Neuro Flashcards by Kara Zabelny

In myasthenia gravis, what happens when you put ice on the patient’s eyelids?

Symptoms transiently resolve

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What is consistent with ophthalmoplegia, areflexia and descending paralysis? Also diplopia, dysphagia, and dry mouth

Botulism. Can be from wound infection, contaminated food, self-injection

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Recall a table of diagnostic tests and treatments for common causes of NM weakness

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How many patients with TBI also have a concurrent C-spine injury?

50%

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Which patients with TBI should get AEDs prophylactically?

GCS <10 or abnormal CT (mod-severe TBI)

Phenytoin or keppra are equally effective, give for 7 days

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Recall TBI grading

Mild- I- no visible injury (mortality 10%)

Moderate - II - cisterns open, <5mm MLS, mall high density lesions (mortality 14%)

Severe - III - cisterns compressed (mortality 34%)

Severe - IV- midline shift >5mm (mortality 56%)

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What are the indications for surgical interventions in SDH?

Craniotomy, not burr holes
>10mm or MLS >5mm. Mortality increases if after 4h. Give 24hr abx prophylaxis

Follow up CT in 36h. Rebleeds in 7%

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Which fluids in TBI are recommended?

Isotonic, non-glucose containing.

Not albumin (SAFE study)
Not too much blood (Hgb 7 no different than 10 in outcomes)
Not hypertonic

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What is the cerebral perfusion calculation and what is the goal?

CPP= MAP-ICP, goal 50-70

Max normal ICP 15

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What is the mechanism behind hyperventilation and reducing ICP?

Causes transient (min-hr) vasoconstriction to reduce blood flow therefore intracranial volume. Meant to be a bridge to definitive therapy
Don’t go under pCO2 30

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What are side effects of mannitol?

Dose 0.25-1gm/kg bolus q2-4hr

Onset 10-15m, max effect 20-60min

Target osmolarity 320

AKI if using more than 200g/day, volume depletion, hyperchloremic alkalosis

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What are hypertonic saline side effects?

Dose 2mL/kg bolus

Target osmolarity 320 and Na <155

Pulmonary edema, hyperchloremic acidosis, vein sclerosis

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What other agents can reduce ICP other than mannitol and 3% NS?

Steroids for tumorgenic edema
Barbituates (but no clinical benefit)
Hypothermia (no clinical benefit)

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What is the preferred timing for craniotomy for elevated ICP

Early- lowers ICP dramatically, but had more unfavorable outcomes

Late- similar good recovery and better mortality

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What thresholds show a positive apnea test?

Start with initial pCO2 35-45, abort for hypoxemia, observe for 10min, pCO2 >60 or 20+ above baseline

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When is ancillary testing for brain death indicated?

Uncertain clinical exam, severe face/head injury, inability to do apnea test (high cord injury/pulmonary disease)

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What options are there for ancillary testing for brain death?

Cerebral angiography
NM scan
TCD
CTA
MRA
EEG (flat for 30min)

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Which causes of seizure are better prognosis versus worse?

Better- AED noncompliance, ETOH, CVA

Worse- hypoxemia, CNS infection, tumor, head trauma

Poor patient prognostic factors: elderly, prolonged seizures, focal onset, medical comorbidities

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What is first line therapy for in-hospital status epilepticus?

Benzos.
Lorazepam- 0.1mg/kg (4mg), 60-90% initial control, slower onset but fewer recurrences, tighter GABA binding

Diazepam- 0.15mg/kg (10mg) faster onset, 42-76% initial control, 50% recurrence within 2hr, rectal form available, can cause vein irritation

Midazolam- 0.25mg/kg (10mg), 42-76% initial control, IM/IV/nasal/buccal, better initial control than lorazepam with no difference in intubation rates or seizure recurrence

What is second line therapy for status epilepticus?

Phenytoin- 18-20mg/kg, can have hypotension and arrhythmias (limit infusion rate to <50mg/min), not dextrose compatible, has propylene glycol

Fosphenytoin- 15-20mg/kg, pro-drug that needs 15min to convert, hypotension (limit to 100-150mg/min), dextrose compatible, available in IM

What is third line therapy in status epilepticus?

In no particular order:
Pentobarbital
Propofol
Phenobarbital
Continuous BZ infusion
Levetiracetam
Valproate

What are the examples of EEG waveforms given in the lecture that are comparable to EKG waveforms?

