Neuro Flashcards
red flags for secondary HA?
S: systemic s/s eg fever, immunocomp, known malignancy, autoimmune dz, coagulopathy,
N: neuro signs, new HA
O: sudden onset
O: age over 50
P: positional, papilledema, pulsatile tinnitus
define thunderclap HA
pain that reaches 7/10 in less than 1 minute
thunderclap HA ddx
bleeds: ICH, sentinel aneurysmal bleed
vascular: carotid dissection, RCVS, cerebral venous thrombosis, PRES
other: acute angle closure glaucoma, acute hydrocephalus,
criteria for LP without CT
normal sensorium, no focal neuro deficits, not immunosuppressed. can get LP before CT
RF for cerebral venous thrombosis
basically anything promoting hypercoag:
peripartum, OCP, recent surgery, protein c or s deficiency, factor 5 leiden etc
cerebral venous thrombosis presentation
variable: from progressive over weeks to thunderclap
can have benign presentation or also pt can have s/s raised ICP, seizures, coma etc
CT for cerebral venous thrombosis
CT venogram and NCCTH
4 types of HA pt who get neuroimaging (NCCTH) in ED
- HA and abn neuro finding (inclu aLOC)
- new sudden onset severe HA aka thunderclap
- HIV + with new HA
- new HA and age > 50 with normal neuro exam
what is PRES
a hypertensive emergency, pts have HTN, encephalopathy and severe HA or visual changes, seiures
what dx needs to be ruled out before dx of RCVS?
SAH
age at which GCA needs to be considered?
> 50
criteria for cluster HA
5 attacks that are:
sevre, unilateral, last 15-180 mins, have circadian or circannual pattern
POUND for migraines?
pulsatile, onset 4-72 hours, unilateral, n/v, disabling
also photo/phonobia
migraine cocktail
toradol, NS and maxeran.
can consider dex, benadryl,
occipital neuraligia? symptoms and cause
shooting/electric pain at posterior of head in distribution of occipital nerve, caused by chrnoic neck tension
can try occipitla nerve block
3 findings of IIH aka pseudotumour cerebri
HA, papilledema, normal neuro exam
most effective tx for post LP HA
epidural blood patch
carotid vs vertebral artery dissection symtptoms
both have HA, neck pain etc,
carotid will have anterior circ stroke s/s
vertebral will posterior stroke s/s
multiple ppl from same area presenting with HA, consider?
CO
ct findings of pituitary apoplexy?
cellar mass (it is a hemorrhage of pituiatary adenoma)
Post LP headache presentation and tx
Occurs within 2 days of LP, worse sitting/standing,
Give simple analgesics, give caffeine, or blood patch if refractory
Happens about 10% of LPs
2 types of hemorrhagic stroke
spontaneous SAH and intrcerebral hemm (aka intraparenchymal)
causes of spont SAH
75% aneurysm rupture, idiopathic, AVM, sympathomimetic drugs
SAH risk factors
HTN, smoking, excessive etoh, PCKD, famhx of SAH, marfan’s Ehlers-Danlos,
rule for SAH r/o
ottawa SAH rule: r/o’s SAH
under 40
no neck pain/stiffness
no LOC
non-exertional onset
not thunderclap
full neck ROM
work up for SAH
if < 6 hrs get NCCTH only, unless extremely high rish for SAH (even if very high risk, liklihood is <1 %)
if > 6 hrs and negative NCCTH –> need an LP or a CTA, there may be a clear indication for either (ie meningitis w/u or known aneurysm or r/o vascular lesion etc)
two CSF tests in SAH
xanthochromia and RBC count ( no definitive cutoff for this)
what is xanthochromia, what cutoff used in SAH LP
= yellowing of CSF d/y bilirubin
it is either + or negative
mgmt of SAH
try and prevent re-bleeding while balancing CPP.
