Neuro Flashcards
What can unilateral HA be
Migraine, trigeminal neuralgia
What can temporal HA be
Temporal arteritis
What can occipital HA be
Tension HA
What can HA with eye association be
Acute glaucoma, temporal arteritis, sinusitis, migraine
What is the difference between HA with gradual vs sudden onset
Gradual = usually benign Sudden = may be more serious
HA characterized as pounding/pulsatile =
Migraine
HA characterized as sharp/stabbing =
Trigeminal neuralgia or cluster HA
HA characterized as pressure/squeezing =
Tension HA
HA associated with anxiety =
Tension HA
HA associated with auras =
Migraine
HA associated with vision change =
Temporal arteritis or gluacoma
HA associated with n/v =
Increased ICP or Migraine
HA associated with lacrimation/rhinorrhea =
Cluster HA
HA associated with photophobia/phonophobia =
Migraine or Meningitis
Migraines affect men or women more?
Women
At what age do migraines usually start? Disappear?
Onset = 10-14 y/o
Disappear in the 50’s
Depolarization theory of migraines =
Depressed activity areas lead to platelet and mast cell activation
Seratonin release may cause migraines how?
Fluctuations in catecholamine levels cause alternating vasoconstriction/vasodilation which causes wall stretching & pain
What are the types of migraines (the most often seen)
Common (w/o aura) or classic (with aura)
What are the indications for imagining in pt presenting with a migraine?
1st/worst migraine
New onset w/ age > 50y/o
Sudden onset HA ("thunderclap")
Abnormal neuro exam
Rapid onset with strenuous activity
HA awakens from sleep
Meningea signs (n/v, altered mental status, personality changes)What is the 1st line Tx of acute migraine?
Excedrin migraine or NSAIDs
What is 2nd line Tx for acute migraine?
Triptans or Dihydroergotamine (DHE-45)
What is the best Tx of migraine (not acute)
Triptans = Sumatriptan (Imitrex) or Treximet (sumatriptan + naproxen)
What are RFs for migraines
Family hx, obesity, sleep apnea, head injury, female,, analgesic overuse, & caffeine
What may cause a rebound HA
Overuse of medication for migraine (> 10 days of the month) especially Narcotics!
What is the Tx of rebound HA
Go cold turkey from the meds that are causing it, try triptan or steroids
When should you start migraine prophylaxis
> 2 HAs/week
Severe HA
Prolonged duration > 2 days
What is the best migraine prophylaxis med?
What else is an option?
Best = Propranolol LA (beta blocker) Other = tricyclic antidepressants or antiseizure drugs (not in preggos though!)
What is a major side effect of the antiseizure drugs?
Unwanted weight gain
What are common features of a Common Migraine
Pulsatile throbbing (50%) Unilateral HA (50%) Lasts hrs - days Associated with n/v Photophobia/phonophobia
What are common features of a Classic Migraine
Aura (20%)
Scintillating scotomas
Fortification spectrum
What is the prodrome phase
Increased excitability/irritability, fatigue, depression, appetite changes/cravings
Aura that occurs without a HA is called…
Acephalgic migraine
Sensory aura =
Numbness, paresthesia, dysphasia
What artery do basilar migraines effect?
What are the SxS?
Artery = basilar artery SxS = HA, vertigo, slurred speech, impaired coordination (younger pts) NO MOTOR DEFECTS
SxS of hemiplegic migraine =
Paralysis on one side of body, may persist x 24hrs w/ or w/o HA
SxS of ophthalmoplegic migraine =
HA, eye pain, vomitting, ptosis
Catemenial migraines occur with…
Menses
Usually disappear with menopause & pregnancy
Occurs 2-3x a day during menses
If a migraine is VERY refractory what might you try to use?
