Neurology Flashcards
High Risk TIA Score
ABCD2
Age >=60
BP >=140/90
Clinical Picture: 2- hemiparesis 1- language, 0 -other
Duration: 2- >=60min, 1 - 10-59min, 0- <10min
DM
ACA Syndrome
Contralateral Leg > Arm Hemiparesis and Numbness
Contralateral frontal signs (grasp reflex)
Left Main (M1) MCA Syndrome
Global aphasia
Left gaze deviation
Superior: Broca, Right Face/Arm > Leg weakness
Inferior: Wernike, Right cortical sensory loss + Right superior quadransonopia
Left superior MCA Occlusion - Syndrome
Expressive (Broca’s) aphasia
Right face/arm > leg weakness
Left gaze deviation
Left inferior MCA Occlusion - Syndrome
Receptive (Wernicke’s) aphasia
Right cortical sensory loss
Right superior quadrantonopsia (pie in the sky)
Right Main (M1) MCA Syndrome
Left hemi-NEGLECT Left cortical sensory loss Left face/arm > leg weakness Left superior quadrantonopsia Right gaze deviation
Left superior MCA occlusion - Syndrome
Broca’s Aphasia
Left face/arm > leg weakness
Right gaze deviation
Right inferior MCA occlusion - Syndrome
Left hemi-neglect
Left cortical sensory loss
Left superior quadrantonopsia
PCA Stroke (occipital)
Contralateral homonymous hemianopsia
Midbrain Stroke (aka Weber’s) from PCA branch occlusion
Ipsilateral CNIII Palsy (down and out, ptosis, mydriasis)
Contralateral face/arm/leg hemiparesis
Medial Medullary Stroke due to occlusion anterior spinal artery
Ipsilateral tongue weakness (deviates away from lesion)
Contralateral arm/leg hemiparesis
Contralateral arm/leg proprioception/vibration loss
Lateral Medullary Stroke (aka Wallenberg) from PICA/vert occlusion
Ipsilateral Horner’s (ptosis, miosis, anhydrosis)
Ipsilateral ataxia/ dysmetria / dysdiadochokinesia
Ipsilateral facial pain/temperature loss
Contralateral arm/leg pain and temperature loss
Vertigo/Nystagmus (away from lesion)
Dysphagia, Hiccups
NO LIMB WEAKNESS
Pons Stroke (due to distal basilar A occlusion)
Ipsilateral CN VI and VII palsy
Ataxia/Dysconjugate gaze/Nystagmus
Contralateral hemiparesis and sensory loss
Vertebro-basilar Stroke
Posterior circulation = cerebellar signs:
- Dysmetria/Dysdiadikokinesia
- Ataxia
- Nystagmus/Vertigo/Drop attacks
- Ipsilateral CNs
- Speech: Dysphagia/Dysarthria
Carotid TIA
Contralateral hemiparesis, sensory loss
Contralateral CNs
Language deficits
Loss of coordination
Complete Cord Syndrome Causes
Traumatic spinal cord injury
Large disc herniation
Abscess, bleed
Transverse myelitis
Complete Cord Syndrome - Presentation
Bilateral UMN pattern weakness below the lesion
Bilateral LMN pattern weakness @ level of lesion
Bilateral complete sensory loss below lesion
Bowel/Bladder dysfunction
If above C3 - diaphragmatic weakness
If above T6 - autonomic dysreflexia
Central Cord Syndrome: Causes
Intramedulary tumor
Syringomyelia
Central Cord Syndrome: Presentation
Bilateral loss of pain/temperature sensation below lesion
UE more affected than LE motor
Normal proprioception, vibration
Anterior Cord Syndrome: Causes
Anterior Spinal Artery infarct
Disc herniation
Anterior Cord Syndrome: Presentation
Bilateral weakness (UMN below lesion, LMN @ level)
Bilateral loss of pain/temperature
Bowel and bladder dysfunction
Normal proprioception and vibration
Posterior Cord Syndrome: Causes
B12 deficiency (subacute combined degeneration) Tabes Dorsalis (syphillis)
Posterior Cord Syndrome: Presentation
Bilateral loss of vibration/proprioception sense
+/- weakness
Normal pain/temperature
Hemicord syndrome: Causes
Trauma: knife, bullet
