Neuro Flashcards
Migraines
Headaches
MCC F > M, genetics, usu presents with aura but no auras are MC,
Vessel vasoconstriction => vasodilation, rush of blood returns causing pain = vasospasms
Sxs:
- unilateral, pulsatile
- preceded by aura 4 to 72 hours - sensory indication
- floaters, vision - sensitivity to light
- sound worsens
- gustatory
- worsens w/ activity - patients like dark, quiet rooms
Dx:
- clinical
Tx:
- Abortive therapy
- Mild - Execedrin w/ caffeine, NSAIDs, aspirin, tylenol
- Moderate - Triptans - Sumotriptan
- CI - unctrl HTN, PVD, CAD
- Preventative therapy
- TCAs - Amtriptyline (less sedating)
- Topiramate/Topamax
- Valproic acid
Tension
Headaches
MC type, younger in 30s
Sxs:
- a/w with stress triggers
- bilateral, band like
- non pulsatile, squeezing
- can last 30 mins to 7 days
Dx: clinical
- episodic - <15 days/month
- chronic - > 15 days / month
Tx:
- NSAID
- Aspirin
- Acetaminophen
- Head & muscle relaxants
Cluster
Headaches
middle aged Males
Sxs:
- unilateral, usually behind eye
- periorbital lacrimation
- Horner’s syndrome
- anhydrosis
- ptsosis
- miosis
- severe
- not relieved by stress- usu pacing
Dx - Brain MRI r/o maladies
Tx:
- 100% O2, 6-10L for 15 minutes
- Subcut sumitriptan
- Prophy w/ CCB - verapamil
Bell’s Palsy
CN VII swelling - compression of nerve => hemifacial weakness/paralysis
A/w Herpes Simplex; r/o Ramsay Hunt Syndrome from Herpes Zoster
Sxs:
- URI preceding
- Acute unilateral facial weakness/paralysis - Upper and lower
- can’t raise eyebrows
- Decreased tearing
- Orbicularis m. - can’t close eyelids
- Dysgeusia - taste impairment
- Ageusia - taste loss
Dx:
- Lyme ddx
- EMG if paralysis > 10 days
Tx:
- short course of prednisone & acyclovir
- eye patch for corneal abrasions
- Sx decompression for CN VII
Vertigo
Sensation of movement in the absence of actual movement
Peripheral
- sudden onset - intermittent
- tinnitus
- hearing loss
- nystagmus - horizontal w/ rotary component
- Dx with Dix Hallpike
Central
- eti MS, brain tumor, head injury
- Gradual onset - continuous
- N/V
- Vertical nystagmus
- No auditory symptoms
- motor, sensory, cerebellar deficits
- Romberg sign
Dx:
- Dix Hallpike - for nonfatigable causes = central etiology
- Audiometry
- EMG
- MRI
Tx:
- Peripheral
- Vestibular suppressants to help w/ auditory sxs
- Diazepam, Meclizine
- Epley manuveur
- Central
- Deep head hanging manuveur
- tx source
Syncope - Neurogenic, Orthostatic, Metabolic, Psychiatric
Loss of consciousness/postural tone 2/2 acute decrease in cerebral blood flow - rapid recovery in consciousness w/o resuscitation
Four main etiologies
Neurogenic Syncope
- Carotid sinus hypersensitivity
- Prodrome sxs before LOC - dizziness, warm/cold, N, pallor, visual disturbances, hearing abns
- Normal PE, and normal EKG
Orthostatic Hypotension
- drop in systlic BP > 20mmHg or
- Reflex tachcyardia of > 20bpm
- Failure of veins to constrict when patient is upright = reduce cardiac output
- MCC deH2O, meds (CCB/BB, alpha Blockers, nitrates, diuretics, TCA)
Metabolic
- hypoglycemia, hypoxia
Psychiatric
- aniety and panic disorders
- young, no cardiac dz, multiple eps
Syncope - Cardiac
Life threatening cause of syncope
Strng fam hx - sudden cardiac death before 50 yo, heart dz, symptoms (CP, palps, SOB)
