Neuro Flashcards
Described as sudden, transitory losses of neurologic function that come on without headache and resolve spontaneously leaving no neurologic sequela.
Transient Ischemic Attacks
Most common origin of TIAs
high grade stenosis (>70%) of the internal carotid artery, or an ulcerated plaque at the carotid bifurcation
Why do we care about TIAs, and what should we do about them?
They are predictive of stroke. Elective endarterectomy can prevent or minimize risk.
Workup and tx of TIAs
Duplex scanning (Ultrasound + Doppler). Surgery (endarterectomy) if a plaque explains the symptoms. Angioplasty and stent can be done if you first put in a filter to stop debris from embolizing to the brain.
Suspect this in a pt who has a stroke w/o headache, and neurological deficits are there >24 hours and leave permanent sequelae
Ischemic stroke.
P.S. In general, ischemic strokes are painless, while hemorrhagic strokes are painful.
Suspect this in a hypertensive pt who gets extreme sudden headache and gets neurological deficits.
Hemorrhagic stroke.
P.S. In general, ischemic strokes are painless, while hemorrhagic strokes are painful.
Imaging you order for stroke, both ischemic and hemorrhagic
CT scan
Goals in tx of ischemic and hemorrhagic stroke patients
Ischemic: Identify lesions that will cause another, look for hemorrhage, and just rehabilitate. If w/in 90 minutes, tPA can help bust the clot.
Hemorrhagic: Control hypertension, rehabilitate.
Suspect this in a pt complaining of extremely severe headache of sudden onset, like no other ever experienced before (a “thunderclap,” a headache that is “sudden, severe, and singular”).
Subarachnoid bleeding from intracranial aneurysms.
Because the blood is in the subarachnoid space (there is no hematoma pressing on the brain), there may be no neurologic findings at all, and the patient is sent home. Luckier patients may have meningeal irritation and nuchal rigidity, and be recognized. Those not recognized often return in 10 days with another bleed, perhaps this time a much worse one (the early one is referred to as the “sentinel bleed”).
Workup for subarachnoid bleeding from intracranial aneurysms
CT scan looking for blood in the subarachnoid space (spinal tap can identify old blood or small amounts of current blood, but it should never be the first test; always start with the CT) and follows with arteriogram to locate the aneurysm (a little devil off the circle of Willis)
Suspect this in a pt w/ progressively increasing headache for several months, worse in the mornings, and eventually accompanied by signs of increased ICP: blurred vision, papilledema, projectile vomiting-and at the extreme of the spectrum, bradycardia and hypertension (due to the Cushing reflex).
Think Brain tumor.
Suspect this brain tumor in a pt w/ inappropriate behavior, optic nerve atrophy on the side of the tumor, papilledema on the other side, and anosmia (Foster-Kennedy syndrome).
Tumor at the base of the frontal lobe
Suspect this brain tumor in youngsters who are short for their age, and show bitemporal hemianopsia and a calcified lesion above the sella on X-rays
Craniopharyngioma
Suspect this brain tumor in women who have amenorrhea and galactorrhea
Prolactinomas
Therapy for prolactinomas
bromocryptine
Consider this in a pt w/ huge hands, feet, tongue, and jaws (and in the USMLE exam by the picture of a man showing both hands on either side of his face in the frontal view, and a long prominent jaw in the lateral view). Additionally, there is hypertension, diabetes, sweaty hands, headache, and the history of wedding bands or hats that no longer fit.
Acromegaly
What causes acromegaly. How can you treat it?
Overproduction of growth hormone by the pituitary gland. Surgical resection if it’s a tumor.
Suspect this in a pt w/ history that suggests pituitary tumor (headache, visual loss, endocrine problems), and the acute episode starts with a severe headache followed by signs of increased compression of nearby structures by the hematoma (deterioration of remaining vision, bilateral pallor of the optic nerves) and pituitary destruction (stupor and hypotension)
Pituitary apoplexy (bleeding into a pituitary tumor)
Tx for pituitary apoplexy
Steroid replacement is urgent. Eventually other hormones will need to be replaced too.
Suspect this in a pt w/ loss of upper gaze and the physical finding known as “sunset eyes” (Parinaud syndrome)
Pineal gland tumor
Classical presentation of brain tumors in children
They are usually in the posterior fossa. They produce cerebellar symptoms (stumbling around, truncal ataxia) and the children often assume the knee-chest position to relieve their headache.
Classic presentation of brain abscess
Many of the same manifestations of brain tumors (it is a space-occupying lesion), but a much shorter timetable (a week or two). There is fever, and usually an obvious source of the infection nearby, like otitis media and mastoiditis.