MS (demyelination)
Hemicord syndrome: Presentation
Ipsilateral loss of pain/temp @ level of lesion
Contralateral loss of pain/temp below lesion
Ipsilateral loss of vib/proprioception @ level + below
Ipsilateral weakness (LMN @ level, UMN below)
Indications for TPA for acute stroke
Last seen normal <=4.5 hrs
NIHSS >=6 or disabling (including aphasia, complete hemianopia, weakness against gravity, vision, disabling for spec person)
>=18 years of age
*can be given even if patient on DAPT
Exclusion criteria for TPA in acute stroke
Absolute:
- ICH on CT Head
- Any major source of current bleed
Relative:
- Past ICH
- Recent major bleed or surgery within 14 days
- On DOAC (but can do EVT)
- Stroke within 3 months
- BP >180/105
- INR >= 1.7 or plts <100
- BG very low or high
Indications for EVT
Last seen normal <= 6 hrs (up to 24 in some circs)
Age >=18
Disabling stroke
Functionally independent at baseline
Expected survival > 3mo
ASPECTS Score >=6
Proximal large vessel occlusion (eg distal ICA / MCA)
*no evidence in posterior circulation stroke, but can consider for basilar thrombus (bc high morb/mort)
BP Targets in acute stroke
If for tPA: <180/<105 x 24hrs
If no tPA: Permissive HTN - only treat if >=220/120 for first 24 hrs (or >160/110 if pregant)
No target for EVT
Timing of ASA in acute stroke
If no tPA and no bleed: 160mg ASAP –> 81
If tPA: Rpt CT head @ 24 hrs post and if no bleed –> ASA (no DAPT)
Indications for DAPT in stroke/tia
- Minor stroke (NIH<=3), non cardioembolic (DAPT x21-30 days then SAPT) - within 12-24h
- High risk TIA (ABCD2 >=4), non-cardioembolic (DAPT x21-30 days then SAPT)
- Stroke or TIA with severe intracranial atherosclerosis >70% (DAPT x3 mo then SAPT)
*Plavix loading dose 300-600mg
Ticag 180mg loading dose then 90BID
Work-up for all strokes
Head/Neck vessel imaging (CTA or MRA)
Holter (2 days, 2 weeks of suspecting cardioembolic)
BW incl A1c/ fasting /75g OGTT, lipids, coags, cbc,
+/- TTE only if suspect embolic or TIA of uncertain cause (+bubble study for PFO if <60yo)
Indications for CEA in carotid stenosis
- Symptomatic carotid 50-99% in men or 70-99% in women (ideal within 48 hrs stroke)
- Symptomatic carotid 50-59% in women (consider)
- Asymptomatic or remotely symptomatic (>6mo) + 60-99% stenosis w/ 5+y life expectancy (consider)
*CAS if not CEA candidate (CEA>CAS if age >70)
*Otherwise, medical management with SAPT/DAPT only
Vertebral artery stenosis = medical Mx
*uncertain benefit in mod/severe stroke if brain alrdy lost
Timing of DOAC initiation after stroke due to Afib
TIA - start within 1 day Minor stroke (NIH < 8): 3 days (rpt CT 1st) Moderate stroke (NIH 8-15): 6 days (rpt CT 1st) Severe stroke (NIH >15): 12 days (rpt CT 1st)
Indications for PFO closure
Age 18-60
Non-lacunar stroke
PFO deemed to be likely cause for stroke
Treatment EXTRA-cranial dissection (carotid or vertebal)
Antiplatelet (if asymptomatic) x3-6 mo
Heparin or warfarin (if symptomatic or floating thrombus) x3-6 mo
*no evidence for DOAC
Treatment of intracranial dissection
Anti-platelet x3-6 months then re-image
NO evidence for anticoagulation
BP Targets in ICH
SBP <140-160 in 24 hrs (aim to get there asap). <140 pref if: - Presenting SBP <=220 - Evidence of expanding hematoma - Onset within 6 hrs of presentation - On anticoagulation
Long term target: <130/80
Causes of tremors
- Resting
- Postural
- Kinetic/Intention
Resting: Parkinsonism (idiopathic, drug induced - symmetrical, LBD, vascular)
