neurology Flashcards
tension headache character
30 minutes to 7 days Typically bilateral location Pressure or tight quality Does not prohibit activity Not associated with nausea
tension headache tx
Treat acute headache with NSAIDs
A tricyclic antidepressant may be needed for prophylaxis
trigeminal neuralgia symptoms
Brief paroxysms of unilateral lancinating pain in the V2 or V3 distribution of the trigeminal nerve, often
triggered by light touch of the affected area
imaging needed for trigeminal neuralgia
MRI to rule out intracranial lesions and MS
tx for trigeminal neuralgia
Select carbamazepine for treatment
medication overuse headache symptoms
Chronic headache that occurs ≥10 days per month in patients using combination analgesics,
ergotamine products, or triptans; chronic headache that occurs >15 days per month in patients using
simple analgesics
chronic migraine characteristics
Headache occurring ≥15 days per month for >3 months
Headache possessing the features of migraine ≥8 days per month
Risk factors include migraine headache frequency or acute medication use >10 days per month
1st and 2nd line tx for migraisn
nsaids
then use triptans if lack of response or severe
treatment for . Migraine that is present on awakening, is associated with vomiting, or is found to escalate rapidly
intranasal triptans or subcutaneous
tx for migraine assoc nausea
Metoclopramide and prochlorperazine
indications to use prophylaxis for migraine
migraines do not respond to therapy
• headache occurs ≥10 days per month
• disabling headache occurs ≥4 days per month
• use of acute migraine medications is >8 days per month
options for ppx tx of migraines
amitriptyline, metoprolol, propranolol, timolol,
topiramate, valproic acid, and venlafaxine. Onabotulinum toxin A is indicated in chronic migraine.
contraindications to triptans
CAD and cerebrovascular disease, brainstem aura, and hemiplegic migraine.
characteristics of cluster headaches
Pain usually periorbital, duration 15-180 minutes, several times per day. Repeating over weeks then
disappearing for months or years. Unilateral tearing and nasal congestion or rhinorrhea, eyelid
edema, miosis and/or ptosis
tx of cluster headaches
acute - triptan and oxygen
chronic veramapil
symptoms of chronic paroxysmal hemicranias
Occurs at least five times daily lasting 2-30 minutes. Responds completely to indomethacin.
Short-lasting Unilateral Neuralgiform headaches with Conjunctival injection and Tearing
Dozens to hundreds of times per day, with durations of 1 to 600 seconds. Typically resistant to treatment.
Hemicrania continua symptoms
Persistent strictly unilateral headache that responds to indomethacin
red flag symptoms for headache (9)
- first or worst headache
- abrupt onset or thunderclap attack
- progression or fundamental change in headache pattern
- abnormal physical examination findings
- neurologic symptoms lasting >1 hour
- new headache in persons >50 years old
- new headache in patients with cancer, immunosuppression, or pregnancy
- association with alteration in or loss of consciousness
- headache triggered by exertion, sexual activity, or Valsalva mane
testing for headaches when red flag symptoms are present
MRI over CT in nonemergency situations
• CT for suspected acute ICH
• ESR or CRP for suspected giant cell arteritis
• LP for suspected infectious or neoplastic meningitis or disorders of intracranial pressure
Subarachnoid hemorrhage
(SAH) clues
Sudden onset of “worst headache of my life”
Many patients have warning “sentinel” headaches
before SAH
carotid or vertebral dissection clues
Neck pain and ipsilateral headache; neurologic
findings in territory of involved vessel
tx with asa heparin or anticoag
clues for thrombosis of cerbral vein or dura sinus
Exertional headache, papilledema, neurologic
findings
Consider in hypercoagulable states, pregnancy, use of
oral contraceptives
Tx LMWH followed by warfarin
Reversible cerebral
vasoconstriction syndrome clues
Recurrent thunderclap headache syndrome, more
frequent in women. Associated with pregnancy,
neurosurgical procedures, exposure to adrenergic or
serotonergic drugs. Imaging shows strokes,
hemorrhages, or cerebral edema
Idiopathic intracranial hypertension (pseudotumor cerebri) is
characterized by
intracranial pressure without identifiable structural pathology. Patients are typically female, obese, and
of child-bearing age. Papilledema is nearly always present.