aim for SBP between (ie may need to decrease)120-160 (but MAP > 80), using labetalol or nicardipine
reverse coagulopathy
pain and emsis control (can do before specific BP mgmt)
mgmt of raised ICP (A CLINICAL DIAGNOSIS)
-rasie HOB to 30 deg
-treat pain and emesis
-3 mL/kg of 3% saline (about 250 mL) or mannitol
-can hyperventilate for 1-2 hrs max, target pcos of 30-35 (last resort)
-neurosurg consult
-keep MAP > 80
what is more common spont SAH or spont intracerebral hemm
spont ICH is twice as common
RF for intracranial hmm
chornic HTN, aneurysm, AVM, brain tumour, cocaine, anticoagulants
blood pressure target for intracerebral hemm,
other big consierdation
SBP about 120-160, MAP> 80
reversal of anticoagulant
acute reversal of warfarin vs DOAC
warfrain: 10 mg vitamin K IV AND PCC dose varies with INR
DOAC: PCC 2000 IU
PCC =octaplex
3 main stroke types and %ages
ischemic 87%
non traumatic SAH 3%
intracerebral = 10%
3 types of ischemic strokes
embolic, thrmobotic, low-flow
onset of symptoms: stuttering vs immediate
suttering can be seen in thrombotic or low-flow
immediate is embolic
list stroke mimics
dont find time of onset in stroke, find the ______
last known well time = time pt was last seen normal, can be extrapolated rom texts messages, freshly made coffee etc
anterior cerebral artery strokes
contralateral leg weakness/numbness
Lt sided: motor aphasia
rt sided: motor hemineglect
Large vessel stroke syndromes
4 classic symptoms of posterior circ stroke
Ataxia
Nystagmus
Ams
vertigo
or 5 D’s
dizziniess
dysarthria
dystaxia
dysphagia
drowsiness
what vessels are postior circ
basilar, post cerebral, vertebral, cerebellar
MCA strokes
-hemiplegia (face and arms), sensory loss contralateral to lesion
-if left sided: aphasia, left gaze preference
if rt sided: left neglect, right gaze preference
%age of left side dominant
all right handed ppl and 80% Lt handed ppl
posterior cerebral artery stroke
contralateral hemianopsia
treatment of carotid and vertebral artery dissection
basically same as all other strokes, if within window can consider lytics, if not candidate give antiplatelets in consultation with neuro
target door to needle time:
<60 mins
why do ppl get CT and CTA in ? stroke
what is only imaging study strictly required to give lytics
NNCTH: r/o bleed, abcess, tumour etc - often acute strokes are not seen on non-con in the first few hours
CTA: look for vessel occlusion/stenosis and ID EVT candidates
BP mgmt in acute ischemic stroke
if no lytics let auto reg up to SBP 220
if lytics, need < 180/105 (including during tpa admin)
lytics inclusion criteria
lytics exclusion criteria
antiplatelets in acute ischemic stroke
if lytics given, no antiplatelets for first 24 hrs
if no lytics, give ASA in first 48 hrs (but asap)
EVT criteria
TIA work up/mgmt
clinical diagnosis. same work up as stroke, ie exclude mimics, then et NCCTH and then CTA. if lesions ID’d d/w neuro, but likely dapt for 3 weeks with loading doses then ASA
meds for lowering BP in acute atroke
labetalol 10-20 mg IV, then 2-8 mg/min
nicardipine
hydralazine
5 broad categories of delirium
primary CNS
systemic dz secondarily affecting CNS (legit almost anything)
exogenous toxins
drug withdrawl and pain
major trauma/surgery
delirium hallucination: auditory or visual?
visual usually
define delirium
fluctuating levels of attention and cognition
delirium screen?
DTS (highly sensitive) if + do B-cam (highly specific)
ddx of AMS/coma
DIMS- E where E is environment: CO, hypo/hyperthermia, hypercarbia, hypoxia
uncal herniaiton syndrome
medial temporal lobe compresses brainstem –> dLOC, then CN 3 gets compresesd leading to blown ipsilateral pupil that s down and out
when to consider non-convulsive status epilepticus?
when seizure activity has stopped, but pt is not awake in 30 mins
acute gait disturbance and AUD?
