Neurology - Misc. Material + Broken Spreadsheets Flashcards
1
Q
Ischemic Stroke
(prevelence in stroke, two types and their frequencies)
A
- 80% of total stroke cases
- Types of ischemic stroke
- Thrombotic (66%)
- Embolic (33%)
2
Q
Hemorrhagic Stroke
(prevelence, cause)
A
- Prevelence - 20% of strokes
- Cause - blood in the brain, usually secondary to uncontrolled HTN
3
Q
Types of Ischemic Strokes
(list and define 2)
A
A stroke due to clot in the brain that occludes blowflow
- **Thrombotic - **Stroke due a clot that forms intracranially, it does not migrate
-
Embolic - Stroke due to a clot that forms extracranially and migrates to the brain. Common locations include
- Heart
- Aortic arch
- Cerebral arteries
4
Q
Carotid Artery Disease
(definition, s/sx, significance)
A
Definition: progressive blockage of the carotid arteries carotid arteries
S/Sx:
- Amaurosis fugax (sudden unilateral blindness)
- Dysphasia
- Unilateral weakness, paralysis, or numbness in extremities
Significance: highly increases risk of stroke
5
Q
FAST Exam
(indication, procedure, result interpretation)
A
(Indication: suspected stroke
Procedure: administer three tests
- Facial movement - smile or show teeth, looking for new lack of symmetry or unilateral movement impairment
- Arm movement - lift patient’s arms together for 90 sec if sitting, 45 sec if supine and ask pt to hold the position for 5 seconds. observe for unilateral arm drift
- Speech - lookfor new speech disturbances, slurring, word-finding difficulties (naming objects)
- (Time - since onset of symptoms, in order to guide treatment algorhythm)
Results: a positive test in any field indicates high liklihood of stroke and warrents immediate hospital transport
6
Q
Cincinnati Prehospital Stroke Scale
(indication, procedure, results implications)
A
Indication: suspected stroke
Procedure:
- Facial droop analysis - have pt show teeth or smile
- Arm drift analysis - have pt close eyes with arms extended for 10 seconds
- Speech analysis - have pt repeat a phrase back to you, “the sky is blue in Cincinnati”
Implications: Positive results indicate high liklihood of stroke
- Facial droop - assymetrical face movement
- Arm drift - unilateral action, either 1 arm cannot move for the test or one arm drifts down more than the other
- Speech - noted slurring, incorrect words, or inability to speak
7
Q
Glascow Coma Scale
(indication, procedure)
A
Indication: Determination of level of consciousness, specifically in the context of brain injury
Procedure: Evaluate patient for the following qualities and assign the appropriate number (see chart for numbers). Scores vary from 3-15
- Eye opening (4 levels)
- Verbal Response (5 levels)
- Motor response (6 levels)
8
Q
NIH Stroke Scale
(define)
A
Neurological exam that assesses severity of neurological impairment. Results are predictive of long term outcome after stroke
higher score = more unfavorable outcome
9
Q
Function of EKG in Stroke Dx
(3)
A
May reveal one or all of the following
- A-fib (clot formation that will embolize)
- A-flutter (clot formation that will embolize)
- Recent MI
10
Q
Exclusion Criteria for T-PA
A
Goal of screening: avoid serious bleeding associated c drug admin
11
Q
ICP and Stroke
(relationship, impt time period, significance)
A
Relationship: increased ICP can lead to cerebral edema, especially in the presence of a large infarction.
Timeframe: cerebral edema peaks b/w 48 and 72 hours
Significance: prolonged ICP associated c massive cerebral infarct can cause secondary coma
12
Q
Mannitol
(indication, MOA)
A
Indication: reduce edema in hemorrhagic stroke
MOA: pull fluid from the brain
13
Q
ABCD2 Score
(indication, components, results)
A
Indication: administered post TIA to determine risk of ischemic stroke within the next 7 days. also determines 2 day score in combined derivation and validation cohorts.
Components: age, BP, clnical features, duration of s/sx, diabetes
- Age > 60 yo = 1 point
-
BP elevation during intial TIA assessment = 1 point
- Systolic > 140 mmHg
- Diastolic > 90 mmHg
-
Clinical features
- __Unilateral weakness = 2 points
- Isolated speech distrubance = 1 point
- Others = 0 points
-
S/Sx duration
- **> **60 min = 2 points
- 10-59 min = 1 point
- < 10 min = 0 points
- Diabetes = 1 point
**Results **determined by total score
- 6-7 = high 2 day stroke risk (8%)
- 4-5 = moderate 2 day stroke risk (4%)
- 0-3 = low 2 day stroke risk (1%)
14
Q
aneurysm and burst aneurysm
A
aquired weakening of vessel wall resulting in a ballooning or dilation in the vessel, bursts under increased arteriol pressure
- suseptability of bursting is proportional to aneurysm diameter
- bleeding is transcient (only a few seconds) but rebleeding is possible
- vasospasm post bleeding is the most dangerous effect of burst aneurysm
- occurs w/i 3 days after hemorrhage
- peaks in severity 1 week post hemorrhage
- due to chemical irritation of BV walls of breakdown prdcts of hemorrhaged bld
15
Q
HA and Vomiting in Stroke Subtypes
A
Sentinatl HA = Similar, less severe HA in 2-3 months preceding stroke
16
Q
Polyneuropathy
A
Neuropathy c mixed branches:
- Somatic
- motor
- sensory
- Autonomic
- sympathetic
- parasympathetic
17
Q
Foot Complications in Diabetic Neuropathy
A
- Denervation of small foot muscles
- Clawing toes
- Altered gait biomechanics
- Increased plantar pressure
- Results in the following
- Calluses
- Ulcerations
18
Q
Charcot Arthropathy
(definition, 7 step pathophys)
A
Definition: Complication of diabetic neuropathy.
Pathophys:
- Decreased bloodflow and altered pressure in foot
- Small muscle wasting, decreased sensation, maldistribution while weight bearing
- Collapse of medial longitudinal arch
- Diabetic arthra (abnormal bone structure) in the foot within the food
- Bony callus replaces arch of foot
- Foot wil rock like a rocking chair while attempting ambulation - Rocker Bottom Deformity
- May be painful of painless
19
Q
Diabetic Neuropathic Pn
(description, 2 txs c 1 MOA)
A
Description: sharp, stabbing pn due to dysfunctional nerves
Medications: Phenytoin/Dilantin, Carbamezpine/Tegretol.