Postural: enhanced physiologic (symmetrical, enhanced by stress, coffee, MDMA, cocaine, EtOH wd, hyperT4), essential, dystonic (asymmetric)
Intention: cerebellar (stroke, wilsons, MS), Li tox
*Psychogenic for all
Clinical features of Parkinsonism
TRAP
Tremor - rest, asymmetric
Rigidity - cogwheel, asymmetric
Akinesia/Bradykinesia (slow and fatiguing w decreasing size of repetitive movement)
Postural instability - festinating shuffling gait, with reduced arm swing freezing, falls
Diagnosis: Parkinson’s Disease
1) Parkinsonism - must have akinesia / bradykinesia AND one of: Tremor OR Rigidity \+ 2) >=2 supportive criteria: -Response to L-dopa +/- L-dopa induced dyskinesias -Rest tremor of limb, -Olfactory loss, -Loss of cardiac sympathetic tone on MIBG scintigraphy \+ 3) No mimics or red flags for alternate diagnosis: -Rapid gait impairment -Autonomic failure w/i 5yrs of onset, -Pyramidal signs, -Early bulbar dysfcn, -Stridor, -Anterocollis, -Severe falls w/i 3y onset, -Bilateral symmetric parkinsonism
Meds and S/E for Parkinson’s Disease
Levodopa-Carbidopa: +++ motor sx imprv, +++ dyskinesias, ++ impulse control disorder /hallucinations /somnolence /ortho HoTN
Dop-Ag (Pramipexole, Ropinorole): ++ motor Sx improv, ++ dyskinesias, +++ ICD/halluc/somnolence/ortho HoTN
MAOBi (Selegiline, Rasagaline): + motor sx improv, + dyskinesias. minimal other S/E (HTN crisis with tyramine, risk serotonin syndrome)
Other drugs and side effects:
- Trihexyphenidyl for tremor and amantadine (C/I in sz) for dyskinesia: both are anticholinergic
- Entacapone (COMT inhibitor so levodopa lasts longer) - same SE as sinemet but orange urine
- Domperidone for orthostatic HoTN (DA ANT): prolongs QT
- Botulinum toxin A for drooling
Treatment algorithm Parkinson’s Disease
If >60-65: L-dopa
If <60 and concerned re: dyskinesias:
- Mild symptoms: MAOBi
- Moderate-Severe Sx: L-Dopa or Dopamine Agonist
Treatments for REM Sleep Behaviour Disorder
Melatonin
Clonazepam
Treatment of drug induced dyskinesias in Parkinson’s
Amantadine
Treatment of orthostatic hypotension in Parkinson’s
Domperidone
Midodrine
Fludrocortisone
Clues for vascular parkinson’s
Vascular RFs Lower body predominant Symmetrical rigidity/bradkinesia Pyramidal signs Falls common Tremor uncommon Poor L-dopa response
Clues for Multiple Systems Atrophy
NO TREMOR
Symmetrical rigidity/bradykinesia
Ataxia, early falls
Predominant orthostatic hypotension, incontinence, ED
Can have pyramidal signs, distal myoclonus, stridor
NO L-dopa response (causes orofacial dyskinesia)
Clues for PSP
NO TREMOR Symmetrical rigidity/bradykinesia Axial > Limb predominant symptoms Vertical gaze palsy and hyperfrontalis Dysarthria early in disease course Poor L-dopa response
Clues for CBD (corticobasal degeneration)
Markedly ASYMMETRIC rigidity/bradykinesia Apraxia, alien limb Cortical sensory loss Aphasia Dystonia Myoclonus (action/tactile stimulated) No L-dopa response
Clues for LBD
Symmetric rigidity/bradykinesia, can hv tremor
Early dementia (precedes/begins within 1y of onset of parkinsonism)
REM Sleep disorder
Visual hallucinations (++sensitive to antipsychotics)
Fluctuating “good and bad days”
Some response to Ldopa but can worsen hallucinations
Features of Horner’s Syndrome (lose sympathetic)
Ptosis
Miosis
Anhydrosis (if 1st/2nd order neuron involved)
NO DIPLOPLIA
Features of CNIII Palsy
(lose parasympathetic)
Ptosis
Diplopia (in oblique gaze, near, looking up/down)
Down and out eye
