Neuro Flashcards
1
Q
red flags for secondary HA?
A
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
2
Q
define thunderclap HA
A
pain that reaches 7/10 in less than 1 minute
3
Q
thunderclap HA ddx
A
bleeds: ICH, sentinel aneurysmal bleed
vascular: carotid dissection, RCVS, cerebral venous thrombosis, PRES
other: acute angle closure glaucoma, acute hydrocephalus,
4
Q
criteria for LP without CT
A
normal sensorium, no focal neuro deficits, not immunosuppressed. can get LP before CT
5
Q
RF for cerebral venous thrombosis
A
basically anything promoting hypercoag:
peripartum, OCP, recent surgery, protein c or s deficiency, factor 5 leiden etc
6
Q
cerebral venous thrombosis presentation
A
variable: from progressive over weeks to thunderclap
can have benign presentation or also pt can have s/s raised ICP, seizures, coma etc
7
Q
CT for cerebral venous thrombosis
A
CT venogram and NCCTH
8
Q
4 types of HA pt who get neuroimaging (NCCTH) in ED
A
- 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
9
Q
what is PRES
A
a hypertensive emergency, pts have HTN, encephalopathy and severe HA or visual changes, seiures
10
Q
what dx needs to be ruled out before dx of RCVS?
A
SAH
11
Q
age at which GCA needs to be considered?
A
> 50
12
Q
criteria for cluster HA
A
5 attacks that are:
sevre, unilateral, last 15-180 mins, have circadian or circannual pattern
13
Q
POUND for migraines?
A
pulsatile, onset 4-72 hours, unilateral, n/v, disabling
also photo/phonobia
14
Q
migraine cocktail
A
toradol, NS and maxeran.
can consider dex, benadryl,
15
Q
occipital neuraligia? symptoms and cause
A
shooting/electric pain at posterior of head in distribution of occipital nerve, caused by chrnoic neck tension
can try occipitla nerve block
16
Q
3 findings of IIH aka pseudotumour cerebri
A
HA, papilledema, normal neuro exam
17
Q
most effective tx for post LP HA
A
epidural blood patch
18
Q
carotid vs vertebral artery dissection symtptoms
A
both have HA, neck pain etc,
carotid will have anterior circ stroke s/s
vertebral will posterior stroke s/s
19
Q
multiple ppl from same area presenting with HA, consider?
A
CO
20
Q
ct findings of pituitary apoplexy?
A
cellar mass (it is a hemorrhage of pituiatary adenoma)
21
Q
Post LP headache presentation and tx
A
Occurs within 2 days of LP, worse sitting/standing,
Give simple analgesics, give caffeine, or blood patch if refractory
Happens about 10% of LPs
22
Q
2 types of hemorrhagic stroke
A
spontaneous SAH and intrcerebral hemm (aka intraparenchymal)
23
Q
causes of spont SAH
A
75% aneurysm rupture, idiopathic, AVM, sympathomimetic drugs
24
Q
SAH risk factors
A
HTN, smoking, excessive etoh, PCKD, famhx of SAH, marfan’s Ehlers-Danlos,
25
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
26
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)
27
two CSF tests in SAH
xanthochromia and RBC count ( no definitive cutoff for this)
28
what is xanthochromia, what cutoff used in SAH LP
= yellowing of CSF d/y bilirubin
it is either + or negative
29
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)
30
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
31
what is more common spont SAH or spont intracerebral hemm
spont ICH is twice as common
32
RF for intracranial hmm
chornic HTN, aneurysm, AVM, brain tumour, cocaine, anticoagulants
33
blood pressure target for intracerebral hemm,
other big consierdation
SBP about 120-160, MAP> 80
reversal of anticoagulant
34
acute reversal of warfarin vs DOAC
warfrain: 10 mg vitamin K IV AND PCC dose varies with INR
DOAC: PCC 2000 IU
PCC =octaplex
35
3 main stroke types and %ages
ischemic 87%
non traumatic SAH 3%
intracerebral = 10%
36
3 types of ischemic strokes
embolic, thrmobotic, low-flow
37
onset of symptoms: stuttering vs immediate
suttering can be seen in thrombotic or low-flow
immediate is embolic
38
list stroke mimics
39
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
40
anterior cerebral artery strokes
contralateral leg weakness/numbness
Lt sided: motor aphasia
rt sided: motor hemineglect
41
Large vessel stroke syndromes
42
4 classic symptoms of posterior circ stroke
Ataxia
Nystagmus
Ams
vertigo
or 5 D's
dizziniess
dysarthria
dystaxia
dysphagia
drowsiness
43
what vessels are postior circ
basilar, post cerebral, vertebral, cerebellar
44
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
45
%age of left side dominant
all right handed ppl and 80% Lt handed ppl
46
posterior cerebral artery stroke
contralateral hemianopsia
47
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
48
target door to needle time:
<60 mins
49
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
50
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)
51
lytics inclusion criteria
52
lytics exclusion criteria
53
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)
54
EVT criteria
55
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
56
meds for lowering BP in acute atroke
labetalol 10-20 mg IV, then 2-8 mg/min
nicardipine
hydralazine
57
5 broad categories of delirium
primary CNS
systemic dz secondarily affecting CNS (legit almost anything)
exogenous toxins
drug withdrawl and pain
major trauma/surgery
58
delirium hallucination: auditory or visual?
visual usually
59
define delirium
fluctuating levels of attention and cognition
60
delirium screen?
