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CCFP-EM > Neuro / Neurosurgical > Flashcards

Neuro / Neurosurgical Flashcards

1
Q

Cerebral Perfusion Pressure Formula

A

MAP - ICP

Cerebral blood Flow = (Carotid Arterial Pressure - JVP) / Cerebral Vasc Resistance.

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2
Q

Physical Exam and Imaging Tests for Measuring / Evaluating ICP

A

Pupillary dilation
Motor Posturing
GCS < 8

CT: Compression of cisterns
Midline shift > 10 mm = High ICP

US: Optic nerve sheath diameter. NOT RECOMMENDED AT THIS TIME

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3
Q

Management Goals in Elevated ICP

A

1) Hemodynamic Stability:
- Normotension (140-180 sBP)
- Normoxia (PaO2 80-120 mmHg), ) >92%
- Normothermia (36-37.9)
Rx: Labetalol 5-20 mg IV, norepi 0.1-0.2

2) Positioning
- Head of bed at 30
- Loose C-spine collar
- Neck midline

3) Pain
- Analgesia
- Anti-emetic (no valsalva)
- Mitigate stimuli (quiet room, limited exam)
Rx: Fentanyl, Ketamine, Zofran

4) Intubate
- Apneic Oxygenation
- Head of Bed at 30 degrees
- Vasopressors ready (Phenyl bolus or Norepi)
- Pretreat: Topical lidocaine if time. Fentanyl 3-5 mcg/kg (give at least 3-5 minutes to work)
- Induction: Ketamine (1-2 mg/kg), Etomidate (0.3 mg/kg), Prop if pressure allows (1-2 mg/kg)
- Paralytic: Succs or Roc
- Gentle placement - minimize glottic stim
- Post-intubation sedation/analgesia: Fentanyl 25-50 mcg/hr or dilaudid infusion (0.2-0.4/hr
- Propofol 0.3 mg/kg/hr

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4
Q

Management of refractory ICP

A

Hypernatremia: Na < 155
- Foley
- Mannitol 1mg/kg over 20 mins
and NS 3% 250 cc over 5 minutes

Hyperventilation as a bridge to procedure / definitive mgmt

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5
Q

Spontaneous ICH management

A

Stop Expansion:
- Reverse anticoags

  • BP control (target 140 mmHg, starting < 220)
    • Rx: Labetalol, hydralazine, enalapril, smooth control is better. insert art line for monitoring
  • Neurosurgical Intervention
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6
Q

Target MAP in isolated spinal cord injury without other hemorrhage / trauma

A

MAP > 90

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7
Q

Target PO2 in Head Injured Airway

A

> 95% . Avoid hypoxia.
Brief hypoxia can lead to significant deleterious effects.

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8
Q

Target pCO2 in the head injured patient

A

35-38 mmHg
ETCO2 = 35%

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9
Q

SAH Rule (headache peaking in < 1 hr, > 15 years, at neuro baseline, atraumatic)

A

Age > 40
Neck pain or stiffness
Limited neck flexion on exam
Thunderclap
Witnessed LOC
Onset during exertion

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10
Q

Differential for thunderclap headache

A

SAH
Dissection
Cerebral venous sinus thrombosis
Reversible cerebral vasoconstriction syndrome
?Paroxysmal Hemicrania

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11
Q

Elements of the FAST-ED Stroke Assessment

A

Face - Any asymmetry with show me your teeth (0-1)
Arms - Pronator Drift (0-2)
Speech - Expressive aphasia naming 3 objects
- Receptive aphasia, 1 or 2 step command
Time from onset (<4.5 or <24 if large vessel)
Eyes: Deviation (can test FOV to finger counting)
Denial / Neglect:
- Does this arm feel weak, who’s arm is this?

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12
Q

Initial stroke labs and management

A

Labs: CBC, INR/PTT, Creatinine, Glucose, liver enzymes and lipid profile
Management: Call stroke code. CT Non-con, with CT-A if infarct. BP reduction to < 185/110 if candidate for thrombolysis, <220 if not a candidate.

