Neurology Flashcards
what are you assessing for in mental status evaluation?
oriented to person, place, and time
5 Major parts of Neuro exam
mental status/ GCS cranial nerves motor/sensation reflexes cerebellar
Most common type of stroke
ischemic → 87%
Risk factors for stroke
HTN DM hyperlipidemia obesity smoking
sudden loss of blood circulation in brain resulting in ischemia and loss of neuro function
ischemic stroke
rupture of small blood vessels with bleeding inside parenchyma
hemorrhagic stroke
How do you differentiate between ischemic and hemorrhagic stroke?
Head CT
MC cause of hemorrhagic stroke
HTN
spontaneous rupture of Berry aneurysm/AVM due to infection, neoplasm
In acute setting, what type of stroke will you not see on CT?
ischemic stroke
Key sign/symptom of CVA/Tia
sudden onset
atypical presentation of CVA/TIA
subtle motor deficits, minimal ataxia, vague facial asymmetry
Most common symptoms of CVA/TIA
slurred speech, facial droop, unilateral weakness (UE/LE or both)
Other symptoms possibly seen with CVA/TIA
aphasia, dysphagia, ataxia, visual changes, memory loss, nause/vomiting
Timeline for resolution of TIA
80% resolve within 60 minutes
all resolve in 24 hours
CVA/TIA Differentials
Bells Palsy hypoglycemia complex migraine hypertensive encephalopathy labyrithitis/meniere's/BPV
when would you manage BP with CVA/TIA
if they are tPA candidate?
if >220/120
185/110
this type of stroke needs strike BP control
hemorrhagic stroke
Meds used to control BP
labetolol/nicardipine/nitroprusside
Timeframe where patient with CVA/TIA can be considered for tPA
less than 4.5 hours
With CVA/TIA if it has been less than 6 hours from last known normal, what therapy can you consider?
endovascular therapy → mechanical thrombectomy/intra-areterial tPA
First step in managing hemorrhagic CVA
stop/slow bleed → strict BP control → evacuation/coils/anti-coag reversal
Reversal for Warfarin/Coumadin
Vitamin K
Reversal for Heparin
Protamine
Potential reversals not NOAC (non-vitamin K Oral Anti-Coagulant)
rivaroxiban (Xarelto)
eloquiz (apixiban)
this bleed crosses suture lines and is usually venous blood
subdural hematoma
this bleed doesn’t cross suture lines and is usually arterial blood
epidural hematoma
MC traumatic head bleed
subdural hematoma
This is due to shearing force causing disruption of veins bridging brain and venous dural sinuses
subdural hematoma
Symptoms of subdural hematoma
HA Nausea/Vomiting personality change decreased level of consciousness speech difficulties impaired vision or double vision weakness
Other signs present with subdural hematome related to trauma
basilar skull fracture
bilateral periorbital ecchymosis (raccoon eyes)
retroauricular ecchymosis (Battle sign)
presence of CSF rhinorrhea or otorrhea
What diagnostic test should you order for subdural hematoma?
Head CT without contrast
Elderly patient on blood thinners, what should you consider when ordering head CT?
delayed bleeds in anticoagulated patients
traumatic accumulation of blood between the skull and dural membrane
epidural hematoma
MC area for epidural hematoma
middle meningeal artery
Why is epidural hematome caught early have excellent prognosis?
underlying brain has usually been minimally injured
Classic presentation of epidural hematoma
Loss of consciousness
interval Lucid period
death
If you see dilated, sluggish or fixed pupils think….
heniation
“worse headache of my life”
subarachnoid hemorrhage
extravasation of blood into subarachnoid space between pial and arachnoid membranes
subarachnoid hemorrhage
most common cause of subarachnoid hemorrhage
trauma
also berry aneurysm or AVM
Thunderclap onset, severe headache, N/V, photo dizziness, seizure, meningismus
subarachnoid hemorrhage
this bleed has HIGH morbidity and mortality
subarachnoid hemorrhage
When is the best time to order CT head for SAH?
within 6 hours
If you are highly suspicious for SAH and negative head CT, what would you order?
LP → after 2 hours but < 24 hours
What will you see on LP for SAH?
XANTHOCHROMIA
non clearing RBC
elevated opening pressure
BP goal for SAH
Medications?
systolic between 110-150/MAP < 130
labetalol, hydralazine, nicardipine
Pain management for SAH
fentanyl > morphine/dilaudid
In SAH patient, what can you give to prevent vasospasms of cerebral arteries?
