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Neuroscience II Exam III - Pharm and Clinical Medicine > CLMD Headaches, Stroke, MS, Seizures, Syncope > Flashcards

CLMD Headaches, Stroke, MS, Seizures, Syncope Flashcards

1
Q

Worrisome signs that may indicate HA of pathological origin (secondary HA)

A 
“Worst headache of my life”
Onset of HA after age 50
Atypical HA for patient
HA with fever
Abrupt onset (max intensity w/i seconds)
Subacute HA with progressive worsening
Drowsiness, confusion, memory impairment
Weakness, ataxia, loss of coordination
Paresthesias, sensory loss, paralysis
Abnormal medical or neurological exam
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2
Q

Labs and other tests indicated for diagnostic evaluation of HA

A

WSR, TSH, CBC, glucose

CT, MRI/MRA, EEG, LP, arteriogram

Dental, ENT, allergy eval

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3
Q

Any pt presenting with a HA with a worrisome history or abnormal exam needs urgent imaging study, LP, and possibly arteriogram. What is important to remember about shortcomings of CT for headache patients?

A

CT can miss 5-10% of subarachnoid hemorrhages and an LP may be needed if the CT is normal

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4
Q

What are the primary HA disorders?

A 
Common migraine (no aura)
Classic migraine (with aura)
Chronic migraine
Tension-type HA
Cluster HA
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5
Q

Intensity, age of onset, gender ratio, location, description, and behavior associated with common migraine (no aura)

A

Intensity: moderate to severe

Age of onset: 35-40 yrs

Gender ratio: F:M = 3:1

Location: unilateral (but can be bilateral)

Description: throbbing, sharp, pressure

Behavior: retreat to dark, quiet room

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6
Q

Describe the aura associated with classic migraine

A

Usually lasts 15-30 mins, sometimes longer

Commonly visual symptoms (e.g., scintillations, scotoma - often hemianopic), but can be anything neurological

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7
Q

Many pts with episodic migraine will ultimately develop chronic migraine. What is the definition of chronic migraine?

A

Headaches occur 15+ days per month, lasting 4+ hours, for a period of at least 3 months, not attributed to another disorder

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8
Q

What causes migraine?

A

Most widely discussed theory is neurogenic inflammation

[trigeminal nerve becomes activated, releasing neuropeptides, causing painful neurogenic inflammation within the meninges, with subsequent effect on the dural vasculature (vasodilation, plasma protein extravasation, and mast cell degranulation)

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9
Q

Intensity, degree of disability, location, and description of tension-type HA’s

A

Intensity: mild to moderate

Disability: may inhibit, but does not prohibit daily activities

Location: bifrontal, bioccipital (may also be neck, shoulders, band-like)

Description: dull, aching, squeezing, pressure — no prodrome or aura

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10
Q

Intensity, gender ratio, location, behavior, and associated symptoms with Cluster HA’s

A

Intensity: severe, excruciating

Gender ratio: F:M = 1:6

Location: 100% unilateral, generally orbitotemporal

Behavior: frenetic, pacing, rocking

Associated sxs: ipsilateral ptosis, miosis, conjunctival injection, lacrimation, stuffy/runny nose

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11
Q

Cluster HAs have recently been associated with what condition?

A

Obstructive sleep apnea

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12
Q

Contraindications to Triptan usage

A

Documented or strong risk factors for ischemic heart disease, other cardiovascular, cerebrovascular, or peripheral vascular disease

Raynaud’s syndrome, uncontrolled HTN, hemiplegic or basilar migraine, severe renal or hepatic impairment, use within 24 hrs of tx with ergotamines, MAOIs, or other 5HT1 agonists

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13
Q

T/F: DHE has same general contraindications as triptans

A

True

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14
Q

DHE protocol (raskin protocol)

A

Metoclopromide or prochloperazine 10 mg IV over 60 seconds. Wait 5 minutes to allow distribution.

Give DHE 0.5 mg IV over 60 seconds. Wait 3-5 minutes.

May repeat 0.5 mg IV if no relief. May repeat every 8 hours for short-term use.

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15
Q

Only FDA approved tx for chronic migraines

A

Botox

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16
Q

HA disorder characterized by excruciating sharp, shooting, electrical quality pain occurring in paroxysms in one or more distributions of the trigeminal n., often frequent throughout the day. Tx is usually carbamazepine or oxcarbamazepine. Other anticonvulsants or rarely surgery can be considered

A

Trigeminal neuralgia

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17
Q

Group of HA disorders characterized by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features — includes cluster HA, paroxysmal hemicrania, hemicrania continua, SUNCT syndrome, SUNA syndrome

A

TAC’s (Trigeminal Autonomic Cephalgias)

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18
Q

What is SUNCT syndrome and what is the typical tx?

