Neurology IV Flashcards
1) Define seizure
2) Give the two main categories
1) A transient occurrence of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain
2) Either focal or generalized
How common are strokes and brain tumors as far as seizure causes go?
1) Stroke: ~15% overall, 49% > age 60 y/o (most common in elderly)
2) Brain tumor: ~ 6% overall, 11% > 60 y/o
Besides idiopathic, stroke, and brain tumor, what are some other seizure etiologies?
1) Head trauma (TBI)
2) Intracranial infection: meningitis, encephalitis
3) Cerebral degeneration
4) Congenital brain malformations
5) Inborn errors of metabolism
What is included in the complete H&P for a seizure patient?
1) Witnessed description of the event
2) Substance abuse
3) Head trauma
4) Cerebrovascular event
5) Cardiac history
6) Sleep d/o
7) Medications: tramadol, bupropion
What 2 medications can induce seizures?
Tramadol and bupropion
1) Seizure tests should include what?
2) What about for the first seizure?
1) Electrolytes (CMP), Glucose, HCG, ECG, EEG
2) Neuroimaging: MRI + contrast
Seizure: Diagnostic Evaluation
1) When would you do a lumbar puncture?
2) What test is essential for diagnosis and classification?
3) What neuroimaging is preferred, MRI or CT? Why?
1) Only if signs of infection
2) EEG
3) MRI preferred over CT; better for identifying structural lesion
-Helps answer “Is the lesion the cause of the Sz?”
Focal seizures:
1) What do Sx depend on?
2) How quick is the onset?
3) Give examples of Sx
Symptoms depend on which lobe is involved and have sudden onset (ex/ rhythmic movements – hands and feet or, hallucinations, flashing lights.)
Focal seizures:
1) Describe temporal lobe seizures.
2) What may the pt be like after a temporal lobe seizure?
3) Is this type common?
1) Bland, quiet, sense of fear, lip smacking/chewing. Patient is unresponsive for a period of time.
2) Pt may be fatigued or confused, or may not remember the episode at all
3) Most common focal seizure
Focal seizures:
1) Describe Frontal lobe seizures. Include when they may occur
2) Is the pt always unconscious?
1) Dramatic, often in the night; shaking of limbs, loud vocalizations.
2) Patient may remain aware throughout.
Focal seizures:
1) Describe the Sx of occipital lobe Sz
2) Describe the Sx of parietal lobe Sz. Are they common?
1) Flashing colors or lights, visual hallucinations. Electrical activity may spread therefore, can be subtle or dramatic.
2) Vertigo, tingling, numbness. Uncommon.
Focal seizures:
1) Pathophys?
2) Etiology?
3) Epidemiology?
1) Hyperexcitability in a neuronal population, increase in voltage, decrease in inhibitory NTs.
2) Structural brain abnormality (head injuries, birth anomalies).
3) 3/1,000 people ~10% prevalence over lifetime.
~3% go on to develop epilepsy.
Generalized Seizures:
1) Tx?
2) Epidemiology/ demographics?
1) Ethosuximide, valproic acid, topiramate, carbamazepine
2) M>F; 5 mil new dx/yr globally, 3.5 mil/yr US
-0.6% children, 8% adults
Generalized seizures:
1) What part(s) of the brain is/ are involved? Sx?
2) How are they diagnosed?
3) What are they associated with? (3 things)
1) Involves both hemispheres; may range from staring (absence 10-20 sec) to lightening-like jerking (myoclonic) to dramatic limb shaking and falling, usually including self injury (tonic-clonic.)
2) EEG (electroencephalogram)
3) Developmental delay, amnesia, and postictal state
Generalized seizures:
1) What are some Sx that may or may not be present?
2) What is the pathophys?
1) +/- LOC, fecal/urinary incontinence, tongue biting
2) Abnormal and excessive neuronal activity
Generalized Seizures:
1) Etiology? (hint: many)
2) DDxs?
1) Hyperventilation, fever, stress, menstrual cycle, trauma, infection, tumor
2) Syncope, TIA, movement disorders, convulsive concussion
Generalized nonmotor seizures:
1) Define absence seizure (aka petit mal) and who they’re common in
2) Is consciousness always impaired? How long do they last?
