Nervous System Flashcards

Question

CN VII Testing Name of Nerve Test (3) (1) = condition where there is inflammation of the facial nerve (motor portion) where the affected side of the face will not move

Answer 1

Facial Close eyes tightly, look up and wrinkle forehead, smile - look for asymmetry and muscle atrophy **Bell's Palsy** = condition where there is inflammation of the facial nerve (motor portion) where the affected side of the face will not move

Answer 2

Vestibulocochlear (Acoustic) **Rubbing fingers or whispering words** **Hearing exam** can be done by rubbing patient’s hair in front of the ear. Alternative is to hold hand up as a sound screen, then whisper a few numbers, and ask the patient if they heard the words.

Answer 3

Glossopharyngeal, Vagus Both control the palate Test = **Open mouth and yawn, tongue blade to test gag reflex, and assess voice clarity** Observe for asymmetry when yawning, uvula should be midline, assess voice clarity and rule out dysarthria

Answer 4

Accessory (Spinal Accessory) **Shoulder shrug and head rotation (**rotate left to right/against hand) Check sternocleidomastoid muscle for atrophy or asymmetry.

Answer 5

Hypoglossal Controls tongue movement Stick out tongue and move side to side - look for atrophy and asymmetry

Answer 6

* CN IX (9):* Innervates movement of soft palate (ask patient to yawn or say “aah” to check voice clarity). * CN XI (11):* The number reminds you of the shoulders shrugging together. * CN XII (12):* Innervates the tongue (midline, no atrophy).

Answer 7

Herpes zoster infection (shingles) of CN V (5) ophthalmic branch can result in corneal blindness. *Rash at tip of nose and the temple area:* Rule out shingles infection of the trigeminal nerve involving the ophthalmic branch (V1).

Answer 8

* Vibration sense:* * Sharp–dull touch:* * Temperature* * Stereognosis* *(Ability to Recognize Familiar Object Through Sense of Touch Only)* * Graphesthesia* *(Ability to Identify Figures “Written” on Skin)*

Answer 9

128-Hz tuning fork Tap the fork lightly, then place one end into the distal joint of each thumb, tips of toes, soles of feet comparing right to left sides for numbness/decreased vibration sense Assess severity of diabetic peripheral neuropathy

Answer 10

Safety pin, toothpick Use the sharp end of a safety pin or toothpick for sharp and head of safety pin or eraser end of a pencil to test dull sensation Vibration sense often the earliest to be affected

Answer 11

*Stereognosis* (Ability to Recognize Familiar Object Through Sense of Touch Only) Place a familiar object (e.g., coin, key, pen) on the patient’s palm and tell the patient to identify the object with eyes closed. *Graphesthesia* (Ability to Identify Figures “Written” on Skin) “Write” a large letter or number on the patient’s palms using fingers (patient’s eyes are closed).

Answer 12

* Upper extremities:* Tell patient to raise both arms in front of them, then pronate and supinate. Tell patient to bend and extend forearms, then push against resistance provided by examiner. * Hands:* Perform full range of motion with hands and fingers, without and with resistance (by examiner). The dominant hand will be slightly larger due to more muscle development.

Answer 13

* Lower extremities:* While supine, tell patient to flex each hip, then raise each leg separately while the examiner provides resistance. Compare legs. * Feet:* Perform full range of motion on toes and ankles; examiner provides resistance. *(gas pedal, up towards nose?)* Gross examination (legs) and fine motor movements (hands). Test walking, using hands for manipulation/pincer grasp, jumping, and so forth.

Answer 14

Have patient stretch out the arms with palms facing up, with eyes open. Tell patient to close eyes. Wait for 20 to 30 seconds. Then tap the arms briskly downward. When positive, one arm goes downward or drifts

Answer 15

**Upper motor neuron diseases** = (stroke, amyotrophic lateral sclerosis [ALS], polio). **Lower motor neuron lesions** = (neuropathy, polio, nerve root compression/radiculopathy) = look for muscle weakness, muscle wasting/atrophy, and fasciculations.

Answer 16

There are 31 pairs of spinal nerve roots, named for their associated vertebral body. Each pair of nerve roots exits at the corresponding level, innervating distinct dermatomal distributions

Answer 17

**0** No response **1+** Low response **2+** Normal or average response **3+** Brisker than average response **4+** Very brisk response (sustained clonus)

Answer 18

Reflex center at L2 to L4. Tap patellar tendon briskly on each side.

Answer 19

Reflex center at L5 to S2 (tibial nerve). With patient’s legs dangling off the exam table, hold the foot in slight dorsiflexion and briskly tap the Achilles tendon. Weak to no response with peripheral neuropathy (diabetes, B12 deficiency anemia).

Answer 20

Reflex center L4 to S2. Stroke plantar surface of foot on the lateral border from heel toward the big toe (plantar flexion is normal response). Babinski’s sign is positive if toes spread like a fan. *Positive:* Adults should have a negative Babinski’s sign. For young infants, Babinski’s sign is considered normal finding.