CCB → Nimodipine
In SAH patient, what do you give to decrease ICP?
Mannitol
what can mimic TIA/CVA?
complex migraine
Gradual onset, unilateral, throbbing/pulsatile
photophobia/hyperacousis, N/V
migraine
Treatment for Acute Migraine
IVF Benadryl compazine toradol magnesium
Why do you avoid opioids with migraines?
cause reboudn headache
group of headaches lasting 15-180 minutes/episode, may be multiple a day
cluster headache
cluster headache lacks …
N/V
aura
photophobia
at least one of the following symptoms must be present for cluster headache
rhinorrhea nasal congestion injection facial swelling ptosis miosis eyelid edema lacrimation
Treatment for cluster headaches
100% oxygen
triptan, DHE
No opioids
systemic inflammatory vasculitis in temproal artery → older people
temporal arteritis (Giant Cell Arteritis)
MC form of systemic vasculitits in adults?
Established risk factors?
temporal arteritis
age and female
New presentation of HA or new type of HA in temporal or occipital area → throbbind and continuous pain
temporal arteritis
Symptom highly predictive of temporal arteritis
jaw claudication
Patient with Temporal Arteritis will have neck, shoulder, torso, and pelvic girdle pain consistent with ….
polymyalgia rheumatica
New onset HA + 50 years or older + elevated ESR
Giant Cell arteritis
Gold standard for diagnosing temporal arteritis
temporal artery biopsy
Component usually seen with temporal arteritis
unilateral visual blurring or vision loss
Laboratory hallmark for temporal arteritis
elevated ESR and C-reactive protein (CRP
> 50 mm/hr
Management for patient presenting to ED with Temporal Arteritis
prednisone (temporal artery biopsy done within 1 week)
Patients with Temporal Arteritis + Acute Visual Changes treatment?
methylprednisolone IV for 3 days
treatment for steroid resistant cases of temporal arteritis
tocilizumab, cyclosporine, azathioprine, methotrexate
cause of peripheral vertigo
vestibular apparatus malfunction → less concerning in ED
cause of central vertigo
cerebellar or brain stem issue → bad
posterior circulation stroke, MS, tumor
sudden onset + tinnitus + hearing loss + N/V + room spinning
peripheral vertigo
ataxia/feel off balance + falls + “feel like wlaking drunk” + dysarthria + dysphagia + focal weakness
central vertigo
suspect central vertigo, order?
MRI
CT not sensitive for posterior circulation
Medical management for vertigo
antiemetic
meclizine/valium
IVF
procedure that can be tried last resort to fix peripheral vertigo
Epley Menauver
1 cause of encephalitis in US
Herpes Simplex Virus
1 cause of encephalitis in immunocompromised patient
toxoplasmosis
viral prodrome seen with encephalitis
several days of fever, HA, N/V, lethargy, myalgia
behavioral/personality changes + decreased level of consciousness + neck pain/stiffness + photophobia + AMS + ataxia + CN defects + seizures + paralysis + dysphagia (particularly in rabies)
encephalitis
this test is done on suspicious lesions for encephalitis
HSV culture → Taznck smear
You see “ring enhancing lesion” on head CT
Encephalitis → due to toxoplasmosis
diagnostic standard for encephalitis
brain biopsy
Treatment for encephalitis
Acyclovir → especially if suspect it is in neonates
#1 cause of bacterial meningitis in adults #1 cause of bacterial meningitis ins kids
pneumococcal in adults
neisseria meningitides
risk factors for meningitis
< 5 and > 60, immunocompromised, DM, CKD, trauma, alcoholism, IV drug abuse, endocarditis, VP shunt
which is worse, bacterial or viral meningitis?
Bacterial → high morbidity/mortality
Fever + AMS + HA + Neck stiffness
N/V, photophobia, nuchal rigidity, PETECHIAL rash, seizure
meningitis
Key finding for meningitis in an infant
bulging fontanelles (+ paradoxical irritability, hypotonia, poor feeding)
Two positive signs for meningitis in infant
Kernig and Brudzinski
first test to order if you suspect meningitis
CT of head → r/o bleed, mass, herniation
diagnostic test for meningitis
lumbar puncture
What are some other thing you may need to test for in HIV patient with meningitis?