Lidocaine, caffeine protocols, or propofol infusions
What sex is cluster HA more common in
Men (4X more)
What is the main RF for cluster HA
Tobacco use - MUST QUIT
What are possible causes of cluster HA
Vascular dilation
Trigeminal nerve stimulation
Circadian rhythms
Pts with cluster HA will often complain they are triggered by…
Alcohol ingestion
Cluster HA SxS/description =
Excruciating stabbing pain (suicide HA)
Unilateral behind the eye, jaw, or teeth
Last 15min - 3hrs
What are the requirements to Dx cluster HA
Must have one of the following:
- Lacrimation, ipsilateral flushing/sweating, ipsilateral nasal DC, conjunctival redness, horner’s syndrome (ipsilaterl ptosis or miosis)
What is the Tx of cluster HA
Triptans
OXYGEN (20min) = complete relief in 78% of pts
Prophylaxis = break the cycle
What are the SxS of tension HA
Vice-like, gripping HA that forms a band across the forehead bilat
Radiates into posterior neck/trapezius
NO n/v, photo/phonophobia & not worse with activity
What is the Tx of tension HA
Non-pharm = exercise, relaxation therapy/counseling, yoga, PT, acupuncture Pharm = NSAIDs, Tylenol, myofascial trigger point injections, TCAs or SSRI
What is the origin of tension HA
It has a myofascial origin
RFs for tension HA
Stress/anxiety, depression, overwork, lack of sleep, posture, conversion syndrome
When does post-traumatic HA occur (be specific not a smart ass)
Within the first 7 days of the injury
Acute: < 2mo after injury; Chronic: >2mo after
What type of HA is it characterized as
Mix of migraine and tension HA
What do pts with post-traumatic HA often develop
Rebound HAs
How do you Tx post-traumatic HA
Hard to treat; treat as the HA it presents as and if that doesn’t work adjust Tx
What is idiopathic intracranial HTN (IIH) also called
Psuedotumor cerebri or benign intracranial HTN (BIH)
Who is most likely to have IIH
Women 15-44 y/o that are obese
What are the SxS of IIH
Retro-orbital pain (worse with movement) Throbbing (worse in morning) N/V Monocular/binocular vision loss Pulsatile tinnitus (60% of pts)
What is the MC PE finding with IIH
Papilledema
What are the diagnostics for IIH
LP opening pressure > 200
MRI neg for masses/hydrocephalus
What is the Tx of IIH
Lifestyle changes Diuretics NSAIDs/TCAs for HA management Large volume LP Sx in extreme cases
Prevelance of trigeminal neuralgia…sex & age =
Sex = women Age = >40y/o with peak of 60-70 y/o
What is the biggest risk for trigeminal neuralgia
Multiple Sclerosis (MS)
Which side is more commonly affected in trigeminal neuralgia
Right side
How is trigeminal neuralgia described
Stabbing, lancinating, electric shock pain that lasts about 2min and occurs multiple times a day or month but becomes more frequent over time
What causes trigeminal neuralgia
Demyelination of trigeminal nerve that causes pain even with light touch
What branches of the trigeminal nerve are MC affected in trigeminal neuralgia
Maxillary and mandibular
Temporal arteritis AKA…
Giant cell arteritis
What is GCA commonly associate with
Polymyalgia rheumatic (50%)
What are the SxS of temporal arteritis
Temporal HA
Jaw claudication
+/- diplopia, visual field cuts, and systemic manifestations
What will PE reveal for temporal arteritis
Tenderness over temporal arteries
Diminished pulses
How is temporal arteritis Dx
Temporal artery biopsy (pos 2 days after starting Tx)
What is the immediate Tx of temporal arteritis
Corticosteroids while biopsy results are being processed
What are the causes of a traumatic brain injury (TBI)
Penetrating injury or closed head injury
What is primary damage in TBI
Skull fx, contusion/bruising, hematomas/blood clots, lacerations, nerve damage (diffuse axonal injury)
What is secondary damage in TBI
Edema & infection
What are the main causes of concussion
Deceleration injury or coup-countercoup injury
Who is most likely to suffer a concussion
Athletes especially in contact sports
What are the main SxS of a concussion
Disorientation
Amnesia
Confusion (vacant stare, delayed answers, poor concentration)
What % of concussions result in LOC
10% will have LOC
What are the MOST COMMON SxS of concussion
HA, dizziness, & impaired executive function
What are the diagnostic tests for consussion
CT or MRI (although minor will appear normal)
What is a Grade 1 concussion
“Ding” concussion, confusion, no LOC, SxS last for < 15min
What is a Grade 2 concussion
No LOC, SxS last > 15min
What is a Grade 3 concussion
LOC
What is the gold standard for determining severity of a concussion
Gasglow Coma Scale
What constitutes as minor, moderate, and severe on the gasglow scale
Minor: 13-15
Moderate: 9-12
Severe: < 8
What is the best Tx of concussion
Rest
Who needs a CT with concussion
There is a long list. Main one to know is seizure, neruo deficits, and anticoagulation ABSOLUTELY requires CT
What is the problem with multiple concussion
It will take longer to heal each time, will result in more easily being concussed again, may lead to more severe issues (like post-concussion syndrome)
The typical course for an athlete to be cleared to resume play takes 5 days. What happens if the symptoms return at any point in that time
Player MUST STOP and rest until they are asymptomatic for 24hrs then they return to the level that they were at before
What is a basal skull fx
Fx at the base of the skull; accounts for % of Fx
What are the most prevalent SxS
Hemotympanum
Battles sign = mastoid process ecchymosis
Raccon eyes = periorbital ecchymosis
CSF leakage from nose/ears
Bleeding between the dura mater and arachnoid layer is called…
Subdural hematoma
Subdural hematoma is caused by…
Tearing of the “bridging veins” during a shearing injury (acceleration-deceleration injury)
What are major RFs for subdural hematoma
Age (elderly) and anticoagulation are major
SxS of subdural hematoma are…
Confusion Slurred speech HA Lethargy LOC N/V Weakness
What is the main diagnostic test? What is its classic result
CT scan
Crescent shape with midline shift of ventricle
What is the Tx of subdural hematoma
Small one = burr holes
Larger one = craniotomy to evacuate clots
Bleeding between the dura mater and skull is called
Epidural hematoma
Epidural hematoma is due to…
Trauma/skull fx
Epidural hematoma is caused by…
Tearing of the middle meningeal artery
What is the classic presentation of epidural hematoma
Initial LOC followed by lucid state
“Talk and die”
What is the diagnostic test of choice? What is the finding/result
CT
Shows biconcave lens (looks like lens with part outside and part inside skull)
What is the Tx for epidural hematoma
Surgical evacuation & ligation of bleeding vessels
Bleeding into the subarachnoid space is…
Subarachnoid hemorrhage
Subarachnoid hemorrhage is usually due to…
Rupture of a cerebral aneurysm (but can also be due to trauma)
What is the classic presentation of subarachnoid hemorrhage
Thunderclap HA or HA of a lifetime
What are other SxS of subarachnoid hemorrhage
HA N/V Stiff neck Confusion Seizure May report popping/snapping prior to HA
What is the diagnostic of choice for subarachnoid hemorrhage?