Answer 21

Kernig's Sign Brudzinski's Sign Nuchal Rigidity These tests are used to assess for **meningeal irritation (meningismus).** All are done with the patient in a supine position. In general, these are more sensitive tests in children compared with adults.

Answer 22

**Flex patient’s hips one at a time, then attempt to straighten the leg while keeping the hip flexed at 90 degrees.** *Positive:* There is resistance to leg straightening because of painful hamstrings (due to inflammation on lumbar nerve roots) and/or complaints of back pain.

Answer 23

**Passively flex/bend the patient’s neck toward the chest** *Positive:* Patient reflexively flexes the hips and knee to relieve pressure and pain (due to inflammation of lumbar nerve roots).

Answer 24

**Tell patient to touch chest with the chin.** Inability to touch the chest secondary to pain is a positive finding.

Answer 25

Mild TBI is defined as a **Glasgow Coma Scale score of 13 to 15** (measured 30 minutes after injury). * Males (2:1) * Early symptoms of acute mild traumatic brain injury (TBI; concussion) includes confusion, headache, dizziness or vertigo, poor balance, and nausea and vomiting. * Most do not lose consciousness. * Antegrade and retrograde amnesia are common after the injury.

Answer 26

**Acceleration/Deceleration** forces on the brain tissue. * motor vehicle accidents (20%–45%) * falls (30%–38%) * occupational accidents (10%) * recreational accidents (10%), * assaults (5%–17%). * Sports with the highest rates of TBI include American football, ice hockey, soccer, boxing, and rugby. * Mild TBI is a common war-time injury for soldiers who participated in combat

Answer 27

Ask patient about details of the accident, such as events leading up to the injury, during the episode, and events that followed after the concussion. Check medication history, inquire if on anticoagulation, chronic acetylsalicylic acid (ASA) therapy, or nonsteroidal anti-inflammatory drugs (NSAIDS; higher risk of brain hemorrhage).

Answer 28

Evaluate mental status, including short-term memory and attention span. Perform a neurologic assessment and CN examination; pay attention to the vision (CN II), pupil exam, extraocular movements (CN II, IV, VI), facial movements (CN VII). Refer patient to the ED if suspected head trauma; needs a CT scan of head (without contrast).

Answer 29

Glasgow Coma Scale score \<15 Seizures or other neurologic deficit(s) Recurrent vomiting Abnormal head CT (e.g., midline shift, hemorrhage, ischemia, mass effect)

Answer 30

Multiple Sclerosis * Peak age 15 to 45yo * More common in women (2–3:1) and Caucasians. * Multiple sclerosis (MS) tends to affect the optic nerves (CN II), spinal cord, brainstem, cerebellum, and white matter. * 4 subtypes * Relapsing-remitting MS (90% of cases) * primary progressive MS (10%), * secondary progressive MS, and * clinically isolated syndrome (about 60% develop MS).

Answer 31

Adolescent to adult female complains of episodes of visual loss, diplopia (double vision), nystagmus, vertigo, problems with balance and walking, foot drop, and numbness and paresthesias on one side of the face. Bowel dysfunction (50%) and/or urinary incontinence (75%). Reports that when bending neck forward/flexion, an electric shock–like sensation runs down the back **(Lhermitte sign**).

Answer 32

MRI of brain and spinal cord Refer to neurologist for management

Answer 33

**Acute Bacterial Meningitis In Adults** A serious acute bacterial infection of the leptomeninges that cover the brain and spinal cord. ***S. pneumoniae*****,*****N. meningitides*****, and** ***Haemophilus influenzae*** (the latter two are gram negative). Is a reportable disease (local health department)

Answer 34

Acute onset of high fever, severe headache, stiff neck (nuchal rigidity), and rapid changes in mental status and LOC. Up to 78% of patients have mental status changes (confusion, lethargy, stupor). Other symptoms include photophobia and nausea/vomiting. Some patients may not present with all three symptoms (triad of fever, nuchal rigidity, and change in LOC); suspect spinal epidural abscess.

Answer 35

CT head Lumbar Puncture CT scan of head *before* lumbar puncture if risk for cerebral herniation

Answer 36

* Papilledema * Focal neurologic deficit * Abnormal LOC * New-onset seizure (within 1 week of presentation) * History of central nervous system (CNS) disease (stroke, mass) * Immunocompromised (HIV, immunosuppressive therapy, solid organ or bone marrow transplant).

Answer 37

* Cerebrospinal fluid (CSF) contains large numbers of white blood cells (WBCs; CSF cloudy). * Definitive diagnosis made from **bacteria isolated from the CSF,** with presence of elevated protein and low glucose levels in the CSF.