VT = seizures
Fine VF = normal
Asystole = dead
Asystole with PVCs in between = burst suppression

If patients have seizures lasting 30+ minutes and coma, how many develop non-convulsive status afterwards?

1/2 within 24hrs of termination

Which brain injury benefits from prophylactic seizure medications?

mod-severe TBI/acute SDH
7 days

What are examples of stroke mimickers?

Hypoglycemia Migraine Seizure Tumor Abscess West Nile Wernicke's Aortic dissection Intoxication Contusion/trauma Na+/Ca++

When can late tpa (up to 9h) be considered?

If there is a large penumbra

What are the risk factors for hemorrhagic conversion after ischemic stroke?

Hypodensity/edema/mass effect on CT (particularly if more than 1/3 MCA distribution), hyperglycemia/Hx DM, Hx CHF, increased time to tPA, increased age

What are the contraindications for tpa?

All times: BG<50, head trauma within 3m, Hx ICH/SAH, brain tumor, active hemorrhage, arterial puncture, platelets <100, heparin with elevated PTT, warfarin with INR >1.7, oral DIT/Xai with abnormal coags, SBP >185 or DBP >110 3-4.5h: 80+yo, NIHSS >25, oral AC, Hx DM with prior stroke Relative: major surgery <14d, GI/GU bleed<21d, seizures, rapidly improving symptoms, MI within 3m, pregnancy

Who is a candidate for endovascular therapy for ischemic strokes?

Pre-stroke Rankin score 0-1, received tPA within 4.5h, large vessel occlusion on CTA, NIHSS>6, best within 6h of symptom onset, use a stent retriever, and comprehensive stroke center May benefit if there's a penumbra up to 24hr (20cc in 80+yo, 30cc in <80, 30-50cc if NIHSS >20 and under 80yo)

What are guidelines for post-ischemic stroke care?

ASA within 24-48h, add plavix for TIA?NIHSS <3, high intensity statin, ICU glucose ranges, treat fevers, SBP under 85 prior to tpa and under 180 after tpa, SBP under 220 if no tpa Avoid: albumin, pentoxifylline, ticagrelor, TTM, hyperbaric oxygen, early mobilization, hypervolemia

When does edema from hemorrhagic stroke occur?

peaks day 5-7

When is ICP monitoring appropriate for hemorrhagic stroke?

GCS <9, hydrocephalus, IVH, exam that suggests herniation

How do you treat warfarin coagulopathy in hemorrhagic stroke?

4 factor PCC (vit K and FFP is slower and lower volume) but otherwise no different in outcomes

Does blood pressure control improve functional outcomes in hemorrhagic stroke?

No, just reduces clot expansion

When is surgical management indicated for hemorrhagic stroke?

Cerebellar bleeds if clot >3cm or if there's brainstem compression or hydrocephalus stereotactic catheter delivered tPA reduced clot size/edema but unclear benefit

What are guideline recommendations for post hemorrhagic stroke management?

Keep SBP<180, DVT ppx at 48h, 4PCC for warfarin, ICP monitor for coma/IVH/herniation/hydrocephalus, surgery for cerebellar or superficial clot, restart anticoagulation during hospitalization Avoid: seizure ppx, recombinant favor VII, hypervolemia, steroids, surgery for deep clots, platelet transfusions for aspirin

What cranial nerve is most commonly affected by a SAH?

3rd nerve palsy

What LP features are consistent with SAH?

Increased opening pressure RBCs if early, xanthochromia if late

What is the BP goal for epidural hematomas?

None- HTN is compensatory. Let it ride.

What treatments are available for dysautonomia due to GBS?

fludrocortisone for volume expansion and midodrine for vascular tone

What neurologic symptoms do you see if fat embolism?

Neuro dysfunction, but not typically coma

What are the common causes of SAH

Cerebral aneurysms, vasculitis, cerebral or spinal AVMs

What are the features of neurogenic shock

Reduced sympathetic tone, hypotension, bradycardia. See in injuries above T6

What are AC reversal agents?

Warfarin- FFP and vit K Apixaban/factor Xa inhibitiors- andexanet alfa or 4FPCC Dabigatran (direct thrombin inhibitor)- idarucizumab

What are the features of acute disseminated encephalomyelitis?

Postinfectious autoimmune encephalopathy which attacks white matter and spares cortical gray matter. See elevated CSF WBC and IgG index. A variant called acute hemorrhagic leukoencephalititis can have multifocal hemorrhage and patchy demyelination. Tx with steroids. Plasmaphoresis is second line. IVIG as last ditch