diagnose and tx pseudotumor cerebri
Diagnosis is confirmed by a CSF pressure >250 mm H2O with normal fluid composition. MRI may be normal or show small ventricles, widened optic nerve sheaths, or a partially empty sella.
tx acetazolamide
epilepsy diagnosis
two or more unprovoked seizures occurring more than 24 hours apart or one unprovoked seizure with a significant ongoing risk of further unprovoked seizure
Focal seizure without alteration of awareness
(formerly simple partial seizures) charateristics
Normal consciousness and awareness
Single neurologic modality (sensory, motor, olfactory, visual, gustatory) involving a
single region of the body, such as the hand or arm
Focal seizure with alteration of awareness
(formerly complex partial seizure) characteristics
Conscious but unresponsive or staring
Automatism (lip smacking, swallowing, or manipulating objects)
Postictal confusion
Primary generalized seizure characteristics
Loss of consciousness or awareness at onset
No prodromal or localizing symptoms
Whole-body stiffening (tonic) and/or jerking (clonic) seizures
Temporal lobe epilepsy
Focal seizures with alteration of awareness preceded by an aura before losing consciousness. Often unaware that they have become impaired and may have no recollection of the seizure. Medial temporal sclerosis is a characteristic finding on MRI.
Idiopathic (genetic)
generalized epilepsy
Any combination of tonic-clonic seizures, absence seizures, and myoclonic seizures. MRI typically normal. EEG may show generalized spike-wave abnormality.
Frontal Lobe epilepsy
Nocturnal complex seizures that awaken patients from sleep. Often associated with underlying structural
pathology (e.g., tumor, vascular malformations).
Myoclonic seizure
A generalized seizure associated with brief, lightning-like jerks of the arms, not associated with loss of
consciousness (misdiagnosed as “jitteriness”).
Convulsive status epilepticus
Characterized by continuous seizure for ≥5 minutes. Most common cause is low AED level. Complications
include aspiration pneumonia, fever, hemodynamic instability, acidosis, PE, and rhabdomyolysis;
associated with a mortality rate of approximately 20%.
symptoms of PNES
- forced eye closure
- long duration
- hypermotor activity that starts and stops
- pelvic thrusting
evaluation needed after first unprovoked seizure
• EEG (although a normal EEG does not rule out a seizure)
• CBC, electrolyte and glucose levels, and toxicology screen
• brain MRI (or head CT in an emergency)
• CSF examination if the patient has fever, prolonged altered mental status after the seizure, is immunosuppressed, or has
a severe headache
how do you diagnose PNES and what population is susceptible to pNES
Inpatient video EEG monitoring is required to make the diagnosis of PNES
PTSD in military
carbamazepine SE
interactions with other hepatically metabolized drugs and increased risk for osteoporosis and
hypercholesterolemia
• valproic acid SE
weight gain, hypercholesterolemia, PCOS, teratogenicity, hepatotoxicity
tompiramate and zonisamide SE
increased risk of kidney stones
• carbamazepine and oxcarbazepine SE
hyponatremia, pancytopenia
all AED have a potential SE of
drug hypersensitivity syndrome, SJS, and suicidal ideation
when can you stop AED
seizure free for 2-5 years
AEDs that are relatively safe in preg
lamotrigine (dose adjustment)
and levetiracetam
most common cause of status epileticus
low blood AED levels
tx for status epilepticus
First-line treatment is IV lorazepam, IV diazepam, or IM midazolam. Patients not taking AEDs should then be treated with phenytoin or fosphenytoin, administered after
5 minutes of continuous seizing
when is Surgical clipping or endovascular coiling of aneurysms are indicated
patients with aneurysms ≥7 mm in the posterior circulation or ≥12 mm in the anterior circulation.
