal – face sensation, chewing
• 6. Abducens – abducts the eye
• 7. Facial – facial expression, taste
• 8. Vestibulocochlear – hearing, balance
• 9. Glossopharyngeal - taste, gag reflex
• 10. Vagus – gag reflex
• 11. Accessory – shoulder shrug
• 12. Hypoglossal – swallowing, speech
• Oh Oh Oh To Touch And Feel A Girls Vagina Ah Heaven

Question 41

A 33-year-old female reports a 10-year history of unilateral, pulsating headache that lasts about 6-10 hours, occurring 3-4x/month. The headache is typically preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm, which lasts about 20 minutes. She reports severe photophobia and phonophobia as well as left-sided cephalgia during the 6-10 hour headache duration. She states the headaches appear randomly. As a result of her headaches, she typically needs to either call in sick or leave work early at least once per month due to headache. She has used OTC meds with partial relief of pain but continued photo- and phonophobia. She currently has a headache of 6 hours in duration that she characterizes as “8 on a scale of 1-10” and neuro exam is WNL. She has not taken any analgesic or other meds in the past 24 hours. Her presentation is consistent with:

a. Migraine with aura
b. Tension-type headache
c. Cluster headache
d. Intracranial lesion

Answer 41

a. Migraine with aura

B is incorrect because: tension-type headaches are typically bilateral

C is incorrect because: cluster headaches are typically behind the eye

Question 42

Which of the following represents the best choice of abortive migraine therapy for a 55-year-old male with poorly-controlled HTN?

a. Verapamil (Calan)
b. Ergotamine (Ergomar)
c. Ibuprofen (Motrin)
d. Almotriptan (Axert)

Answer 42

c. Ibuprofen (Motrin)

B and D are incorrect because: these cannot be used with poorly controlled HTN

A is incorrect because: CCBs were determined to be less effective as migraine therapy

Question 43

An 86-year-old female patient on anticoagulation therapy for atrial fibrillation was admitted to the trauma service after a fall in which she hit her head on the stove. She was complaining of headache and left leg pain. Diagnostic evaluation reveals a normal head CT and right-sided intertrochanteric hip fracture. Upon arrival she was awake, alert, and oriented with a GCS of 15. The nurse calls you to the bedside because the patient is becoming increasingly lethargic. Her neuro exam reveals a GCS of 7. Your priority intervention is to:

a. Order a CT of the head
b. Intubate the patient
c. Order a CT of the chest
d. Consult neurosurgery

Answer 43

b. Intubate the patient

B is correct because: Need to protect the airway first; GCS ≤ 8 = intubate

Question 44

You are evaluating a 52-year-old male patient with an evolving CVA. His wife reports that just one hour ago they were getting ready to sit down to dinner and reports, “He was fine.” Shortly after sitting he began to act “weird” and couldn’t speak properly. She also noticed that he could not stand or walk normally. He was rapidly transferred via 911 to emergency care. Which of the following is an absolute contraindication to TPA therapy?

a. A NIHSS score of 15
b. A BP of 170/120
c. He had an anterior wall MI 6 months ago
d. A INR of 1.3

Answer 44

b. A BP of 170/120

B is correct because: you need to get the BP down to < 180/110

C is incorrect because: this is a relative contraindication

D is incorrect because: this isn’t a risk

Question 45

Match each patient with the preferred first-line neuroimaging technique (CT, MRI, or no imaging):

1. a 56-year-old man following a MVC with a possible skull fracture
2. a 22-year-old female in her second trimester of pregnancy and experiencing multiple seizures
3. a 33-year-old woman with a history of throbbing, pulsating headache that occurs a few days prior to the start of menses.

Answer 45

a. 56-year-old in MCV – CT without contrast
b. 22-year-old female with multiple seizures – MRI
c. 33-year-old female with headaches – no imaging

Question 46

Match each of the following patient descriptions with the most likely type of intracranial bleeding (subdural hematoma, epidural hematoma, or subarachnoid hemorrhage).

a. A 56-year old smoker who experienced a “thunderclap” headache followed by confusion and vomiting. There is no report of any traumatic event preceding these findings. He has poorly-controlled HTN and consumes moderate amounts of alcohol daily
b. A 47-year-old woman who experienced a transient loss of consciousness after falling and banging her head on a bathroom sink. She complains of dizziness and headache and exam reveals a fixed pupil in her left eye
c. A 73-year-old man fell 3 weeks ago hitting his head and presents to the ED with a 3 week history of headaches and a seizure earlier today. The wife reports a gradual decline in mental status over the past 2 weeks.

Answer 46

a. A 56-year-old with a “thunderclap” headache – subarachnoid hemorrhage
b. A 47-year-old experiencing LOC after hitting head on the sink – epidural hematoma
c. A 73-year-old who fell 3 weeks ago and a 3 week history of headache and seizure – subdural hematoma

Question 47

A 37-year-old female presents complaining of depressed mood. While considering a diagnosis of depression, the AGACNP knows that which of the following must be present?

a. Weight change (increase or decrease)
b. Loss of interest or pleasure in activities
c. Diminished concentration
d. Decreased energy

Answer 47

b. Loss of interest or pleasure in activities

Question 48

A 52-year-old male patient presents to the ER with a chief complaint of sudden-onset facial paralysis. He awoke this morning and couldn’t move the left side of his face or close his eye. He reports minimal facial discomfort. Which cranial nerve is affected?

a. V
b. VI
c. VII
d. VIII

Answer 48

c. VII

C is correct because: this is the facial nerve, responsibleble for things like facial expression and taste

A is incorrect because: V is trigeminal - face sensation, chewing

B is incorrect because: VI is abducens - abducts the eye

D is incorrect because: VIII is vestibulocochlear - hearing and balance

Question 49

Which of the following should be given first in status epilepticus?

a. Lorazepam (Ativan)
b. Phenytoin (Dilantin)
c. Phenobarbital (luminal sodium)
d. Fosphenytoin (Cerebryx)

Answer 49

a. Lorazepam (Ativan)

A is correct because: benzos are first line

Question 50

You admit a 41-year-old female patient who admits to significant alcohol abuse of > 10 years duration. She clearly is poorly nourished. Which of the following vitamins would be the first priority for parenteral administration?

a. A
b. B
c. C
d. D

Answer 50

b. B

Question 51

A 17-year-old male with recent bacterial infection complains of progressively worsening lower extremity weakness for the past 3 days. On exam, he has moderate weakness in the lower extremities and now exhibits mild weakness in the upper extremities. The AGACNP considers that the most likely diagnosis is:

a. Guillain-Barre syndrome
b. Thromboembolic CVA
c. Transient ischemic attack
d. Multiple sclerosis

Answer 51

a. Guillain-Barre syndrome

A is correct because: Demyelination of peripheral nerves, ascending paralysis, autonomic manifestations, usually self-limiting

Question 52

A 72-year-old male patient is participating in a PT evaluation s/p orthopedic surgery. As the patient is getting out of bed he suffers a syncopal episode. Which of the following orders are most appropriate for this patient initially? (select all that apply)

a. A 12-lead EKG
b. A CT of the head
c. Orthostatic vital signs
d. Consult cardiology
e. Consult neurology

Answer 52

a. A 12-lead EKG]
c. Orthostatic vital signs

B is incorrect because: it is too soon for a scan

D is incorrect because: you need to do a cardiac exam before calling a consult

E is incorrect because: you need to do a neuro exam before calling a consult