Answer 38

CBC with differentia and platelet count, metabolic panel, coagulation profile, and blood cultures × 2. Gram stain and culture and sensitivity (C&S) of CSF fluid and blood are needed (before antibiotics are begun) Do not delay antimicrobial therapy if LP delayed by imaging studies. Obtain blood cultures and start empiric antibiotics as soon as possible.

Answer 39

* Adults:* Third-generation cephalosporin IV plus chloramphenicol IV * Older than age 50:* Amoxicillin IV plus third-generation cephalosporin IV Prophylaxis of close contacts with rifampin PO or ceftriaxone IM **Pneumococcal** vaccination shown to decrease incidence

Answer 40

Patients who recover usually have permanent neurologic sequelae. Older patients have a higher mortality rate due to the presence of comorbid conditions.

Answer 41

Migraine without aura ## Footnote At risk patients = Adult females Aggravating Factors = Red wine, MSG, Aspartame, Menstruation, Stress

Answer 42

Migraine With Aura ## Footnote At risk patients = Adult females Aggravating factors = Foods high in tyrosine

Answer 43

Trigeminal Neuralgia (CN V) At Risk Patients = Older adults and Elderly Aggravating Factors = Cold food, cold air, talking, touching, chewing

Answer 44

Cluster Headaches ## Footnote At risk patients = Middle-aged males Aggravating factors = Occurs at same time daily in clusters for weeks to months

Answer 45

Giant cell arteritis (temporal arteritis) ## Footnote At risk patients = Older patients and elderly Aggravating Factors = Medical emergency; can cause blindness if not treated, Polymyalgia rheumatic common in these patients

Answer 46

Muscle Tension Headaches ## Footnote At risk patients = Adults Aggravating Factors = Stress

Answer 47

Migraine headache with aura (precedes onset of migraine headache) may present as scotomas (blind spots on visual field) or flashing lights that precede the headache. Females with a positive family history are at higher risk (3:1). In children, migraine headaches can present as abdominal pain.

Answer 48

An adult woman complains of the gradual onset of a throbbing headache behind one eye that gradually worsens over several hours. Reports sensitivity to bright light (photophobia) and noise (phonophobia). Frequently accompanied by nausea and/or vomiting, which can be severe. Migraines can last from 3 to 72 hours and may become bilateral if not treated.

Answer 49

Neurologic exam will be normal. Rest in a quiet and darkened room with an ice pack to forehead. *Nausea*: Drink ginger ale or cola; chew dry toast or saltine crackers. Avoid heavy, fatty meals. *Avoid precipitating foods or activities:* * Monosodium glutamate (MSG) in Chinese food; chocolate; nitrates/nitrites found in hot dogs, luncheon meat, and sausage * Red wine, beer, caffeine * Sleep changes, stress, barometric weather changes

Answer 50

Odor trigger such as tobacco smoke, perfumes, and strong odors Visual triggers such as strobe lights, sunlight, glares Emotional or psychical stress

Answer 51

First, rule out **cardiovascular disease**. * Do not use (or mix) triptans or ergots if history or signs of ischemic heart disease (myocardial infarction [MI], angina), cerebrovascular accident (CVA), transient ischemic attacks (TIAs), uncontrolled hypertension, or hemiplegic migraine. * Warn patient of possible flushing, tingling, chest/neck/sinus/jaw discomfort. * Supervise first dose, especially if patient has risk factors for cardiovascular disease (e.g., diabetics, obese, males \>40 years, high lipids). Give first dose in office (theoretical risk of an acute MI).

Answer 52

Consider EKG monitoring if patient is at high risk for heart disease. Higher risk of serotonin syndrome if combined with selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs; duloxetine [Cymbalta], venlafaxine [Effexor]). Do not combine or start within 2 weeks of monoamine oxidase inhibitor (MAOI) use. Do not combine with ergots or within 24 hours of ergot use (e.g., ergotamine/caffeine or Cafergot).

Answer 53

Analgesics +/-, NSAIDS Analgesics ie Extra Strength Tylenol * If migraine headache with nausea or vomiting, also prescribe oral or rectal antiemetic drug. * Educate patient that it is best to take pain medication as soon as pain starts, rather than waiting until it is severe.

Answer 54

Oral triptans or combination sumatriptan–NSAID/naproxen (Treximet). * If associated with severe nausea or vomiting, use non-oral agents such as subcutaneous sumatriptan (Imitrix), nasal sumatriptan, and zolmitriptan (Zomig) with antiemetic drug.

Answer 55

*Calcitonin gene-related peptide (CGRP) antagonists**:* Rimegepant (Nurtec) Ubrogepant (Ubrelvy) Erenumab (Aimovig) fremanezumab- (Ajovy) galcanezumab-gnlm (Emgality)

Answer 56

ketoconazole, itraconazole, clarithromycin Grapefruit juice, St. John’s wort. Has numerous major drug interactions.