CT without contrast (best within 12hrs then sensitivity decreases)
What is the diagnostic test to do if CT is inconclusive for suspected subarachnoid hemorrhage
Lumbar puncture (LP); presence of blood is positive result
What is the Tx of subarachnoid hemorrhage
Depends on size, location, etc.
Tx includes clipping or coiling procedures
Which type of stroke is more common; hemorrhagic or ischemic?
Ischemic (87% of all strokes)
Which causes more hemorrhagic strokes…intracerebral hematoma (ICH) or subarachnoid hematoma (SAH)
Intracerebral hematoma
What is the main cause for hemorrhagic stroke
Ruptured berry aneurysm (80%)
AV malformations also cause hemorrhagic stroke; what are the SxS of this
Pulsatile tinnitus, HA, & seizures
Where do most aneursyms occur/develop
Develop at the branching points of arteries
Where is the most common location for an aneurysm to occur
Anterior communicating artery
Why is hemorrhagic stroke so important (think prognosis)
B/c 10-15% die before reaching the hospital and 25% within the 1st 24hrs
1/3 of survivors will have neuro deficits
What are the management goals for hemorrhagic stroke
SBP < 140-160 w/o fluctuations
Monitor cardiac dysrythmias
ICP monitoring (< 20mmHg)
Normothermia
What is a sentinel bleed
A small bleed or warning leak at the site several days before the larger event; accompanied by milder HA, neck stiffness, and nausea
What are complications of hemorrhagic stroke
Rebleeding
Hydrocephalus
Cerebral ischemia (d/t vasospasm)
What are the two causes/types of ischemic stroke
Thrombotic or embolic
Which is more common…thrombotic or embolic ischemic stroke
Thrombotic
What causes thrombotic ischemic stroke
Atherosclerosis (injured endothelial lining allows platelets to adhere -> plaque formation)
What is the origin of most embolic ischemic strokes
Carotid arteries & heart (a-fib vegetation)
What is the least common cause of ischemic stroke
Lucunar infarcts
What is a TIA
Transient ischemic attack; sudden onset of neurological deficit including speech, hemiparesis, and monocular blindness
What is amaurosis fugax
Sudden, monocular blindness described as a shade/curtain being pulled over the affected eye
What diagnostic test do you do for ischemic stroke
Head CT (or MRI)
TEE for uspected cardiac source
Carotid US for carotid artery stenosis
What is the main way to differentiate TIA vs CVA
TIA = symptoms resolve within 24hrs (most within 10 minutes)
Why is TIA cause for concern
Stroke follows TIA within 90 days in 20-25% of cases
If ischemia occurs at the anterior circulation what artery is commonly invovled
Anterior cerebral artery
What are the SxS of anterior circulation ischemia
Confusion, amnesia, personality change, cognitive change, contralateral hemiparesis & sensory impairment, if left there is expressive aphasia, & eyes deviate TOWARD affected side
If ischemia occurs at the anterior circulation what artery is MOST commonly invovled
Middle cerebral artery
What is a common SxS of middle cerebral artery infarct
Neglect of the affected side
If ischemia occurs in the posterior circulation what arteries are commonly affected
Posterior inferior cerebellar artery
Vertebrobasilar artery
Posterior cerebral artery
What are SxS of posterior ischemic stroke
Nystagmus, ataxia, vertigo, dysphagia, dysarthria
What is TPA
Tissue plasminogen activator = clot buster
What are the indications for TPA
Age > 18
NIH stroke scale of 5+
< 3hrs since onset of SxS
How quickly should TPA Alteplase be given
10% of dose as immediate bolus and remainder given within 60min
Are there risks with TPA? If so why use it?
Yes there are risk; increases risk for ICH but we still use it since it prevents 11-13 deaths and disability for every 100 pts (benefit > risk)
What is the most common complication in stroke pts
Depression (30%)