- Block Na channels
- Dec transmission at NMJ
both of these are anti-seizure meds
20
Q
Diabetic Deep Aching Pn Tx
(3 c MOAs)
A
- Amitriptyline/Elavil (tricyclic antidepressant)
- Block serotonin and NE uptake
- Block muscarinic receptors
- Inhibit pn neurotransmission
- Gabapetin/Neurontin - GABA analog that inhibits pn and neurotransmission
- Duloxetine/Cymbalta - Serotonin/norepinephrine reuptake inhibitor
21
Q
Gludrocortisone or Midrodine
(MOA, indication)
A
Indication: treat postural hypotension associated c diabetic neuropathy
MOA:
- Mieralcorticoid activates aldosterone receptors
- Inc Na reabsorption
22
Q
Metochlopramide/Reglan
(indicaiton, MOA)
A
Indication: treat gastroparesis of diabetic neuropathy
MOA: Dopamine antagonist causing antiemetic and cholinergic activity to facilitate gastric emptying
23
Q
Labile BP
(definition, associated condition)
A
**Associated **with Guillain Bare Sydrome
Defined as blood pressure that fluctuates abruptly and repeatedly, often causing symptoms such as headache or ringing in the ears
24
Q
Elevated PRO in Guillain Barre Syndrome
(explaination, dx study)
A
Explaination: release of the protein myelin sheaths into the CSF
Dx Study: LP will reveal high protein levels in CSF
25
Kerning's Sign
| (indication, procedure, positve test)
**Indication**: test for meningitis
**Procedure**:
1. Place pt supine c hips flexed at 90º
2. Attempt to extend leg @ knee
**Positive Test**:
1. Resistance to extension at knee to \>135º
2. Pain in lower back or posterior thigh
26
Brudzinski's Sign
| (indication, procedure, positive test)
**Indication**: test for meningitis
**Procedure**:
1. Place pt supine
2. Passively flex head towards chest
**Positive Test**: associated flexion at knees and hips
27
Jolt Accentuation of HA Test
| (indication, procedure, positive test)
**Indication**: test for meningitis
**Procedure**:
1. Pt flexes head horizontally 2-3x / second
**Positive Test**: pt reports exacerbation of HA
28
Contrast CT
| (Indication)
Indicated to dx brain abscess, as to highlight the pathology compared to non-contrast
29
Define Cerebrovascular Accident (CVA)
Reduced blood flow to the brain
30
Etiology, Cerebrovascular Accident (CVA)
(2 categories, prevelence, 10 risk factors)
_Prevelence_: Third most common cause of death in US
_Risk Factors_:
1. Male
2. Black (compared to white)
3. HTN, extra blood in vessels
4. Hypercholesterolemia/hyperlipidemia, stiff vessels
5. Diabetes mellitus, elevated glucose
6. OCP’s (oral contraceptives), hypercoaguable
7. Cigarette smoking, hypercoaguable
8. Heavy alcohol use
9. AIDS
10. **Carotid artery disease**
_Two types_:
1. Ischemic
2. Hemorrhagic (aka intracranial/intracerebral hemorrhage)
31
Pathophysiology, Cerebrovascular Accident (CVA)
(2 categories)
**Hemorrhagic Stroke**
* Bleeding in the brain
* Rapid but unpredictable progression due to unpredictability of bleeding progression
**Ischemic Stroke**
1. Thrombotic Stroke
* Clot originates in brain artery
* As the clot grows in size, the symptoms worsen until causing total occlusion
* Often preceded by TIA
* Usually evolve in predictable stepwise progression:
2. Embolic Stroke
* Clot migrates from a part of your body to the brain
* Clot will not cause s/sx until it lodges in a small intracranial vessel
* Occur abruptly without warning
**Further complications in all strokes**
* Poor blood distribution affects neurologic fctn of brain
* Cerebral edema
* Intracranial pressure increase
32
S/Sx, Cerebrovascular Accident (CVA)
(signs - 5 categories, 3/1/1/2/4 specifics
symptoms - 5 categories, 4/2/2/3/3 specifics)
_Symptoms_
* General
* Abrupt onset c duration \>24 hours
* Correlate c are c area of brain supplied by effected vessel – deficits are contralateral to damage
* Anterior circulation only (anterior/middle cerebral artery)
* Visual field defects
* Proximal to anterior communicating artery
* +/- confusion
* **Middle Cerebral Artery** (side nonspecific for symptoms)
* Homonymous hemianopsia
* Contralateral deficit usually in upper extreme
* Posterior circulation only (vertebral artery, basilar artery)
* Vertigo
* N/V usually second to the vertigo
* Visual disturbances
* Diplopia
* Bilateral blurring or blindness
* Dysarthria
_Signs_
* General
* Correlate c are c area of brain supplied by effected vessel – **deficits are contralateral to damage**
* Hemisensory deficit
* Hemiparesis, progressing to hemiplasia
* **Most important predictive signs for acute stroke**
1. **Facial paresis**
2. **Arm drift/weakness**
3. **Abnormal speech**
* Anterior circulation only (anterior/middle cerebral artery)
* Aphasia
* Apraxia
* Proximal to anterior communicating artery, minimal damage, limited to
* Contralateral leg (and sometimes arm) weakness
* Contralateral leg paresthesia
* **Middle Cerebral Artery**
* Side nonspecific
* Conjugated eye deviation towards lesion
* LOC secondary to cerebral hemisphere swelling
* Contralateral deficit usually in upper extrem
* Left
* Aphasia
* Right
* Difficulty drawing/interpreting spatial relationships
* Posterior Circulation only (vertebral and basilar arteries)
* Coma
* Drop attacks
* Ataxia
33
Differential Dx, Cerebral Vascular Accident (CVA)
(16)
1. Migraine aura
2. Postictal symptoms
* Paresis (Todd’s paralysis)
* Aphasia
* Neglect
3. Brain tumor
4. Functional defect (conversation reaction)
5. Head trauma