Suspect this in an older (60’s) patient with extremely severe, sharp shooting pain “like a bolt of lightning” in the face, brought about by touching a specific area and lasting about 60 seconds. Normal neuro exam, but they might have an unshaven area in the face (the trigger zone, which the patient avoids touching)
Trigeminal neuralgia (tic douloureaux)
Suspect this in a patient who, several months after a crushing injury, develops constant, burning, agonizing pain that does not respond to the usual analgesics. The pain is aggravated by the slightest stimulation of the area. The extremity is cold, cyanotic, and moist.
Reflex sympathetic dystrophy (causalgia)
Dx and Tx of reflex sympathetic dystrophy
Successful sympathetic block is diagnostic.
Surgical sympathectomy is curative.
Most common cervical spine level involved in trauma?
C2. Followed by C6-7
This cervical level supplies the shoulders
C4
What dermatome is: Shoulders? Nipples? Umbilicus? Knees? Perianal area?
Shoulders = C4 Nipples = T4 Umbilicus = T10 Knees = L4 Perianal = S4-5
What spinal level is responsible for: biceps reflex? Brachioradialis reflex? Triceps reflex? Patellar tendon? Achilles tendon?
Biceps = C5/C6 Brachioradialis = C6 Triceps = C7 Patellar tendon = L4 Achilles = S1
Term: Sensory or Motor Dysfunction Caused by Pathology of a Nerve Root.
Radiculopathy
Clinical Signs and Symptoms Associated with Radiculopathy?
Main sign: burning, tingling pain that radiates down the limb.
Other signs: lower motor neuron signs such as loss of reflexes, weakness, and diminished sensation along dermatomal distributions
Term: Sensory or motor dysfunction caused by pathology of the spinal cord
Myelopathy
Clinical signs and symptoms associated with Myelopathy
Intermittent neck pain that radiates into the shoulders or occiput.
Clinical findings: bilateral upper motor neuron signs such as diffuse hyper-reflexia, weakness and numbness in the extremities, and upward-going toes (Babinski’s sign)
What is spinal shock
temporary, concussive-like syndrome associated with flaccid paralysis below the level of injury with loss of all reflexes, as well as urinary and rectal tone.
What is SCIWORA
Spinal Cord Injury With Out Radiographic Abnormalities
Most common complication following exposing the anterior spine for decompressive surgery
Recurrent laryngeal nerve injury -> hoarse voice, dyspnea. Risk of aspiration.
This type of hemorrhage results in hemotympanum
epidural hemorrhage
Criteria of TBI
a period of loss of consciousness, loss of memory for events immediately before or after the accident, alteration in mental state at the time of the accident, and/or focal neurologic deficit.
What can it mean when a pt has Raccoon Eyes? Battle’s Sign?
Raccoon eyes are bilateral periorbital ecchymosis. Battle’s sign is retroauricular ecchymosis. These signs should raise the suspicion of a basilar skull fracture.
type of herniation when you have an ipsilateral blown pupil and contralateral paralysis.
Uncal herniation
What Is Cushing’s Triad? What Does It Mean?
Hypertension, bradycardia, and an irregular respiratory rate. It’s the response to increased intracranial pressure (ICP).
At what point in the GCS is a person considered to have severe head trauma?
8 and below
What test should you do on a person who you suspect has an intracranial hemorrhage?
CT without contrast
Why should you not use succinylcholine or ketamine on a TBI patient
They increase ICP. Use Rocuronium or etomidate itself
Normal ICP. When is treatment indicated?
5-15 mmHg.
>20 mmHg treatment is indicated
When hyperventilating for increased ICP, what pCO2 should you aim for?
30-35 mmHg
Why give mannitol for increased ICP?
Mannitol is an osmotic diuretic. It increases the tonicity of the extracellular space, which causes a shift of water from
the intracellular space (brain parenchyma) to the extracellular space. By expanding the plasma volume, it also reduces hematocrit and blood viscosity which increases cerebral blood flow (O2 delivery) and reduces ICP.
Do you give corticosteroids to a trauma pt w/ brain edema?
No. Won’t work.
Conditions when you need a craniotomy for a brain hematoma
midline shift >10 mm, hematoma thickness >5 mm, or ICP >20 mmHg.
What is brain death
Irreversible cessation of the entire brain function including the brain stem.
Criteria for brain death
Pt must be: GCS of 3, euthermic (>32.2 °C), PaO2 greater than 90 mmHg, SBP greater than 100 mmHg, and pt cannot be sedated or paralyzed.
Declaration of brain death requires absence of brainstem reflexes (corneal, gag, oculocephalic, and oculovestibular), no response to deep central pain, and the agreement of two physicians. If the above criteria are met, an apnea test is performed.
The patient is disconnected from the ventilator and observed for respiratory effort. If there is no evidence of spontaneous respirations with a PaCO2 >60 mmHg, and the other criteria are met, the patient meets the criteria for brain death.
