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My CCFP > Neurology > Flashcards

Neurology Flashcards

1
Q

Acute management of cluster headaches

A

100% O2 @ 6-12 L/min x 15min
+
Sumatriptan 6mg s/c* or 20mg i/n
Zolmitriptan 5mg i/n* or 10mg PO
or Lido 4-10% i/n
or Octreotide

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2
Q

Bridging Treatment of cluster headaches

A
  1. Unnilateral greater occipital nerve block w/ Methylpred 80mg + 2mL 2% Lido
  2. Pred 60mg PO x 5d then ↓10mg q2d or Methylpred 100mg PO then taper
  3. Ergotamine
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3
Q

Prophylaxis for cluster headaches

A
  1. Verapamil 80mg TID **ECG @ baseline
  2. Ergotamine
  3. Topiramate 100mg/d (CI : nephrolithiasis)
  4. Lithium 300mg OD then ↑300mg qwk
  5. Valproic Acid 5-20mg/kg, Melatonin 10mg HS, Baclofen 15-30mg, Neuromodulators
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4
Q

Diagnostic Criteria of Cluster Headaches

A

5xHA w/ :
1. severe UNIlateral orpital/temporal pain lasting 15-180minutes

  1. ≥1 autonomic sx (UNI+IPSI) : conjunctival injection, lacrimation, congestion/rhino, eye/forehead edema, miosis/ptosis, agitation
    **Think parasympathetic
    **Think Horner Syndrome

Frequency : 8/d ad q2d

Circadian : episodic or chronic

50% have migraine sx

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5
Q

Investigations for Cluster Headaches

A

Usually clinical, no imaging unless red flags
Can do TSH, prolactin, pituitary function

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6
Q

Name the red flags of headaches

A

SNOOP4
Systemic sx
Neuro sx
Onset (sudden/thunderclap)
Older pts (>50)
Papilledema (optic disc swelling)
Postural aggravation (incr standing/DD)
Preciptiated by valsalva
Pattern change

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7
Q

DDx : Cluster Headaches

A

MM…IT ACHES!
Migraine
Meningitis
Increased intracranial pressure
Tension HA, Temporal/Giant Cell Arteritis
AV malformation
Cluster migraine
HTN
Eye disorder (glaucoma, refractory error)
Sinusitis, SAH, systemic illness

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8
Q

For suspected subarachnoid hemorrhage (SAH), what is the initial investigation?

A

Non-contrast CT scan of the head; if negative and suspicion remains high, follow with lumbar puncture (LP) to check for xanthochromia 12 hours after symptom onset.

**CT scans may miss small or early bleeds, especially if done more than 6 hours after symptom onset

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9
Q

If you suspect temporal arteritis (Giant Cell Arteritis), what tests should you order?

A

Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) as initial screens, followed by temporal artery biopsy if ESR/CRP are elevated and clinical suspicion remains high.

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10
Q

For a patient with suspected temporal arteritis, what treatment should be initiated promptly, even before confirmation?

A

Start high-dose corticosteroids (e.g., prednisone 40-60 mg daily) to prevent vision loss, especially if there are symptoms like jaw claudication or vision changes.

Consider Aspirin: Low-dose aspirin (81 mg daily) may be given to reduce ischemic complications, such as stroke.

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11
Q

In a patient with suspected SAH and a negative CT, what is the next diagnostic step?

A

Perform a lumbar puncture (LP) to look for xanthochromia, which indicates the presence of blood breakdown products in the cerebrospinal fluid.

**12 hours after symptom onset for + LP

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12
Q

What does an elevated ESR in a patient over 50 with a new headache indicate?

A

It raises suspicion for temporal arteritis (Giant Cell Arteritis); initiate corticosteroids promptly and consider biopsy.

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13
Q

What are potential contraindications for lumbar puncture in the workup of a headache?

A

Increased intracranial pressure due to mass lesion (risk of herniation), coagulopathy, and localized infection at the puncture site.

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14
Q

What are the initial steps in managing a patient with suspected meningitis?

A
  • Begin empirical antibiotics immediately (e.g., ceftriaxone + vancomycin ± ampicillin if Listeria is a concern).

Perform a lumbar puncture for CSF analysis.
Do not delay antibiotics for imaging or LP if meningitis is strongly suspected.