3) Are they obvious? Explain
1) Absence seizures (AKA petit mal) – kids, “staring spell” (non-responsive)
2) Characterized by brief impairment of consciousness with abrupt start and end
-May be very brief; seconds (like, ”miss a word or two when talking”)
3) Witness may miss and patient has no recollection; no aura or postictal period
Generalized nonmotor seizures:
1) True or false: these may have mild involuntary movements. Explain.
2) Almost always start in _____________, frequently cease by age __________, or replaced by other forms of generalized seizures.
1) True, but rare
2) childhood; 20 y/o
Generalized nonmotor seizures: Tx? (2 things)
Valproic acid (Depakote)
+
Ethosuximide
List the 5 different types of generalized motor seizures
1) Tonic
2) Clonic
3) Tonic-clonic
4) Myoclonic
5) Atonic
1) Quick jerking without LOC describes what type of motor seizure?
2) What is a DDx for atonic seizures? Describe what these motor seizures are like
1) Myoclonic
2) DDx syncope; sudden drop attack, loss of muscle tone, LOC
Motor seizures
1) What are tonic seizures? What are they the opposite of?
2) Jerking muscles, convulsions, and LOC sound like ______ seizures.
3) What are tonic-clonic seizures like?
1) Rigid or increased muscle tone; rigidity followed by LOC (opposite atonic)
2) clonic
3) Rigid with LOC followed by convulsions and postictal period
Generalized motor seizures
Tonic-clonic seizure (grand mal seizures):
1) What are they like? What is the onset?
2) What is the tonic phase? How long does it last?
3) What abt the clonic phase?
4) Is there a postictal phase? Explain
1) Bilaterally symmetric & without focal onset
Abrupt onset: rigid, convulsions and LOC; falls to ground
2) Very stiff/rigid lasting ~10–60 seconds
3) Generalized convulsions and jerking of the limbs
4) Postictal phase w. variable Sx; confused, amnesia, HA
Generalized motor seizures
What are some Sx of tonic-clonic seizure (grand mal seizures) besides convulsions?
1) Bladder and bowel release
2) Self-trauma: fall or biting self
Status Epilepticus:
1) Define it
2) Pathophys?
3) Etiology?
1) 2 or more seizures without conscious recovery in between attacks. Enduring epileptic condition (> 30 min.)
2) Failure of normal inhibitory pathways (GABA)
3) N/c with anti-epileptic meds or: alcohol withdrawal, drug overdose, intracranial infections or neoplasms, metabolic disorders, fevers, strokes
Status Epilepticus:
1) Epidemiology (incl. demographic)
2) DDx
2) Tx
1) Rare, 10-40/100,000/yr mostly young and elderly
2) Seizures due to hypoglycemia, electrolyte imbalance, alcohol withdrawal, cocaine, bacterial meningitis, herpes encephalitis, arrhythmias, brainstem ischemia
3) ABCs; benzos (lorazepam 4 mg IV bolus (2 mg/min)); repeat x 1 in 10 min if needed,
-then may add phenytoin to maintain control;
-phenobarbital if no response to benzos
1) Define epilepsy
2) True or false: All epileptics have seizures, not all seizures develop epilepsy
1) Chronic condition characterized by at least 2 unprovoked seizures at least 24 hours apart
2) True
List the 3 components of epilepsy
1) Distinct onset and end
2) Clinical signs
3) Abnormal synchronous electrical activity of the brain
1) _____% of population may experience a seizure during lifetime
2) What % of people develop epilepsy?
1) ~10%
2) ~3%
Differentiate between provoked and unprovoked single seizure Txs
1) Provoked: ID and treat underlying condition (ex/drug abuse, brain tumor, stroke, fever)
2) Unprovoked single seizure: often not treated unless recurs, i.e., first single seizure not treated with anti-seizure Rx
AEDs (Anti-Epileptic Drugs):
1) Are not necessary for who?
2) When should you Tx?
1) Individuals with a single new onset seizure or infrequent seizures
2) Only if there is a high risk of recurrence (EEG and or MRI +)
AEDs (Anti-Epileptic Drugs):
Immediate AED therapy (compared to delay of Tx) pending a 2nd seizure is likely to reduce ___________ risk within the first 2 years, but not improve __________ or prognosis over a _________ term
recurrence; QOL; longer term (- > 3 years)
Epilepsy:
1) Treated patients should be seizure free for ____ years on Rx prior to consideration of medication withdrawal in appropriate patients.
2) Does withdrawal work?