A

Shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing

Excruciating, burning, stabbing electrical HA in periorbital area lasting seconds to a few minutes, occurring frequently throughout the day

Onset is typically men over age 50; tx is usually anticonvulsants — particularly lamotrigine

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19
Q

Paroxysmal hemicrania is very similar to cluster HA but shorter in duration and increased in frequency (>5x/day). This condition is exquisitely responsive to what pharmacologic therapy?

A

Indomethacin

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20
Q

In terms of subtypes of stroke, 80% are _____ while 20% are ______

A

Ischemic; hemorrhagic

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21
Q

Symptoms of stroke affecting the left hemisphere

A

Aphasia, right-sided sensory symptoms, right-sided motor symptoms, right visual field cut

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22
Q

Symptoms of stroke affecting the right hemisphere

A

Left hemineglect, left-sided sensory symptoms, left-sided motor symptoms, left visual field cut

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23
Q

Symptoms of stroke affecting the cerebellum

A

Ipsilateral ataxia, vertigo, nystagmus

24
Q

Symptoms of stroke affecting the brainstem

A

Cranial nerve findings with contralateral hemisensory or hemimotor symptoms, vertigo

25
Q

T/F: it is very important to treat acute HTN right away when someone presents with a stroke

A

False — acute HTN is common in acute ischemic stroke and in most cases should NOT be treated

26
Q

What are some important considerations regarding IV access in stroke patients

A

All stroke patients need to have IV access

IVFs should not include glucose, as hyperglycemia is associated with worse neurologic outcomes

If tPA is a consideration, two IV access sites will be needed to eliminate venipuncture after infusion

27
Q

What labs/tests are important to order on emergent stroke patients?

A 
CBC with diff
PT, PTT
Full chemistry panel + fingerstick glucose
UA
CXR
28
Q

What is the NIH stroke scale?

A

Score ranges from 0 (normal) to 42 (coma) and can be used to predict hemorrhagic conversion as well as indication for potential intra-arterial intervention

Score <10 = 2-3% risk of hemorrhage

Score >20 = 17% risk of hemorrhage

Important if tPA or intra-arterial intervention is consideration

29
Q

In what time frame must tPA be administered if it is to be used in acute ischemic stroke?

A

Must be initiated within 3 hours of onset of symptoms (probably better within 1.5 hrs)

30
Q

Eligibility criteria for IV tPA

A

Age 18+, Dx of ischemic stroke with clinically apparent neurological deficits, No stroke or head trauma in preceding 3 mos, No major surgery in preceding 14 days, No hx of intracranial hemorrhage, no rapidly resolving symptoms, no symptoms suggesting SAH, no GI or GU hemorrhage in last 21 days, no arterial puncture at noncompressible site in last 7 days, no seizure at onset of symptoms, PT<15s or INR<7 without use of warfarin, PTT within normal range if heparin given in preceding 48 hours, platelet count>100,000mm3, blood glucose >50mg/dl, SBP <185 and DBP <110

31
Q

In what clinical situations is warfarin (or NOAC) generally indicated for use in a stroke pt?

A 
Atrial fibrillation
Prosthetic valve
Myocardial infarction
Atrial septal defect
Hypercoagulable state
Large vessel disease
Aortic arch disease
32
Q

Most promising intervention in acute stroke

A

Endovascular therapy (intra-arterial thrombolysis with clot retrieval)

33
Q

Disorder of the brain and spinal cord characterized by a tendency for periods of increasing and decreasing symptoms and signs, which result from loss of nerve tract myelination at multiple sites in the CNS

A

Multiple sclerosis

34
Q

Most common neurologic symptoms that MS patients present with

A 
Paresthesias
Gait disturbance (e.g., transverse myelitis)
Weakness
Visual loss (e.g., optic neuritis)
Urinary difficulty
Dysarthria
Hemiparesis
35
Q

4 types of MS

A

Relapsing-remitting (45-50%)
Secondary progressive (20-25%)
Primary progressive (15-20%)
Benign (10-15%)

36
Q

Studies used to make dx of MS

A

MRI of the head, cervical and thoracic spine — typically see ovoid lesions of high signal on T2WI in the periventricular white matter and in the spinal cord. Acute lesions may enhance.