Answer 57

**Erenumab (Aimovig)** is used to **prevent (prophylaxis)** both episodic and chronic migraine headaches in adults. It is made up of monoclonal antibodies. Autoinjector pen is used once a month at home. *Serotonin 5-HT-1F receptor agonist:* Lasmiditan (Reyvow) – Do not use within 8 hours of driving or operating heavy machinery (causes dizziness).

Answer 58

**Ergot alkaloids are potent vasoconstrictors.** ## Footnote Do not mix with other vasoconstrictors (e.g., triptans, decongestants). Common side effect is nausea. Ergots and triptans should not be given within 14 days of an MAOI.

Answer 59

* Prochlorperazine*: Intramuscular (IM), intravenous (IV), suppository, by mouth (PO). * Trimethobenzamide (Tigan)*: IM, suppository, PO. * Ondansetron (Zofran*): IM, IV, PO. Off-label use for acute severe nausea and/or vomiting.

Answer 60

* Beta-blockers* * Tricyclic antidepressants (TCAs)* * Selective norepinephrine reuptake inhibitor (SNRIs)* * Anticonvulsants*

Answer 61

* Beta-blockers:* Propranolol (Inderal) daily or twice a day (other beta-blockers can also be used) * Tricyclic antidepressants (TCAs):* Amitriptyline (Elavil) at bedtime (HS) * Other TCAs:* Desipramine (Norpramin), imipramine (Tofranil), nortriptyline (Pamelor) * Selective norepinephrine reuptake inhibitor:* Venlafaxine (Effexor) * Other drug classes:* Anticonvulsants (valproate, topiramate)

Answer 62

*(Vasoconstricting Drugs)* ## Footnote Suspected or known cardiovascular disease (angina, MI, peripheral arterial disease) Suspected or known CVA and/or TIAs Hyperlipidemia, males older than 40 years of age, menopausal females Uncontrolled hypertension Complex migraine (i.e., basilar/hemiplegic migraine)

Answer 63

Distinguish the drugs used for abortive treatment versus chronic prophylaxis. Answer options may list the drug class instead of the generic name.

Answer 64

**Migraine with Brainstem Aura (Basilar or Hemiplegic Migraines)** Stroke symptoms without one sided body weakness (hemiplegia)

Answer 65

**A systemic inflammatory disorder of the medium and large arteries (vasculitis) of the body.** * Acute onset of a unilateral headache that is located on the temple and associated with temporal artery inflammation. * Visual loss is not uncommon and occurs in 15% to 20% of patients (despite availability of steroids). * Peak incidence is between ages 70 and 79 years.

Answer 66

An older man complains of headache on his temple along with marked scalp tenderness on the same side. Presence of an indurated cord-like temporal artery that is warm and tender. Sometimes accompanied by jaw claudication (pain with chewing that is relieved when he stops chewing). Complains of visual symptoms such as amaurosis fugax (transient monocular loss of vision or partial visual field defect) or blindness. Can be accompanied by systemic symptoms such as low-grade fever and fatigue. Sedimentation rate is markedly elevated

Answer 67

Elevated ESR and CRP * ESR Normal range * Men = 0 and 22 mm/hour * Women = 0 and 29 mm/hour * ESR/sedimentation rate in Giant Cell Arteritis (often reaches 100 mm/hour or more).

Answer 68

Temporal artery biopsy by ophthalmologist or surgeon Refer to ophthalmologist, rheumatologist, or ED *stat.* High-dose steroids are part of first-line treatment (prednisone 40–60 mg by mouth daily).

Answer 69

**Permanent blindness** may occur if not diagnosed early (ischemic optic neuropathy).

Answer 70

Temporal arteritis is treated with high-dose prednisone for several weeks. Refer to rheumatology specialist for management. Sedimentation rate is a screening test for temporal arteritis (elevated).

Answer 71

Because temporal arteritis can cause blindness, regard with high index of suspicion. If history and physical exam are suggestive, treat with oral steroids as soon as possible, or refer to ED. For temporal arteritis, order sedimentation rate and CRP. Both will be elevated. Serial labs (ESR, CRP) should be ordered until symptoms improve and should be monitored frequently.

Answer 72

PMR is an inflammatory condition seen almost exclusively in people age 50 or older. Peak incidence is between ages 70 and 79 years. It is more common in females. The cause is unknown. * The **ESR** is elevated mildly to severely (20% sedimentation rate 104 mm/hour); **CRP** is also elevated. * PMR patients are at very high risk (up to 40%–50%) of developing **temporal arteritis.** Educate patients diagnosed with PMR on how to recognize symptoms of temporal arteritis.

Answer 73

Bilateral joint stiffness and aching * (lasting 30 minutes or longer, commonly in the morning hours) located in the posterior neck, shoulders, upper arms, and hips (pelvic girdle). Pelvic girdle symptoms * include groin pain and pain at lateral aspects of the hips, which may radiate to the posterior thigh area. Has difficulty putting on clothes, hooking bra in the back, or getting up out of bed or a chair. Gel Phenomenon - Severe morning stiffness and pain * can last until the afternoon if not treated with steroids. Symptoms usually respond quickly to oral steroids (e.g., prednisone daily).