1) ~2 years
2) Depends on epileptic syndrome; some persist for life and will have seizure after Rx withdrawn
Epilepsy:
1) Risk of recurring seizure remains ___________ even in good candidates.
2) Surgical resection may be an option for what pts?
1) high (20-70%)
2) Refractory (to Rx) focal epilepsies
Who has a High Risk of Seizure Recurrence? (7 groups)
1) Status epilepticus
2) History of TBI
3) Brain lesion on neuroimaging
4) Focal neurological abnormalities on exam
5) Intellectual disability
6) Abnormal EEG (with epileptiform discharges)
7) High Risk Seizure Types: Focal, absence, myoclonic or atonic seizures
1) < _____% of MVA are attributable to seizures.
2) ____________ interval is best indicator of driving safety; longer the interval, the less likely MVA
3) The longer ________ restricted, the lower the compliance
1) <0.1%
2) Seizure free
3) driving
General recommendation in TN a __________ seizure free (on treatment) interval before driving resumed, or ________ for initial license
1) 6-month; 12 mo
True or false: state laws vary regarding seizures and driving and few states require health care providers report patients with seizure
1) True
-Know your own state laws
What does TDOT say about seizures and driving?
TDOT “shall suspend and/or not issue a DL to anyone who suffers from uncontrolled epilepsy, momentary lapse of consciousness or control due to epilepsy, cardiac syncope, DM, or other conditions until the person has remained seizure free or lapse free for 1 yr (or symptoms controlled for > 6 mo,) and then only upon receipt of a favorable medical statement from the person’s medical professional.”
Transient Ischemic Attack (TIA):
1) Define it. How long does it typically last?
2) Pathophys?
3) Etiology?
1) Focal neurologic symptoms of presumed ischemic origin with the absence of infarction on brain imaging (usually resolved in minutes).
2) Transient interruption of blood flow.
3) Vascular disease, embolization (a fib, endocarditis,) hematologic (clotting disorders, Sickle cell, polycythemia).
Transient Ischemic Attack (TIA):
1) Epidemiology: _____% of stroke patients and ____-_____% of patients with TIA will have stroke within 90d, esp older pts and pts with _______.
2) 3 DDxs?
3) Txs?
1) 15%; 5-15%; DM
2) Focal seizures, migraine aura, hypoglycemia
3) Treat underlying disorder (DM, HTN, hematologic disorders.):
a) CEA, statin or anticoagulation if appropriate
b) d/c smoking, weight reduction
c) Echo, urgent neuro consult
TIA work up should include what? (4 things)
1) Carotid doppler US
2) Echocardiography
3+4) ECG and Heart Rate monitor to evaluate for AF
List the 4 features that increase risk of stroke after TIA
1) Age > 60
2) Diabetes
3) Speech or motor difficulties as part of presentation
4) Episode duration > 10 minutes
-None of above factors = minimal risk
AHA/ASA recommends the ABCD2 score to calculate a patient’s what?
Short-term risk of developing a CVA
Which of these medications is best to reduce risk of recurrent stroke after mild stroke or TIA?:
A. ASA
B. Clopidogrel
C. ASA + dipyridamole (Aggrenox)
D. ASA + Clopidogrel
D. ASA + Clopidogrel (short term use)
(dual therapy with aspirin and an antiplatelet)
TIA urgent evaluation:
1) Why should you order a non-contrast CT?
2) Why should you use an MRI?
3) Why should you use neurovascular imaging?
1) R/o bleed
2) To determine tissue damage; negative = TIA
3) To evaluate large artery disease
(Carotid artery disease = source of emboli)
TIA urgent evaluation includes what? (4 things with different parts)
1) Non-contrast CT
2) MRI
3) Neurovascular imaging
4) Cardiovascular evaluation:
a) ECG (enzymes as part of initial labs)
b) Event monitor
c) Echocardiogram
TIA urgent evaluation:
1) Why is there are cardiovasc. eval?
2) What part of the cardiovasc. eval is a part of initial labs?
3) What part is for paroxysmal AF?
4) What are 2 reasons to use an Echocardiogram?
1) R/o cardiogenic source of emboli
2) ECG (enzymes as part of initial labs)
3) Event monitor
4) Thrombus, valvular disease
What is TIA routine management?
Guideline directed medical management
1) HTN
2) Dyslipidemia
3) DM
4) Smoking/lifestyle modifications
5) Antiplatelet (ASA + clopidogrel)
6) Anticoagulation if appropriate – AF, valvular disease
A patient presents to you having had a single new unprovoked motor seizure. Your first step in treatment would be?
