Neuro AC Exam

Question 1

Difference between primary headache and secondary headache

Answer 1

Primary - not associated with any other diseases, HA is the diagnosis
Secondary - associated with or c/b other conditions, generally will not resolve until the cause has been addressed

Question 2

Examples of primary headaches

Answer 2

tension, migraine, cluster

Question 3

Examples of secondary headaches

Answer 3

tumor, intracranial bleeding, increased ICP, medications (nitrates), meningitis, GCA, etc.

Question 4

What does the SNOOP pneumonic refer to

Answer 4

RED FLAGS for headaches and when you should consider a secondary cause and do a further workup
S = systemic symptoms (fever, weight loss) or secondary HA risk factors (HIV, malignancy, pregnancy, anticoagulation, marked BP increase)
N = neuro signs and symptoms (confusion, impaired alertness or consciousness. nuchal rigidity, papilledema, etc.)
O = onset (sudden, abrupt, with exercise, sexual activity, coughing, etc.)
O = onset (age older>50 or <5)
P = prior HA hx, positional, palilledema

Question 5

Tension-type HA characteristics

Answer 5

30min - 7 days (usually 1-25h with 2+ of the following characteristics)
pressing, non-pulsatile pain
mild-moderate intensity
bilateral
notation of 0-1 of the following: nausea, photophobia, or phonophobia
F>M

Question 6

Migraine w/o aura characteristics

Answer 6

4-72hrs with 2+ of the following
unilateral
pulsating, moderate to severe pain
aggravated by normal activity (walking)
during the HA 1+ of the following - N/V, photophobia, photophobia
F>M
positive family hx

Question 7

migraine with aura characteristics

Answer 7

HA occurs with or after aura
focal dysfunction of cerebral cortex or brain stem causes >/= 1 aura symptoms to develop over 4min, or 2+ symptoms occur in succession
dread, anxiety, unusual fatigue, nervousness, excitement, GI upset, visual or olfactory alterations
no aura symptoms should last > 1h – if this occurs refer to neuro for seizure workup
high correlation with family hx

Question 8

cluster type HA characteristics

Answer 8

tendency of HA to occur daily in groups or clusters
clusters usually last several weeks-months then disappear for months-years
usually occur at characteristic times (same season, same time of day, etc.)
HA location is usually behind 1 eye with a steady, intense, severe pain that lasts 15min-3h
commonly occurs with Ipsilateral autonomic sign-lacrimation, conjunctival injection, ptosis, nasal stuffiness
M>F

Question 9

Primary HA treatment options

Answer 9

lifestyle modifications
Analgesics - NSAIDs. Tylenol - limit to 2 days/week
Rescue therapy - opioids, antiemetics **, short term use of corticosteroids
Migraine-specific meds - triptans, ergot derivatives - CAUTION in pregnancy, CV disease, uncontrolled HTN
High flow O2 for cluster HA
Control meds - Mg++ and riboflavin

Question 10

What is the most important historical component for a stoke patient

Answer 10

time of symptom onset

Question 11

Hospital-based care for ischemic stroke patient

Answer 11

stabilization, hx, neuro exam and stroke scale (NIHSS), finger stick, CT, ECG, metabolic panel, CBC, cardiac markers, PT/INR and PTT

Question 12

Management of HTN in stroke

Answer 12

if a patient is a candidate for tPA - acute BP reduction should be instituted if SBP > 185 or DBP > 110
If patient is not a candidate for tPA withhold BP drugs unless SBP > 220 or DBP > 120

Question 13

What does the NIHSS used for and what does it mean

Answer 13

NIHSS is the stroke scale
<4 = good prognosis, no tPA necessary
4-20 = ideal tPA
>20 = severe deficit, no tPA

Question 14

Absolute contraindications for tPA for acute ischemic stroke

Answer 14

current ICH
subarachnoid hemorrhage
active internal bleeding
recent (w/in 3mo) intracranial or intraspinal surgery or serous head trauma
presence of intracranial conditions that may increase the risk of bleeding
bleeding diathesis
current severe uncontrolled HTN

Question 15

What are the three types of intracranial bleeding

Answer 15

subarachnoid
epidural
subdural

Question 16

Subarachnoid hemorrhage cause, s/s, and treatment

Answer 16

rapid arterial bleeding into the subarachnoid space secondary to a cerebral aneurysm or head injury
s/s - thunderclap headache**, vomiting, confusion/LOC, seizures
treatment - surgical intervention, BP control
“worst headache of my life”

