Neuro Flashcards
Different gait abnormalities that are associated with various neurologic disorders
Magnetic Gait - normal pressure hydrocephalus
–Wide based, unsteady
–Feet stuck to the floor like magnets
Parkinsonian Gait
–Shuffle, no arm swing, slouched over
–Multiple steps to turn around
Symptoms of ischemic stroke and things you would be worried about
Symptoms start suddenly over the course of minutes
–Negative symptoms - take things away
–Unipolar
Facial droop, unipolar arm weakness, speech problems
Symptoms happen on the opposite side of the body from the stroke area
Left sided - Right hemiparesis, speech problems
Right sided - Left hemiparesis, visual/spatial problems
Things you would be worried about are last time known well to determine if tPA is indicated.
What is a hemorrhagic conversion
Blood flow is restored to a part of the brain that had been necrotic and when blood returns to this necrotic area, it immediately bleeds
What are the two types of stroke and how do we tell the difference?
Ischemic and hemorrhagic
Most common is ischemic caused by emboli
Able to tell difference with a non-contrast head CT stat to look for bleed
What is the Cincinnati Prehospital Stroke Scale
Facial droop
Arm drift
Speech difficulty
If 1/3 finds are abnormal, 72% probability of ischemic stroke. If all 3 are abnormal, 85% probability of ischemic stroke
How soon do we want to give tPA (window from last known well and window from arrival to the ED)
Want to give tPA within 3 hours of symptom onset and 1 hour of arrival to the ED
Can give up 4.5 hours if meets all criteria
Who might be appropriate for tPA
Inclusion criteria:
–Age 18 years or older
–Clinical diagnosis of ischemic stroke with a measurable neurological deficit
–Time of onset less than 3 hours
Exclusion criteria:
–Evidence of intracranial hemorrhage on non-contrast CT
–Clinical suspicion of subarachnoid hemorrhage even with normal CT
–CT shows multilobar infarct
–Hx of intracranial hemorrhage/stroke
–Uncontrolled HTN
–Current use of ACs
–Age >80
What systolic blood pressure should be goal s/p stroke
SBP> 140
Can give IV labetalol for treatment of HTN
Anticoagulation s/p stroke
Generally not indicated d/t the risk of hemorrhagic bleed.
ASA is the mainstay
Presentation of TIA
Sudden dimming or loss of vision (amaurosis fugax) unilaterally - ipsilateral
Half vision
Paresthesia of the contralateral arm, leg or face
Transient Aphasia
Slurred speech
Mental confusion
TIA is often an important warning sign that stroke may occur soon
Lasts less than 1 hour with no residual deficits
Two types of intracranial hemorrhage
Intra-axial hemorrhage (within the brain)
–Caused by rupture of aneurysms
–Difficult to treat because need to pass through brain tissue in order to get there
Extra-axial hemorrhage (just outside brain tissue)
–Epidural hemorrhage - between dura mater and skull - caused by trauma
—-Presents as LOC then lucid then deterioration then vomiting then LOC again
–Subdural hemorrhage - tearing of the bridging veins in the subdural space between dura mater and arachnoid mater
—-Can start slowly and progress over several days
–Subarachnoid hemorrhage - can result from trauma, rupture of aneurysms or ateriovenous malformations.
—-Worst headache of my life - sudden onset
Imaging and SAH
Non contrast Head CT can show SAH as long as sxs started within the last 6 hours.
A lumbar puncture will need to be done if negative NCHCT to assess for blood in CSF
Lumbar Puncture tubes
1: cell count and diff
#2: Chemistry (protein and glucose)
#3: Microbiology studies
#4: Cell count and diff again
Presentation and treatment of Brain Herniation
Presents as coma, abnormal posturing, vomiting, unequal pupils
Cushings Triad of Increased ICP:
-Increased SBP
-Decreased HR
-Slowing, irregular RR
Treatment: Hydralazine to lower the BP but not the HR
Intracranial hemorrhage treatment
Due to serious threat of respiratory failure, early intubation is often needed
Raise the head of the bed to >30 degrees
Medications:
–AntiHTN treatment to bring MAP <110
–Mannitol and hypertonic saline can reduce swelling of the brain
–Fosphenytoin is given in case of seizures
Surgery:
–If hematoma is greater than 3cm then surgery is required.
–External Ventricular drain (EVD) to drain excess CSF or blood to allow for swelling
Definition of brain death
Cerebral death - brain stem is still alive so HR and RR continue without aid but rest of brain is dead
Whole brain death is the death of cerebrum and brain stem - needs life support
–No response to pain
–Absent cranial nerve reflexes
–EEG shows no brainwave activity at all
The provider has an ethical responsibility, absent one’s own personal beliefs, to discontinue life support to a dead person
How to manage status epilepticus
Defined as seizure lasting longer than 30 mins
Given risk for threatened airway, should be intubated immediately
Medicines:
Diazepam 10mg IV over 2 minutes, may be repeated after 10 mins
Regardless of response to diazepam should give either:
–Phenytoin 18-20mg/kg IV at a rate of 50mg/min
or
–fosphenytoin 18-20 PE/kg at a rate of 150PE/min
If no response to diazepam and phenytoin:
Phenobarbital 10-20mg/kg IV at a rate of 50mg/min
Should be getting EEG
Symptoms of brain tumors
Generalized or focal disturbances of cerebral function
increased ICP
Personality changes
Intellectual decline
Emotional lability
Seizures
Headaches
Nausea
Types of brain tumors: Glioblastoma Multiforme
Presents commonly with nonspecific complaints and increased ICP
Rapidly progressive with a very poor prognosis
What is the most common primary tumor to metastasize to the brain
Lung carcinoma