eti:
- Arrhythmias - MCC of cardiac syncope
- ischemia
- Valvular abn
- aortic stenosis
- cardiac tamponade
- pacemaker malfunction
Syncope Work Up/ Diagnosis
Conditions that can mimic syncope but not true syncope - Seizures, stroke, sleep disturbances, ad incjury
Dx:
- PE and comprehensive Hx
- Get the #, frequency, and duration of episodes
- Onset, triggers, position & recent changes prior to syncopal eps
- Most patient w/ prodromes - Neurocardiogenic or orthostatic hypotension
- Medications
- Vital signs
- EKG
- TTE - structural heart disease
- CT Scan
Stroke - Ischemic
Ischemic (85%) vs Hemorrhagic
Risk factors: HTN*, athersclerotic disease, hypercholesterolemia, DM, Afib, carotid artery disease, smoking, age, fam hx, M
2/3 are thrombic; 1/3 are embolic
Thrombic - clot that forms inside the brain vessel, usu follows a TIA
Embolic - clot that forms elsewhere and travels to the brain - acute presentation
Causes lack of blood flow to a specific brain area - surrounding that area is the penumbra (is still perfused by collateral vessles; can be saved if reperfused quickly)
Sxs:
- Facial drooping
- Arm weakness
- Speech difficulties
- Time - get reperfused ASAP
Dx:
- Non-contrast Head CT - differentiates btwn hemorrhagic and ischemic
- MRI - more sensitive
- Carotid duplex scan - degree of stenosis
- EKG - MI or A-Fib
- MRA - level of stenosis in head
Tx:
-
t-PA therapy - within 3 hours of onset.
- Do not initiate if
- > 3 h
- unctrl HTN,
- bleeding disorder or anticoagulated,
- hx of recent trauma or surgery
- Do not give Aspirin within 24 hrs if + t-PA
- Do not initiate if
-
Aspirin - best If given w/in 24 hr of symptom onset
- if within 3 h - give thrombolytics
- if > 3 h = give aspirin, if allergic give Clopidergrel/Plavix
- Supprotive tx - ABC, O2, IV fluids
-
Gradual BP control
- IV labetalol 20mg
- Do not give antihypertensives unless SBP >200, DBO > 120, MAP >130mmHg
- Carotid endarterectomy - if > 70% stenosed
Intracerebral Hemorrhage
Stroke
Hemorrhagic Stroke (15%)
Bledding into the brain parenchyma
Eti - MC d/t sudden increase in HTN, Ischemic stroke converts to hemorrhagic stroke - reperfusion causes bleeding into dead tissues = hemorrhagic
Sxs:
- Abrupt onset of focal neurological deficity - sxs depending on location of bleed
- Anterior or MCA - numbness and muscle weakness
- Broca’s Area - slurred speech
- Wernicke’s area - difficulty undertanding speech
- PCA - vision
- Headache
- confusion
- aphasia
Dx:
- Non contrast CT or MRI
- CT angio for specific location
Tx:
- BP control with IV labetalol
- Reduce ICP - Mannitol
- Craniotomy - skill removed to drain blood and relieve pressure
Subarachnoid Hemorrhage
Stroke
Bleeding into the CSF - outside brain parenchyma
Eti:
- Traumatic injury
- Aneurysms - MCC saccular cerebral aka berry aneurysms
- most on anterior Half
- marfan’s syndrome
- Rupture with ICP
- Arteriovenous Malformation
Sxs:
-
Sudden onset severe headache - THUNDERCLAP headache
- worse headache of life
- Nuchal rigidity - blood irritating meniges
- Seizures
- N/V
- Decr LOC
Dx
-
Non contrast CT
- most are negative if < 2 hrs, most sensitive > 12 h
- if negative - do CSF
- CSF via LP
- Xanthochromia - yellowish blood
- Fresh Red blood
- C/i if ele ICP (??)
