Neurology Flashcards
When is a HINTS exam indicated?
In Acute Vestibular Syndrome:
Acute-onset, continuous vertigo, associated with:
Gait unsteadiness
Nausea and/or vomiting
Spontaneous or gaze-evoked nystagmus
What is a positive HINTS exam and what does it mean?
Head impulse - loss of corrective saccade
Nystagmus - direction-changing OR any nystagmus other than unidirectional in the direction of gaze
Skew - horizontal skew
Positive test is ANY of these and indicates a central cause for vertigo
Diagnostic criteria for Meniere’s disease
Recurrent attacks of spontaneous vertigo associated with tinnitus and hearing loss in the same ear.
-2 episodes lasting >20mins
-audiometric confirmation of sensorineural hearing loss
-tinnitus and/or perception of aural fullness
-exclusion of other causes
Diagnostic criteria for BPPV
Brief recurrent episodes of vertigo triggered by head movements
Canadian CT head rule
Inclusions:
GCS 13-15
LOC
Witnessed deterioration
Amnesia to HI event
Exclusions:
Age <16
Blood thinners
Seizure following HI
High risk criteria:
-Vomiting >2x
-GCS <15 at 2 hours
-Age >65
-Suspected open or depression skull fracture
-Evidence of basilar skull fracture
Medium risk criteria:
-RETROGRADE amnesia >30mins
-“Dangerous” mechanism
PECARN or other paediatric CTH high risk criteria
(PECARN)
Any age
-GCS <14
-Signs of open/depressed/basilar skull fracture
-Signs of AMS
Other
-Concern for NAI
-Seizure
-Focal neurological deficit
-Visible trauma to scalp
-GCS <15
GCS
Eyes
4 - spontaneously open
3 - open to voice
2 - open to pain
1 - no response
Voice
5 - coherent
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1- no response
Motor
6 - obeys commands
5 - localises to pain
4 - withdraws from pain
3 - decorticate posturing (flexion to pain)
2 - decerebrate posturing (extension to pain)
1 - no response
Diagnosis Orthostatic Hypotension
Measure BP and HR when lying supine for 5 mins, repeat after 1 and 3 mins standing
OH = >20mmHg drop in BP
Associated increase in HR indicates benign reversible causes eg dehydration
Medication causes/exacerbations of orthostatic hypotension
Alpha blockers
Beta blockers
TCAs
Vaso/venodilators (ISMN/GTN/sildenafil)
Anticholinergics
Dopamine agonists
Diuretics
Aetiology of orthostatic hypotension
Primary autonomic dysfunction:
Multisystem atrophy
Parkinsons
Lewy body Dementia
Primary autonomic failure (chronic)
Acute autonomic neuropathy
Secondary autonomic dysfunction:
Clear association with another illness
Dehydration/volume loss
Medications
UTI
Deconditioning/immobilisation/hospitalisation
Several known associated medical conditions:
-amyloid
-DM
-alzheimers
-malignancy
-MS
-autoimmune
-renal failure
Treatment of orthostatic hypotension (non-pharmacologic and pharmacologic)
Non-pharmacologic:
-avoid prolonged standing - use cocktail posture, squatting, hand clasping
-liberalise salt and water intake (10g salt, 1.5-2L water per day)
-avoid medication triggers
-raise head of bed
-care with standing
-exercise programme
-avoid hot environments eg showers
-stockings or abdominal binder
-cup of water
-small frequent meals
-avoid alcohol
Pharmacologic:
-fludrocortisone 0.1-0.3mg/day (unless background HTN/CHF)
-midodrine 2.5-10mg tds
-desmopressin nasal spray
-atomoxetine
-methylphenidate
-pyridostigmine
First seizure in adults. Causes and management.
Infections
Epilepsy
SOL
Metabolic derangement
Medications/toxins
Check glucose and Na
CTH
LP if immunocompromised
Pregnancy test
Not to drive
Definition and Management of status epilepticus
> 5mins of seizure activity OR
More than one seizure in a 24 hour period without recovery between
Check glucose
Monitor vital signs
Give 4-8mg lorazepam or 10mg diazepam IV
18mg/kg phenytoin
50ml of 50% glucose (or 2ml/kg of 25% in children)
Thiamine 100mg IV
ECG monitoring
Control hyperthermia
Assess acid base balance
Risk factors for stroke
Increasing age
Fijian Indian
Smoking
HTN
Hypercholesterolaemia
DM
AF
Carotid bruit
FHx heart disease
Management of TIA
Acute assessment <7 days if:
-crescendo TIAs
-AF
-on anticoagulants already
-known carotid stenosis
-ABCD2 score =/> 3
Discuss all other cases
Cervical artery dissection
Risks
Hx
Exam
Risks
Marfans/EDS/IO/fibromuscular dysplasia
Trauma
Migraine with aura
Recent infection
Vasculopaths
Smoking
HTN
Increased age
Hx
Neck pain (esp if vertebral) and neurological defect
Headache - sudden onset, unilateral
Vision changes (carotid) OR
Ataxia/dysarthria/diplopia/vertigo/visual field defect (posterior)
Exam
Expanding neck haematoma
Horners syndrome
Neuro deficit
Neck tenderness
Vascular bruit
Cluster headache risk factors
Male 4:1
Age 40-50
Smoking
FHx
Alcohol
Cluster headache features
Unilateral HA + autonomic features eg
-lacrimation
-sweating
-mitosis
-ptosis
-conjunctival effusion
-nasal congestion/rhinorrhoea
Associated restlessness/agitation
Lasting 15-180 mins
Occurring in clusters (up to 8 per day)
Cluster HA treatment
High flow O2
IM/IN tryptans
Ottawa SAH rule
HA peaking <1 hour and no neurological findings:
-age 40+
-thunderclap headache
-neck stiffness
-onset during exertion
-witnessed LOC
-neck stiffness on exam
Has sensitivity of 100%, specificity 15%
Migraine diagnosis
At least 5 episodes lasting 4-72 hours
POUND
Pulsating intensity, photophobia/photophobia
Of 4-24 hours duration
Unilateral
Nausea/vomiting
Disabling
Migraine with aura
Visual, sensory or speech symptoms developing gradually, lasting 5-60 mins and completely reversible
Associated headache
Headache red flags
Age >50
Cancer
Thunderclap
Onset with exercise/sex/cough
Worst headache of life
Neurological sx
Fever
Neck pain or stiffness
HIV
Associated with exertion
Pregnancy or postpartum
Orange flags
Temporal artery tenderness
Personality change
Cerebral venous thrombosis features
Women:men 3:1
Young adults and children affected
Headache
Papilloedema
Decreased visual acuity
Pain with eye movements
Seizures
Decreased LOC
Focal neuro deficits
Peripartum
Oestrogen use
