Neurologic Emergencies Flashcards
Status epilepticus definition
5+ mins of clinical or electrographic seizure activity OR 2+ seizures without recovery in between
Refractory status epilepticus
Failure of benzo + 1 AED
In 30% patients
20% die
SE Rapid initial management
- Airway - oral, lateral decubitus
- Breathing - bag mask, O2, sat probe, RT
- Circulation - cardiac monitor, IV access
- Check glucose
SE Initial management
1 abortive and 1 maintenance drug
Abortive - early
- Lorazepam 0.1 mg/kg
- Diazepam 0.2 mg/kg
- Midazolam 10 mg
Maintenance
- Phenytoin - 20 mg/kg
- Fosphenytoin 20 mg/kg
- Valproic acid 40 mg/kg
- Levetiracetam 60 mg/kg
Refractory SE Management
- ICU
- Midazolam infusion
- Propofol infusion
- Pentobarbital infusion
Aim for burst suppression for 24 hr before taper
Monitor for NCSE with continuous EEG
SE Investigations
Labs
Glucose, ABG, lactate (up), CBC (inc WBC), lytes (hypoK), extended lytes (all hypo), Cr up, NH4 up, tox screen Les, AED level (don’t tx level), prolactin up, beta HCG
Imaging
- CT head (tumor, pus, blood)
- MRI brain (cortical lesion)
- EEG
SE Tx Cause
Metabolic
- Hypoglycemia - thiamine, D50
- Restart missed AEDs
- Tx withdrawal
- Tx toxicity
- Correct lytes -Na, Ca, Mg
Structural
- Meningitis
- Encephalitis HSV1>2
- Stroke
- CVT
- Ischemic encephalopathy
- HTN - PRES
- Autoimmune
Epilepsy definition
2+ unprovoked seizures >24 hr apart OR
1 unprovoked seizure with >60% recurrence risk OR
Epilepsy syndrome
Focal seizure
- Aware or impaired awareness
- Motor or non motor onset
- Focal to bilat tonic clonic
EEG - focal IEDs, slowing
Rx - epilepsy surgery
Generalized seizure
Motor - tonic clonic, myoclonic, atonic, tonic, clonic
Non motor - absence
EEG - generalized spike and wave
Rx
- AEDs
- Vagal nerve stimulator
- Ketogenic diet
Unknown seizures
Motor or non motor
Tx
Broad spectrum AEDs
Seizure features vs other causes
Prodrome/Risks - Sleep deprived, from sleep, photic stimulation, hyperventilation, alcohol use During spell - Positive sx - Vocalization - Deju vu - Epigastric rising - Head turning - Incontinence - Flushing - Tongue biting Postdromal - Tongue biting - Confusion, somnolence - focal neuro deficit
Syncope features vs. other causes
Prodrome/risk - Light head, sweat, sit/stand, defecation/micturition, palps During spell - Brief convulsions - Pallor, diaphoresis Postdromal - Alert
TIA features vs. other causes
Prodrome/risk - CV risk factors During spell - Negative symptoms - Sudden onset - Max deficit at onset - <10 mins Postdromal - Alert
Migraine aura features vs. other causes
Prodrome/risk - FHx - Motion sickness, cyclical vomiting, adverse childhood experience During spell - Gradual migration of sx over 5-60 mins - Scintillating scotomas - Paresthesias - Positive and negative sx Postdromal - Sev, unlit throbbing HA - Photo/phono/osmophobia - N/V
Risk of recurrence
21-45% after first - greatest in first 2 years
60%+ if abnormal EEG or MRI
EEG
- Routine low yield ~30%
- 50% within 24 hrs event
- 50% sleep deprivation
- 70% serial EEGs
AED Options - Broad
Valproate Lamotrigine Levetiracetam Clonazapam Clobazam Topiramate
AED Options - Focal
Avoid in idiopathic generalized: Carbamazepine Oxcarbazepine Eslicarbazepine Phenytoin Gabapentin
Okay:
Phenobarbital
Pregabalin
Lacosamide
AED Options - Absence
Valproate
Ethosuximide
AED Options - Myoclonic
Valproate
Levetiracetam
AED Tolerability and other SFx