CMV, cryptococcal
order of testing and treating suspected meningitis
Blood culture → empiric antibiotics → CT and LB
Antibiotics for meningitis in neonate
ampicillin
cefotaxime
gentamycin
AND acyclovir
antibiotics for meningitis in 3 mo - 7 year old
cefotaxime
ceftriaxone
+/- Vanc
antibiotics for meningitis in 7 - 50 year old
rocephin
Vanc
Ampicillin (if at risk for Listeria)
Treatment for viral meningitis (HSV and CMV specifically)
supportive care
HSV → acyclovir
CMV → Ganciclovir/foscarnet
treatment for fungal meningitis
amphotericin B
What patients are brain abscesses more common in?
immunocompromised
How do brain abscess symptoms differ from meningitis?
sinusitis or otitis 1-7 weeks prior
Diagnostic test for brain abscess
CT Head with contrast
Treatment for brain abscess
cefotaxime PLUS metronidazole
Fever + midline back pain + neurological deficits → think?
epidural abscess
High risk patients for epidural abscess
IV drug users !!
immunocompromised
recent surgery/procedure
MC organism in epidural abscess
Staphylococcus aureus
Early urinary sign for epidural abscess?
Late urinary sign for epidural abscess?
urinary retention → first
Incontinence → late
gold standard for diagnosing epidural abscess
MRI with and without contrast
Cause of Cauda Equina
compression of multiple lumbosacral nerve roots below the conus medullaris
low back pain (radicular) + unilateral or bilateral sciatica + saddle and perineal hypoesthesia/anesthesia + bowel/bladder issues + loss of rectal tone
cauda equina
Diagnostic test is confirmative of cauda equina
MRI
PVR for bladder dysfunction, poor DRE
acute demyelinating neuropathy with preogressive ASCENDING SYMMETRICAL weakness → progresses over hours to days
Guillain-Barre Syndrome
when will Guillain-Barre Syndrome present?
2-4 weeks after respiratory or GI illness
How will symptoms of Guillain-Barre Syndrome present?
ascending and symmetrical
Subtle + descending symptoms
epidural abscess
Diagnostic test for Guillan Barre Syndrome ?
Descripotion of findings?
LP
Protein → elevated
glucose → normal
color → clear or xanthochromia
Treatment of Guillan Barre Syndrome.
What should you not give?
IV immunoglobulin (IVIG) OR plasma exchange NO steroids
What do you want to order on patient with GBS?
PFT → get baseline to track
Two types of seizures
generalized → tonic-clonic, grand mal
partial → localized to one area of the brain
Two types of partial seizures
Simple → no LOC
Complex → altered LOC
HTN + Edema + Proteinuria → 20 weeks to 8 weeks postpartum
eclampsia
result of high body temperature but no underlying condition, self limited, 6 mo - 5 yr, MC in children
febrile seizures
treatment of active seizure
protect airway + suction + roll onto side + IV ativan STAT + IVF + normal seizure med or Phenytoin
what do all seizures have that pseudoseizures do not?
post-ictal state → amnesia, sleepiness, Ha, myalgia
Patient present with new onset seizures → what do you think?
mass or trauma
If you suspect exlampsia related seizure what do you administer?
IV magnesium
1 cause of brekathrough seizure
noncompliance of meds
Complications of Status Epilepticus
Hyperthermia, acidosis, hypotension, respiratory failure, rhabdomyolysis, aspiration
criteria for Status Epilepticus
2+ seizures with incomplete recovery
first line management of Status Epilepticus
Ativan
Second and Third line management for Status Epilepticus
second → phenytoin or fosphenytoin
third → intubate, phenobarbitol
Bell’s Palsy is dysfunction of ___
CN VII (Facial nerve)
sudden symptom onset (48 hr) + symptoms on unilateral side + upper/mid/lower face
Bell’s Palsy
1 cause of Bell’s Palsy
HSV infection
Bell’s Palsy usually presents after a
URI
How do you differentiate Bell’s Palsy from Stroke?
Stroke will SPARE the FOREHEAD
Bells palsy will NOT
Deep ear pain and vesicular rash
Ramsay-Hunt
duration of Bell’s Palsy
3 weeks - up to 6 months
Treatment for Bell’s Palsy
prednisone
