Neurology Precision & Pearls #1 Flashcards
Describe a tension headache.
What is the treatment for this type (the MC type of primary headache)?
Bilateral, band-like, nonpulsatile steady headache. Worse with stress, fatigue, noise, glare. Not worse with routine activity. No auras.
NSAIDs, local heat
Describe a migraine headache.
Explain what an aura is, what the most common type of aura is, and some things that make migraines worse.
Lateralized, pulsatile headache with nausea/vomiting, photophobia, phonophobia.
Worse with routine activity, alcohol, and hormones.
Auras: focal neurologic symptoms that last < 1 hour. Visual auras are the MC type.
Treatment for migraines (symptomatic AND prophylactic)
Symptomatic (abortive): NSAIDs, Acetominophen, Aspirin. Triptans or Ergotamines.
–Dopamine blockers (Metoclopramide, Promethazine) given with Diphenhydramine to prevent extrapyramidal symptoms. IVF and place patient in a dark/quiet room.
Prophylactic: BB or CCB (first line). TCAs, Anticonvulsants (Valproate, Topiramate), NSAIDs
Explain the MOA of Triptans and some adverse effects of these medications
Triptans, such as Sumatriptan and Zolmiatriptan, are serotonin agonists that cause vasoconstriction and block the pain pathway.
Adverse Effects: chest tightness, nausea, vomiting, malaise
What are cluster headaches? Explain them and what they feel like.
What is it also associated with?
Multiple high intensity headaches with brief duration. Worse at night and with alcohol/stress/foods.
Unilateral, severe periorbital or temporal pain lasting < 2 hours and then resolving. Nasal congestion, rhinorrhea, conjunctivitis.
Horner’s Syndrome: miosis, ptosis, anhidrosis.
Treatment for cluster headaches
What can be given as prophylaxis (specific medication)
100% oxygen
Verapamil for prophylaxis
What imaging, if any, is done for a headache?
CT is first line
If negative, then an LP looking for blood or xanthochromia (SAH)
4-vessel angiography after confirmed SAH
What is the hallmark exam finding of a patient with a postdural puncture headache?
Postural headache that worsens with sitting/standing and improves when supine
Treatment for a postdural puncture headache
Bed rest, hydration, caffeine
Epidural blood patch (headache gone in seconds) if conservative management fails
A subarachnoid hemorrhage is MC due to what? This occurs at what artery?
Name two significant risk factors for a SAH.
a ruptured berry aneurysm at the anterior communicating artery
Smoking and hypertension
Explain the symptoms of a subarachnoid hemorrhage.
What is Kernig Sign?
What is Brudzinski Sign?
Sudden, intense thunderclap headache that is unilateral and described as the “worst headache of my life.”
The patient may also have meningeal signs: nuchal rigidity, etc.
Kernig Sign: extension of knee = neck pain.
Brudzinski Sign: hips/knees flex when neck flexes
Imaging and diagnostics that are done for a subarachnoid hemorrhage?
CT scan without contrast (initial)
If CT negative, do LP to look for blood or xanthochromia (yellow to pink CSF due to breakdown of RBC’s)
Treatment for a SAH
-Supportive: bed rest, stool softeners
-Nimodipine: reduces cerebral vasospasms
-Nicardipine, Labetolol: lower BP
-Decrease ICP: Mannitol, head elevation
-Surgical: endovascular coiling or clipping to prevent rebleeding
Ischemic strokes are the MC type of stroke. What is the MC etiology for this type of stroke? Name the biggest risk factors.
Embolic cause is the MC cause
Hypertension (biggest RF), smoking, makes, DM, A-fib, family history
What are some things you should look for on exam and in the history of a patient with a suspected stroke?
Look for hemiparesis, hemiplegia, gait ataxia, heck vision, check for hemianopsia, urinary incontinence, vertigo, nystagmus, diplopia, focal neuro symptoms, meningeal symptoms
-Neglect to one side of the body, impaired speech, personality changes, confusion, hallucinations, double vision, etc.
With a stroke, the patient can have anterior circulation symptoms or posterior circulation symptoms. Describe them both.
Anterior: contralateral arm/leg weakness and sensory deficits. Contralateral homonymous hemianopsia. Facial drooping, slurred speech, etc.
Posterior (V’s): vertigo, visual changes, vomiting. Nystagmus, nausea, coma.
What’s the best initial diagnostic to rule out hemorrhagic cause of stroke?
However, what is the most accurate diagnostic?
CT head without contrast (may be negative in the first 6-24 hours)
MRI brain = most accurate
Immediate management of a patient with a stroke
-If within 3 hours of symptom onset: Alteplase (if no bleeding disorder)
-Mechanical thrombectomy within 24 hours of symptom onset and if anterior circulation affected.
However, if the symptom onset of a stroke is 3-4.5 hours ago, what is the treatment?
Aspirin and long-term management
Long-term management: Antiplatelet therapy (Aspirin, Clopidogrel, Dipyridamole)
-Also initiate statin therapy regardless of LDL level
The Middle Cerebral Artery is the MC artery involved in a stroke.
Name the symptoms of this artery being involved.
-Contralateral sensory/motor deficits greater in the face and arm
-Involves lower half of face (can raise forehead)
-Contralateral homonymous hemianopsia.
-Gaze preference toward side of lesion
-Dominant hemisphere (left MC): aphasia (Broca - expressive or Wernicke- sensory), math comprehension
-Nondominant hemisphere (right MC): flat affect, impulsivity, impaired judgment, no insight, neglect of other side
With an anterior cerebral artery (ACA) stroke, what symptoms would you expect?
-Contralateral sensory/motor deficits greater in the leg/foot.
-Face is usually spared.
-urinary incontinence
-Contralateral homonymous hemianopsia
-Personality and cognitive deficits
With a posterior cerebral artery (PCA) stroke, what symptoms would you expect?
Think of V’s for vertebral
-Vertigo with nystagmus
-Vomiting
-Vision changes
With a vertebrobasillar artery stroke, what symptoms would you expect?
-“Crossed symptoms”
–Ipsilateral cranial nerve deficits with contralateral motor/sensory deficits
–Diplopia, dizziness, vomiting, ataxia
–Asymmetric but bilateral deficits!!!!
Remember, one side face, other side body.
What’s the pneumonic to remember the order of the cranial nerves?
Name them.
Only one of the two athletes felt very good victorious and healthy
I (Olfactory), II (Optic), III (Oculomotor), IV (Trochlear), V (Trigeminal), VI (Abducens), VII (Facial), VIII (Vestibulocochlear), IX (Glossopharyngeal), X (Vagus), XI (Accessory), XII (Hypoglossal)
What is the pneumonic to remember motor/sensory in the cranial nerves?
Describe the sensory and motor functions of each nerve.
Some say money matters but my brother says big butts matter more
-Olfactory: smell
-Optic: pupillary light reflex, VA, VF
-Oculomotor: inferior rectus muscle
-Trochlear: superior oblique rectus
-Trigeminal: muscles of mastication, light touch to three divisions of nerve
-Abducens: lateral rectus muscle
-Facial: muscles of facial expression, taste (anterior 2/3 of tongue) and external ear
-Vestibulocochlear: hearing, balance, proprioception
-Glossopharyngeal: swallow/gag reflex, taste (posterior 1/3 of tongue)
-Vagus: voice/gag reflex, relays to brain about organs
-Accessory: shoulder shrug, turn head
-Hypoglossal: tongue (inspect for asymmetry)
