Neuro (8%)

Question 1

Encephalopathy

Answer 1

 Delirium and acute confusional state during an acute condition of cerebral dysfunction in the absence of structural brain disease
 Manifestations – non-specific/based on etiology – impaired attention, decreased alertness, hallucinations, seizures, tremor, disturbed sleep-wake cycle
 Treatment – treat underlying condition, review MAR, discontinue meds with CNS toxicity, fall precautions, restraints (last resort)

Question 2

Epidural hematoma

Answer 2

• Rapid accumulation of blood from an ARTERIAL source between the dura mater and the skull
• Can be caused by fractures to the temporal or parietal skull and/or injury to the middle meningeal artery
• Often a “lucid interval” where patients have few symptoms then progressive neurologic deterioration
• Manifestations – headache, transient LOC, unilateral fixed or dilated pupil is classic, n/v, dizziness
• Diagnostic – CT of head
• Treatment – surgical intervention if significant, BP control

Question 3

Subdural hematoma

Answer 3

• Damage to the bridging VEINS causing blood to accumulate under the dura mater
• Can be acute or chronic
• Common in elderly and those with etoh abuse
• Manifestations – headache, gradual LOC/change in mental status, seizures
• Treatment – surgical intervention if significant, watch and weight, anti-seizure prophylaxis for 7 days (most patients will fall into the “watch and wait” category)

Question 4

Hydrocephalus

Answer 4

 Disorder in which an excessive amount of CSF accumulates
 Obstructive and communicating hydrocephalus are mainly seen in children
 Normal pressure hydrocephalus is most common in adults
 Etiology – intraventricular and/or subarachnoid hemorrhage, meningitis, Paget disease
 Manifestations – 3 cardinal features – gait difficulty (most prominent, “magnetic gait”, short steps), cognitive disturbances (decreased attention, concentration), and urinary incontinence
 Diagnostics – MRI is test of choice
 Treatment – shunting (VP or VA) if suitable

Question 5

Symptoms of increased ICP

Answer 5

 Early – headache, n/v, change in mental status/LOC, change in behavior
 Late – unresponsive, dilated or non-reactive pupils, posturing, Cushing’s triad (bradycardia, widened pulse pressure, and apnea)

Question 6

Meningitis

Answer 6

• Infection of the pia pater and the arachnoid mater of the brain
• May be infectious, chronic, or aseptic
• Manifestations – severe headache, nuchal rigidity, high fever, AMS, Kerning’s sign (patient supine, pain elicited by passive extension of knee), Burdzinski’s sign (flexion of neck causes flexion of hip and knee)
• Diagnostics – LP as soon as diagnosis is suspected (CT scan first to rule out space-occupying lesion)
• Treatment – high-dose parenteral antibiotics if purulent suspected (bacterial), may need dexamethasone (can help with inflammation)
• Antibiotics – 3rd generation cephalosporin (ceftriaxone, ceftazidime)

Question 7

Spinal fluid characteristics of bacterial vs. viral meningitis

Answer 7

• Bacterial (purulent) – cell count: 200-200,000; glucose < 45; protein >50 (usually very high); markedly high opening pressure
• Viral – cell count: 100-1,000; normal glucose (50-80); protein > 50 (but < purulent); normal opening pressure

Question 8

Myasthenia gravis

Answer 8

• Autoimmune dysfunction of acetylcholinesterase
• Often insidious but often “unmasked” by infection that leads to exacerbation
• Manifestations – muscle weakness (typically descending) that worsens with activity and improves with rest; fluctuating muscle weakness; fatigue with chewing
• Diagnostics – serum acetylcholine receptor antibodies (AChR), EMG studies
• Treatment – acetylcholinesterase inhibitors (mestinion – titrate to 60-120 mg every 3-4 hours), prednisone, plasmapheresis, IVIG