6. Mitochondrial disorder (eg, mitochondrial encephalopathy c lactic acid acidosis and stroke-like episodes or MELAS)
7. Multiple sclerosis
8. Spinal cord disorders
* Compressive myelopathy
* Spinal dural ateriovenosis fistula
9. Subdural hematoma
10. Syncope
11. Systemic infection
12. Toxic – metabolic disturbance
13. Hypoglycemia
14. Exogenous drug intoxication
15. Transient global amnesia
16. Viral encephalitis (eg herpes simplex encephalitis)
34
Diagnostic Studies, Cerebral Vascular Accident (CVA)
(6 categories, 4/3/1/1/10/1 specifics)
1. Stroke determination tests
* FAST exam
* Cincinnati Prehospital Stroke Scale
* Glascow coma scale
* NIH stroke scale, to predict outcome
2. Imaging
* Noncontrast brain CT to differentiate b/w ischemic and hemorrhagic
* Carotid US, especially if bruits noted
* ECHO
3. EKG
4. Lumbar puncture (only c suspected hemorrhage or vascular malformation)
5. Bloodwork
* Potentially abnormal in hemorrhagic stroke
1. CBC
2. Plt
3. PT
* Potentially abnormal in ischemic stroke
1. Cholesterol
2. Lipids
* Blood glucose
* Coexisting MI pts
1. Troponin
2. CK MB (may have coexisting MI)
* BUN/Cr (for coexisting renal failure)
* Antinuclear factor (ANA, for autimmune disease)
6. Hemorrhagic stroke only: Check level of dysphagia (thus risk of aspiration pneumonia)
35
Medical Tx, Cerebral Vascular Accident (CVA)
(3 categories, 4/5/6 specifics)
1. Ischemic Stroke
1. Emergency management:
1. ABC's (especially in brainstem strokes)
2. **Restore blood flow to brain by reversing ischemia source**
3. Thromboembolic therapy - recombinant tissue plasminogen **(t-PA) within 3-5 hours of s/sx onset**
2. Treat increased ICP before cerebral swelling peaks (48-72 hrs)
* Medicate to reduce edema
* Manage BP – dec by 15% if extremely hypertensive:
* Systolic \> 220 mmHg
* Diastolic \> 120 mmHg
3. Antiplatelet therapy (for ischemic stroke, prevent additional clots)
4. Anticoagulant therapy (for cardiac embolus) – heparin is first line
2. Hemorrhagic Stroke – treated more conservatively than ischemic stroke
* Emergency Measures
* ABC's
* Manage HTN
* Anti-edema meds
* Mannitol
* Corticosteroids
* Test for dysphagia
* DVT/PE prophylaxis – Parenteral heparin
* Supportive tx after emergent period
* PT/OT
* Social support (prevent depression)
* Speech therapy
3. Long term, depends etiology
* BP ctrl
* Lipid ctrl
* Smoking cessation
* Anti-thrombotic therapy
* Diabetes ctrl
* Weight reduction
36
Emergency Tx, Cerebral Vascular Accident (CVA)
(2 categories, 3/2 specifics)
1. Ischemic stroke
* ABC’s (especially in brainstem strokes)
* Restore bloodflow to the brain by reversing ischemia source
* Thromboembolyc therapy - Recombinant tissue plasminogen activator (T-PA) within 3-5 hours of s/sx onset
2. Hemorrhagic stroke
* ABC’s
* Manage HTN
37
Pt Education/Prevention, Cerebral Vascular Accident (CVA)
(2)
1. Considered the most disabling neurologic disorder
2. Encourage pts to stick to tx routines and support groups to avoid depression and increased disability
38
Clinical Pearls, Cerebral Vascular Accident (CVA)
(4)
1. Most expensive neurologic disorder to the country as a whole
2. Occlusions proximal to anterior communicating artery junction are usually well tolerated due to collateral circulation from the opposite side
3. Most common artery in stroke is middle cerebral artery
4. Screen patients aggressively for T-PA administration to avoid high risk of significant bleeding (many pts are not eligible)
39
Define Lacunar Infarct
Lesions in short penetrating cerebral arterioles
40
Etiology, Lacunar Infarct
| (1)
Associated c **uncontrolled DM and HTN**
41
Pathophysiology, Lacunar Infarcts
| (2)
1. HTN and/or DM puts excessive pressure on arterioles of the deep brain
* Basal ganglia
* Pons
* Cerebellum
* Deep cerebral white matter
2. Pressure causes lesions \< 5mm diameter on brain tissue
42
S/Sx, Lacunar Infarct
| (2 signs, 1 symptom)
**Symptoms** relating to direct condition, but poor ctrl of DM or HTN is evident
* HA
* Usually no s/sx directly related to stroke
**Signs** None relating to direct condition, but poor ctrl of DM or HTN is evident
43
Differential Dx, Lacunar Infarct
| (4)
1. Stroke
2. HTN
3. DM
4. HA
44
Diagnostic Tests, Lacunar Infarct
| (1)
Brain CT usually reveals **small, punched out hypodense areas, although it could be normal**
* Often times CT is obtained for seemingly unrelated condition like HA
45
Medical Tx, Lacunar Infarct
| (1)
Treat the underlying condition aggressively with the following
* HTN meds
* Glucose
46
Patient Ed/Prevention, Lacunar Infarct
| (1)
Good prognosis when underlying conditions are controlled
47
Define Transcient Ischemic Attack (TIA, Mini Stroke)
Sudden onset and short duration of focal neurologic deficits secondary to cerebral circulation disturbance
48
Etiology, Transcient Ischemic Attack (TIA, Mini-Stroke)
(2)
1. Elderly
2. Vascular disease (smokers)
49
Pathophysiology, Transcient Ischemic Attack (TIA, Mini-Stroke)
(1)
Usually carotid or vertebral vascular disturbance
50
S/Sx, Transcient Ischemic Attack (TIA, Mini-Stroke)
(symptoms - 2 general qualities, 2 categories, 2/3 specifics)
signs-2 general quaities, 2 categories, 3/4 specifics)
_Symptoms_
1. General
* **Sudden onset of artery-specific s/sx**
* **Duration \<24 hrs, usually only a few minutes**
2. **Internal carotid artery**
* Unilateral weakness or numbness in upper extremity and sometimes lower extremity
* Amaurosis fugax, or other visual s/sx
