Neurology 2 Flashcards by Kevin G

What types of stroke have no Tx to reverse them?

Hemorrhagic stroke

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Surgical drainage will NOT help where?

outside of the Posterior Fossa

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If patient is already on Aspirin at the time of stroke, after 3 hours what would you give for Tx?

Add Dipyridamole
or
Switch to Clopidogrel

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Most common type of headache?

Tension headache

though it is a dx of exclusion

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Type of Headache?

Visual disturbance, systemic symptoms such as muscle pain, fatigue, & weakness

Giant Cell Arteritis

- also includes Jaw Claudication

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Type of Headache?

Ass’d w/ obesity, venous sinus thrombosis, oral contraceptives, & vitamin A toxicity

Pseudotumor Cerebri

- Mimics a brain tumor w/ nausea vomiting, & visual disturbance

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Type of Headache?

Mimics a brain tumor w/ nausea vomiting, & visual disturbance

Pseudotumor Cerebri

- Ass’d w/ obesity, venous sinus thrombosis, oral contraceptives, & vitamin A toxicity

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PE findings in Tension headaches?

None

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PE findings in Migraine?

Usually none, but rare cases have aphasia, numbness, dyarthria, or weakness

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PE findings in Cluster headache?

Red, tearing eye w/ rhinorrhea

- Horner syndrome occasionally

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PE findings in Giant Cell Arteritis?

Visual loss

- Tenderness of the Temporal area

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PE findings in Pseudotumor Cerebri?

Papilledema w/ diplopia from 6th cranial nerve (abducens) palsy

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What does Pseudotumor Cerebri show on LP?

Increased pressure only.

CSF itself is normal

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Most accurate Dx test for Giant Cell Arteritis?

Biopsy.

Also ass’d w/ markedly elevated ESR

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Tx?

Tension headaches

NSAIDS & other analgesics

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Tx?

Migraine

Triptans or Ergotamine as abortive therapy

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Tx?

Cluster headaches

Triptans, Ergotamine, or 100% Oxygen as abortive therapy

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Tx? 
Giant Cell (Temporal) Arteritis

Prednisone

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Tx?

Pseudotumor Cerebri

Weight loss

Acetazolamide - to dec CSF prod
Steroids help
Repeated LP rapidly lowers ICP
Place V-P shunt or fenestrate (cut into) the Optic Nerve if medical therapy doesn’t control

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Prophylaxis Tx for Cluster headaches?

Verapamil

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Prophylaxis Tx for Migraines? When do you give proph Tx?

Propranolol
Give this if having 3 or more migraines per month

others include CC-blockers, TCAs, SSRIs, Topiramate, Botulinum toxin injections

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Trigeminal Neuralgia Tx?

Oxcarbazepine or Carbamazepine

Baclofen & Lamotrigine also have been effective
Gamma knife surgery if meds ineffective

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Postherpetic Neuralgia Tx?

TCAs, Gabapentin, Pregabalin, Carbamazepine, or Phenytoin

Topical Capsaicin helpful
Most antiepileptic meds are effective, but none of them in more than 50-70% of patients

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Indication for Zoster vaccine?

All persons >60 yrs.

Status Epilepticus Tx?

1st = Benzodiazepine - if persists, give Fosphenytoin or Phenytoin - if still persists, give Phenobarbitol - if still, give neuromuscular blocking agent such as Succinylcholine, Vecuronium, or Pancuronium to allow intubation & anesthesia such as Midazolam or Propofol

IV Phenytoin adverse effects?

Hypotension & AV block (Class 1b anti-arrhythmic) | Fosphenytoin has fewer SEs & same efficacy

Can neuromuscular blocking agents stop seizure?

No, they just stop muscular contraction or the external manifestation of the seizure

What is a partial seizure?

Seizure focal to one part of the body | Can be simple (intact consciousness) or complex (loss or alteration of consciousness)

Opioids used for diarrhea?

Loperamide & Diphenoxylate

Opioid used for cough suppression?

Dextromethorphan

Tramadol MOA?

- Very weak opioid agonist - Also inhibits 5HT & NE reuptake "Tram-it-all"

Initial Tx for MS?

- Steroids during exacerbations | - B-interferons or glatiramer Acetate (Copaxone) for proph

How long should a patient be seizure-free for you to D/C antiepileptics?

2 years

Dx? | Sudden onset severe headache w/ meningeal irritation (stiff neck, photophobia), & fever

Subarachnoid Hemorrhage (ruptured aneurysm of ant. circle of Willis) - LOC in 50% due to inc'd ICP

How does SAH differ from meningitis?

SAH is very sudden in onset & is ass'd w/ LOC

SAH: best initial test?

CT w/out contrast (95% sensitive)

SAH: most accurate test?

Lumbar Puncture showing bleed

Normal WBC:RBC ratio in CSF?

WBC:RBC = 1:500 - 1:1000

In general, when do you use contrast on CT?

When looking for mass lesions like cancer or abscess. | Do NOT use contrast when looking for blood!

After SAH dx, how do you determine which vessel ruptured?

CT angiography, standard angiography w/ catheter, or MRA

Best initial Tx for bacterial meningitis?

Vancomycin, Metronidazole, & Ceftriaxone

Pseudotumor Cerebri: ass'd w/ what 4 things?

- Obesity - Venous Sinus Thrombosis - Oral Contraceptives - Vitamin A toxicity

4 primary presenting symptoms of meningitis?

- Fever - Headache - Neck stiffness (nuchal rigidity) - Photophobia

Meningitis: best initial test?

Meningitis: most accurate test?

Suspected Meningitis: | When would a head CT be necessary prior to LP?

Only if there is a possibility of a space-occupying lesion. I.e. if there is: - Papilledema - Seizures - Focal neurological abnormalities - Confusion interfering w/ neuro exam

Papilledema - what's it look like on fundoscopic exam?

Blurred, fuzzy disc margin | from increased ICP

When do you give ABX prior to LP in suspected meningitis?

If there is a c/i to IMMEDIATE LP, then give ABX as first step

What test is indicated if patient has received ABX prior to LP in suspected meningitis?

Bacterial Antigen Detection (Latex Agglutination Test) -- necessary b/c of ABX, culture may be falsely negative - - extremely specific - - not sensitive enough to exclude if negative

Decorticate posturing consists of what?

Upper-extremity adduction and flexion at the elbows, wrists, and fingers, together with lower-extremity extension, which includes extension and adduction at the hip, extension at the knee, and plantar flexion and inversion at the ankle

Decerebrate posturing consists of what?

Upper-extremity extension, adduction, and pronation together with lower-extremity extension

Decorticate posturing means what?

This occurs with dysfunction at the cerebral cortical level or below and may reflect a "release" of other spinal pathways

Decerebrate posturing means what?

Traditionally implies dysfunction below the red nucleus, allowing the vestibulospinal tract to predominate

Which response to pain has better prognosis -- decorticate or decerebrate?

Decorticate

Major cause of morbidity in the first 24 hrs after SAH?

Rebleeding

Major cause of morbidity 3-10 days after SAH?

Vasospasm (likely caused by arterial narrowing @ base of brain due to degradation of blood & its metabolites leading to cerebral infarction)

How to prevent vasospasm following SAH?

Initiate tx w/ Nimodipine

How to detect vasospasm following SAH?

CT angiography