A. no medication
B. start oral valproic acid
C. start on AED based on type of seizure
D. start IV phenytoin
A. no medication
Stroke (CVA):
1) Define it and list its Sx
2) What are the 2 types?
1) Sudden onset of neurologic deficits from a cerebrovascular origin.
-HA, vomiting, flashing lights, facial droop, unilateral weakness, vision loss, speech disruption
2) Ischemic or hemorrhagic
1) What is the pathophys of ischemic strokes?
2) What is the pathophys of hemorrhagic strokes?
Include which is more common
1) (87% of US strokes) thrombotic or embolic occlusion of a vessel leading to in the cerebrum
2) HTN > microaneurysms on vessels or AVMs, -hemorrhage can extend to ventricles or subarachnoid space, causing further symptoms
What is the etiology of ischemic strokes?
Vascular disease, embolization (a fib, endocarditis,) hematologic (Antiphospholipid Antibody Syndrome, Sickle cell, polycythemia)
Stroke (CVA):
1) Epidemiology?
2) DDxs?
3) Tx?
1) 5th leading cause of death in US and leading cause of disability
2) Seizure, infection, tumor, toxic/metabolic disorders, complicated migraines
3) 1) minimize disability, 2) prevent recurrent stroke; treat underlying cause if known
IV thrombolytics (tPA-tissue plasminogen activator) for ischemic strokes (CVA):
1) Gives some improvement of disability at ______ days. The sooner after the stroke it is given, the _________ the results.
2) How soon after a stroke must it be given?
3) What is the downside?
1) 90; better
2) Within 3 hours
3) Many contraindications (GI bld, recent anticoagulant or ASA use… )
Ischemic stroke Tx (besides IV thrombolytics) include what?
1) Embolectomy
2) Neuro consult, admit to stroke unit, tight BP control (esp first 72 hrs)
3) Early rehab
4) +/- decompressive hemi-craniotomy
5) Antiplatelet and anticoagulants
How do you Tx a **hemorrhagic* stroke?
1) ABCs
2) Neurosurgery consult -admit to ICU/stroke unit
3) Lower sBP 140-180 mmHg IV labetalol or nicardipine
4) Treat underlying cause if any
5) d/c any anticoagulation and reverse any coagulopathies
6) Ventricular drainage or hematoma evacuation
Which is the most common source of emboli resulting in stroke?
A. cerebral arteries
B. carotid arteries
C. aortic arch
D. vertebral basilar arteries
E. heart
E. heart
Which is the most common exam finding in a stroke patient?
A. Bowel and bladder release
B. LOC
C. EOM dysfunction
D. Unilateral weakness and speech disturbance
D. Unilateral weakness and speech disturbance
H & P by experienced provider in an emergency setting has what percent sensitivity for dx of stroke and TIA?
92%
Stroke:
1) What is key to diagnosis? What should you focus on?
2) Explain how timing is crucial
1) History/exam is key; focus on symptoms and signs of focal neurologic injury
2) Timing = last known baseline state; crucial for assessment and treatment options
List the presentation/ Sx of stroke (6)
1) Acute onset with maximal focal neurologic deficit that is consistent with a vascular territory
2) Arm or leg weakness (loss of strength)
3) Speech disturbance (aphasia or dysarthria)
4) Facial weakness
5) Arm or leg paresis (sensory loss)
6) Headache or dizziness
NIH stroke scale (NIHSS):
1) What is it?
2) How long does it take?
3) What does it do?
1) 15 item scale; determines severity of stroke
2) Experience provider ~5 minutes to complete
3) Helps distinguish stroke from other
NIH stroke scale (NIHSS): What are the 3 aspects of its chief utility?
1) Reliably evaluate stroke severity (to determine whether tissue plasminogen activator administration is appropriate)
2) Predicts prognosis
3) Requires training to use effectively
How do you interpret NIH Stroke Scale scores?
important
8 or less = mild (no rtPA)
9-15 = moderate
16 + = severe
Ischemic stroke recap:
1) What should the focused H&P include?
2) Labs?
1) Establish time of onset of symptoms (last witnessed asymptomatic time,) NIH stroke scale
2)Need a few to determine eligibility, others pending
Glucose, CBC, coag panel
Ischemic stroke recap:
1) What do you need to interpret within 45 mins of a pt being triaged for stroke?
