Neuro

Question 1

Subarachnoid Hemorrhage

Answer 1

Cause: ruptured cerebral aneurysm

S&S: sudden and rapid onset of severe headache, “the worst headache of my life.” N/V, neck pain, or stiffness, photophobia, and visual changes. Rapid decline in LOC
Positive Brudzinski and/or Kernig signs
Vitals: HTN, high temp, tachy

Dx: unenhanced CT scan, can detect in first 24hr

Question 2

Acute Bacterial Meningitis

Answer 2

S&S: triad of fever, nuchal rigidity, and change in LOC
high fever, severe HA, stiff neck (nuchal rigidity), and meningismus w/ AMS. Classic purple petechial rashes, N/V, photophobia
Red flag: lethargy, confusion, coma

At risk: neonates, infant, and elderly

Dx: If risk of cerebral herniation, do CT prior to LP
LP: diagnosed with isolated bacteria

Tx:
Adults: Third-generation cephalosporin IV plus chloramphenicol IV
Older than age 50: Amoxicillin IV plus third-generation cephalosporin IV

Question 3

Acute stroke (Cerebrovascular Accident)

Answer 3

Embolic (87%) or hemorrhagic (13%)

S&S: acute stuttering/speech disturbance, one-sided facial weakness, and one-sided weakness of the arms and/or leg (hemiparesis). Severe headache

Risk: poorly controlled HTN, afib

Tx: ED
Initial imaging is non-contrast CT then MRI
Can give alteplase up to 4.5 hr from start of symptoms

Question 4

Multiple sclerosis

Answer 4

Patho: autoimmune dz, antibodies attack the myelin sheath, demyelination

S&S: Episodic visual loss or diplopia. Trouble w/ balance and walking, and numbness/parasthesias on one side of face. W/ urinary incontinence (75%) and/or bowel dysfunction (50%).
Positive Lhermitte sign: bending neck forward/flexion, an electric shock-like sensation down back

Dx: MRI of brain and spinal cord

Refer to neuro

Question 5

Giant Cell Arteritis (Temporal Arteritis)

Answer 5

S&S: Acute onset of headache at on one temple, pain can be excruciating/burning pain over temporal artery. Temple is indurated, reddened and cord-like temporal artery. Abrupt onset of visual disturbances and/or transient blindness of affected eye (amaurosis fugax). May c/o jaw claudication or pain.

At risk: PMR

Dx: high ESR and CRP
Temporal artery biopsy gold standard

Tx: refer to ophthalmologist or rheumatologist or ED
High dose steriods

Complications: can lead to blindness

Question 6

Folstein Mini-Mental State Exam (MMSE)

Answer 6

ORAL

Orientation (name, age, address, job, time/date/season)
Registration (Recite three unrelated words. Distract patient for 5 minutes, then ask the patient to repeat the words.)
Attention and calculation: Spell world backward or indicate serial 7s (subtract 7 starting at 100)
Language: While speaking to patient, look for aphasia (impairment in language resulting in difficulty speaking)

Question 7

Neuro maneuvers

Answer 7

Kernig’s Sign
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.

Brudzinski’s Sign
Passively flex/bend the patient’s neck toward the chest (Figure 1).
Positive: Patient reflexively flexes the hips and knee to relieve pressure and pain (due to inflammation of lumbar nerve roots).

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

Question 8

Acute mild traumatic brain injury (concussion)

Answer 8

S&S: confusion, headache, dizziness or vertigo, poor balance, and nausea and vomiting. Most do not lose consciousness. Can have antegrade and retrograde amnesia.
GCS 13-15 30 min after injury

Dx: needs noncontrast head CT

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

Question 9

Migraines

Answer 9

Aura: cotomas (blind spots on visual field) or flashing lights that precede the headache. Woman w/ fam history

S&S: gradual onset, throbbing behind one eye, photophobia, phonophobia, N/V. Can become bilateral

Tx:
Abortive - sumatriptan (imitrex)
-do not give w/ CVD dz
-supervise first dose
-risk of serotonin syndrome w/ SSRI or SNRI
-dont use w/in 2wk of MAOI
Ergotamine/caffeine (Cafergot):
-potent vasoconstrictors
-SE nausea

Mild-moderate = tylenol or NSAID

Moderate-severe = triptan or combo triptan/NSAID (Treximet)

Prophylaxis:
-beta-blocker, TCA, SNRI, anticonvulsants

Question 10

Migraine with Brainstem Aura (Basilar or Hemiplegic Migraines)

Answer 10

Rare type and subset of migraine with aura.