Answer 74

The trigeminal nerve (CN V) has three divisions: the ophthalmic (V1), maxillary (V2), and mandibular (V3) branches. Most cases are caused by compression of the nerve root by an artery, vein, or tumor, causing a unilateral facial pain that follows one of the branches of the trigeminal nerve. The pain is usually located close to the nasal border and cheeks, but it can move to other areas of the face. There are three types: classic, secondary (underlying disease), and idiopathic. More common in women and peaks in the 60s.

Answer 75

An older adult complains of the sudden onset of severe and sharp shooting pains on one side of her face or around the nose that are triggered by chewing, eating cold foods, and cold air. The severe lacerating pain (piercing knifelike pain) lasts a few seconds to 2 minutes. Pain is precipitated by a stimulus on any area of the trigeminal nerve. The patient may stop chewing or speaking momentarily (few seconds) if it causes the pain. Has recurrent paroxysms of unilateral facial pain that follows the distribution of the trigeminal nerve (CN V).

Answer 76

High doses of Anticonvulsants such as Carbamazepine (Tegretol). Muscle Relaxants (Baclofen, Robaxin, Norflex, or Flexeril) effective when used with anticonvulsant * Oxcarbazepine (Trileptal) most recently used as first-line drug with fewer side effects. * Gabapentin and topiramate also used effectively. Topical lidocaine intraoral application to reduce pain if severe in mouth

Answer 77

MRI or CT To rule out tumor/artery pressing on nerve or MS ## Footnote **_Craniotomy_ for microvascular _decompression_** referral If MRI detects lesion or arterial/venous compression **_Surgical_ therapy (_rhizotomy, radiofrequency, nerve block_)** for refractory cases

Answer 78

Bell’s Palsy **Herpesvirus** activation is suspected to be the most likely cause of majority of cases. * Facial paralysis can progress rapidly within 24 hours. * Skin sensation remains intact, but tear production on the affected side may stop. * Most cases resolve spontaneously.

Answer 79

An older adult reports waking up that morning with one side of his face paralyzed. Complains of difficulty chewing and swallowing food on the same side. Unable to fully close eyelid on affected side.

Answer 80

High Dose Glucocorticoid + Valacyclovir/Acyclovir Early treatment with high-dose oral glucocorticoids (60–80 mg/day) × 7 days and wean *plus* valacyclovir (1,000 mg three times a day) or acyclovir (400 mg five times daily) × 7 days. Best if treatment started as soon as possible, within 3 days of onset.

Answer 81

**Artificial tears** (liquid, gel) every hour while patient is awake to protect cornea from drying and ulceration Use protective glasses or goggles. At night, use ointment (containing mineral oil and white petrolatum) and cover with eye patch.

Answer 82

**Corneal Ulceration** Prolonged cases (several weeks) may leave permanent neurologic sequelae, such as **permanent facial weakness,** in up to 10% of patients. **Recurrent attacks** happen in 7% to 14% of cases.

Answer 83

Cluster Headache

Answer 84

Abrupt onset; may get agitated during a headache episode. The attacks happen several times a day (cluster). Individual attack last from 15 minutes to 3 hours. Resolves spontaneously but may return in the future in some patients. More common in **adult males in their 30s to 40s**. **Increased risk of suicide** if it persists (due to severe intensity of pain).

Answer 85

A 35-year-old man complains of the abrupt onset of recurrent episodes of brief “ice-pick” (lacerating pain) headaches behind one eye, above the eye/brow area or temporal area, that are accompanied by autonomic symptoms such as tearing and clear nasal discharge (rhinitis). Some may have drooping eyelid (ptosis). May be pacing the floor during an acute attack.

Answer 86

High-dose Oxygen at least 12L/min by mask\* Continue oxygen treatment for 15 minutes. Do not use high-dose oxygen if patient has chronic obstructive pulmonary disease (COPD). Sumatriptan (Imitrex) 6 mg subcutaneous injection or intranasal route as initial therapy or combination with high-dose oxygen. Melatonin 10 mg immediate-release tablet taken in the late evening (found to reduce headache frequency). Capsaicin 0.025% smear on ipsilateral nostril × 7 days may help.

Answer 87

CCB verapamil by mouth daily if chronic If dose \>400 mg EKG monitoring due to risk of bradycardia, right bundle branch block (RBBB), or complete heart block. Avoid grapefruit juice.

Answer 88

Suicide Higher risk of suicide (males) compared with the other types of chronic headaches.

Answer 89

**Tension Headache**

Answer 90

An adult patient complains of a headache that is “band-like” and feels like “someone is squeezing my head.” The pain is described as dull and constant. Often accompanied by tensing of the neck muscles. The headache may last several days. Patient reports recent increased life stressor(s).

