Neuros

Question 1

Vertigo

Answer 1

DDx Peripheral (vestibular apparatus, VIII)
Meta]
Drugs (Ototoxicity)

Org(Otos)]

• *BPPV** (otoliths) – brief (<1min) intermittent episodes that change with head position, positive Dix-Hallpike
• *Meniere** (increased endolymph) – attacks of vertigo preceded or accompanied by reduced hearing, tinnitus, and pressure or sense of fullness in ear, followed by residual hearning loss
• *Otosclerosis**

Infect]
Acute vestibular neuritis (viral) – develops over hours and takes days/weeks to resolve, viral etiology
Acute labyrithitis (viral, bacterial, drugs) – tinnitus and auditory symptoms, ENT infection, in extreme cases can be febrile or toxic​
Ramsay Hunt syndrome (herpes zoster oticus – deafness, facial nerve palsy, vessicles in the external auditory canal

Struct]

• *Perilymphatic fistula** – activities that can cause barotrauma eg. heavy lifiting
• *Cholesteatoma**

DDx Central (brain stem and cerebellum)
Haim]
Cerebeller CVA/TIA – constant vertigo (VIII) WITH focal deficits – diplopia (III, IV, VI) - double vision or abnormal EOM, dysarthia (VII) - speaking or facial asymetries, dysphagia (IX, X) - swallowing, dysmetria (cerebeller) - truncal/appendicular ataxia, weakness or sensory loss – any findings from descending or ascending tracts running through the brainstem, nausea, vomiting

Org(Cephalo)]

• *Migraine – POUND**
• *Cerebellopontine angle tumour**

ID]
men>women

HPI]
Peripheral
Drugs (Ototoxocity) – Aminoglycocides (Gentamycin)
BPPV – brief (<1min), intermittent, changes with head position
Menieres – tinnitus, reduced hearing, sense of fullness
Otosclerosis – age, arthritis
Acute vestibular neuritis (viral) – develops over hours and takes days/weeks to resolve
Acute labrinthitis (viral, bacterial, drugs) – tinnitus, ENT infection
Ramsay Hunt syndrome (herpes zoster oticus – deafness, facial nerve palsy
Perilymphatic fistula – activities that can cause barotrauma eg. heavy lifting
Cholesteatoma

• *Central**
• *CVA/TIA** – constant vertigo, neuro deficits – double vision or abnormal EOM, speaking or facial asymetries, trouble swallowing, walking, weakness or sensory loss, nausea, vomiting
• *Migraine –** POUND
• *Cerebellopontine angle tumour**

PMHx]
HTN (CVA)
CAD (CVA)
DM (CVA, disequilibrium)
Afib (CVA)

Meds]
HTN (dysequilibrium)
Loop directics (dysequilibrium
Baclofin (dysequilibirum)
Anticholinergic drugs (dysequilibrium)
ASA (ototoxicity)
Aminoglycosides (ototoxicity)
Platinum based chemotherapy drugs (ototoxicity)
Anti-coagulants (CVA)

SHx]
Smoking (CVA)

FHx]
TIA/CVA

O/E]
General – ALOC
Neuros (general) – motor or sensory focal deficits
Neuros (CN) – unequal/fixed pupils (CVA), abnormal EOM (CVA), vertical nystagmus (CVA, drugs), direction changing nystagmus (CVA), facial asymmetries (CVA), abnormal gag reflex
Neuros (cerebeller) – trucal ataxia, appendicular ataxia – dysmetria (finger to nose), dysdiadochokinesia,

Note: Balance depends on central (visual) and peripheral (vestibular system and proprioception).Inperipherial ataxia,balance is good with eyes open and then gets worse when eyes are closed.Proprioceptive ataxiaandvestibular ataxia are different forms of ataxia that have different etiologies. In vestibular ataxia the patient will lose balance to the side of the affected vestibule. In proprioceptive ataxia there is usually degenration of nerves such as in diabetes.
In cerebeller ataxia, balance is compromised with eyes open AND closed.

Romberg test and tandem Romberg test can be used to look for peripheral ataxia where the patient loses balance when the eyes are closed. In the tandem Romberg test, the patient will lose balance toward the affected vestibular side.

Note: Nystagmus that is always the same direction with patients gaze is vestibular. If the lesion is peripheral, the fast phase is toward the good side, and away from the affected side. The affected side is the slow phase as this side is not functioning properly.

**Note: HINTS exam is used to differentiate between vestibular neuritis (peripheral) vs stroke (central). Performed on patients who have hours or days of CONTINOUS ONGOING vertigo and spontaneous nystagmus.

HI - Head Impulse - normal in stroke (central), abnormal in vestibular neuritis (peripheral)

N - Nystagmus (fast beat) - direction changing in stoke, unidirectional in horizontal plan in vestibular neuritis, often nystagmus resolves when HI remains but nystagmus can be brought on by headshake, called headshake induced nystagmus.
In periperal nystagmus the fast beat points toward the good ear, the slow beat is toward the affected ear.