3. Vertebrobasilar artery
* Vision disturbances
* **Homonymous hemianopsia**
* Bilateral blurring or blindness
* Diplopia
* Vertigo
* Resultant N/V
* Drop attacks
_Signs_
1. General
* **Sudden onset of artery-specific s/sx**
* **Duration \< 24 hrs, usually only a few minutes**
2. **Internal carotid artery**
* Dysphasia/aphasia
* Unilateral paralysis in upper (and sometimes lower) extreme
* **Carotid bruit**
* **Absent c stenosis \>95%**
3. Vertebrobasilar artery
* Dysarthria
* Hemiplegia
* Ataxia +/- bilateral weakness or numbness
* CN palsies
51
Differential Dx, Transcient Ischemic Attack (TIA, Mini-Stroke)
(4)
1. Seizure disorder, postictal s/sx
2. Migraine
3. Syncope
4. Brain tumor
52
Diagnostic Tests, Transcient Ischemic Attack (TIA, Mini-Stroke)
(2 categories, 1/3 tests)
1. **Carotid US** to determine degree of stenosis in carotids
* \>70% stenosis is significant
2. Bloodwork
* Diabetes
* Glucose
* Hgb A1C
* Lipid studies
53
Medical Tx, Transcient Ischemic Attack (TIA, Mini-Stroke)
(5)
1. Prophylactic anti-platelet therapy
* ASA
* Clopidigrel
2. Warfarin, if cardiogenic
3. BP ctrl
4. Lipid management
5. Behavior change – discontinue EtOH and tobacco
54
Surgical Tx, Transcient Ischemic Attack (TIA, Mini-Stroke)
(1)
Endocardectomy if stenosis \>70%
55
Emergency Tx, Transcient Ischemic Attack (TIA, Mini-Stroke)
(1)
Act quickly, but this is not as emergent as a stroke
56
Pt Education/Prevention, Transcient Ischemic Attack (TIA, Mini-Stroke)
(2)
1. 33% of TIA pts will suffer a stroke within 5 yrs
2. Prognosis - 7 and 2 day stroke risk determined via ABCD2 score
57
# Define Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
Inracranial bleeding due to a burst weakened cerebral blood vessel
58
Etiology, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
(2 categories)
1. Presence of saccular (berry) aneurysm in 75% of cases
* Males and females have equal risk
2. Intracranial AV malformation in \<10% of cases
* Males have greater risk than females
* Ages 20-50 due to hereditary control
59
Pathophysiology, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
(4)
1. Ruptured cerebral aneurysm causes bleeding into subarachnoid space
2. Blood released directly into CSF under high pressure
3. Rapid increase in ICP
4. Coma
60
S/Sx, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
(2 symptoms, 2 categoreis of signs)
1. Symptoms
* Sudden onset of severe HA
* “Worst HA of my life”
* Thunderclap HA
* N/V (~50%)
2. Signs
* Tinnitus, in the event of AV malformation
* Decreased GCS due to meningeal irritation and edema from hemorrhage
1. Confusion
2. Stupor
3. Coma
4. Nuchal rigidity
61
Differential Dx, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
(14)
1. Migraine aura
2. Postictal symptoms
* Paresis (Todd’s paralysis)
* Aphasia
* Neglect
3. Brain tumor
4. Functional defect (conversation reaction)
5. Head trauma
6. Mitochondrial disorder (eg, mitochondrial encephalopathy c lactic acid acidosis and stroke-like episodes or MELAS)
7. Multiple sclerosis
* Spinal cord disorders
* Compressive myelopathy
8. Spinal dural ateriovenosis fistula
9. Subdural hematoma
10. Syncope
11. Systemic infection
12. Toxic – metabolic disturbance
* Hypoglycemia
* Exogenous drug intoxication
13. Transient global amnesia
14. Viral encephalitis (eg herpes simplex encephalitis)
62
Diagnostic Tests, Cerebral Aneurysm c Subarachnoid Hemorrhage
(3)
1. Noncontrast Brain CT
2. **LP,** esp in the presence of normal head CT
* Elevated cerebral spinal pressure - increased opening pressures
* Grossly bloody spinal fluid
3. Cerebral angioplasty when convenient, as 20% of pts will have multiple aneurysms
63
Medical Tx, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
(3)
1. Strict bed rest
2. Mild sedation
3. Stool softeners to prevent valsalva
64
Emergency Tx, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
(4)
1. **Immediate diagnosis to prevent imminent death**
2. Supportive tx to prevent repeated rupture of affected vessel
* HTN management
* Prevent inc ICP
3. Strict bedrest
4. Mild sedation
65
Prognosis, Cerebral Aneurysm c Subarachnoid Hemorrhage (SAH)
50% mortality
66
Define Intracerebral Hemorrhage (ICH)
Stroke due to bleeding within the cerebral cavity, deep to all dural layers
67
Etiology, Intracerebral Hemorrhage
| (5)
1. **HTN (most common)**
2. Bleeding disorders
3. Brain tumor
4. AV malformations
5. Having a risk factor
* Smoking
* Advanced age
* Anticoagulant use
68
Pathophysiology, Intracerebral Hemorrhage (ICH)
(5)
1. Sheer stress on cerebral vessels (like high blood flow) will cause small breaks in walls
* Smaller penetrator arteries branching off major intracrerebral arteries
2. Pseudoaneurysm development due to breaking and weakness
3. Hemorrhage results when large pseudoaneurysms develop and fully rupture wall
4. Bleeding progresses when clotting system unable to compensate for ruptured wall
5. Tissue pressure and intravrascular pressure **keeps bleeding localized**
69
S/Sx, Intracerebral Hemorrhage (ICH)
| (1 general, 3 signs, 3 symptoms)
Gradual progression (**1-2 days**) with quick deterioration once symptoms and signs begin
**Symptoms**:
1. HA in 50% of pts
2. N/V present in the event of HA
3. Neurologic signs depend on area of brain involved
**Signs**:
1. HTN
2. Decreased LOC as ICP rises
3. Neurologic signs depend on area of brain involved
70
Differential Dx, Intracerebral Hemorrhage (ICH)
(14)