Answer 91

NSAIDs first line * Naproxen sodium BID, Ibuprofen QID, or Aspirin every 4 to 6 hours. * Acetaminophen is an option if unable to tolerate NSAIDs (preferred option during pregnancy) * Diclofenac TID if poor response to NSAIDs Combination drugs such as ibuprofen or aspirin with caffeine For patients who do not get satisfactory pain relief from single agent

Answer 92

Limit butalbital use to three times or less per month. Current guidelines do not recommend the use of opioids or butalbital as initial therapy for tension-type headache (TTH). Muscle relaxants are not recommended; they can be addicting for some patients.

Answer 93

*Stress reduction and relaxation* Try yoga, tai chi; exercise several times per week; gradually reduce and stop caffeine intake; follow a regular eating/sleep schedule; pursue counseling with therapist.

Answer 94

**Defined as headache occurring 15 or more days per month due to overuse of acute headache medications for \>3 months.** Caused by overuse of abortive medicines such as analgesics, NSAIDs, aspirin, combination NSAID or acetaminophen with caffeine, butalbital, barbiturates, ergots, triptans, or opioids. * More common in women. * Patients with migraine who are depressed or anxious may be at risk. * Patient complains of daily headaches (or almost daily headaches). May be accompanied by irritability, depression, and insomnia.

Answer 95

* (OTC) analgesics or triptans limit to ≤9 days a month. * NSAIDs, limit use to ≤15 days per month. * Butalbital, limit to ≤3 days per month. Treatment is to discontinue the medicine immediately (if not contraindicated) or gradually taper the dose and/or reduce frequency.

Answer 96

Transient Ischemic Attack * high risk for a subsequent stroke and needs urgent evaluation and treatment. * The timing for resolution (24 hours, included in previous definition) has been removed. * It is now known that permanent neurologic damage can occur with TIAs (as seen in CVAs or strokes). TIA is also known as a “ministroke” or “minor stroke.” Depending on severity of the TIA, the signs and symptoms can be subtle to severe. The longer the episode of the TIA, the higher the risk of ischemic brain damage. The TIA can progress into a full-blown stroke. Signs and symptoms of CVA or stroke can be insidious and start a few days before the major episode occurs.

Answer 97

ABCD2 score **Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes** Predicts who is at high risk for suffering a subsequent stroke after a TIA within the next 7 days Score of ≥3 = refer to ED

Answer 98

A TIA is a major warning sign; 15% of patients with stroke report a previous TIA. The major risk factor for stroke is hypertension.

Answer 99

Adult to elderly patient reports acute onset of one-sided weakness of the right arm and right leg accompanied by dizziness, vertigo, and poor balance. The patient is difficult to understand because his speech is slurred (dysphasia). When instructed to smile and grimace, the right side of his face has no movement and is lopsided. Patient is accompanied by a spouse who reports that he has a history of hypertension, atrial fibrillation, hyperlipidemia, and type 2 diabetes. If symptoms progress to stroke, one-sided weakness worsens, and LOC ranges from confusion and stupor, to coma. If a TIA episode, the signs and symptoms eventually resolve, but patient remains at higher risk of future stroke.

Answer 100

Age ≥60 years History of TIA or ischemic stroke within 30 days of index event History of diabetes Systolic BP ≥140 mmHg *or* diastolic BP ≥90 mmHg Unilateral weakness Isolated speech disturbance TIA duration \>10 minutes

Answer 101

**F** Face drooping (Instruct patient to smile. Is face lopsided?) **A** Arm weakness (Instruct patient to raise both arms. Does one arm drift downward?) **S** Speech difficulty (Instruct patient to say, “The sky is blue.”) **T** Time to call 911 (Even if symptoms go away, call 911.)

Answer 102

Consider hospitalization within first 24 to 48 hours if (high risk of early stroke): ## Footnote Presence of known cardiac, arterial, or systemic etiology of brain ischemia that is amenable to treatment ABCD2 questionnaire score of ≥3 Patient’s first TIA or duration of TIA is ≥1 hour High risk for cardiac emboli (e.g., atrial fibrillation) Symptomatic internal carotid stenosis \>50% Hypercoagulable state Crescendo TIAs (two or more TIAs in 1 week)

Answer 103

Refer patient to ED for further evaluation. Find out cause of TIA (or stroke), such as atrial fibrillation, carotid/vertebral atherosclerosis, hypercoagulable state, cocaine use, hypertension. Perform workup to find the extent of brain damage. Schedule CT and/or MRI scan as soon as possible (within first 24 hours of the episode). Diffusion-weighted MRI is the preferred imaging method. Rule out intracranial hemorrhage before starting aspirin (50–325 mg/day), plus extended-release dipyridamole or clopidogrel. Maintain BP \<140/90 mmHg.