Wernicke’s, tx with IV thiamine
epilepsy definition
someone at risk for recurrent seizures
define status epilepticus and refractory status
seizure for >5 mins or 2 seizures without regaining normal consciousness in between
-refractory = seizing despite 2 or more IV anti-epileptics
general seizure classification (by morphology)
how long do absence seizure generally last?
a few seconds
simple vs complex focal seizure
simple = no alteration in consciousness
complex= consciousness is affected
important historical questions in ?seizure
presence of aura, abrupt vs gradual onset, loss of bowel/bladder, presence of oral injury, focal vs general
common seizure triggers
med changes (including new med, dose, brand name to generic), non-compliance, sleep deprivation, infection, electrolyte abn, increased strenuous activity, substance use/wd, head trauma/ICH, glucose, eclampsia hypo/hyperthermia
sequalae of seizures
aspiration, oral trauma/laceration, posterior should dislo,
todd’sparalysis
transient focal deficit after seizure that resolves within 48 hrs
common seizure mimic
syncope, PNES, hyperventilation syndrome, hypoglycemia, movement d/o, migraine
one test that can differentiate PNES from seizure
normal lactate shortly after seizure makes PES more likely… note usually clears within 30 mins
only tests needed if known seizure d/o and presenting with one seizure
glucose, pertinent medication levels
who gets CT head in seizure
first time seizure or change in seizure morphology or clinical concern for intracranial lesion (even if other cause ID’d)
mgmt of uncomplicated (ie < 5 mins of seizure)
turn on side, be ready to suction airway/bag when seizure stops, get IV access, have meds ready in case still seizing at 5 mins
does a first time seizure usually get anti-convulsants?
nope, not unless they are at known risk for more seizure (ie epileptic based on w/u)
status epilepticus algo
tx of eclamptic seizure
4 g magsul then 1g/hr infusion
ddx based on AVS, t-EVS, s-EVS
BPPV
vestibular neuritis
labyrinthitis
Meniere’s
Vesibular schwanoma
perilymph fistula
vestibular migraine
cereberlla/brainstem stroke
posterior circ TIA
cerebellar hemorrhage
what 2 criteria need to be present to do HINTS?
ongoing persistent vertigo AND spont or gaze evoked nystagmus
if pt cannot stand on own from vertigo, what needs to be ruled out?
central cause of vertigo
if s-EVS and DHT negative, what test is next? how do you do it?
suppine roll test, looks for Horizontal canal BPPV (second most common type).
pt lays on back, turn head to either side, + test if pure horizontal nystagmus
how to do DHT? what nystagmus is +?
upbeat and rotational.
pt wits up, lay them flat quickly with head hanging and turned to 45deg
how to do Epley?
start with DHT, then rotate head to other side, then turn onto lateral deubitus, then sit up.
hold each position for 30 seconds or for time the have vertigo plus another 30 seconds
how to do HINTS plus?
Head impulse: test vestibulo-ocular reflex (should be impaired in perpherla vertigo).
-gently move head back and forth, then move quickly to midline, pt should be looking at drs nose. if there is catch up saccade, reflex is effed and indicates peripheral vert
nystagmus: test for spont and gaze evoked nystagmus. if biderctional= central
test of skew: cover-uncover test
hearing loss- ifnew hearing loss, think central
how do you test for spont and gaze evoked nystagmus?
spont; pt looks straight ahead
gaze evoked, ask them to look side to side “staring through paper” as fixation can mask nystagmus
criteria for DHT?
vertigo, < 2 mins, brought on by head movement
AND
no spont or gaze evoked nystagmus
post epley plan
pt will still feel “off” for a few days.
if successful, d/c
if unsuccessful rpt once in ED
if second attempt not successful, pt to do at home bid until symptoms resolve and have them f/u with FP or physio
3 types of nytagmus on DHT
vertical/rotational = post canal (most common)
horizontal –> horizontal canal –> do supine roll test
if downward on DHT they may have ant canal BPPV
can AVS/central vertigo also worsen with head movement
YES
vertigo + what is central
dizziniess
dysarthria
dystaxia
dysphagia
drowsiness
aka D’s
typical nystagmus in vestibular neuritis
horizontal with rotational component, unidirectional… find this by testing for spont or gaze evoked nystagmus
should you ever do DHT and HINTS+ in same pt?