SCARED-P Sedation Cog impairment Ataxia/dizzy Rash Emesis/GI Diplopia/visual change Pregnant - NO VALPROATE
Other
- OP
- HypoNa - carb, oxcarb, eslicarb
- Psych - levetiracetam
- SJS - carb, oxcarb, pheny, lamo
- PR long - lacosamide
- Weight gain - VA
- Weight loss - topi
- CI - topi, clobazam
- Sedating - clob, phenobarbitals
AED Adherence and cost
BID>TID
Newer most expensive than older
AED in pregnancy
Levetiracetam
Lamotrigine
AED Interactions
- Renal - levetiracetam
- Valproate CYP inhibitor
AED Mood stabilizers
Valproate
Lamotrigine
Carbamazepine
Epilepsy Safety/Driving
- Avoid climbing, swimming, driving
- MedicAlert
Driving - 1st seizure unprovoked = 3 months
- Epilepsy - 6 mos seizure free on meds
- Medication change - 3 mos
Epilepsy non pharm management
- Stop alcohol and drugs
- Sleep hygiene
- Trigger avoidance
- Screen anxiety, dep, SI
GBS Defn
Acute monophasic inflammatory demyelinating polyradiculoneuropathy
Causes sensory loss, ascending paralysis, areflexia
GBS Risk Factors
Infection - C jejeni, flu, HIV, Zika
Influenza»_space;> flu shot
GBS Treatment
Nonambulatory patients within 4 weeks of symptoms 1. IVIG - 2g/kg over 2-5 d OR 2. PLEX - No steroids - Don't use both
GBS Acute management
- ABCs - tele, BP, FVC q4h
- Intubate if:
FVC<20
MIP 0 to -30
MEP <40
Predictors of resp failure in GBS
30% patients have it Onset to admission <7 d FVC <60% predicted Facial weakness Inability to cough, lift head, lift arms, stand
Dysautonomia in GBS
70% of patients have it Sinus tachy Paroxysmal HTN Ortho HOTN Brady, AV block Urinary retention Ileus
Investigations in GBS
- FVC
- PVR
- MRI whole spine with Gad (R/O acute myelopathy)
- CBC, lytes, BUN, Cr, INR/PTT
- LP - albumincytologic dissociation (protein >0.45, WBC <5, if WBC high check HIV)
- EMG/NCS = absent F waves, conduction block (best 2 wks post)
- Anti Gq1b Ab
History GBS
Monophasic
85% walking by 1 year
5% go on to have chronic inflammatory demyelinating polyradiculoneuropathy
Tx: IVIG or steroids
CIDP Defn
- Most common chronic AI neuropathy
- Progressive symmetrical proximal and distal weakness, large fibre sensory loss, areflexia, fatigue over 2 mos
- Usually spares CN, resp, autonomic
CIDP Dx
- EMG/NCS - acquired demyelination
- CBC, lytes, liver renal, thyroid B12, A1c, SPEP/UPEP, immunofixation, FLC, methylmalonic acid
- Maybe LP
- Maybe MRI spine with gab
- Maybe nerve U/S
CIDP Tx
- IVIG q3 week
2. Pred 1 mg/kg
When to suspect treatable neuropathy
Typical pattern
- Distal symmetric polyneuropathy
1. Paresthesia migrate feet to legs
2. Lose ankle reflexes
3. Dec sweating in feet
4. Atrophy extensor digitorium brevis
5. Toe flexor/extensor weakness
6. Paresthesias at knees –> fingertips
Red flags
- Asymmetrical
- Acute onset
- Early motor involvement
- Sig autonomic involvement
Myasthenia Gravis Features
Autoimmune destruction of the POST synaptic NMJ
Bimodal - young F 20s, old M 60s
Fatiguable weakness:
- Ocular - ptosis, binocular diplopia, pupil sparing
- Bulbar - dysarthria, dysphagia, chewing fatigue, head drop
- Resp - orthopnea
- Extremities - prox>distal weakness
MG Investigations
- PFT - FVC
- Serum AChR Ab
- EMG/NCS
- RNS (rpt nerve stimulation)
- SFEMG - CT chest - R/O thymoma
- CBC, lytes, Cr, TSH, CK
Acute Management Myasthenic Crisis
- ABC
- Intubate if:
FVC <20
MIP 0 to -30
MEP <40
Immunosuppression myasthenia crisis
- PLEX or
- IVIG 2 g/kg over 2-5 d
Hold pyridostigmine while intubated
Caution high dose pred = worsen resp
Maintenance Tx MG