Answer 104

1. **Emboli** (local obstruction of an artery), 2. **Thrombosis** (debris originating elsewhere that blocks an artery), 3. **Hemorrhage** -(2 types) 1. **Intracerebral** (bleed directly into the brain) 2. **Subarachnoid** (bleeding into subarachnoid space and CSF). The obstruction or bleeding causes permanent damage to the brain

Answer 105

**Atrial Fibrillation and Hypertension.** * Aneurysms, trauma, bleeding abnormalities, and use of anticoagulants (e.g., warfarin [Coumadin]) * Use of stimulants (cocaine/illicit drugs), sickle cell disease, diabetes, oral contraceptive use, smoking, and thrombophilia. * Blacks, Hispanics, and American Indians/Alaskan Natives have a higher prevalence of stroke. * An ischemic stroke is due to emboli that broke off from thrombus formation in the body; common locations are the lower extremities and the heart (atrial fibrillation).

Answer 106

A patient with embolic stroke presents with the abrupt onset of difficulty speaking, unilateral hemiparesis, and weakness of the arms or legs (or both). Patients with hemorrhagic stroke often initially present with severe headache, nausea/vomiting, photophobia, and nuchal rigidity that is accompanied by hemiparesis and difficulty speaking.

Answer 107

*Subarachnoid hemorrhage SAH or intracerebral hemorrhage (ICH):* Sudden onset of severe “thunderclap” headache that is described as “the worst headache of my life.” The pain from the headache may radiate to the neck or back. Rapid decrease in LOC (coma, death). SAH usually begins abruptly compared with more gradual ICH.

Answer 108

Vomiting is more common in hemorrhagic strokes (compared with embolic strokes). Usually caused by a ruptured aneurysm or vascular malformations. “Sentinel headache” may be seen in SAH. About 30% of patients have minor hemorrhagic episodes that present with sudden severe headache as the only symptom.

Answer 109

Signs and symptoms are dependent on artery involved. **Middle cerebral artery** is the largest cerebral artery, and it is the **most commonly affected by stroke**. For example: * *Left middle cerebral artery occlusion of the superior branch*: Right side of face, right arm, right leg weakness, hemianopia, with expressive aphasia (Broca’s area) * *Right middle cerebral artery:* Left side of face, left arm, left leg with hemineglect and possible hemianopia

Answer 110

Call 911. Assess the ABCs as soon as possible; check for airway patency, chest movement, breath sounds from both lungs, and circulation. Check vital signs and neuro status.

Answer 111

Assess the ABCs and stabilize patient. Initial imaging study in the ED is CT scan (without contrast) and then an MRI study. Time is critical; do not delay antithrombolytic therapy, and check blood glucose (must be \<180 mg). According to 2019 American Heart Association (AHA) Stroke Guidelines, **alteplase can be given up to 4.5 hours from start of symptoms.**

Answer 112

* Homonymous hemianopia:* Visual field loss involving either the two left halves (or the two right halves) of the visual field. Most common cause is stroke. There are many types of hemianopia. * Perform screening test:* Visual fields by confrontation.

Answer 113

Left sided Homonymous Hemianopia = Left side is blind The diagram at right shows the intact and missing visual fields of a person who has left-sided homonymous hemianopia. The “x” signifies the missing visual fields, and the “==” are the intact visual field.

Answer 114

Damage to **Temporal Lobe** ## Footnote ***Apraxia****:* Patient has difficulty performing purposeful movements. ***Broca’s aphasia:*** Also known as “expressive aphasia.” Patient comprehends speech relatively well (and can read) but has extreme difficulty with the motor aspects of speech. Speech length is usually less than four words. ***Wernicke’s aphasia:*** Also known as “receptive aphasia.” Patient has difficulty with comprehension but has no problem with producing speech. Reading and writing can be markedly impaired.

Answer 115

*Frontal lobe damage:* Affects intelligence, executive skills, logic, and personality reside. Damage will cause dementia, memory loss/difficulties, inability to learn.

Answer 116

Treatment includes **BP reduction, statins, antiplatelets, anticoagulants, and carotid revascularization.** Lifestyle and dietary changes help to reduce risk of stroke. Remove or treat the cause of the emboli (e.g., atrial fibrillation; control hypertension). *Rehabilitation:* Physical therapy, occupational therapy, speech therapy. Patient should be in the care of a neurologist.

Answer 117

* For embolic strokes:* Anticoagulation therapy; statin therapy; keep international normalized ratio (INR) between 2.0 and 3.0. * For hemorrhagic strokes:* Avoid heparin, warfarin, aspirin, NSAIDs.

Answer 118

Naproxen sodium (Naprosyn, Aleve) BID or ibuprofen (Advil, Motrin) TID to QID *Side effects:* GI pain/bleeding/ulceration, renal damage, increased BP in hypertension

Answer 119

sumatriptan succinate (Imitrex) injection, inhalant, PO tablets, or sublingual tablets. For acute pain, give injection subcutaneously (onset 10 minutes). *Side effects:* Nausea; dizziness; vertigo; drowsiness; discomfort of throat, nose, and/or tongue.