Question 17

Epidural hematoma cause, s/s, and treatment

Answer 17

injury to the middle meningeal artery secondary to fracture to the temporal or parietal skull – rapid accumulation of blood beta the dura and the skull
s/s - HA, transient LOC**, unilateral fixed/dilated pupil, N/V, dizziness
Treatment - surgical intervention if significant, BP control
“usually baseball player questions”

Question 18

Subdural hematoma cause, s/s, and treatment

Answer 18

damage to bridging veins cuasing blood to accumulate under the dura
can be acute or chronic
s/s - HA, general LOC or change in mental status, seizures
treatment - surgical intervention if significant, watch and wait, anti-seizure prophylaxis (7 days, kepra)

Question 19

Subdural hematoma cause, s/s, and treatment

Answer 19

damage to bridging veins causing blood to accumulate under the dura
can be acute or chronic
s/s - HA, general LOC or change in mental status, seizures
treatment - surgical intervention if significant, watch and wait, anti-seizure prophylaxis (7 days, kepra)

Question 20

Early signs of increased ICP

Answer 20

HA, N/V, changes in mental status or LOC, changes in behavior

Question 21

Late signs of increased ICP

Answer 21

unresponsiveness, dilated pupils or nonreactive, posturing, Cushing’s triad

Question 22

What is Cushing’s triad

Answer 22

Bradycardia, widened pulse pressures, apnea

Question 23

Signs and symptoms of meningitis

Answer 23

severe HA, nuchal rigidity, high fever, altered mental status, kernig’s sign, brudzinski sign

Question 24

What is Kernig’s sign

Answer 24

patient is lying supine, pain is elicited by passive extension of the knee (this leads to increased ICP)

Question 25

What is brudzinski sign

Answer 25

Flexion at the neck causes involuntary flexion of the knee and hip

Question 26

Diagnostic testing for meningitis

Answer 26

LP as soon as diagnosis is suspected, CT scan first to r/o space-occupying lesion if: papilledema, coma, seizures, focal neuro findings

DO NOT PERFORM A LUMBAR PUNCTURE IN THE PRESENCE OF SIGNS OF INCREASED ICP OR IF THEY ARE SEIZING

Question 27

Treatment for meningitis

Answer 27

high dose parenteral antibiotics, if purulent is suspected, may need dexamethasone

Question 28

Compare and contrast spinal fluid characteristics for bacterial vs viral meningitis

Answer 28

cell count - bacterial (PMN or neutrophils present) viral (lymphocytes present)
glucose - low in bacterial (<45), normal in viral (>50)
opening pressure - high in bacterial, normal in viral

Question 29

Autonomic dysreflexia - location, cause, s/s, treatment

Answer 29

spinal cord syndrome - injury above T6
usually caused by traumatic injury
s/s - exaggerated autonomic responses - above the level of injury = diaphoresis + flushing, below the level of injury = chills + vasoconstriction, HTN, bradycardia, HA, nausea
treatment - remove stimulus, manage autonomic manifestations

Question 30

Brown-Sequard syndrome - location, cause, s/s, treatment

Answer 30

penetrating trauma to the spinal cord (anywhere) - usually hemisection injury
s/s - ipsilateral motor disturbance + proprioception, contralateral loss of pain + temp
treatment - immobilization, transfer to trauma, steroids (sometimes)

Question 31

Central cord syndrome - location, cause, s/s, treatment

Answer 31

cervical spinal cord
cause - hyperextension injury (MVA, fight)
s/s - upper and LE weakness (more deficits in upper), varying degrees of sensory loss - impaired pain, temp, light touch, position sense below the level of the injury
treatment - ICU for 24h, monitor for autonomic dysreflexia, HTN

Question 32

Most reliable testing for neuroimaging

Answer 32

CT (used most of the time), MRI used for a more thorough evaluation (infection, concussion/TBI, lesions, masses, acute stroke/TIA, dementia eval, seizures, temporal lobe epilepsy)

MRI ARE CONTRAINDICATED IN PATIENTS WITH PACEMAKERS AND METAL IMPLANTS

Question 33

First line medication of status epilepticus

Answer 33

lorazepam (benzodiazepine should be first)

Question 34

which vitamin should be priority for chronic alcohol abusers

Answer 34

vitamin B

Question 35

Characteristics of GBS & treatment

Answer 35

demyelination of peripheral nerves – paralysis usually works its way up and is self-limiting. concern for respiratory function. will eventually resolve, patients may have profound UE weakness
treatment: IVIG, plasmapheresis, lose dose heparin if hospitalized

Question 36

Myasthenia gravis characteristics & treatment

Answer 36

destruction of acetylcholinesterase
patients will have profound weakness
tx: acetylcholinesterase inhibitors, prednisone, plasmapheresis, and IVIG