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13
Q

Meningitis microbiology

A

1) S. Pneumo (gram +ve diplococci)
2) Neisseria Meningitides (gram -ve diplococci)
3) Listeria (gram +ve bacilli)
4) H Flu
5) TB
6) Lyme, Ricketsia

Viral
1) Enterovirus
2) HSV
3) ++ other

Fungal

Other:
- SLE
- Vasculitis
- Drug Induced
- Carcinomatosis
- Sarcoidosis

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14
Q

LP Results for Bacterial Meningitis

A

> 500, >80% neuts, Protein elevated, Gluc <50% of serum

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15
Q

Seizure Type

A

Simple Partial
Complex Partial (LOC)
Generalized

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16
Q

2nd causes of seizure

A

Metabolics: Hypo Na, Ca, glucose
Drugs / Infection: Anticholinergic, antidepressants, Sympathomimetics, Toxic EtOH, Isoniazid, Shrooms
CNS: Meningitis, encephalitis
Lesions: Hemorrhage, tumors, stroke, vasculitis, hydrocephalus
Febrile Seizure
Trauma
Eclampsia

17
Q

ABCD2

A

Age > 60 y
BP > 140/90
Unilateral Symptoms
Diabetes
Duration - <60 mins

18
Q

tPA Exclusion

A

Age < 18
Rapidly improving
Bleeding on CT
History of ICH
Known AVM
Endocarditis
Bleeding diathesis (platelet < 100k, INR > 1.7, heparin in last 48 hours
Active internal bleeding
BP > 185/110
Head trauma in last 3 months / Nsx or stoke

Relative
Recent GI or GU bleed
Seizure at onset
Recent LP
Recent puncture at noncompressible site
Pericarditis
Pregnancy

19
Q

Encephalitis mostly viral

A

Arboviruses
Mosquito and tick born
HSV
EBV / CMV
Rabies

Mgmt: 10 mg/kg IV Q8H

20
Q

Headache types and treatments

A

Primary:
Migraine: Triptans (sumatriptan), NSAIDs, Dopamine agonists, DHE
Cluster: High flow O2 (works 70%), Sumatriptan or DHE, verapamil for prophylaxis
- Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial swelling, miosis
Tension

Reversible:
- RCVS
- Coital migraine
- Post LP

Secondary Causes:
- Vascular
- Infectious
- Neoplasm
- ICP
- Eyes
- Drugs
- Toxic: Carbon monoxide
- Hypoxia, Hypoglycemia, hypercapnia, pre-eclampsia

21
Q

GCA - Temporal Arteritis Criteria

A

3 of 5:
- Age > 50
- New onset localized headache
- Temporal artery tenderness / decreased pulse
ESR > 50
- + biopsy

22
Q

Headache Red Flags

A

Systemic signs and symptoms
Neuro symptoms
Onset after age 40
Onset sudden
Pattern Change

Exertional
Worse lying flat
Morning symptoms / waking from sleep
Pregnancy

23
Q

Carotid and Vertebral Dissection

A

Most common cause of stroke in < 45
Symptoms:
- Unilateral neck pain, headache around the eye / frontal area.
- Usually acute onset
- Ipsilateral Horner, contralateral stroke or TIA symptoms

Vert: occiput or posterior neck pain, signs of brainstem TIA or stroke

CONSIDER WITH NECK PAIN AND NEURO SYMPTOMS

24
Q

CVST

A

Symptoms:
- Headache +/- neuro symptoms
- Focal syndrome
- Diffuse encephalopathy
- Caused by high ICP and local ischemia

1% of all strokes

Risk Factors:
Most common 20-50 yrs
Female x 3
Oral contraceptive - 6 fold increase, 30 fold when patient obese)
Pregnancy
APLS
Malignancy
Any hypercoag state - DM2, nephrotic syndrome, HIT,
HEENT infections
Instrumentation or surgery

25
Q

Ataxia Types and Features

A

Motor: Ipsilateral findings. If Vermis involved, more central / trunkal ataxia

Sensory: Difficulty ambulating, weakness, falls.
- Worse with loss of vision / eyes closed

Testing: Rapid alternating movements (motor)
- Romberg Test (sensory)

26
Q

Vertigo Types and Red Flags

A

Red Flags:
- Diplopia
- Dysarthria
- Dysmetria
- Dysphagia

Central vs Peripheral:
HINTS
Head Impulse: Central = NO corrective saccade
Nystagmus: Central - vertical, bidirectional
Test of skew: Cover / uncover