TS - Test of skew - vertical corrective saccade of eye when uncovered, abnormal in central finding and normal in vestibular neuritis

Dix-Halpike (BPPV) - start with pateint seated and head turned 45 degress to side being tested, quickly lower to supine position with head angled backward (head in extension) off bed, positive when there is a 5-10 second delay and then there is rotational or upbeating/downbeating nystagmus

INVESTIGATIO]
L(H)/Haim] WBC (acute labrythitis, non specific dizzyness)
L(H)/Meta] SMA7 (non specific dizzyness, presyncope)
L(H)/Hor] TSH

I]

• *ECG** (cardiac causes)
• *CT** (acute labrythitis, trauma) – only 10% sensitive for posterior fossa strokes
• *MRI** – more specific than CT but cannot exclude a stroke diagnosis particularly in the first 24-48 hours

RECIPERE]
BPPV
NP/Pro] Epley maneuver
P/Consult] ENT outpatient

Meneires
NP/Nut] Dietary restrictions – salt, caffeine, tobacco
P/Naus, Vom] {Serc} Betahistine 8-16mg PO TID
Note: Betahistine is an antagonist of the H3 receptor and an agonist of H1 receptor, therby dilating blood vessels in the inner ear and helping to reverse the endolymph hydrops. There is also increased serotonin in the brainstem and inhibiting the vestubular nuclei.
P/Org(Nephros)] Lasix
P/Consult] ENT outpatient consult for glycerol testing and vestibular evoked myogenic potentials

Acute vestibular neuritis
P/Naus, Vom]
{Antivert} Meclizine 25-50mg PO
OR {Gravol} 50mg PO
Note: Antivert is an H1 antagonist which depresses labyrith excitibility and vestibular stimulation.
P/Consult] ENT outpatient consult

Acute bacterial labyrinthitis
P/Infect] IV Abx
P/Consult] ENT consult

Ramsay Hunt (Herpes zoster oticus)
P/Infect] Valacyclovir 1g PO TID x7days

CVA/TIA
P/Neuros] tPa if within 4 hours of symptoms
P/Consult] Neurology/Neurosurgery

Question 2

Headache

Answer 2

DDx]
Primary
Org(Cephalos)]
Tension – bilateral,“band like”, associted with cause such as sleep, stress, depression
Migraine – unilateral, pulsating, photophobia, phonophobia, auras, worse with physical activity, gradual onset 4-72 hours, nausea, vomiting, neurological deficits – aphasia, hemiparesthesias, hemiparesis
POUND – Pulsatile, One day duration 4-72 hours, Unilateral, Nausea/Vomiting, Disabling
Cluster – unilateral orbital, supraorbital or temporal lasting 15-180 minutes, myosis, ptosis, lacrimation, nasal congestion, rhinorrhea, conjunctival injection, typically middle aged men, precipated by exertion/stress
Medication overuse syndrome – on medication for headaches such as opioids, caffeine, OTC meds

DDx]
Secondary – NEW ONSET
Haim]
Central Venous Thrombus – seizure, stroke, no characteristic history, papilledema, hypercoagulable state such as thrombophilia, pregnancy, medications (OCP), cancer, inflammatory disorders, waxing and waning neurological findings, complications
include ICH -> coma -> death

Meta]
CO poisioning – nausea, vomiting, syncope, exposure, multiple patients, cherry red mucous membranes, cerebeller ataxia

Org(Cephalos)]
IIH (Ideopathic Intracranial Hypertension, Pseudotumour cerebri) – young female of child bearing age not necessarily obese, visual loss/disturbance, headache xweeks/months, N, V, OCP, Vitamen A, tetracycline, papilledema with normal LOC
Diagnostic criteria:
1. Signs of elevated ICP
2. Non-focal neuro exam except abducens nerve paresis
3. Normal neuroimagingstudy CT w contrast
4. Increased CSF pressure
5. No other cause of increased ICP (tumour, encephalitis)
Sinusitis – anterior face (maxillary sinus), forehead (frontal sinus), behind eyes (ethmoid sinus), diffuse (sphenoid)
Diagnostic criteria (4 or more):
1. colored nasal discharge
2. visible purulent nasal discharge
3. maxillary toothache
4. poor response to decongestants
5. abnormal transillumination

Org(Ophthalamos)]
Acute glaucoma – eye pain, blurred vision, nausea, vomiting, mid-dilated non reactive pupil, elevated IOP>20

Org(Vasculo)]
SAH – “thunderclap” sudden onset with maximal intensity, WHOL, precipated by exertion – such as weight lifting, sexual activity, defactation, coughing- - nausea, vomiting, syncope, photophobia, neurological deficits, meningismus, ALOC
SDH (Subdural hematoma) – history of trauma, elderly, alcoholics, on anticoagulants, ALOC
CAD (Cervical Artery Dissection) (carotid, vertebral) – unilateral anterior headache (ICA), posterior neck pain (VA), majory trauma (penetrating or blunt), minor trauma (rotational neck movment (yoga), couging, whiplash, chiropractor), stroke symptoms, age<40
Internal carotid artery – MCA (face, arm), ACA (leg, arm)
Vetebral artery – posterior fossa symptoms (vertigo, ataxia, dysmetria)
Horners syndrome – miosis, ptosis, anhydrosis