1. Migraine aura
2. Postictal symptoms
* Paresis (Todd’s paralysis)
* Aphasia
* Neglect
3. Brain tumor
4. Functional defect (conversation reaction)
5. Head trauma
6. Mitochondrial disorder (eg, mitochondrial encephalopathy c lactic acid acidosis and stroke-like episodes or MELAS)
7. Multiple sclerosis
8. Spinal cord disorders
* Compressive myelopathy
* Spinal dural ateriovenosis fistula
9. Subdural hematoma
10. Syncope
11. Systemic infection
12. Toxic – metabolic disturbance
* Hypoglycemia
* Exogenous drug intoxication
13. Transient global amnesia
14. Viral encephalitis (eg herpes simplex encephalitis)
71
Diagnostic Tx, Intracerebral Hemorrhage (ICH)
(7 tests in 2 categories)
* Non-contrast brain CT shows highly contained bleed
1. Blood evaluation
2. CBC
3. Plt count
4. PT
5. PTT
6. LFT’s
7. BUN, Cr
* LP is contraindicated due to brainstem herniation, but sometimes necessary c comorbidity of subarachnoid hemorrhage
72
Surgical Tx, Intracerebral Hemorrhage (ICH)
Prompt neurosurgery, if pt is a candidate
73
Emergency Tx, Intracerebral Hemorrhage (ICH)
(6)
1. ABC’s
2. Discontinue anti-platelet drugs
3. IV manitol – reduce ICP
4. IV labetolol – reduce BP conservatively, want to avoid ischemic stroke
5. Coagulate
* FFP
* Vitamin K (if on warfarin)
* Protamine (if on heparin)
6. Seizure prophylaxis due to inc ICP and reduced cerebral blood flow
74
Prevelence and Prognosis, Intracerebral Hemorrhage (ICH)
Second most common cause of stroke
30 day mortality rate = 35%
75
Define Alzheimer's Dementia
Progressive degenerative disorder of cerebral cortex, esp frontal lobe
76
Etiology, Alzheimer's Dementia
| (3 categories, 1/3/3 specifics)
1. Age – typically begins in 60’s or 70’s
2. Risk factors
* Heredity – asst c chromosomes 1, 14, 19. 21
* Lower education level
* Female gender
3. Protective factors
* Higher education
* Cognitive exercises (word finds, puzzles, word scrambles)
* Social support
77
Pathophysiology, Alzheimer Dementia
| (3 categories, 3/3/1 specifics)
* Three coexisting findings in cerebral cortex
1. **Intracellular neurofibrillary tangles**
* Fibrous Tau protein that usually provides microtubule support will cause neuronal death by forming tangles
2. **Extracellular neuritis plaques**
* a.Composed of degenerating axons and dendrites
* b.Adjacent to tangles
* c.Composed of unbalanced (over or under produced) ß amyloid protein is toxic
3. **Neuronal loss** – signaling degeneration
* Change in neuronal tissue causes brain shrinkage and death in systematic order
1. Memory cells
2. Language centers
3. Remaining brain – advanced disease and cortical atrophy
* Widespread neuron degeneration leaves gaps in brain’s messaging system, causing s/sx
78
S/Sx, Alzheimer Dementia
| (1 general, 3 categories for each)
**Symptoms** Steady and progressive memory loss and other cognitive defects
1. Problems c memory/visuospatial abilities
* Becoming lost in familiar surroundings
* Inability to copy geometric design on paper
2. Personality and behavioral change noted as disease progresses
* Wandering
* Inappropriate sexual behavior
* Aggressiveness
3. Further decline with later disease
* Hallucinations
* Delusions
* S/Sx of depression
**Signs** Steady and progressive memory loss and other cognitive defects
1. Inability to perform complex motor tasks
2. Inappropriate social behavior
3. Late stage disease, consider Hospice care
* Inability to sit up
* Inability to hold head up
* Difficulty eating/swallowing
* Weight loss
* Bladder/bowel incontinence
* Recurrent respiratory/urinary infections
79
Differential Dx, Alzheimer Dementia
| (2, c differentiating factors)
1. Mild Cognitive Impairment
* Pt has memory problems c mild deficits but can complete ADLs
2. Delirium
* More acute onset c fluctuating course
* Deficits are more attention-centered than memory-centered
80
Diagnostic Tests, Alzheimer Dementia
| (3 categoreis, 2/8/2 specifics)
1. Screening tests
* Mini cog test for all elderly pts
* Comprehensive Mini Mental Screening Exam if pt failed Mini Cog
2. Metabolic R/O tests, will all be normal in pure AD
* CBC
* Vitamin B12
* Heavy metal screens
* Serum electrolytes – Na, Ca
* Serum glucose
* TSH
* Renal and liver fctn tests
* Drug/alcohol screen
3. Brain pathology R/O
* Noncontrast brain CT
* Stroke
* Subdural hematoma
* MRI brain in younger pts c focal neuro deficits
* Tumor
81
Medical Tx, Alzheimer Dementia
| (4 categories, 1/1/2/2 specifics)
1. Be sure to R/O all other possibilities
2. Refer to educational materials and ensure safe living environment (see below)
3. Treat cognitive impairment
* AChesterase inhibitors
* Tacrine/Cognex
* Donepazil/Aricept
* N methyl D aspartic acid (NMDA) antagonists to regulate glutamate and improve memory in severe Alzheimer Disease
* Memamtine/Namenda
4. Behavioral Tx
* Help in office and educate caregivers on out of office on behavior
* Use simple language to communicate c pt
* Break down activities into simple components
* “Distract, no confront” when pt disturbed by troublesome issue
* Provide structure and routine
* Discontinue all un-necessary meds
* Antipsychotics, lack of strong evidence but still highly used. “Start low and go slow” to avoid hyperglycemia, wt gain, and stroke
* Risperidone/Risperdal
* Olanzapine/Zyprexa
* Clozapine/Clozaril
82
Pt Education/Prevention, Alzheimer Dementia
(6)
The majority of tx is working with the pt and family to ensure knowledge and safety
