Neuro Flashcards
CNS involvement: WHERE + symptoms
-
Upper motor neuron: Sx in face, arm, leg
- Stroke, brain, neoplasm
-
Spinal cord: BL, sensory level, brisk reflexes
- transverse myelitis
- *always consider bowel and bladder w/spinal cord!
PNS involvement: WHERE + symptoms
- Radicular pattern: dermatome, e.g., shingle, radiculopathy. Radiculopathy changes with position!
- Neuropathy: Localized to distribution of nerve, weakness, loss of sensation, e.g., carpal tunnel
- Polymyositis: localized to muscle, muscle tenderness. E.g., statin myopathy
2 main questions for yourself when pt presents with a HA
- Primary vs secondary
- Dangerous to wait?
Examples of primary HAs
- Migraine
- Cluster headache
- Autonomic cephalgia
- Tension Type Headache
- Chronic daily Headache
- HA syndrome associated
Examples of secondary HAs
- Giant cell arteritis
- Brain infections
- Brain hemorrhage
- Idiopathic, intracranial HTN
- Low CSF pressure
- Car accidents – HA s/t muscle spasms
Sx & diagnostics of low CSF pressure HA
- Severe throbbing HA w/bending, lying down
- Nausea
- Normal neuro
- Possible CSF rhinorrhea
- May happen s/t car accidents, surgeries
- Imaging: cerebellum going into foramen magnum. CSF pressure is low, so brain sinks when stand.
Tx for Low CSF pressure HA
- Look for CSF leak (often cannot find)
- May heal on their own
- Managed w/pain meds
Cluster HA and gender
More women than men
BUT if men have HA, more likely to be cluster
Why do people often have visual symptoms (e.g., stars, black, flashes) before syncope?
Retina is highly vascular and metabolic, senses any difference in circulation
Types of partial seizures
Simple partial, complex partial, partial seizures with secondary generalization
Types of Generalized seizures
- Tonic-clonic (grand mal)
- Absence (petit mal)
- Myoclonic
S/S of stroke
- Sudden numbness or weakness of the leg, arm, or face
- Sudden confusion or trouble understanding
- Sudden trouble seeing in one or both eyes (amaurosis fugax – carotid artery plaque lands in central retinal artery then body clears)
- Sudden trouble walking, dizziness, loss of balance or coordination (brain hemorrhage)
- Sudden severe HA w/no known cause
2 types of stroke
Ischemic
Hemorrhagic: sudden is almost always vascular
Multiple mechanisms of stroke
4 cardinal signs of parkinsonism
- TREMOR
- Bradykinesia: most disabling
- Rigidity
- postural instability: late sign
Need 2 for Dx
3 clinical types of multiple sclerosis
- Relapsing
- secondary progressive: more insidious
- primary progressive: chronically progressive from onset
Tempo of cerebral mass lesions (tumor, subdural)
Progressive but fluctuating
(Cecil)
Tempo of seizures and migraines
Episodic course
(Cecil)
Tempos of strokes
Abrupt ictal onset with worsening for 3-5 days followed by partial or complete recovery
(Cecil)
Acute onset of neuro sx suggests
Vascular cause of seizure
(Cecil)
Subacute onset of neuro sx suggests
Mass lesion, e.g., tumor or abscess
(Cecil)
Waxing and waning course w/exacerbations and remissions of neuro sx indicates
Demyelinating cause
(Cecil)
Chronic and progressive neuro sx suggests
Degenerative cause
(Cecil)
What does fatigue indicate, in terms of neuro diagnosis?
- Not likely to reflect definable dz
- More likely outside of PNS or CNS
- Exceptions: neuromuscular junction DOs such as myasthenia gravis, UMN dz e.g., MS, diseases that cause EPS (e.g., parkinson’s), or impair sleep
(Cecil)
Imaging recommended for low back pain, with or w/o radiculopathy?
Not typically necessary unless red flags
- Recent significant trauma or minor trauma at >50yo
- Unexplained wt loss
- Unexplained fever
- Immunosuppression
- Hx cancer
- Hx prior local surgery
- Systemic do, bone or arthritic do
- IV drug use
- Age >70yo
- Focal neuro deficit w/progressive sx
- Duration >6w
- Thoracic spine pain
Most common causes of low back pain by age
Mechanical!!
- 20-40: muscle strain (back, unilateral, acute onset, worse w/standing and bending)
- 30-50: herniated nucleus pulposus (back, unilateral, acute onset w/prior episodes, worse w/sitting and bending)
- >50: OA (back, unilateral, insidious onset, worse w/standing)
- >60: spinal stenosis (leg, bilateral, insidious, worse w/standing)
(Cecil)
Most common cause of cardioembolic stroke
Afib
(Cecil)
Clinical manifestations / neuro deficits in setting of ischemic stroke
- Depends on involved vascular territory
- Embolic: usually maximal deficit at onset
- Atherothrombotic: may be stuttering onset
- “Abrupt onset of focal neuro deficit in distribution of a specific vascular territory”
(Cecil)
Initial labs for suspected stroke
At ED
- Partially to R/O other causes
- CBC & PLT
- PT/INR, aPTT, Glc, electrolytes, renal function tests, troponin, O2 sat
- Urgent ECG
- CT or MRI as soon as stable
Other tests depend on pt (pregnancy, tox screen, etc)
Significance of CBC in evaluation of stroke
WBCs: infective cause, e.g., Infective endocarditis; infection can also cause recurrence of sx in setting of prior stroke
Significance of polycythemia in setting of suspected stroke
Hyperviscosity can lead to occlusion of small intracranial vessels
Significance of thrombocytopenia in setting of suspected stroke
May reveal underlying coagulation disorder / contraindictation to tPA
Significance of glucose in setting of suspected stroke
Hypo and hyperglycemia may cause strokelike sx
Significance of impaired renal function in setting of suspected stroke
Risk factor for ischemic stroke, may increase risks of using thrombolytic and anticoagulant agents
Significance of electrolyte abnormalities in setting of suspected stroke
Can cause neuro sx, e.g., hyponatremia
Brain CT vs MRI in setting of suspected stroke
- CT: more accessible
- MRI: more likely to show acute ischemic injury, but not for pts w/metal implants, cardiac pacemakers, difficult in unstable pts
Treatments for ischemic stroke
tPA or endovascular therapy (if not tPA candidate)
How much time between symptom onset and tPA administration?
< 3 hours
No more than 4.5 hours
(Cecil)
Primary prevention of ischemic stroke
Healthy lifestyle
Treat RFs (afib, HTN, DM, carotid stenosis)
(Cecil)
Secondary prevention after TIA or stroke
- Lifestyle
- Antiplatelet if not C/Is – esp short term dual antiPLT tx (asa & clopidogrel)
- Tx risk factors
- Stenting or endarterectomy
(Cecil)