Question 9

Guillian-Barre

Answer 9

• Acute inflammatory polyneuropathy/paralyzing illness provoked by infection, inoculation, or surgery
• Manifestations – begins in lower extremities and ascends bilaterally, weakness, ataxia, bilateral paresthesia progressing to paralysis
• Diagnostics – CSF has high protein concentration; EMG shows delayed conduction; spirometry monitor q6h
• Treatment – NO STEROIDS, admit to ICU for supportive care (intubate if needed), IVIG 400 mg/kg/day x5 days

Question 10

Parkinson’s disease

Answer 10

• A degenerative CNS disorder resulting from an imbalance of dopamine and acetylcholine
• Manifestations – resting tremor, rigidity, bradykinesia, “pill rolling”, can progress to impaired swallowing and decreased autonomic movement
• Management – pharmacologic options focus around increasing amount of dopamine – Carbidopa-Levodopa (Sinemet) is gold standard and average duration of response to med is 5 years; Selegiline is another option

Question 11

Epilepsy (everything but treatment)

Answer 11

• Person has recurrent seizures d/t chronic, underlying process, 2 or more unprovoked seizures
• Etiology – non-compliance with meds (#1), most seizures in ICU are provoked and not considered epilepsy (electrolyte disturbances, cerebral edema, infection, drugs, etc.)
• Focal seizure – one hemisphere; can be simple (remain conscious) or complex (altered consciousness, but not loss)
• Generalized – both hemispheres; convulsive (tonic-clonic with loss of consciousness) or non-convulsive (typical has automatisms [lip smacking, blinking, chewing or atypical is absence)

Question 12

Seizure treatment

Answer 12

• Immediate resolution of seizures – lorazepam 2mg IVP, max 10 mg
• Treat/correct underlying cause
• Antiepileptic drug therapy (AED) is individualized – phenytoin, levetiracetam (Keppra), valproic acid, etc.

Question 13

Tumors

Answer 13

• Earliest sign of tumor – ipsilateral pupillary dilation
• Glioblastoma – most common cause of malignant primary brain tumor, treatment = surgery, chemo, radiation
• Meningioma – common primary brain tumor; s/s = headache, seizure, focal neuro deficits; treatment depends on size – surgical resection
• Primary adenoma – hormone hypersecretion, visual impairment, headaches; treatment – transphenoidal surgery

Question 14

Autonomic dysreflexia

Answer 14

• Injury location – above T6
• Cause – traumatic injury
• Symptoms – exaggerated autonomic responses – above level of injury has diaphoresis and flushing; below level of injury has chills and vasoconstriction; other symptoms include HTN, bradycardia, headache
• Treatment – remove stimulus/treat injury, manage autonomic manifestations

Question 15

Brown-Sequard syndrome

Answer 15

• Injury location – anywhere along the cord
• Cause – penetrating trauma (“cut” halfway through the cord)
• Symptoms – ipsilateral (same side) motor disturbance; contralateral loss of pain and temperature sense
• Treatment – immobilization, transfer to trauma, steroids

Question 16

Central cord syndrome

Answer 16

• Injury location – cervical spinal cord
• Cause – hyperextension injury
• Symptoms – upper and lower extremity weakness (more in upper); varying degree of sensory loss below level of injury
• Treatment – ICU monitoring for 24 hours; monitor for autonomic dysreflexia, HTN, and bradycardia; usually resolves on own; most are mild and self-limiting

Question 17

Subarachnoid hemorrhage

Answer 17

• Bleeding into the subarachnoid space secondary to cerebral aneurysm or head injury
• Rapid accumulation of blood from ARTERIAL source
• Most common causes are uncontrolled HTN or vascular malformations
• Manifestations – thunderclap headache, “worst headache of my life”, vomiting, confusion/LOC, seizures
• Treatment – surgical intervention, BP control; SBP goal 120-160; nimodipine for BP control and vasospasm, cardene IV is SBP> 160