1. Awareness of Alzheimer’s Association is critical – http//:www.alz.org
2. Local support groups
3. Vigilant 24/7 supervision – family or day care centers
4. Respite care for family caretakers
5. Prognosis 3-15 years.
6. Hospice care recommended for end stage pts (last 6 mo of life)
83
Clinical Pearls, Alzheimer Dementia
* 7th leading cause of death in US
* Ranks high in list of expenses in US medical dollars
* Pts c dementia frequently have to make medical decisions and the provider must ascertain pt’s ability to do so by evaluating 5 essential components of decision making
1. Ability to express choice
2. Understanding relevant info and risk/benefit stratification
3. Comprehension of problem and consequences
4. Ability to reason
5. Consistency
***History is vital for dx and staging***
* Order of s/sx appearance (intellectual decline, behavior change, personality change)
* Presence of other neurologic s/sx (like motor decline)
* Previous stroke
* Peripheral neuropathy
* Risk factors for HIV
* Family hx
* Medications and recent med changes
84
Define Vascular Dementia
Memory loss due with a vascular etiology
85
Etiology, Vascular Dementia
| (2 diseases, 6 risk factors)
15-20% of dementia cases. Includes two disease types and can coexist c Alzheimer dementia
1. Lacunar dementia
2. Multi-cortical infarct dementia
Risk factors: any risk for vascular disease
1. Age
2. Htn
3. Cigarette smoking
4. A-fib
5. DM
6. Hyperlipidemia
86
Pathophysiology, Vascular Dementia
Repetitious minor hemorrhages lead to cortical degradation and death
87
S/Sx, Vascular Disease
| (9 symptoms, 1 sign)
_Symptoms_ Gradual **stepwise** occurrence
* Loss of computational ability
* Problems c word finding
* Inability to concentrate
* Impaired ADLs
* Complex disorientation
* Social withdrawal
**Differentiating lack of the following**:
* Depression
* Inattentiveness
* Loss of social graces
_Signs_ Gradual **stepwise** occurrence
* Impaired ADLs
88
Differential Dx, Vascular Dementia
| (2)
1. Other types of dementia
2. CVA
89
Diagnostic Tests, Vascular Dementia
| (3 categories, 2/8/2 tests)
1. Screening tests
* Mini cog test for all elderly pts
* Comprehensive Mini Mental Screening Exam if pt failed Mini Cog
2. Metabolic R/O tests, will all be normal in pure AD
* CBC
* Vitamin B12
* Heavy metal screens
* Serum electrolytes – Na, Ca
* Serum glucose
* TSH
* Renal and liver fctn tests
* Drug/alcohol screen
3. Brain pathology R/O
* Noncontrast brain CT
* Stroke
* Subdural hematoma
* MRI brain in younger pts c focal neuro deficits
* Tumor
90
Medical Tx, Vascular Dementia
| (2)
1. Ctrl HTN and DM
2. Treat the symptoms
* Insomnia – hynotics, melatonin agonists, benzos
* Agitation – low dose antipsychotics
* Depression – SSRI’s Educate caregivers (see below)
91
Pt Education/Prevention, Vascular Dementia
(4)
1. Vigilant 24/7 supervision – family or day care centers
2. Respite care for family caretakers
3. Preparation of advanced directives
4. ID and reduce home hazards and add safety equipment
92
Define Lewy Body Dementia
Dementia often associated c **Parkinson’s Disease**
93
Etiology, Lewy Body Dementia
Second most common cause of dementia, 10-22% of cases
Risk factors:
1. \>75 yo
2. Male
3. Potential genetic predisposition
94
Pathophysiology, Lewy Body Dementia
| (3)
1. Lewy body formation in deep cortex, substantia nigra, and other brain areas
* LB = round, eosinophilic nitracytoplasmic inclusions in nuclei of neurons
2. Neurons containing LB die
3. Cognitive impairment results
95
S/Sx, Lewy Body Dementia
(symptoms - 2 stages, 3/2 steps
signs - 1)
_Symptoms_**:**
Present **before** memory impairment (opposite of Alzheimer)
* Attention deficits
* Executive fctn impairment (dec job performance)
* Visuospatial impairment
* Getting lost
* Misjudging distance
* Missing stop signs
Present **with or after** memory impairment
* Visual hallucinations
* Cognitive fluctuation
* “Blanking” episodes
* Confusion
* Speech/motor arrest
* Excessive somnolence
_Signs_: Parkinsonism
96
Differential Dx, Lewy Body Dementia
1. Other dementias
2. Parkinson’s medication rxn
97
Diagnostic Tests, Lewy Body Dementia
| (2)
1. Optional = radiologic testing
* Brain MRI will show cerebral atrophy c preservation of hippocampal structure in mediotemporal lobe
2. Definitive dx only possible c tissue sample to expose Lewy bodies, but c comorbidity of Parkinson’s the correct dx can often be assumed
98
Medical Tx, Lewy Body Dementia
| (5)
1. Treat PD
2. Anticholinesterases to restore brain ACh and slow neuronal degeneration
3. Standard medication to tx s/sx
* Insomnia – hynotics, melatonin agonists, benzos
* Agitation – low dose antipsychotics
* Depression – SSRI’s
4. Exercise program to maximize motor fctn
5. Educate pt and family, see Pt Ed section
99
Pt Education/Prevention, Lewy Body Dementia
(4)
1. Vigilant 24/7 supervision – family or day care centers
2. Respite care for family caretakers
3. Preparation of advanced directives
4. ID and reduce home hazards and add safety equipment
100
# Define Delerium
Acute fluctuating disturbance of consciousness associated c cognitive impairment or development of perceptual disturbances that is **secondary to an underlying medical problem**
101
Etiology, Delirium
| (4, 15 risk factors)
_Presence of associated underlying medical problem_
* Infection
* Coronary ischemia
* Hypoxeima
* Metabolic disturbance (acidosis, electrolyte disturbance)
_Risk Factors_
1. Hospitalized pts
* Unfamiliar setting
* Loss of independence
* Altered sleep schedule
2. Male
3. Severe illness
4. Hip fx (due to change in environment0
5. Thermal disturbance (hyper or hypothermia)
6. Hypotension (dec cerebral perfusion)
7. Malnutrition
8. Polypharmacy (most common cause)
* Addition of a new drug
* Withdrawal from an old drug
* Relationship between drugs
9. Psychotropic drug use
10. Metabolic disorders
11. Urinary catheter use (UTI and sepsis)
12. Brain disorder
* Stroke
* TIA
13. Depression
14. Alcoholism
15. Drugs, especially in the elderly
* Benzodiazepine
* Opioids
* Diphenhydramine (OTC!)