+/- Mydriasis (Pupil spared in ischemic or partial compressive)
Indications to obtain head imaging in CN3 Palsy
1) CNIII Palsy with mydriasis +/- pain (hints at compressive)
2) Incomplete CN III palsy without mydriasis
*r/o PCOM aneurysm
Causes of Horner’s Syndrome & Ix
Lesion in 1st order neuron (from brain down spinal cord):
- Stroke/Bleed
- Tumor
- Demyelination
- MRI brain
Lesion in 2nd order (out @ SC, up in vessels along SC)
- T1 radiculopathy
- Pancoast tumor
- MRI Cspine/CT chest
Lesion in 3rd order neuron (from sup symp ganglion up carotids into face)
- Carotid dissection
- Carotid aneurysm
- CTA neck/brain
HINTS Exam - Results demonstrating peripheral lesion
Unidirectional horizontal nystagmus
Positive head impulse test (corrective saccade w/ rotation)
Negative test of skew (vertical misalignment of eyes)
HINTS Exam - demonstrating central lesion
Direction changing or vertical/torsional nystagmus
Negative head horizontal test (no corrective saccade)
Positive test of skew (vertical misalignment of eyes)
Clues of Polyneuropathy (dz of 2+ nerves)
Symmetric, Length dependent peripheral neuropathy
Sensory >motor
Large fibre sensory > small fibre sensory
Tingling precedes numbness
Cramps precedes weakness (eg toe flexor/extensor weakness)
Loss of ankle reflexes
Axonal (can be determined by NCS/EMG)
Red flags for alt dx: asymmetry, acute onset, early motor loss, significant autonomic involvement
Causes of polyneuropathy
Metabolic: DM, B12 deficiency (can be assoc’d w/ metformin), Hypothyroidism, CKD, Cirrhosis
Drugs: Chemo (Vincristine), EtOH, heavy metals
Idiopathic sensory neuropathy of the elderly (ISNE)
Charcot marie tooth
Causes of mononeuropathy multiplex (dz of multiple, individual, named nerves) and polyradiculopathy (dz of nerve roots)
Inflammatory: Small/med vessel vasculitis (GPA, eGPA, PAN), SLE, Sjogren’s, RA, Sarcoid
Infectious: HepC, HIV
Cancer: Myeloma, Lymphoma, leukemia, amyloid
Foot Drop (weak dorsiflexion): L5 vs Peroneal Nerve
L5: All muscle groups sitting cross-legged weak
- Weak hip abduction
- Weak knee flexion
- Weak Ankle inversion
- Weak ankle eversion and dorsiflexion *Both
Peroneal:
- Hip abduction, knee flexion, ankle inversion normal
- Weak ankle eversion and doriflexion *Both
Finger Abduction Weakness: Ulnar vs C8/T1
C8/T1
- Weak EIP (2nd finger extension)
- Weak APB (thumb abduction)
- Weak FPL (thumb flexion)
- Weak finger abduction*
Ulnar
- Weak finger abduction only* Both
- Sensation to 5th finger deficit
Finger/Wrist Extension weakness: C7 vs radial
C7:
- Strong brachioradialis
- weak pronator teres and triceps
- abn triceps reflex, normal brachioradialis
- *weak finger and wrist extension - both
- sensation to 3rd finger abn, back of hand normal
Radial: (drinker)
- Weak brachioradialis
- Strong pronator teres and triceps
- normal triceps reflex, abn brachioradialis
- *weak finger and wrist extension - both
- sensation to 3rd finger normal, back of hand abn
LP landmarks:
- Spinal cord ends at what level (ie conus medullaris)
- Cauda equina
- Iliac crests
Conus medullaris L1/2
Cauda equina S2 (PSIS)
Iliac crests L3/L4
Diagnosis of epilepsy
> =2 unprovoked seizures >24 hrs apart OR
1 unprovoked seizure with epileptiform EEG/abn MRI OR
Epilepsy Syndrome
Tx for generalized seizures
Valproate Keppra (eg levetiracetam) Lamotrigine Clonazepam Clobazam Topiramate
*other tx: vagal nerve stimulator, ketogenic diet
Tx for myoclonic seizures
Valproate
Keppra (eg levetiracetam)
(Avoid dilantin - can exacerbate myoclonus)