Multimodality evoked potentials (SSEPs, VEPs, BAER)

LP for CSF analysis — presence of oligoclonal bands and/or increased IgG index/synthesis rate are typical in MS pts

37
Q

What is the only drug available for primary progressive MS?

A

Ocrevus (ocrelizumab)

38
Q

Medications used to treat an acute exacerbation in MS

A

High dose corticosteroids

ACTH or IVIG can be used in those who do not tolerate steroid tx

39
Q

What is a clinically isolated syndrome (CIS) as it relates to differential dx of MS?

A

Can be either monofocal or multifocal

Monofocal: single neurologic sign or symptom that is caused by a single lesion (e.g., optic neuritis in one eye)

Multifocal (aka ADEM): 2+ signs or symptoms caused by lesions in more than one place (e.g., optic neuritis in one eye + hemiparesis)

40
Q

When do CIS patients have a high risk of developing MS?

A

When CIS patients have multiple demyelinating lesions on MRI, they have 60-80% chance of developing MS within several years

[compared to those who do not have multiple demyelinating lesions who have ~20% chance]

41
Q

What are some conditions that can mimic MS?

A

Autoimmune dz (SLE with cerebritis, CNS vasculitis, polyarteritis nodosa with transverse myelitis)

Devic’s disease (Neuromyelitis optica)

B12 deficiency, lymphoma or leukemia with CNS involvement, spinocerebellar ataxias, vascular malformation (spinal cord AVM), infections, granulomatous disease (sarcoid), metachromatic leukodystrophy, adrenomyeloleukodystrophy

42
Q

_____ is generally defined as 2+ unprovoked seizures

A

Epilepsy

43
Q

Which type of seizure are you MOST likely to find on a single EEG?

A

Petit mal (with HV) = 90% positive on single EEG!

vs. all types (40%), generalized tonic/clonic (20%), and partial (30%)

44
Q

Percent positive for epilepsy (all types) with ____ sleep-deprived EEGs = 85%

A

3

45
Q

What is the difference in classification of a seizure as partial or generalized?

A

Partial — seizure activity begins on one side of the brain (includes simple partial, complex partial, and secondarily generalized)

Generalized — both sides affected (includes absence, tonic-clonic, myoclonic, tonic, clonic, atonic, clonic-tonic-clonic)

46
Q

Characteristics of simple vs. complex vs. secondary generalized partial seizures

A

Simple: focal motor or sensory activity, no LOC, lasts seconds, no post-ictal state

Complex: nonresponsive staring, possible preceding aura, automatisms, LOC, lasts 1-3 mins, +post-ictal state

Secondary generalized: bilateral tonic-clonic activity, LOC, lasts 1-3 mins, +post-ictal state

47
Q

Characteristics of absence seizures (generalized)

A

Nonresponsive staring, rapid blinking, chewing, clonic hand motions, LOC, lasts 10-30 seconds, no post-ictal state

48
Q

Characteristics of tonic-clonic seizures (generalized)

A

Bilateral extension followed by symmetrical jerking of extremities, LOC, lasts 1-3 mins, +post-ictal state

49
Q

Characteristics of atonic seizures (generalized)

A

Sudden loss of muscle tone, head drops, or patient collapses, LOC, variable duration, +post-ictal state

50
Q

Characteristics of myoclonic seizures (generalized)

A

Brief, rapid symmetrical jerking of extremities and/or torso, LOC, lasts less than a few seconds, minimal post-ictal state

51
Q

One single combination of AEDs that has been shown to be synergistic in the tx of epilepsy (especially for primary generalized seizures)

A

Valproic acid + lamotrigine

52
Q

Condition characterized by prolonged seizure (generally greater than 10 minutes) or repeated seizures without recovery in between

A

Status epilepticus

53
Q

What should women with epilepsy take as a supplement when on an AED?

A

Folic acid — since most AEDs are folate-depleting

54
Q

What AED must be avoided in pregnancy because of its known teratogenic effects?

A

Valproic acid

55
Q

Describe the condition of Transient Global Amnesia

A

Sudden, temporary, isolated episode of memory loss

No other neurologic signs or symptoms

Patient knows self and close family/friends, but may not recognize others

Usually lasts a few hours then resolves, usually doesn’t recur

Neuroscience II Exam III - Pharm and Clinical Medicine (10 decks)

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