2) What do you need to determine? What should you do next?
3) What do you need to review the criteria for?
1) STAT NCCT brain (image of brain)
2) Ischemic vs. hemorrhagic stroke
-Quick re-assessment of exam findings; repeat NIH stroke scale & compare to baseline
3) rtPA (time from baseline normal is within 3 - 4.5 hours)
-rtPA in appropriate patients without delay
rTPA contraindications include what? (4 things)
Recent surgeries, tumors, anticoagulants, GI bleeds, ischemic stroke within past 3 months
CAD
1) Carotid endarterectomy (CEA) is beneficial after stroke when _______________________ stenosis is 70% or greater.
2) Endarterectomy is reasonable with ipsilateral stenosis of _____% to _____% in patients who are at lower surgical risk.
3) What may be a reasonable alternative to endarterectomy in certain low-risk patients
1) ipsilateral extracranial internal
2) 50% to 69%
3) Carotid artery stenting
Arteriovenous malformation (AVM):
1) What is it?
2) Size?
3) What can it develop? What do most do?
4) What can they cause in the brain?
5) Tx?
1) Congenital vascular malformations formed from a focal malformation of an arteriovenous communication without intervening capillaries.
2) Size ranges from so tiny can barely be noted to massive mass like lesions
3) Aneurysm or hemorrhage.
-Most bleed at some point
3) Rec seizure, HA, mass effect, bleeds
4) If needed: surgery, embolization, cautery
Cerebral Aneurysm Rupture:
1) What are the Sx?
-What % chance of death?
2) What is the pathophys?
1) Severe headache, focal neurologic symptoms, coma or death.
->50% chance of death
2) Focal distortion of blood vessel wall (ex/ berry aneurysm in ant circle of willis)
Cerebral Aneurysm Rupture:
1) Etiology?
2) Epidemiology?
3) DDxs?
1) HTN, developmental abnormality (but most develop over time,) smokers, females, OCP use, + FH, polycystic kidney ds
2) More common in younger patients; 30,000 cases dx in US/yr (35 mil)
3) Head trauma, SAH, cerebral arterial dissection, ruptured AVM
Cerebral Aneurysm Rupture Tx? (7)
1) ABCs, emergent brain imaging, neurosurgery consult (clip or coil, but not stent)
2) Once stable, CTA = many pts have > 1 aneurysm (mirror aneurysm)
3) sBP < 130 (avoid any vasodilators that could worsen ICP)
4) Shunt for hydrocephalus
5) Frequent neuro checks
6) Prophylactic anticonvulsant meds
7) Nimodipine 60mg q4hr (improves outcomes and decreases vasospasms.)
8) Maintain euvolemia + monitor for hyponatremia
Intracranial Hemorrhage:
1) What are the 2 kinds? What are the Sx?
2) Pathophys?
1) Intraparenchymal or subarachnoid; sudden onset excruciating HA (“worst HA of my life,”) focal neurologic symptoms, +/- coma, sudden death (25-50%,) can occur anytime of day/night
2) Rupture of intracerebral (berry) aneurysm or AVM
Intracranial Hemorrhage:
1) Etiology?
2) Epidemiology?
3) DDxs?
1) Trauma, aneurysm rupture, HTN or developmental overtime
2) SAH 5% of all strokes, typically younger patients
3) Head trauma, arterial dissection, vasculitis
Intracranial Hemorrhage: What is the Tx?
Neurosurgery consult; prevent rebleed:
1) Admit to ICU/stroke center
2) ABCs, prevent neurological complications, pain management, BP control, monitor ICP, fluids to euvolemia
3) Many patients with SAH develop hydrocephalus; drain with intraventricular catheter
Syncope:
1) Define it
2) Pathophys
3) Etiology
1) Transient loss of consciousness for a few seconds
2) Excessive vagal tone or impaired control of peripheral circulation
3) Heart disease, age > 60, stress
Syncope:
1) Epidemiology?
2) DDxs?
3) Tx?
1) ~30% of adults will experience at least 1 episode
2) Seizure, TIA, hypoglycemia
3) Counterpressure maneuvers (Valsalva: squat, bear down, abdominal contraction)
-Treat underlying cause
High Risk of Seizure Recurrence:
What are the high risk seizure types?
Focal, absence, myoclonic or atonic seizures
