Lecture 10 - Neuro Flashcards by Indy P

Where is the CSF?

subarachnoid space between arachnoid and pia mater

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What is the number one reason an epilepsy pt gets brought into the ER?

not taking their meds

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Generalized seizure

loss of consciousness

Convulsive/Tonic-Clonic
Non-convulsive (absence)

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Convulsive/Tonic-Clonic Seziure

has both tonic and clonic movements with post seizure mental status change

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Non-convulsive (absence)

pt does not lose postural tone

brief loss of responsiveness with minor motor activity such as blinking or staring

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Partial Seizures

no loss of consciousness

Simple: isolated motor symptoms such as tonic or clonic movements
may spread across one side of body “Jacksonian March”
may also include sensory changes

Complex:
pt has aura (nausea, fear, olfactory hallucinations) followed by impaired responsiveness
may also have stereotyped motor movements

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Simple partial seizure

isolated motor symptoms such as tonic or clonic movements
may spread across one side of body “Jacksonian March”
may also include sensory changes

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Complex partial seizure

pt has aura (nausea, fear, olfactory hallucinations) followed by impaired responsiveness
may also have stereotyped motor movements

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What is the workup for seizures in the ER?

glucose testing
screen for EtOH and drug abuse
MRI (more commonly CT used in the ER) for structural brain abnormalities, strokes, tumors
look for potential infections (meningitis, sepsis, etc)

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What drugs are used in the ER for seizures?

Phenytoin
valproic acid
carbemezepine
(first line for most seizures)

ethosuximide and valproic acid are first line for generalized, non-convulsive seizures

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What is the current definition of status epilepticus?

ongoing seizure activity for 10+min, or 2+ sequential seizures within less than 30 minutes

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Lowenstein Algorithm

used for treatment of status epilepticus (treatment ans assessment happen concurrently)

1) secure airway and give high flow O2
2) give glucose if blood sugar is low
3) consider thiamine and magnesium if pt is known alcoholic
4) LORAZEPAM 2mg IV q minute up to 0.1mg/kg
5) phenytoin 20mg/kg IV at 50mg/min (if lorazepam did not work —to help prevent seizure in the next few hours)
6) RARE: phenobarbital/general anesthesia

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GBS

guillain barre syndrome

a rapidly evolving (hours to day), symmetric (roughly), polyradicular, demyelinating neuropathy, usually affecting motor function > sensory function

typically believe this is an autoimmune response to infection

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If you get _________ infection, you are at higher risk of GBS?

campylobacter jejuni

but other infections can cause this too, this is just the only one that has a known association

this is just your immune complexes start to attack you myelin

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What is the classic hx of a pt presenting with GBS?

I had a cold about a week ago
I got over it like usual

now I have some tingling in my legs, and fatigued
Its progressed, and now I can’t walk

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What questions do you NEED to ask to help determine if this is GBS?

WHEN did these sxs start? (this dz is hours to days)
Have the sxs CHANGED? (progression of sxs in GBS)
Did you have a RECENT ILLNESS?
Can you breathe okay?
Any tingling?
Pain? (GBS is NOT pain)

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What are 2 things you MUST have to be dx with GBS?

progressive weakness in arms and legs

areflexia

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What tests are you doing in GBS?

normal admission labs (CMP, CBC, coags)
serial PFTs
LP (elevated protein, but few cells in CSF)
EMG/NCV testing
any tests to rule out other etiologies (CT, etc)

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What LP would you expect to see for GBS?

elevated protein but few cells in CSF

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What is the treatment for GBS?

admission to hospital with Neuro Critical Care unit

IV immunoglobulin (IVIG) --given over a couple of days (\$\$\$\$$)
or 
plasmaphresis -- similar to dialysis --hooked up to a machine for hours for 5 days

Watch pt closely for need of intubation 
Initiate cardiac monitoring 
pain control - gabapentin 
PT - to avoid contractures (we have no idea if these pts will have this dz for 4 days or months, so start PT day one) 
DVT prophylaxis 
psych support (including family)

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How does plasmaphresis work?