Answer 120

Contraindicated for patients with **cardiovascular comorbidities, since it causes vasoconstriction** (coronary artery spasm, MI, transient myocardial ischemia), arrythmias (atrial fibrillation, ventricular fibrillation, ventricular tachycardia). Triptans should not be given within **24 hours of an ergot.** Do not give within **14 days of an MAOI.**

Answer 121

ce pack on forehead; rest in quiet and darkened room Sumatriptan SC injection; use injection or nasal spray formulation triptan if severe nausea Ketorolac IM with antinausea injection Prochlorperazine IM for nausea

Answer 122

TCAs (Amitriptyline) Beta-blockers (propranolol, metoprolol, timolol) Do not use BB if age 60 or smoker/chronic lung disease, do not use it SNRI (Venlafaxine) especially if comorbid generalized anxiety disorder, panic disorder Anticonvulsant (Topiramate, Valproate) Do not use BB if age 60 or smoker/chronic lung disease, do not use it

Answer 123

High-Dose Steroids ## Footnote Refer to ED or ophthalmologist *stat* Screening Lab Test: ESR ↑

Answer 124

100% oxygen at 12 L/min; use mask; intranasal 4% lidocaine

Answer 125

May become **suicidal\*** Spontaneous resolution; can recur

Answer 126

Anticonvulsants Carbamazepine (Tegretol) or Phenytoin (Dilantin) Check Serum levels Use for several weeks to months; watch for drug interactions

Answer 127

NSAIDs, acetaminophen, hot bath/shower, massage Stress reduction, yoga, biofeedback

Answer 128

Acetaminophen (Tylenol) four times a day as needed *Side effects:* Hepatic damage Prophylaxis (must be taken to work daily)

Answer 129

*Tricyclic Antidepressants* * Amitriptyline (Elavil), nortriptyline, doxepin, or imipramine * Side effects: Sedation, dry mouth, confusion in older adults *Beta-Blockers* * Propranolol (Inderal LA) or atenolol (Tenormin) daily. Careful with older patients. * Contraindications: Second- or third-degree atrioventricular (AV) block, asthma, COPD, bradycardia

Answer 130

*Selective Norepinephrine and Serotonin Inhibitors* * Venlafaxine (Effexor) daily at bedtime. * Consider if patient has both migraine and depression, generalized anxiety disorder, panic disorder, chronic anxiety. *Antiseizure Medications* * Topiramate (Topamax) * If discontinuing drug, withdraw gradually over a few weeks to minimize risk of seizures or withdrawal symptoms

Answer 131

**Median nerve compression due to swelling of the carpal tunnel.** Commonly caused by activities that require repetitive wrist/hand motion. * Both hands affected in 50% of patients. * More common in women (3:1). * Other factors that increase risk are hypothyroidism, pregnancy, rheumatoid arthritis, and obesity.

Answer 132

An adult female patient complains of gradual onset (over weeks to months) of **numbness and tingling** (paresthesias) on the thumb, index finger, and middle finger areas. Hand grip of affected hand(s) is weaker. May complain of problems lifting heavy objects with the affected hand. Symptoms are worsened by **repetitive actions** of the hand or wrist and during sleep. Chronic severe cases involve **atrophy of the thenar** eminence (the group of muscles on the palm of the hand at the base of the thumb), which is a late sign. History of an occupation or hobby that involves frequent wrist/hand movements.

Answer 133

Tap anterior wrist briskly *Positive:* “Pins and needles” sensation of the median nerve over the hand after lightly percussing the wris

Answer 134

Engage in full flexion of wrist for 60 seconds *Positive:* Tingling sensation of the median nerve over the hand evoked by passive flexion of the wrist for 1 minute

Answer 135

Recognize both Tinel’s and Phalen’s signs (tests for carpal tunnel syndrome [CTS]) or compression of median nerve). Instead of being called CTS, may be called inflammation of the median nerve. Alternative headache remedy is an herb called butterbur. With the exception of muscle tension headaches, which are bilateral, all of the headaches seen on the exam (and notes) are unilateral.

Answer 136

* Muscle tension:* Causes band-like head pain; may last for days. * Migraines:* Can last from 3 hours to 72 hours. * Cluster:* Only headache accompanied by tearing and nasal congestion; severe pain is behind one eye/one side of head. Occurs several times a day. Spontaneously resolves. Seen more in middle-aged males. Treated with high-dose oxygen (contraindicated in COPD).

Answer 137

* Trigeminal neuralgia (tic douloureux):* Pain on one side of face/cheek is precipitated by talking, chewing, cold food, or cold air on affected area. * Giant cell arteritis/temporal arteritis:* Indurated temporal artery, pain felt behind eye/scalp. Treated with high-dose steroids or other anti-inflammatory medication. Untreated may lead to blindness.