Symptoms 1. Pyridostigmine 60 TID - GI, cholinergic crisis, bronchorrhea Disease Modifying 1. Prednisone 2. Azathioprine 3. MMF 4. PLEX 5. IVIg 6. Eculizumab
Thymoma in MG
If thymoma = refer to surgery
If no thymoma - elective if <60 yo, AChRAb pos, disease <5 year
Drugs to avoid in MG
- Anesthestic - NM
- ABx - FQ, AG, macrolide
- CV - BB, procainamide, quinine
- Anti PD1 MAbs - nivolumab, pembrolizumab
- Botulinum
- Chloroquine/HCQ
- Mg, Li
- Steroids - in crisis
Headache DDx Primary
Primary 1. Migraine 2. Tension 3. Trigeminal autonomic cephalalgia Other: cluster, paroxysmal hemicarnia, SUNCT/SUNA Secondary DANGEROUS
HA Ddx Secondary
Vascular - Ischemic stroke/thrombosis - Hemorrhage - Dissection - GCA - PRES - Pituitary apoplexy - AVM Space occupying - Tumor - Hydrocephalus - Idiopathic intracranial HTN Infection - Meningitis, encephalitis, abscess - Sinusitis, otitis Ophtho - Acute glaucoma - Iritis - Optic neuritis
Red flags in HA
SNOOP4 Systemic - fever, wt loss, IS Neuro - s/sx Onset - thunderclap Older >50 Pattern change, positional, pulsatile tinnitus, precipitated by cough/valsalva
Secondary HA Investigations
- CT/CTA/CTV H&N
- MRI Brain
Other - CBC, lytes, Cr
- ESR/CRP - GCA
- DVT - CVT
- Blood cultures
- LP
Idiopathic Intracranial HTN
Headache plus:
Transient visual obscurations
Pulsatile tinnitus
Weight gain
Spontaneous intracranial HOTN
HA plus worse standing
Meningitis
Headache
Fever
Photophobia
Neck stiffness
HSV Encephalitis
HA
Fever
Encephalopathy
GCA
HA Fever Weight loss Scalp tender, jaw claudication, transient monocular vision loss proximal myalgias Anemia
Reversible cerebral vasoconstriction syndrome
HA
Recurrent thunderclap
Pregnant
Cannabis/decongestant use
PRES
HA
HTN
Cyclosporine/tac
Dissection
HA
Neck pain
Horner syndrome
Pituitary apoplexy
HA Vision loss Diplopia HOTN Pregnant
Dx Migraine w/o Aura
5+ HA attacks lasting 4-72 hr with no better explanation
2 of:
- Unilateral
- Pulsatile
- Mod-sev
- Aggravated by/avoid routine physical activity
PLUS 1 of:
- N/V
- Photo/phonophobia
Tx of status migrainosus
Oral
- NSAID - ASA, diclofenac, Ibuprofen, Naproxen
- Acetaminophen
- Triptans
Parenteral
- IVF
- MgSO4
- Antiemetic - maxeran, domperidone
- Ketorolac
- Dexamethasone
Peripheral nerve block
Neurostimulation
NO OPIOIDS, BARBITURATES
Multiple Sclerosis Epi
F>M Northern Europeans Relapsing remitting type 90% Primary progressive Secondary progressive
Clinically isolated syndrome
First demyelinating attack
Monophasic clinical episode of acute or subacute onset
Patient reported symptoms
Findings typical of MS
Reflects a focal or multifocal inflammatory demyelinating event in CNS +/- recovery
No fever or infection
If MRI lesions 70% develop MS
If non 20% develop MS
MS Optic neuritis
Painful eye movements
Monocular vision and colour loss or scotoma
RAPD
1/3 mild disc swelling
MS Brainstem/cerebellar syndrome
Bilateral INO Diplopia Dysarthria Ataxia Gaze evoked nystagmus Vertigo Facial numbness CN6 palsy
Incomplete transverse myelitis
Sensory loss Asymmetric limb weakness Urge incontinence ED Lhermitte - neck flexion = spinal electric shock sensation
Uhthoff phenomenon
Heat exacerbation
Ddx MS
- Demyelinating - ADEM, NMO, MOG
- Inflammatory - Sarcoid, SLE, Sjogrens, GPA, Behcets
- Infx: post infxn demyelination, HIV, PML, HTLV, syphilis, Lyme, Bartonella, TB
- Metabolic - B12/Cu def
- Lymphoma
- somatization
- Vascular - vasculitis, malformation, migraine
Macdonald Criteria for RRMS