DTS (highly sensitive) if + do B-cam (highly specific)
61
ddx of AMS/coma
DIMS- E where E is environment: CO, hypo/hyperthermia, hypercarbia, hypoxia
62
uncal herniaiton syndrome
medial temporal lobe compresses brainstem --> dLOC, then CN 3 gets compresesd leading to blown ipsilateral pupil that s down and out
63
when to consider non-convulsive status epilepticus?
when seizure activity has stopped, but pt is not awake in 30 mins
64
acute gait disturbance and AUD?
Wernicke's, tx with IV thiamine
65
epilepsy definition
someone at risk for recurrent seizures
66
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
67
general seizure classification (by morphology)
68
how long do absence seizure generally last?
a few seconds
69
simple vs complex focal seizure
simple = no alteration in consciousness
complex= consciousness is affected
70
important historical questions in ?seizure
presence of aura, abrupt vs gradual onset, loss of bowel/bladder, presence of oral injury, focal vs general
71
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
72
sequalae of seizures
aspiration, oral trauma/laceration, posterior should dislo,
73
todd'sparalysis
transient focal deficit after seizure that resolves within 48 hrs
74
common seizure mimic
syncope, PNES, hyperventilation syndrome, hypoglycemia, movement d/o, migraine
75
one test that can differentiate PNES from seizure
normal lactate shortly after seizure makes PES more likely... note usually clears within 30 mins
76
only tests needed if known seizure d/o and presenting with one seizure
glucose, pertinent medication levels
77
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)
78
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
79
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)
80
status epilepticus algo
81
tx of eclamptic seizure
4 g magsul then 1g/hr infusion
82
ddx based on AVS, t-EVS, s-EVS
83
BPPV
84
vestibular neuritis
85
labyrinthitis
86
Meniere's
87
Vesibular schwanoma
88
perilymph fistula
89
vestibular migraine
90
cereberlla/brainstem stroke
91
posterior circ TIA
92
cerebellar hemorrhage
93
what 2 criteria need to be present to do HINTS?
ongoing persistent vertigo AND spont or gaze evoked nystagmus
94
if pt cannot stand on own from vertigo, what needs to be ruled out?
central cause of vertigo
95
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
96
how to do DHT? what nystagmus is +?
upbeat and rotational.
pt wits up, lay them flat quickly with head hanging and turned to 45deg
97
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
98
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
99
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
100
criteria for DHT?
vertigo, < 2 mins, brought on by head movement
AND
no spont or gaze evoked nystagmus
101
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
102
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
103
can AVS/central vertigo also worsen with head movement
YES
104
vertigo + what is central
dizziniess
dysarthria
dystaxia
dysphagia
drowsiness
aka D's
105
typical nystagmus in vestibular neuritis
horizontal with rotational component, unidirectional... find this by testing for spont or gaze evoked nystagmus
106
should you ever do DHT and HINTS+ in same pt?
FUCK NO
107
what imaging should you get in ? cerebellar/brainstem stroke (aka post circ stroke)/
CT/CTA, obvs MRI is best but wont happen
108
second most common cause of vertigo in ED? very often missed
vestibular migraine (tx like migraine)
109
Diagnostic criteria for vestibular migraine
110
how does GBS present?
bilateral, ascending paralysis/weakness and hyporeflexia
typically preceded by infection or vaccination
111
mgmt of GBS
-assess resp status (use vital capacity)
- intubate prn, earlier the better
-IVIG and admission
112
what is Bell's palsy
cranial nerve 7 palsy, results in unilateral facial parlaysis (whole face) as "stroke spares" forehead
113
2 things to r/o in Bells palsy
stroke and ear pathology (OM, mastoiditis, Ramsey Hunt)
114
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
115
expected course of Bell's palsy
most recover in 3/52, 15% will have permanent damage
116
potential complication of bell's palsy
corneal injury, can prophylaxes with artificial tears
117
what is Ramsey Hunt
can cause bells palsy and is from HSV inner ear infection.. tx with steroids and antivirals
118
if acute or chronic neuropathy (central or peripheral) AND erythema migrans, tick bite or arthritis, consider _____
Lyme disease
119
Hall mark of ALS
Upper and lower motor neuron pathologies
120
Myasthenias pathophys
Autoimmune destruction of acetylcholine receptors at NMJ
121
Symptoms/signs of MG
Fatigable weakness, ocular muscle weakness (diploia, ptosis),
122
Ddx of MG
Botulism, lambert eaton
123
Acute myasthenic crisis
MG with resp distress, needs intubation, IVIG, PLEX
Often precipitated by meds, aka the “antis”
124
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
125
Treatment for acute MS flare?
Methyl prednisolone burst and taper
126
most common bact meningitis pathogens
strep pneumo
GBS
Neisseria meningitidis
H influenza
listeria
127
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
128
RF for bact meningitis
129
coag related contraindications to LP
INR > 1.5, plts < 20
130
what to send CSF for in LP
Gram stain, culture, cell count, glucose, protein
131
how quickly can CSF sterilize after starting ABX
2 hours for meningococcal, 6 hrs for pneumococcal
132
Ct before LP criteria
133
CSF findings for bact vs viral meningitis
134
do you delay abx for neuroimaging or LP for ?meningitis
NEVER
135
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
136
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
137
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
138
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
139
viral meningitis vs encephalitis symptoms
enceph has AMS, focal neuro symptoms, seizures
140
sources of brain abcess
otogenic
odontogenic
sinogenic
penetrating trauma
post neuroSx
idopathic
141
most common organism for spinal epidural abcess?
MSSA/MRSA
142
triad of spinal epidural abcess?
back pain (most common), fever, neuro deficits (only about 30% have all 3)
143
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