Take out antigen-antibody complexes —filtering (similar to dialysis

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What is the prognosis of GBS?

if pt is hospitalized in a tertiary care center, <5% mortality

85% of GBS pts achieve full recovery within 6-12 months

a small percentage of pts go on to have chronic deficits such as foot drop, muscle weakness or abnormal sensory sxs

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Do stroked follow vascular or functional territories?

vascular (MCA, etc)

What is the most common type of stroke?

ischemic

MCA

What does the MCA supply?

the motor function in the brain for hand and face and tongue

Ischemic vs hemorrhagic stroke?

ischemic: 80% - blood clot hemorrhagic: 20% - rupture - -SAH - -IPH (ICA)

What is the most important question to ask your potential stroke pt?

WHEN did this start? dictates treatment

Acute onset of WORST HA of your life

higher likelihood of hemorrhagic stroke/SAH

ACA stroke

anterior cerebral artery contralateral leg weakness greater than arm weakness

Left temporal stoke

speech

PCA stroke

posterior cerebral artery deficits may be hidden until formally tested light touch and pinprick sensation may be markedly decreased may have visual cortex defects

Vertebrobasilar artery stroke

cranial nerve deficits on one side of face with limb weakness on other side of body

What is the most important initial test for dx a stroke?

dry head CT (must be getting CT within 25 minutes from arrival and read within 40 minutes) - must be normal and glucose

Before giving TPA, what must you know?

when the stroke started | what their INR is on

What are the three times of ischemic strokes?

(in order of prevalence) 1) thrombotic: caused by narrowing of vascular lumen with subsequent platelet adhesion and clot formation 2) embolic: emboli travel from heart or carotids and travel to cerebral vasculature 3) hypoperfusion: usually caused by heart failure or abrupt in decrease BP (think about treatment of HTN crisis, you could cause this stroke and renal failure)

What do you see on CT for ischemic stroke?

nothing after 3-6 hours there will be something on the CT scan, but then its too late for TPA

What is the time frame for tPA?

4.5 hours from the onset of sxs

Slides right after tPA

go back over a read | NOT DONE HERE

What is the main causes of ICH?

HTN

What is the treatment of ICH?

neurosurgery eval mannitol possible surgical decompression

What are the causes of SAH?

AV malformation aneurysm trauma

What are the CT findings of a SAH?

fresh blood in subarachnoid space and not in a common vascular distribution

What are the CT findings of a ICH?

fresh blood (hyperintense/bright white) on CT in a known vascular distribution

If you are highly suspicious of SAH, but the CT scan is normal, what should you think?

still probably SAH but the blood has diffused throughout the space, so you should do an LP to check for RBC the requirement for LP has changed recently. "if pt receives CT scan within 6 hours of onset of the thunderclap HA and CT is negative, LP is not required." pt must have a good clear story

What is the treatment for SAH?

call neurosuregy pts with large bleeds may be eligible for surgical decompression measures should be taken to help pt avoid increase in ICP (anti-seizure, antitussives, antiemetics) HTN should be managed to avoid re-bleed Nimodipine 60mg po q6h should be given to decrease vasospasm

Who gets subdural hematomas?

old people alcoholics d/t atrophy of parenchyma

How do pts with subdural hematoma present?

``` LOC laceration or bruising on head N/V confusion smell of EtOH difficulty ambulating ```

Crescent-shaped on CT

subdural hematoma often a mass effect and midline shift

What is the cause of epidural hemorrhage?

blunt force trauma to temporal or parietal regions usually associated with a skull fracture in an adult epidural hemorrhage of the MIDDLE MENINGEAL ARTERY (usually the skull fracture is what lacerates the middle meningeal artery)

How do pts with epidural hematoma present?

``` Obvious site of trauma to head LOC does pt have signs of elevated ICP such as blown pupil or changes in BP focal neuro deficits hemotympanum CSF otorrhea or rhinorrhea ```

Lens or balloon shape on CT

epidural hematoma usually a mass effect with midline shaft

How is epidural hematoma treated?

evacuation of the blood by a neurosurgeon if there are no neurosurgery resources available, surgeons or emergency physicians may attempt burr holes

Lucid interval

epidural hemorrhage

What is the most common cause of seizure in pts greater than 40?

tumor | stroke

What is the most common cause of seizure in pts below age of 10?

``` idiopathic febrile birth injury metabolic infection trauma ```