Tx for absence seizures
Valproate
Ethosuxamide
Tx for focal seizures
NO valproate or Keppra Oxcarbazepine/Carbemazepine Dilantin (eg Phenytoin) Gabapentin/Pregabalin Lacosamide
*other tx: epilepsy surg
Side effects of AEDs
- interactions with other meds
- what to avoid in idiopathic generalized epilepsy
SCARED-P
Sedation (eg clobazam, phenobarb)
Cytopenia/ Cog impairment (eg topramate, clobazam)
Ataxia
Rash (SJS risk with phenytoin, lamotrigine, carbemaz)
Emesis/GI upset
Diplopia
Pregnancy risk (eg do not start valproate, lamotrigine, levetiracetam) - monitor levels in T3
Others: OP, hypoNa (-bazepines), PR prolong (lacosamide), weight gain (valproate), weight loss (topiramate)
- interactions with antibiotics, OCP, anticoag
- avoid phenytoin in idiopathic generalized epilepsy (juvenile myoclonic epilepsy)
Definition of status epilepticus
Clinical/subclinical seizures for >=5 minutes or
>=2 seizures without recovery in between
Definition of refractory status
Ongoing status despite 1 abortive tx and 1 AED
Abortive Treatments for seizures
Lorazepam 4mg IV
Midazolam 10 mg IM/buccal
Diazepam 20mg PR
AEDs for status
Dilantin (phenytoin)
Keppra (levetiracetam)
Valproate
Treatment for refractory status
Midazolam/Propofol/Phenobarb infusion
Target burst suppression for >24hrs before tapering
-Monitor for nonconvulsive status w/ continuous EEG (esp if paralyzed or intubation)
Causes of seizure
Metabolic: Hypoglycemia, hypoPO4, hypoCa, hypo Mg, hypoNa
Vascular: Stroke, Bleed, Sinus venous thrombosis, PRES
Infectious: Meningoencephalitis, Tb, crypto, toxo, sepsis (Febrile sz)
Neoplastic: Primary brain CA, Mets
Drugs: Cocaine, TCAs, ASA, bupropion, imipenem, penicillin, clozapine, missed AED
Withdrawal: EtOH, Benzos, barbiturate
Clinical features of Guillian-Barre Syndrome
Ascending motor and sensory loss with NO REFLEXES
Dysautonomia: labile BP/HR, urinary retention, ileus
Respiratory failure: as disease progresses
*Triggered often by antecedent GI/Resp infection (eg campylobacter, influenza, HIV, Zika, flu vaccine)
Indications for intubation in GBS and Myasthenia
20-30-40
- FVC <20ml/kg
- MIP 0 to -30 cm H2O
- MEP <40 cm H2O
Treatment of GBS
If nonambulatory within 4 weeks of symptoms:
- IVIG 2g/kg over 2-5 days (no role for repeat IVIG)
- 2nd line = PLEX
- SLP for oropharyngeal weakness, PT/OT, bladder/bowel care
- ETT rf: onset to admission <7d, FVC<60% predicted, can’t cough/ stand/ lift head or arms, facial weakness
NO STEROIDS for GBS, only CIDP
Treatment of CIDP (>2mo)
IVIG q3 weeks or SCIG
Pred 1mg/kg
Clinical presentation Myasthenia Gravis (AI destruction of post-synaptic NMJ)
Fatiguable weakness of:
- ocular muscles: ptosis, binocular diplopia, pupil sparing
- bulbar muscles: dysarthria, dysphonia, dysphagia, chewing fatigue, head drop
- resp muscles: orthopnea
- extremities (prox >distal)
Investigations in Myasthenia Gravis
Antibodies: AcHrAb, MUSK, LRP4
FVC/PFTs
CT chest to r/o thymoma
EMG/NCS: single fiber EMG of frontalis; repetitive nerve stim for decrement
Treatment Myasthenia Crisis
PLEX
2nd line: IVIG 2g/kg over 2-5d
- hold pyridostigmine when intubated (manage airway secretions)
- caution with high dose pred (can worsen resp status)
Maintenance treatment for Myasthenia Gravis
Pyridostigmine (for symptoms) - S/E: GI, bronchorrhea, cholinergic crisis
DMARDS:
- Pred (lowest dose),
- Aza (S/E: leukopenia, transaminitis)
- PLEX (S/E hypogamma, hypoCa, arrhythmia)
- IVIG,
- Eculizumab (S/E: meningococcal infxn)
