Neuro Flashcards
ABCD2 Score
- Age >=60
- Blood pressure (HTN)
- Clinical features
- speech disturbance but no unilateral weakness = 1
- unilateral weakness = 2
- Duration
- >= 10 min = 1
- >= 60 = 2
- Diabetes
Cutoffs for carotid endarterectomy
- >= 70% stenosis within 2 weeks
- some benefit for >= 50 % within 2 weeks
- with symptoms
Miller-Fisher variant of Guillain-Barre Syndrome
Ataxia, eye muscle weakness, areflexia but usually no limb weakness.
Classic Findings of Guillain-Barre Syndrome
Symmetric ascending paralysis with areflexia
Brachial Plexus arises from which spinal levels?
C4-T1
Definition: status epilepticus
- 5 minutes of either continuous seizure activity or 2 or more sequential seizures without full recovery of consciousness between the seizures
Definition: refractory status epilepticus
- sz continues despite 2 drugs
Lorazepam Dose Status Epilepticus
Lorazepam (best IV agent)
- 0.1 mg/kg, max 4 mg IV/IM, may repeat x 1 in 4 minutes
- onset 1-5 min (15-30 min IM), duration 12-24 h
Midazolam Dose Status Epilepticus
midazolam (best IM agent)
- 10 mg (0.2 mg/kg) IM x 1, no repeats
- onset 5-15 min, duration 1-6 h
- 5-10 mg (0.1-0.2 mg/kg) IV
- onset 1-5 min, duration 1-6 h
- 0.2 mg/kg intranasal (max 10 mg)
Lab work to differentiate between sz and PNES
- prolactin within 20 min of event > 2x ULN predictive or true sz but not perfect
- lactate rises causes WAG acidosis (resolves within 30 min)
Approach to sz in known epileptics
- check drug levels, glucose
- if low, give loading dose (PO or IV)
- DC home when stable
- if therapeutic and sz not more freq than expected, DC home
- if can’t check (keppra) and noncompliant, give usual home dose before DC
- If compliant and therapeutic and increased freq/duration of seizures, speak with neurology about adding on agents or adjusting dose
- f/u 1-3 days if changing dose
Approach to first-time sz
- plain CT Head, ext lytes, tox screen, CBC, ECG
- if no secondary cause, MTO, DC with f/u, no tx
-
children:
- > 6 months, single afebrile sz not requiring tx = DC home with outpt MRI if back to neuro baseline
- no routine labs needed in complex febrile or afebrile sz, use clinical picture
-
neonates:
- full septic workup + extended lytes + abx with any sz
- lactate, ammonia, amino acids + urine amino acids
Parasitic cause of sz in developing world
Neurocysticercosis
- most common cause sz in developing world
- CNS infection by larvae of taenia solium taperworm
- sz from parasite degenerating, leaving fibrosis
Baseline rate of aneurysms in gen pop
2-6%
Sensitivity of CT (-) for SAH
- CT (-): 98% sens @ 6 h, 90% @ 24 h, 50% @ 1 wk
How long does it take for xanthochromia to develop in SAH?
- 12h
SAH Treatment
- HOB 30 deg
- glu, temp control, reverse anticoag
- SBP < 140
- labetalol/nicardipine
- nimodipine 60 mg PO Q4h (start within 96 h of onset)
- for vasospasm, risk of which is greatest 2 days-3 weeks
Autonomic Dysreflexia
- in patients with spinal lesions/open neural tube defects
- paroxysmal sympathetic + parasympathetic hyperactivity initiated by stimuli below level of lesion
- bladder distension, fecal impaction, fracture
- sweating, flushing, ha, htn, bradycardia, piloerection
- tx is remove stimuli
Symptoms of Myesthenia Gravis
- prox muscle weakness relieved by rest
- facial and bulbar muscle weakness
- ptosis, diplopia, internuclear opthalmoplegia
- usually no sensory, reflex, or cerebellar deficits
Myesthenia Gravis (Read Through)
Evernote “Chronic Neurological Disorders”
Optic Neuritis
- usually monocular, painful vision + colour vision loss over several days
- often preceded by retrobulbar/extraocular muscle pain reproducible by periorbital palpation
- often RAPD (Marcus Gunn pupil)
- hallmark of MS
Multiple Sclerosis (Read Through)
“Chronic Neurological Disorders”
Lambert-Eaton Syndrome
- weakness that gets better with exercise
- hand grip increases in strength over time
- paraneoplastic syndrome
- no specific treatment, refer neuro/medicine
Parkinson’s Disease
- resting tremor
- cogwheel rigidity
- bradykinesias, akindesias
- impaired postural reflexes
- sensory deficits, extremity pain
- cardiac dysrhythmias, orthostatic hypotension, dyskinesias, dystonias from dopaminergic therapy
- sometimes drug holiday/reduction in dose may help, discuss with neuro
GBS Syndrome
- symmetric ascending paralysis, no sensory deficit
Classic GBS CSF Finding
- cytoalbuminologic dissociation (high protein, low WBC)
GBS (Read Through)
“Acute Peripheral Neurologic Disorders”
Bell’s Palsy
Important physical exam test
Tx
Dispo
- may be preceded by pain behind ear
- r/o otitis/mastoiditis
- test EOM (should be full)
- prednisone 1 mg/kg daily x 7d
- no benefit to antivirals
- patch eye if incomplete closure, f/u urgent optho
- if can close, artificial tears
- f/u GP or ENT within 7d
Ramsey Hunt Syndrome
- HZV of geniculate ganglion
- may also have CN VIII involvement with vertigo, nausea, hearing loss
- prednisone + valacyclovir 1 g TID x 7d
Botulism Clinical Syndrome
- descending, symmetric paralysis
- CN + bulbar affected first
- diplopia, dysarthria, dysphagia, blurred vision
- pupils often dilated, nonreactive –> important to differentiate from myesthenia which has normal pupils
- may have anticholinergic syndrome
- floppy infant with constipation and weak cry
- no sensory deficit, no pain
Botulism (Read Through)
“Acute Peripheral Neurologic Disorders”
Vertigo (Read Through)
“Vertigo”
Trigeminal Neuralgia
- tic douloureux
- severe pains lasting only seconds
- no pain between episodes
- tx: carbamazepine 100 mg PO BID –> GP to increase, refer to neurologist
Seizure Meds that can be measured
- phenytoin (Dilantin)
- carbamazepine (Tegretol)
- valproic acid (Epival)