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15
Q

Clinical presentation of giant cell arthritis or temporal arthritis

A

HEAD PAIN
Headache : new, unilateral, temporal region
Elevated ESR/CRP
Age > 50
Double vision, vision loss or other visual disturbances
Pain in jaw (jaw claudication)***
Atemporal artery tenderness
Inflammatory symptoms (systemic sx, PMR sx)
Needs steroids immediately

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16
Q

Physical exam findings in patients with giant cell arthritis or temporal arthritis

A

Temporal Artery: Often tender, enlarged, or pulseless upon palpation.
Fundoscopy: May show signs of ischemic optic neuropathy if visual symptoms are present.

17
Q

What are potential complications of GCA/temporal arthritis?

A

Permanent Vision Loss: Often from anterior ischemic optic neuropathy; irreversible if untreated.
Stroke: Increased risk, particularly ischemic stroke.
Aortic Aneurysm and Dissection: GCA can involve large arteries, increasing the risk of thoracic aortic aneurysms; periodic imaging may be warranted.

18
Q

What scores do you use for imaging in concussions?

A

Pediatrics : PECARN or CATCH2

Adults : Canadian CT Head Rules or NEXUS

19
Q

What are the signs of basal skull fracture?

A

CSF leak (rhino/oto)
Hemotympanum
Racoon Eyes
Battle Sign

20
Q

DDx : stroke

A

TIA
Brain tumor
Hypoglycemia
Subdural hematoma
SAH / Subarachnoid bleed

21
Q

Differentiate hemorrhagic from embolic/thrombotic stroke

A

Hemorrhagic: RF HTN, HA, V, increasing sx
Ischemic: RF AFib or carotid disease, sudden deficit

CT Head C-, ECG for AFib, CTAfor vascular

22
Q

Eligibility for thrombolysis

A

4.5hrs from symptom onset , BP <180/105

6h for EVT baloon

23
Q

Antithrombotic treatmenet for TIA or stroke

A

ASA 160-325mg then 81mg qd
Plavix/Clopidogrel 300-600mg then 75mg qd x 21d
Then continue w/ just one of the two

24
Q

LDL and BPand A1c target post stroke

A

<1.8 mmol/L
<140/90 (DM2 <130/80)
<7 or <6.5% (FBG 4-7, PP 5-10)

25
Q

List 4 risk factors for meningitis

A

immuno‐compromised individuals
alcoholism
recent neurosurgery,
head injury,
recent abdominal surgery,
neonates,
aboriginal groups,
students living in residence

26
Q

Name the common pathogenes of meningitis (bacteria and viral)

A
  • Bacterial: pneumococcus (60%), meningococcus (15%), GBS (15%), H. flu, Listeria.
  • Viral: HSV, CMV, Herpes, Coxsackie, Enteroviruses.
27
Q

Name emergent and urgent causes of headache

A

emergent: intracranial/subarachnoid hemorrhage (ICH/SAH), carbon monoxide poi‐ soning, hypertensive emergency, space‐occupying lesions, basilar artery dissection, central venous throm‐ bosis.

urgent: temporal arteritis, idiopathic intracranial hypertension (i.e. pseudotumor cerebri), acute glaucoma.

28
Q

Name your serum investigations for meningitis

A
  • CBC with differential (looking for elevated white count and a left shift).
  • Blood and CSF cultures (blood cultures are positive in most patients with bacterial meningitis (Kanegaye et al.), and can be useful if lumbar puncture is delayed, as empiric parenteral antibiotics should not be delayed for lumbar puncture).
  • Serum glucose (to calculate CSF/blood glucose ratio).
  • Renal function (as part of fluid resuscitation and general sepsis protocol).
  • Coagulation profile (if petechia/purpura and DIC suspected).
  • Electrolytes.
29
Q

When would you CT prior to LP?

A

 intracranial pressure (ICP) is a relative contraindication to LP in meningitis, due to the risk of cerebral herniation

– >60yo.
– Immunocompromised (i.e. HIV, transplant patient, or immunosuppressed). – Seizure within 1 week of presentation.
– Neurological findings (i.e. LOC, palsies, speech deficits).
– History of CNS disease (i.e. mass lesion, stroke, or focal infection).

30
Q

What next steps do you do in regards to public health for a patient w/ meningitis

A
  • Chemoprophylaxis should be offered to all persons having close contact with an IMD case during the infectious period (the 7 days before onset of symptoms in the case to 24 hours after onset of effective treatment).
  • Appropriate agents for chemoprophylaxis include ciprofloxacin, rifampin, and ceftriaxone
31
Q

What components of the CSF analysis post LP help in diagnosis?

A

Gram stain
Culture and sensitivities
WBC
CSF-to-serum glucose
Protein
Neutrophil %

My CCFP (8 decks)

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