Tx:
- emergency surgery
- Clip artery - pressure
- Catheter to insert coil to promote clot formation
- BP control - CCBs to prevent vasospasms
Transient Ischemic Attack
Transient ep of neurologic dysfunction d/t focal brain, retinal or cord ischemia = no acute Infarction
Sxs:
- Sudden onset neurological deficit
- Lasts minutes to < 1 hr
- Reversal of sxs within 24 hrs
- Atherosclerotic plaques reducs BF in ICA
- 10% of TIA will have a stroke in 30 days
Dx:
- Non contrast CT
- MRI more sensitive
- Carotid doppler US
Tx:
- ABCD2 Score - likelihood of stroke In 2 days
- risk is highest 24 hrs after initial event
- Carotid endarterectomy if ICA or CCA stenosis >70%
Altered Level of Consciousness / Coma
D/t systemic infx or metabolic problems or vascular events
Systemic approach to properly ID etiology and treat appropriately to prevent further damage
History and PE - neurological exam to r/o focal deficit
Consider ABC - airway, braething, circulation
- CBC, electrolyte panel, Ca. mg, phosphorus
- urine tox
- Serum ammonia
- ABG
- blood culture
- EKG and CXR
Imaging - CT scan, MRI diffusion and contrast, LP
Tx:
- Admin thiamine and dextrose
- consider naloxone for opiate OD
Glascow Coma Scale
Score < 8 = coma or severe brain injury
Encephalitis
Eti - usually viral (MCC HSV, CMV if IMC)
Reye’s Syndrome - rapidly progressing encephalopathy w/ hepatic dysfx, usual post-flu/URI
- Babinski, hyperreflexia
- Aspirin/salicylate use, vomiting, confusion => seizures/coma
Sxs:
- Flu like illness
- fever, headaches, AMS
- Seizures
- Personality changes
- exanthema
Dx:
- LP and MRI
- PCR for viruses
- Kernig’s absent
- Brudzinski absent
Tx:
- Supportive care
- Acyclovir 10mg/kg IV q8hr started promptly
- Empiric abx given until bacterial mengitis r/o
Meningitis
Eti: bacterial - community acq’d MC S. pneumo or N. meningitidis (G+ diplococci) - likely if pt has a rash
Neonates = E. Coli / S. agalatiae; >50-60 = Listeria/Cryptococcus neoformans
Aseptic - usu viral and negative blood cultures
Sxs:
- no mental status changes - r/o encephalitis
- Kernig’s sign - neck pain w/ knee extension
- Brudzinski sign - leg raise w/ bent neck
Dx:
- LP - check if ICP and papillaedema - get a CT if unsure
- Bacteria
- Incr Protein, decr glucose (bacteria likes glucose), increased OP
- Viral
- normal pressure, increased WBC
Tx:
- Aseptic - symptomatic or IV acyclovir for HSV
- Bacterial - dexamethasone + empiric IV antibiotics (cephalosporin, Vanco, pencillin)
- Household contacts - Tx with Rifampin, Cipro, Levaquin, azithro, ceftriaxone
Epidural Hematoma
Transient LOC from injury => LUCID => HA, unilateral weakness
traumatic IC hemorrhage after skull fracture => MC Middle menigeal artery => blood fills space btwn dura and skill
Dx
- non contrast CT - unilat convexity - lens usually temporal region => Lemon
Tx
- small - observation
- severe - surgery => burr hole, trephination, craniotomy, craniectomy
- Surgical craniotomy
- ICP management - mannitol, hyperventilate, steroids, or ventricular shunt
Subdural Hematoma
Head injury from fall => Sudden blow tears blood vessels, usu eldery w/ multiple falls => presents w/ neurological sx (AMS/neuro signs) => etoh or elderly
Sxs:
- injury to bridging veins - acute = 48 hrs
- subacute 3- 14 days
- chronic > 2 wks = elderly
- Blood collects btwn dura and arachnoid mater
Dx
- non contrast CT - crescent shape concave hyper density