Question 18

Ischemic stroke

Answer 18

• The most important historical component is the time of symptom onset
• Obtain a history to rule out conditions that mimic stroke (ex: hypoglycemia, OD, infection, etc.)
• Manifestations – sudden numbness or weakness, confusion, difficulty speaking, trouble seeing, dizziness, severe headache without cause
• All patients should have a head CT or MRI, ECG, and labs
• Most patients with HTN will demonstrate a decrease in BP after a few hours without intervention
• If patient is a candidate for tPA, BP reduction should be done if SBP > 220 or DBP > 110
• TPA needs to be started within 4.5 hours of symptom onset

Question 19

Absolute contraindications to TPA for ischemic stroke

Answer 19

• Current intracranial bleeding
• Subarachnoid hemorrhage
• Active internal bleeding
• Recent intracranial or intra-spinal injury or serious head trauma < 3 months ago
• Bleeding diathesis
• Current severe uncontrolled HTN

Question 20

NIHSS stroke scale scores

Answer 20

• < 4 = good prognosis, no TPA
• 4-20 = mild to moderate stroke, idea TPA candidate
• > 20 = severe deficit, no TPA

Question 21

Traumatic brain injury (everything except treatment)

Answer 21

 Non-generative, non-congenital insult to the brain from an external mechanical force leading to permanent or temporary impairment of function
 Can be primary (from injury itself) or secondary (a consequence of injury – cerebral edema, increased ICP, ischemia, etc.)
 Severity scores – GCS – mild (GCS 13-15), moderate (GCS 9-12), severe (GCS ≤ 8)
 ABCDE initial surgery
 Neuroimaging – head CT

Question 22

Traumatic brain injury management

Answer 22

 Oxygenation
 Maintain euvolemia and frequent labs to check electrolytes
 DVT prevention (caution, risk for hemorrhagic conversion is highest in first 24-48 hours)
 If ICP > 20 – HOB to 30 degrees, monitor CVP, CSF removal 1-2 ml/min for no greater than 3 minutes at a time, Mannitol bolus 0.25-1 g/kg q4-6h PRN
 Seizure prophylaxis – Keppra, valproic acid, or phenytoin for 7 days
 CPP (CPP = MAP – ICP) should be ≥ 60 to ensure adequate brain perfusion
 Inpatient rehab is most common form of rehab for severe TBI patients

Question 23

Primary vs. secondary headache

Answer 23

• Primary – not associated with other disease; ex: migraines, tension-type, cluster
• Secondary – associated with or caused by other conditions; ex: tumor, intracranial bleeding, increased ICP, etc.

Question 24

Headache “red flag” symptoms

Answer 24

• SNOOP
• S – systemic symptoms – fever, weight loss
• N – neurologic signs – new neuro finding, confusion, impaired alertness, etc.
• O – onset (time) – sudden, abrupt, “thunderclap”; onset with exertion, sexual activity, coughing, etc.
• O – onset (age) – older > 50 years, younger < 5 years
• P – prior headache hx (change in quality or frequency), positional, papilledema (visual problems)

Question 25

Primary headache treatment

Answer 25

• Lifestyle modification – recognize and avoid triggers, regular exercise, correct posture, etc.
• Analgesics – NSAIDs, acetaminophen (limit use to 2 treatment-days per week)
• Rescue therapy – when standard therapy ineffective or specific symptoms are present– opioids, antiemetics, short course of corticosteroids
• Migraine-specific meds – the “-tripans”, caution in pregnancy and uncontrolled HTN
• Prophylactic (controller) meds – beta blockers (propranolol), TCAs (amitriptyline), anti-epileptic drugs (gabapentin)
• Indication for prophylaxis – use any product > 3x/week, ≥ 2 migraines/month that produce severe symptoms ≥ 3 days, poor symptom relief with abortive therapies, presence of concomitant medical conditions (ex: HTN)

Question 26

Cluster headache

Answer 26

• Headaches occur daily in groups or clusters and last several weeks to months and then disappear
• Typically located behind 1 eye with a steady, intense, “hot poker in the eye” sensation
• Often has ipsilateral autonomic signs such as lacrimation, conjunctival injection, and nasal stuffiness