* Antipsychotics
102
Pathophysiology, Delirium
Largely based in theory involving neurotransmitter dysfunction, cytokine release, second messenger disturbance, or changes in BBB permeability
103
S/Sx, Delirium
| (4 symptoms, 1 sign)
_Symptoms_:
1. **Acute onset of**
* **Confusion**
* **Agitation**
2. Somnolence
3. Withdrawal
4. Psychoses
_Signs:_
1. Hallucinations
104
Differential Dx, Delirium
| (3)
1. Aphasia
2. Stroke
3. Depression
105
Diagnostic Tests, Delirium
| (4 categories, 10/3/13/4 specifics)
1. REVIEW MEDS!! Some common meds include
* NSAIDs
* Analgesics
* Opioids
* Antibiotics
* Anticholinergics
* Anticonvulsives
* Antidepressants
* GI agents
* Antipsychotics
* Herbs
2. Confusion assessment score
* Acuity of onset and fluctuation (required)
* Inattention (required)
* One or both of the following
* i.Disorganized thinking
* ii.Altered level of consciousness
3. Lab work
* CBC (WBC, Hct, Hgb to assess infection and amount of blood)
* Electrolytes
* BUN/Cr
* Glucose (hypoglycemia)
* Ca
* LFT’s (liver failure)
* UA (infection)
* EKG (ischemia, MI)
* Serum Mg
* Serum drug levels
* ABG (metabolic acidosis/alkalosis)
* Blood cultures (sepsis)
* Urine toxicology
4. Imaging
* CXR (pneumonia)
* CT brain (TIA, stroke)
* LP
* EEG
* Differentiate delirium from dementia
* Diffuse slowing of background rhythm
106
Define Diabetic Neuropathy
Neuropathy associated c longstanding and/or uncontrolled diabetes
107
Etiology, Diabetic Neuropathy
| (4)
1. Prolonged hyperglycemia
2. Vascular weakness and insufficiency
3. Nerve infarction
4. Denervation of small foot muscles
108
S/Sx, Diabetic Neuropathy
| (8 symptoms, 7 signs)
_Symptoms_: More commonly LE than UE
1. Stocking glove paresthesia
2. Numbness
3. Pn
4. Dyesthesia (burning)
5. Parathesia
6. Dec vibratory sensation
7. Dec deep tendon reflexes
8. Autonomic complications
9. Bowel/bladder/gastric dysfunction
10. Sexual dysfunction
_Signs_: More commonly LE than UE
1. **Charcot foot c rocker bottom deformity**
2. **Calluses on feet**
3. **Ulcerations in periphery**
4. Toe clawing
5. Autonomic complications
* Postural hypotension
* Cardiac arrhythmias
6. Diminished pedal pulse
7. Gangrenous appendages
109
Differential Dx, Diabetic Neuropathy
| (4)
1. Uremia
2. Megaloblastic anemia
3. Autoimmune/CT disease
4. Hypothyroidism
110
Diagnostic Tests, Diabetic Neuropathy
| (3, 1 c 4 specifics)
1. Usually a clinical dx
2. Nerve conduction studies
3. Labs
* Uremia R/O - BUN/Cr
* Megaloblastic anemia R/O - CBC
* Autoimmune/CT disease R/O - ANA, RF
* Hypothyroidism R/O - Ft4, TSH
111
Medial Tx, Diabetic Neuroapthy
| (7 categories, 1/2/3/3/1/1/3)
1. Maintain tight glucose ctrl
2. Treat neuropathic pn (sharp, stabbing)
* Phenytoin/Dilantin
* Carbamezine/tegretol
3. Treat deep constant aching pn
* Amitriptyline/Elavil
* Gabapentin/Neurontin
* Duloxetine/Cymbalta
4. Treat postural hypotension
* Inc salt intake
* Compression stockings
* Fludrocortisone or Midrodine
5. Podiatry
6. Treat gastroparesis – Metochloraminde/reglan
7. Treat ED – phophodiesterase inhibiters
* Sildenafil/Viagra
* Vardenafil/Levitra
* Taladafil/Cialis
112
Pt Ed/Prevention, Diabetic Neuropathy
Continue to ctrl diabetes after acute situation is ameliorated
113
Define Guillain Barre Syndrome
Demylenation of myelin sheath in muscle fibers
114
Etiology, Guillain Barre Syndrome
| (2, 1 c 3 specifics)
* Most commonly, autoimmune demyelinating polyneuropathy
* **May relate to preceding infection c Campylobacter jejuni**. S/Sx often follow
* Minor infection
* Immunization
* Surgery
115
Pathophysiology, Guillain Barre Syndrome
Demylenation of myelin sheaths in muscle fibers
116
S/Sx, Guillain Barre Syndrome
| (2 symptoms, 6 signs)
_Symptoms_
1. Sensory deficits common but less severe than motor deficits
2. Pn in \>85% pts
_Signs_
1. **Symmetrical extremity weakness beginning distally and extending proximally**
2. **More serious proximal muscle effects than distal muscle effects**
3. **Dec/Absent DTR’s**
4. CNS defects 45-75% of time
5. Sig. autonomic dysfunction in later progression
* Tachycardia
* Arrhythmia
* Labile BP
* Disturbed sweating
* Sphincter disturbance
* Paralytic ileus
6. Death, if respiratory or swallowing muscles effected
117
Differential Dx, Guillain Barre Syndrome
(1)
Diabetic neuropathy
118
Diagnostic Tests, Guillain Barre Syndrome
(2)
1. Nerve conduction study for denervation or axonal loss
2. LP, CSF will reveal
* Elevated PRO
* Normal cell count
119
Surgical Tx, Guillain Barre Syndrome
| (1)
Plasmapheresis
120
Medical Tx, Guillain Barre Syndrome
| (4)
1. Hospitalization in ICU c close respiratory and cardiac monitoring
2. Pick one
* Plasmapheresis by removing responsible proteins
* Speed recovery
* Reduce extent of neuro damage
* IV immunoglobulin
3. Rehab c PT/OT/speech therapy
121
Emergency Tx, Guillain Barre Syndrome
| (1)
Monitor ABC’s upon immediate ICU hospitalization
122
Pt Ed/Prevention, Guillain Barre Syndrome
(2)
*Prognosis is positive*
* Recovery may take several months but is possible
* 20% of pts left c persistent disability
123
Alternate Name, Guillain Barre Syndrome
Acute Idiopathic Polyneuropathy