Thymectomy
Indications for thymectomy in Myasthenia
1) MG with thymoma on CT chest
2) No thymoma but elective if:
- Age <60 +
- Positive AChRAb +
- Disease duration <5 years
Drugs that can trigger myasthenia crisis
Neuromuscular blockade PD-1 inhibitors (eg pembro, nivolumab) Antibiotics: FQs, macrolides, aminoglycosides CV: BB, procainamide Plaquenil botox Mg Lithium Glucocorticoids
Clues to sinus venous thrombosis as cause of headache
Hypercoagulable (OCP, pregnancy, CA)
Female
Seizures
Signs of high ICP on exam
Clues to carotid or vertebral dissection as cause for headache
Headache with neck pain + horner’s
Clues to RCVS (reversible cerebral vasoconstriction syndrome) as cause for headache
Recurrent thunderclap headache Pregnancy Decongestant or cannabinoid use Vasoactive meds (eg triptans) Intracranial vessel beading
Clues to PRES as cause for headache
Hypertensive
On cyclosporine or tacrolimus
MRI: vasogenic edema in parietal/occipital
RF: AKI, CKD, HUS, TTP, Sickle cell, Eclampsia, vasculitis, porphyria, HyperCa, hypoMg, sepsis, transplantation, exposure to iodine contrast
Drugs: VEGFi, cisplatin, chemo, IFNa, IVIG, MTX, Ritux, TKI
Clues to pituitary apoplexy as cause for headache
Pregnant/post-partum
Diplopia or vision changes
Hypotension
Idiopathic intracranial HTN (IIH):
-Pt, Dx, Tx
Young fat female on birth control
Signs of high ICP with positional changes (H/A, vision changes, papilledema)
CN6 palsy (diploplia)
Pulsatile tinnitus
Ix: LP opening pressure >200-250
Tx: weight loss, NSAIDs, acetazolamide +/- lasix, +/- surgery if vision loss
Diagnosis Migraine
> =5 episodes of HA lasting 4-72 hrs w/o better explanation:
=2 of: Unilateral, pulsating, moderate-severe, aggravated by routine activity, causing avoidance of routine activity
PLUS
= 1 of: Nausea, vomiting, photophobia, phonophobia
Diagnosis Multiple Sclerosis
- MS Most likely diagnosis +
- > =1 clinical attack (CIS) +
- Dissemination in space (>=2 clinical attacks, >=2 clinical syndromes at 1 time, >=2 lesions on imaging) +
- Dissemination in time (>= 2 clinical attacks, + oligoclonal bands, lesions of differing ages on MRI)
Treatment of acute MS Attack
If functionally disabling (optic neuritis, weakness):
Methylpred 1g IV x3-7 days then taper
2nd line: PLEX (if poor steroid response)
Chronic treatment of MS to decrease relapse and lesion accumulation
Injections: B-interferon, glatiramer
Oral: dimethyl fumarate, teriflunomide, fingolimod, siponimod, cladribine
Infusions: - mabs
HSCT
*nonpharm: exercise, smoking cessation, vitamin D
Treatment of Migraines
-Nonpharm: sleep, stress, avoid trigger, check medication over use (NSAID<15, triptan<10/mo)
-Pharm:
NSAID: ASA, diclofenac, ibuprofen, naproxen, tylenol
Triptans: Suma-, Riza-, Zolmi-
IV: ketorolac, metoclopramide, domperidone, Mg (aura), Dex, dihydroergotamine
- Peripheral neve block
- Neuro stimulation
*Do not use: opioids, barbituates, dex, haldol, tylenol, magnesium, opiates, diclofenac, VPA,
Contra-indications to Triptan therapy for migraines
History of CAD, Stroke, TIA, PVD
Uncontrolled HTN
History of hemiplegic or basilar migraines
Presentation of pseudobulbar palsy
1) UMN CN 5, 6, 9, 10, 11, 12 palsies
2) Dysphagia
3) Dysarthria
4) Hyperreflexic jaw jerk
5) Pseudobulbar affect (emotional lability)
Causes of pseudobulbar palsy
1) ALS
2) Parkinson’s Disease
3) PSP
4) Tumor/Stroke
5) TBI
6) MS
Lacunar stroke syndrome
Pure Motor - contralat face, arm, leg weakness