FUCK NO
what imaging should you get in ? cerebellar/brainstem stroke (aka post circ stroke)/
CT/CTA, obvs MRI is best but wont happen
second most common cause of vertigo in ED? very often missed
vestibular migraine (tx like migraine)
Diagnostic criteria for vestibular migraine
how does GBS present?
bilateral, ascending paralysis/weakness and hyporeflexia
typically preceded by infection or vaccination
mgmt of GBS
-assess resp status (use vital capacity)
- intubate prn, earlier the better
-IVIG and admission
what is Bell’s palsy
cranial nerve 7 palsy, results in unilateral facial parlaysis (whole face) as “stroke spares” forehead
2 things to r/o in Bells palsy
stroke and ear pathology (OM, mastoiditis, Ramsey Hunt)
tx of Bell’s palsy
steroids and antivirals, thought to be benefit but also no difference in a/e
pred 60 mg od for 1 week with valtrex 1 g po tid for 1 week
expected course of Bell’s palsy
most recover in 3/52, 15% will have permanent damage
potential complication of bell’s palsy
corneal injury, can prophylaxes with artificial tears
what is Ramsey Hunt
can cause bells palsy and is from HSV inner ear infection.. tx with steroids and antivirals
if acute or chronic neuropathy (central or peripheral) AND erythema migrans, tick bite or arthritis, consider _____
Lyme disease
Hall mark of ALS
Upper and lower motor neuron pathologies
Myasthenias pathophys
Autoimmune destruction of acetylcholine receptors at NMJ
Symptoms/signs of MG
Fatigable weakness, ocular muscle weakness (diploia, ptosis),
Ddx of MG
Botulism, lambert eaton
Acute myasthenic crisis
MG with resp distress, needs intubation, IVIG, PLEX
Often precipitated by meds, aka the “antis”
MG vs lambert eaton?
Similar pathophys, clinically weakness of LE gets better with repetition
Similar tx
Note LE is associated with underlying malignancy 1/2 the time
Treatment for acute MS flare?
Methyl prednisolone burst and taper
most common bact meningitis pathogens
strep pneumo
GBS
Neisseria meningitidis
H influenza
listeria
two of what 4 features are seen in most pts with bact meningitis
HA (most common), fever (second most common), neck stiffness, AMS
note: focal neuro symptoms/seizure happen 25% of time
RF for bact meningitis
coag related contraindications to LP
INR > 1.5, plts < 20
what to send CSF for in LP
Gram stain, culture, cell count, glucose, protein
how quickly can CSF sterilize after starting ABX
2 hours for meningococcal, 6 hrs for pneumococcal
Ct before LP criteria
CSF findings for bact vs viral meningitis
do you delay abx for neuroimaging or LP for ?meningitis
NEVER
empiric abx for ?batc meningitis in adults
CTX 2g and vanc 20 mg/kg
-add ampicillin if etoh, immunocomp or >50 years to cover listeria
-also add acyclovir if ?HSV
when is dex helpful in bact meningitis
if given at same time or before, in pneuomcoccal can reduce hearing loss and morbidity/mortality
10 mg IV q6h X 3 days
proph against close meningitis contacts
helpful in meningococcal or H influenza, give cipro 500 mg od X1 or ctx 250 IM X1.
to close contacts: household, exposed to secretions or those who intubate w/o PPE
dont need to give if exposure beyond 2/52
treatment for viral meningitis?
usually supportive, admit if toxic looking and wait for CSF culture to come back w/o bacteria, treat HSV meningitis with acyclovir
viral meningitis vs encephalitis symptoms
enceph has AMS, focal neuro symptoms, seizures
sources of brain abcess
otogenic
odontogenic
sinogenic
penetrating trauma
post neuroSx
idopathic
most common organism for spinal epidural abcess?
MSSA/MRSA
triad of spinal epidural abcess?
back pain (most common), fever, neuro deficits (only about 30% have all 3)
SEA diagnosis
need high index of suspicion
-normal CRP is sensitive, but obvs not specific
-BCx + 60% of time
-do not do LP if considering SEA
- MRI with gad is gold standard, CT no overly helpful