Acute Vestibular Syndrome:
- Spontaneous nystagmus
- Continuous vertigo, exacerbated by movement

27
Q

Peripheral Vertigo Causes

A

BPPV
Meniere’s - Ear fullness and hearing loss
Labrynthitis - Recent URI or AOM. Tinnitis and hearing loss
Acute vestibular neuronitis
Ramsay Hunt - HSV 8th cranial nerve
Ototoxicity
CN VIII lesions

28
Q

CN Palsies

A

III - Levator of eyelid and 4 eye muscles and pupil constriction (down and out eye)
- Causes: Congenital, aneurysm (PCOM), Ischemic (DM, HTN), trauma, migraine
*if pupil sparing, likely benign

IV - Trochlear nerve. Superior oblique muscle. 40% trauma, 30% idiopathic, 20% to vascular, 10% are tumor/aneurysm

VI - Abducens nerve. LR. Affected eye cannot abduct past midline.
Causes: Tumor, aneurysms, fracture, CVST

V: Trigeminal neuralgia
- Facial pain
- Tx: Carbamazepine and analgesia

VII Bell’s Palsy:
Most commonly due to HSV, can also be due to Lyme, HIV)
- Usually a viral prodrome
- Non-forehead sparing
- Can have loss of tase on anterior 2/3 of tongue
- Bell Phenomenon: Eye rolls back when closing eye
DDx: Lyme, Ramsay Hunt, Otitis Externa, Acoustic Neuroma
Tx: Steroid and antivirals vs Abx if Lyme suspected

29
Q

Spinal epidural abscess RF

A

IV drug use
Endocarditis
Renal Failure
Diabetes
EtOH
Dental Abscess

30
Q

Spinal Neoplasm most common met

A

Lung
Breast
Lymphoma

31
Q

Neuromuscular Disorders:
- Presentation/features and treatment

A

1) Guillain-Barre Syndrome
- Acute demyelinating polyneuropathy
- Preceding viral illness.
- Campylobacter jejuni, URI
- Ascending symmetric parasthesias and motor weakness
- Miller Fisher Variant: Opthalmoplegia, ataxia and decreased reflexes
Dx: EMG, CSF (increased protein and lymphocytes)
Tx: IVIG, plasmapheresis

Diptheria:
- Toxin mediated multisystem illness
- Respiratory or skin
- Toxin release and peripheral neuropathy

DM2 Peripheral Neuropathy:
- Distal symmetric
- Can have CN 3,4,6

ALS:
- UMN disease with associated LMN disease
- Anterior horn cell neuronopathy
Tx: Riluzole, supportive therapy

Myesthenia Gravis:
- AI disease of the NM junction
- Antibodies against the ACh receptors
- Associated with thymoma
Sx: Fatiguable weakness. Improves with rest. Ocular muscle weakness. Improved with cold
- Myesthenic Crisis: Resp failure requiring mechanical ventilation. Triggers include infection and medications
Tx: Plasmapheresis, IVIG, Thymectomy

Lambert -Eaton:
- Anitbodies that reduce ACh at NMJ. Associated with cancers SCC lung
- Symptoms improve with repeated movement. (Primarily leg)
- Autonomic symptoms to dry mouth and impotence

Botulism:
- Toxin mediated
- Descending flaccid paralysis
- Diplopia, dysarthria and dysphagia early
Tx: Supportive and horse serum antitoxin

Tick Paralysis:
- Should find an attached feeding tick

Periodic Paralysis:
- Muscle ion channelopathy. Hyper and hypo K are most common

32
Q

Multiple Sclerosis

A

CNS Demyelination
- Lesions separated by time and space
- Optic neuritis most common first presentation
- LE > UE: loss of strength, vibration/propriception, increased tone and reflexes
- Internuclear opthalmoplegia
- Uhthoff phenomenon: symptoms worse with increase temperature
- Lhermitte phenomenon: electrical shock with neck flexion

33
Q

Parksinson’s Disease

A

4 main findings:
- tremor
- rigidity
- akinesia
- postural instability

CCFP-EM (20 decks)

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