Pure Sensory - contralat face, arm, leg sensory sx
Secondary Stroke Prevention Targets: HTN, Lipids, DM
HTN:
<140/90 or past stroke/TIA
<130 for small subcortical stroke
<130/80 for diabetic w stroke
Lipid
Start statin
LDL <1.8
Add ezetimibe to max statin dose if LDL>1.8
Add PCSK9i (evolocumab) if LDL>1.8 & CV dz
Add icosapent ethyl 2g BID if TG >1.5 & DM or CV dz on statin
DM:
Target A1C <7%
Add SGLT2 or GLP1-R Ag if above 7% on meds
Lifestyle Mx after stroke for 2ndary prevention
Diet: plant protein, low trans/sat fat, low cholesterol <200mg/d (Mediterranean) Na<2g/d Exercise 4-7d/wk BMI 18.5-25 Waist <88cm (F), <102 (M) EtOH <10 (F), <15 (M) Smoking cessation
Embolic stroke undetermined source (ESUS) 2ndary prevention
ASA 81g
NO evidence for anticoagulation if no afib
Stroke in young (<55yo) risk factors (most important and MC)
Most important rf: HTN, DLPD, Smoking
MC: Cardioembolic and Dissection
ICH workup & care (VTE ppx, sz, steroids)
- CTA (or MRA) to assess for underlying lesion during admission
- Consider MRI for cerebral amyloid angiopathy, mass, AVM, AVF
- External ventricular drain if dec LOC and hydrocephalus
- VTE ppx w/ IPC then LMWH at 48h once hematoma stable
- Sz does not need AEDs
- ICP: steroids can cause harm
Features of essential tremor
Symmetric Postural / action Fam Hx Response to EtOH Signif level of impairment
Parkinsonism Ddx
Idiopathic
Parkinson plus disorders: LBD, PSP (vertical gaze palzy or saccades), MSA, CBD
Vascular (lower extremity parkinsonism)
Drug-induced (DA R ANT): antipsychotics, metoclopramide
Genetic: Wilson’s
Toxins: Manganese
Idiopathic PD course
Preceding: anosmia, REM behavior sleep, constipation
Early: asymmetric tremor/ rigidity/ bradykinesia
Late: postural instability/falls, dementia, hallucinations, autonomic dyscn
Vasculopath with sudden complete painless unilateral vision loss
Central retinal artery occlusion with cherry red spot
Unilateral eye pain and vision loss
-pale disk?
Acute optic neuritis
Pale disk = prior optic neuritis
Poor peripheral vision, painless,
Elevated eye pressure
Large cup to disk ratio and pale disk
Glaucoma
Ophthalmoscope findings in DM and HTN
DM:
Micro-aneurysm
Neo-vascularization
HTN:
AV nicking, copper wiring, disk edema
Cotton wool spots, Hard exudates, Flame hemorrhages
Diploplia Anatomy + Fcn (CN, sympathetic, cavernous sinus)
LR6SO4
CN3: MR, IR, SR, IO
- Elevates eyelid (via levator palpebrae superioris)
- Pupil constriction (via parasympathetic)
Sympathetics
- Eyelid elevation (via Muller’s)
- Pupil dilation
Cavernous sinus: CN3, 4, V1/V2 (facial sensation), sympathetics
Diploplia Q's: Monocoular vs binocular Horizontal vs vertical vs oblique Worse with near vs far Looking L/R vs up/down
Monocular (psych, optho)
Binocular (EoM eg thyroid, NMJ eg MG, CN3/4/6, nucleus 3/4/6 in brainstem eg stroke/MS, INO eg stroke/MS)
Horiz (CN6), Vertical (CN4), Oblique (CN3)
Near (CN3/4), Far (CN6)
Worse L/R (CN6), up/down (CN3/4)
CN6 palsy DDx and Ix
Ddx:
- Brainstem: stroke, demyelination, tumor
- Cavernous sinus: fistula, aneurysm, dissection, tumor, inflamm, infxn
- False localizing: increased ICP from tumor, IIH, venous sinus thrombosis, trauma
Ix:
CT/CTA intracranial vessels for cavernous sinus pathology
MRI brain with GAD (for tumor, inflamm, infxn)
MRI brain w/ MRV or CTV (for VST), then LP (for IIH)
LP Contraindications and Pre-imaging contraindications
C/I:
- INR>1.7
- Plt<50
- Papilledema, raised ICP secondary to mass
- Cannot safely undergo