S&S: resemble stroke w/o hemiplegia ( unilateral or bilateral hemianopic visual disturbance, vertigo, ataxia, dysarthria with bilateral tingling, or numbness of the face)
Followed by throbbing occipital headache and nausea

Tx: same as migraine

Question 11

Polymyalgia Rheumatica

Answer 11

Cause: unk, inflammatory

Risk: Almost exclusively in people age 50 or older.

S&S: Bilateral joint stiffness and aching (lasting 30 minutes or longer, commonly in the morning hours “gel phenomenon”)
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.

Dx: high ESR and CRP

Tx: symptoms respond quickly to steroids

Question 12

Trigeminal Neuralgia (Tic Douloureux)

Answer 12

Cause: Compression of the nerve root, causing a unilateral facial pain that follows one of the branches of the trigeminal nerve (ophthalmic, maxillary, mandibular)

S&S: sudden unilateral pain on side of face or nose. Triggered by stimulus along the nerve. Pain is lacerating, can last a few minutes. Can be triggered by chewing, cold air.

Dx: Obtain MRI or CT scan to rule out a tumor/artery pressing on a nerve or M

Tx: High dose anti-convulsant (carbamazepine, Oxcarbazepine)

Question 13

Bell’s Palsy

Answer 13

Patho: unilateral facial paralysis d/t dysfunction of motor branch of facial nerve

Cause: suspected to be herpesvirus activation

SS&S Sudden facial paralysis. Sensation intact. Tears productive may stop. Trouble chewing/swallowing. Unable to fully close eye.

Tx: High dose oral glucocorticoids + valacyclovir or acyclovir within 3 days of onset
Artificial tears to protect eye

Complications: corneal ulceration, long term sequelae

Question 14

Cluster HA

Answer 14

S&S: Recurrent episodes of brief “ice-pick” (lacerating pain) excruciating pain behind one eye. Lacrimation, nasal congestion, and clear rhinitis. Conjunctival injection (red eyes), ptosis (droop eyelid), and miosis (constriction of pupil) on the ipsilateral side (same side as headache)

Tx:
For acute attack use high-dose oxygen, sumatriptan (imitrex). Can use melatonin in evenings.
Prophylaxis: CCB verapamil

Complications: inc risk of suicide

Question 15

Tension-type HA

Answer 15

Emotional/psychic stress in some people causes the muscles of the scalp and the neck to become chronically tense (or in contraction).

S&S: This is a bilateral headache that can last for several days. Pain feels “band like or squeezing,” dull and constant

Tx: NSAIDs
Can use combo w/ caffeine
Not recommended to use opioids, muscle relaxers or butalbital

Question 16

Medication-Overuse Headache (Rebound Headache)

Answer 16

LAsts 15 or more days per month after acute HA meds for 3 months

Tx: dc medication or taper

Question 17

Transient Ischemic Attack

Answer 17

Transient episode of neurologic dysfunction caused by focal ischemia (brain, spinal cord, or retinal ischemia) without acute infarction of the brain as seen in stroke
“ministroke” or “minor stroke.”
High risk for stroke

Signs and symptoms of CVA or stroke can be insidious and start a few days before the major episode occurs

The ABCD2 score (Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes) is a clinical prediction tool that helps to predict who is at high risk for suffering a subsequent stroke after a TIA within the next 7 days (Table 1). For an ABCD2 score of ≥3, refer patient to ED for hospitalization.

Question 18

Carpal Tunnel Syndrome

Answer 18

Median nerve compression due to swelling of the carpal tunnel.

S&S: gradual onset (over weeks to months) of numbness and tingling (paresthesias). Hand grip is weaker. Symptoms are worsened by repetitive actions of the hand or wrist and during sleep
Late sign: atrophy of the thenar eminence

Tinel’s Sign
Tap anterior wrist briskly
Positive: “Pins and needles” sensation of the median nerve over the hand after lightly percussing the wrist
Phalen’s Sign
Engage in full flexion of wrist for 60 seconds (Figure 2)
Positive: Tingling sensation of the median nerve over the hand evoked by passive flexion of the wrist for 1 minute