- MS most likely AND
- 1 CIS AND
- Dissemination in space and time
DIS - 2+ clinical attacks OR - 2+ lesions in 2+ of regions DIT - 2+ clinical attacks OR - 1 MRI: gad enhancing and non enhancing lesions OR - 2 MRIs - new T2/gad lesion on F/U scan OR - CSF specific oligoclonal bands
MS Investigations
- MRI brain and CT spine with gad
- LP for oligoclonal bands IgG index
Other
- Basic lab work
- B12, TSH, SPEP
- ANA, ESR, CRP, ENA, ACE, ANCA
- VDRL, LYME, HIV, HTLV
- Visual evoked potentials
- NMO/MOG Ab
Treatment MS attack
If functional disabled = high dose CS speeds recovery
- Optic neuritis
- Motor weakness
Doesn’t change degree of recovery or reduce risk of future attack
Methylpred 1000 mg IV daily 3-7 d and taper
PLEX if poor steroid response
Disease modifying therapy RRMS
- Decrease relapse rate
- Decrease MRI brain lesions
- Lower risk conversion
Injections - Beta interferon - Glatiramer acetate Oral - Dimethyl fumarate - Teriflunomide - Fingolimod - Siponimod - Cladribine Infusion - Natalizumab, alemtuzumba, ocrelizumab HSCT Lifestyle - Physical activity - Stop smoking - Vit D 4000 IU daily
Neuro manifestations COVID
Anosmia Ageusia Acute ischemic stroke Encephalopathy/encephalomyelitis HA Mylagia, rhabdo ICH GBS Bell's palsy
Encephalopathy Management
- ABC
- Thiamine, dextrose, Naloxone
- Hyperthermia - cooling blankets, antipyretics
- Consider empiric ABx/antivirals
Inv
- Tox screen
- CT/MRI head
- EEG
- LP
Herpes Encephalitis
HSV1 reactivation <1 wk AMS, aphasia, ataxia, memory, focal seizure Inv - MRI - LP - inc RBC, lymph's, glucose normal - EEG - high amp slow waves - HSV CSF PCR
Otologic Vertigo
Sx - Hearing loss, Tinnitus, Aural fullness - Severe vertigo - Head trauma - With head postures, cough Exam - HINTS benign - Unidirectional nystagmus - Dix Hallpike positive Ancillary - Audiology - Vestibular testing - CT temporal bone
Neurologic Vertigo
Sx - Diplopia - Dysphagia, dysarthria - Hemiparesis, hemisensory loss - Migraine, MS, stroke Exam - HINTS concerning - Direction changing nystagmus - Skew deviation - Horner - Ataxia - Focal weakness - Gait instability Ancillary - MRI brain
Medical Vertigo
Sx - Syncope, SOB, palps - Only when standing Exam - Murmur - Ortho HOTN Ancillary - Holter, echo, lytes, med review
Psychogenic vertigo
Sx - Constant for mos - Panic attacks Exam - Positive signs: Hoover sign, distractibility, suggestibility, entrainment, waxing/waning
HINTS Exam
Peripheral vs central vertigo
- Head impulse test
- P: abnormal, corrective saccade
- C - normal, no correction - Nystagmus
- P: unidirectional, horizontal
- C: horizontal, direction changing, vertical, tosional - Test of Skew
- P: no skew deviation
- C: skew deviation
Lateral medullary syndrome (Wallenberg)
Infarct of vertebral or PICA - N/V, vertigo - Ipsilateral Horner - Ipsilateral face pain/temp loss - Contralateral body pain/temp loss - Ipsilateral cerebellar ataxia - Ipsilateral dysphagia/dysarthria - Hiccups NO LIMB WEAKNESS
Horner’s syndrome
Miosis - constrict
Ptosis - droopy lid
Anhidrosis - no sweat
Damage to sympathetic nerves
Bell’s Palsy
Unilateral drooping
Ptosis
Cannot close eye
Pregnancy considerations
Epilepsy - Avoid AEDs - valproate - Drug level monitor MS - Improved relapse rate, inc risk PP 3-4 mos - Methylpred tx - Glatiramer and interferon best for immediate pregnancy HA - Tylenol, sumatriptan, nerve block, neurostimulation Stroke - Risk permpartum to 6 weeks post - avoid gad - offer TPA/EVT