Pre-imaging C/I:
- FND
- New seizure
- GCS<10 or ALOC
- Immunocompromised
- Anatomical issues: instrumentation, tethered cord, chiari malformation, local skin infxn
ALS Features
- LMN (atrophy, fasciculations, weakness) at level of lesion
- UMN (spasticity, hyperreflexia, brisk jaw jerk, upgoing toes) below lesion
- Progressive asymmetric limb weakness
- Bulbar symptoms: pseudobulbar affect, dysphagia, dysarthria, tongue wasting,
- Frontotemporal degen: cog / behav decline
- Fam Hx
ALS Tx
- Riluzole (survival benefit)
- Edaravone (decrease functional decline)
- Mulitdisplinary clinics
Symptom based:
- Drooling: anticholinergic, oral suction, botox
- Spasticity: baclofen, botoz, BZD, CBD, tizanidine, PT
- Cramps: tonic water, gabapentin, baclofen
- Depression/anxiety: SSRI/SNRI
- Respiratory, home NIV if: orthopnea, MIP<40, FVC <65% (upright) or <80% (seated/supine), CO2>45, or abN nocturnal oximetry and sleep disordered breathing
- Nutrition: high calorie and carbs
- Early enteral tube if aspiration, bulbar sx, dysphagia, 5-10% wt loss, >1 point BMI drop or BMI<18.5, FVC dropping below 50%
Driving restrictions: seizure
First unprovoked = 3 mo
Epilepsy: 6mo sz free on meds
Med change: 3 mo
GBS/CIDP Ix
MRI spine + GAD (nerve roots and cauda equina may enhance) to r/o acute myelopathy (mimic)
FVC
PVR
LP: albuminocytologic dissoc (high prot, low WBC)
EMG/NCS shows absent F waves and conduction blocks (CIDP shows acquired demyelination)
+/- Anti Gq1b AB
Nerve US in CIDP shows focal enlargement
Headache red flags
SNOOP4
Systemic: fevers, weight loss, immunosuppression (HIV, steroids, cancer, preg)
Neuro symptoms: meningismus, encephalopathy, papilledema
Onset: thunderclap - peaks <1min
Older >50y
Pattern change, positional , pulsatile tinnitus, precipitated by cough or valsalva
Headache differential
Primary:
- Migraine,
- Tension,
- Trigeminal autonomic cephalalgia (cluster, paroxysmas hemicrania, short lasting unilateral neuralgiform/cranial autonomic eg SUNCT/SUNA, hemicrania
Secondary (red flags)
- Vascular: stroke, venous thrombosis, hemorrhage, dissection, GCA, RCVS, PRES, pituitary apoplexy, AVM
- Space occupying: tumor, IIH, hydrocephalus
- Infectious: meningitis, encephalitis, abscess, sinusitis, otitis
- Opthalmologic: acute glaucoma, iritis, optic neuritis
Clues for Spontaneous intracranial hypotension
Worse standing
MS syndromes
Optic neuritis: painful eye movements, RAPD, monocular vision/color loss, 33% mild disk swelling
Brainstem/cerebellar syndrome:
- Bilateral INO, diploplia, gaze evoked nystagmus, vertigo
- Dysarthria, ataxia,
- Facial numbness, 6th nerve palsy
Incomplete transverse myelitis
- Sensory loss
- Asymmetric limb weakness
- Urge incontinence
- ED
- Lhermitte
-Uhthoff (worsening with heat)
MS Ddx
Demyelinating: ADEM, NMO, MOG
Inflamm: Sarcoid, SLE, Sjogren’s, GPA, Behcet
Infectious: post-infectious demyelinating, HIV, PML, HTLV, syphilis, Lyme, Bartonella, TB
Metabolic: B12/Cu deficiency
Neoplastic: lymphoma
Pysch: somatization
Vascular: vasculitis, migraine, vascular malformation
B12 vs Neurosyphilis
Pupils: B12 normal vs/ Argyle Robertson
Both hv dementia and altered mental status
Both have loss of vibration and proprioception
B12: UMN weakness, increased tone in legs, hyperreflexia, clonus
Syphilis: NO reflexes in LE, normal tone/power
Pinpoint pupils
PinPoint Pupils (think 4Ps) Pontine hemorrhage Phosphate (organophosphate) Pain killer (Opioid) Pilocarpine (glaucoma eye drops)