124
Define Myasthenia Gravis
Degenerative autoimmune neurologic disease affecting ACh receptors
125
Etiology, Myasthenia Gravis
| (3)
1. Insidious onset of autoimmune action
2. Sometimes asst c exacerbating coincidental infection
3. Risk factor = females
126
Pathophysiology, Myasthenia Gravis
| (1 general, 3 cellular level)
* Sporadic but progressive muscle weakness and abnormal fatigability of skeletal muscle (esp facial muscles, 95% of pts have facial weakness)
* Relapses and remissions lasting up to several weeks
* Cell course
1. Antibody destruction of NMJ ACh receptors
2. Block in neuromuscular nervous transmission
3. Weakness
127
S/Sx, Myasthenia Gravis
| (4 symptoms, 5 signs)
_Symptoms_
1. Start day c energy but fatigue significantly throughout day but **improves c rest**
2. **Diplopia**
3. **Difficulty chewing/swallowing**
4. Normal sensation
_Signs_
1. **Ptosis**
2. Respiratory difficulty
3. Limb weakness, especially in proximal muscles
4. Normal DTR’s
5. Slumped head, cannot resist force on head
128
Diagnostic Tests, Myasthenia Gravis
| (3)
1. CXR to R/O coexisting thymoma
2. ACh receptor antibody assay (+80 – 90% pts)
3. **Dx confirmation c improvement by short acting anticholinesterase edrophonium**
129
Medical Tx, Myasthenia Gravis
| (4)
* Cholinesterase inhibitor (pyridostignmine) for transient strength improvement
* If refractory,
* Corticosteroids
* Immunosuppression
* IV IgG
130
Surgical Tx, Myasthenia Gravis
| (2)
1. Thymectomy
2. Plasmapheresis if refractory to thymectomy
131
Define Bell's Palsy
CN VII Palsy
132
Etiology, Bell's Palsy
| (3, 1/2/2)
1. Idiopathic, 60% is right-sided
2. Categoires
* Complete – paralysis of all CN VII muscles
* Incomplete – variable weakness in different CN VII muscles
3. Risk factors
* Pregnancy
* DM
133
Pathophysiology, Bell's Palsy
| (3 points, not process description)
1. Facial paresis of lower motor neuron
2. Inflammation involving facial nerve
3. Theory – reactivation of herpes simplex virus in geniculate ganglion
134
S/Sx, Bell's Palsy
| (3 symptoms, 4 signs)
_Symptoms_
1. Pain around ear (CN VIII nerve involvement)
2. Disturbed taste sensation (Chorda tympani involvement)
3. Hyperacusis (stapedius muscle nerve fiber involvement)
_Signs_
1. Abrupt facial paresis:
* Cannot close eye
* Cannot raise eyebrow
* Cannot smile on affected side
135
Differential Dx, Bell's Palsy
| (6)
1. Stroke
2. Tumor
3. Lyme disease
4. AIDS
5. Sarcoidosis
6. Herpes zoster
136
Diagnostic Tests, Bell's Palsy
| (2, 1 c 4 specifics)
* **Clinical dx**
* Rule out other differential dx if suspected
1. MRI Brain, tumor
2. Lyme titer, Lyme disease
3. CXR/CT chest, sarcoidosis
4. Herpes zoster titer, HZV
137
Medical Tx, Bell's Palsy
| (3)
1. **60% resolve spontaneously in days to months**
2. Corticosteroids shorten course if given within 5 days of s/sx
3. Symptomatic tx
* Eye lubrication
* Eye patch
138
Pt Education/Prevention, Bell's Palsy
| (2, 1 c 4 specifics)
* Most cases make full recovery
* Incomplete recovery more common in the following
1. Pts presenting c severe pn
2. Complete palsy
3. Hyperacusis
4. Advanced age
139
Define Complex Regional Pain Syndrome
Rare disorder of extremities characterized by autonomic and vasomotor instability
140
Etiology, Complex Regional Pain Syndrome
(2)
1. Most cases are preceded by minor trauma to bone, soft tissues, and nerves
2. Most commonly shoulder-hand syndrome, but any nerve can be involved
141
Pathophysiology, Complex Regional Pain Syndrome
(4 steps)
*Findings are not limited to distribution of single peripheral nerve*
1. Original injury initiates pain impulse carried by sensory nerves to CNS
2. Pn impulse triggers impulse in sympathetic NS which returns to original site of injury
3. Sympathetic impulse triggers inflammatory response à vessel spasm that leads to swelling and inc pn
4. Pn triggers another initial response, establishing **cycle**
142
S/Sx, Complex Regioal Pain Syndrome
_Symptoms_ Can progress to chronic condition
* **Diffuse, localized, burning pn** (arm, hand, leg, foot)
_Signs_ Can progress to chronic condition
* **Diffuse swelling of involved extreme**
* **Color/temperature disturbance of limb**
* **Limited ROM**
* Osteoperosis
* Contractures
* Useless claw limb (in progressed conditions)
143
Differntial Dx, Complex Regional Pain Syndrome
(8)
1. CNS dysfunction
2. Radiculopathy
3. Plexopathy
4. Vascular disorder
5. Monomelic amyotrophy
6. Autoimmune/rheumatologic disorder
7. Infection
8. Demylinating disease
144
Dx Tests, Complex Regional Pain Syndrome
(2)
1. **Clinical dx**
2. Bone scan will show inc. uptake in involved extrem
145
Medical Tx, Complex Regional Pain Syndrome
(2 tiers, 1 and 3)
*Treat aggressively!*
* Mild
* NSAIDS
* Severe
* Prednisone x 2 weeks
* Tricyclic antidepressants – nortiptyline
* Anti-convulsants – Gabapentin
146
Pt Ed/Prevention, Complex Regional Pain Syndrome
(2)
* Early mobilization after injury or surgery reduces likelihood of development
* Early tx offers best prognosis for recovery
147
Alternate Name, Complex Regional Pain Syndrome
Reflex Sympathetic Dystrophy
148
Define Bacterial Meningitis