all patients with TIA require
- emergent head CT without contrast (to rule out intracranial hemorrhage)
- ECG and telemetry or event monitoring (to rule out AF)
- vascular studies (cerebrovascular ultrasonography or cerebrovascular MRA, CTA)
- echocardiography (to rule out LV or valvular thrombus
abcd2 scoring system
Age ≥60 y 1
Blood pressure ≥140/90 mm Hg 1
Clinical Symptoms
• focal weakness with the TIA 2
• speech impairment without weakness 1
Duration of TIA
• ≥60 min 2
• 10-59 min 1
Diabetes mellitus present 1
what abcd2 score do you hospitalize
> /=3
what kind of stroke should you consider in older adults with persistent, acute-onset vertigo
vertibral basilar
how quickly do you need to administer tpa
within 3 hours or 4.5 hrs in selective patients
exclusion criteria for tpa
- age >80 years
- severe stroke
- diabetes mellitus with a previous infarct
- anticoagulant use
increased risk of bleeding, diagnosis of ICH, or SBP
>185 mm Hg and DBP >110 mm Hg
additional stroke treatment acutel
- treat temperature >38.0 °C (100.4 °F) with acetaminophen
- administer normal saline to maintain euvolemia
- give aspirin, 325 mg, unless thrombolysis is planned
- start DVT prophylaxis within 48 hours
only times to start antihypertensive therapy early in acute stroke instead of permissive htn
- SBP is >220 mm Hg, DBP is >120 mm Hg, or MAP is >140 mm Hg
- thrombolytic therapy is planned, and SBP >185 mm Hg or DBP >110 mm Hg
- ACS, aortic dissection, or end-organ damage is present
whats considered a small SAH
<7 mm posterior or <12 mm anterior circulation can be monitored by MRI
most common location/cause of SAH
results from the rupture of saccular (“berry”) aneurysms of the circle of Willis.
eye symptoms in SAH
(third nerve palsy and dilated pupil
what should you do if SAH is suspected but CT negative
Do CSF to look for erythrocytes or xanthochromia.
Tx for SAH
• Treat ruptured aneurysms with surgical clipping or endovascular coiling within 48 to 72 hour
• Maintain BP <140/80 mm Hg to prevent rebleeding.
• Select oral nimodipine for 21 days to prevent vasospasm and improve
neurologic outcomes.
what needs to be done in the setting ICH and cocaine use
Cerebral angiography is indicated for patients <45 years of age with ICH related
to cocaine use
what score on mini mental is associated with dementia
<24
routine testing/imagining for dementia
Routinely obtain brain imaging with CT or MRI to detect nondegenerative causes that would alter management, such as cerebrovascular disease, neoplasm, subdural hematoma, or hydrocephalus. Screen all patients for depression.
when to obtain LP in dementia
- rapidly progressive dementia
- age of onset <60 years
- history of malignancy or paraneoplastic disorders
- suspicion for acute or subacute infection; immunosuppressed or immunodeficiency state
- positive syphilis or Lyme serology
- systemic autoimmune disease; suspected CNS autoimmune or inflammatory disorder
diagnose Gradual memory loss, aphasia, apraxia, agnosia, inattention, and decrease in
executive function
alzheimer disease
diagnose: Imaging or history positive for stroke responsible for impairment of at least
one cognitive domain
Common findings include focal neurologic findings, depression, pseudobulbar
palsy, gait abnormalities, and urinary difficulties
vascular neurodegenerative disorder
Mild parkinsonism characterized by postural instability and gait difficulty,
fluctuating cognition, delusions, and visual hallucinations
dementia with lewy body
Early and prominent personality changes, behavioral disturbances including
disinhibition and impulsivity, diminished frontal and/or temporal lobes on MRI,
onset before age 60 years
Frontotemporal dementia, behavioral variant
Dementia, shuffling gait, urinary incontinence, and ventriculomegaly in the
absence of past history of meningitis, SAH, or trauma
Normal-pressure hydrocephalus
Choreoathetosis and dementia, autosomal dominant pattern of
inheritance
Huntington disease