Infla]
Temporal (Giant Cell) arteritis – unilateral, throbbing, tender temporal artery, jaw claudication, vision changes, age>50 and more commonly women
Diagnostic criteria (3/5):
1. New onset localized headache
2. Age>50
3. temperal arter tender/decreased pulse
4. ESR>50
5. Biopsy – vasculitis, granuloma

Oncos]
​Brain Mass/Lesion – progressive, morning, exertional, N, V, new onset seizure, papilledema, focal neurological deficits, aphasia

Infect]
Meningitis – headache, traid (fever, nuchal rigidity, AMS (Altered Mental Status)) - absence of all three rules out meningitis, photophobia, nausea, vomiting, lethargy, neurological deficits
jolt accentuation – turn head right and left, 2-3 rotations per second, if the headache gets worse the test is positive, if the headache does not get worse the test is negative - absence of jolt accentuation has a sensitivity of 100% for ruling out meningitis
Kernig/Brudzinski – low sensitivity (cant rule out), high specificity (can rule in)
Note: Bacteria – neisseria meningitidis, streptococcus pneumoniae, haemophilus influenza, listeria monocytogenes. Viral – enteroviruses (85%), herpes viruses

• *HPI]**
• *Primary**
• *Tension – bilateral, “band-like”,** associated stress, sleep, depression
• *Migraine – unilateral, aura, photophobia, phonophobia, worse with activity**
• *POUND – Pulsatile, One day onset, Unilateral, Nausa/Vomiting, Disabling**
• *Cluster – unilateral orbital, lacrimation, congestion, lasting 15 min to 2 hours, middle aged men, precipatated by stress/exertion**
• *Medication Overuse** – on medication for headaches, opioids, OTC

Secondary – NEW ONSET
CVT – HA->seizure->stroke, hypercoaguable state such as pregnancy, thrombophillia, OCP, cancer
CO poisioning – nausea, vomiting, group exposure
IIH -- young female of child bearing age not necessarily obese, visual loss/disturbances
Diagnostic criteria:
1. Signs of elevated ICP
2. Non focal neuro exam except abducens nerve paresis
3. Normal neuroimagingstudy CT w contrast
4. Increased CSF pressure
5. No other cause of increased ICP (tumour, encephalitis)
Sinusitis – tenderness over sinuses
Diagnostic criteria (4 or more):
1. colored nasal discharge
2. visible purulent nasal discharge
3. maxillary toothache
4. poor response to decongestants
5. abnormal transillumination
Acute glaucoma – eye pain, blurred vision, mid-dilated non reactive pupil, elevated IOP>20
SAH – “thunderclap” (sudden onset, maximal onset, differnt from other HAs), WHOL, on exertion, neck pain, nausea, vomiting
SDH–history of trauma, elderly, alcoholics, anticoagulation
CAD – major or minor trauma (yoga, chiropractor), unilateral anterior headache (ICAD), posterior neck pain (VCAD), age <40
Temporal (Giant cell) arteritis – throbbing, unilateral, jaw claudication, age>50, women
Diagnostic criteria (3/5):
1. New onset localized headache
2. Age>50
3. temperal arter tender/decreased pulse
4. ESR>50
5. Biopsy – vasculitis, granuloma
Brain mass/lesion – progressive, morning, exertional, nausea, vomiting
Meningitis – triad (fever, nuchal rigidity, AMS) – absence of all 3 rules out, photophobia, nausea

PMHx]
HTN (SAH)
Cancer (CVT)
Inflammatory disease (CVT)
Immunocopromised ie. HIV (Meningitis, Brain mass lesion)

Meds]
OCP (CVT, IIH)
Tetracycline (IIH)
Anticoagulants (SDH)

SHx]
EtOH (SAH, SDH)
Smoking (SAH)
Living conditions – college dorms, military barracks (Meningitis)
Pregnant (CVT)

• *O/E]** HTN (SAH), febrile (meningitis) GCS (SAH, SDH)
• *General** – ALOC (SAH, SDH, meningitis), jolt accentuation test (meningitis), neurological deficits – brain mass/lesion, migraine, meningitis, CVT, CAD
• *Neuros (general)** – truncal ataxia (CAD/VA), hemiparesis/paraesthesias/decreased power to arms or legs, spasticity (increased tone), increased reflexes (migraine, CAD/ACA, CAD/MCA, CVT)
• *Neuros (CN)** – visual disturbances (migraine, IIH, temporal arteritis), blurred vision (glaucoma), mid-dilated pupil (glaucoma), papilledema (CVT, brain mass/lesion, IIH, SAH), photophobia (migraine, meningitis), facial asymmetries/paraesthesias (CAD/MCA)
• *Neuros (Cerebeller)** – dysmetria (VA), dysdiadochokinesia (VA)
• *HEENT** – elevated IOP>20 (acute glaucoma)

POCUS – papilledema (CVT, brain mass/lesion, IIH, SAH) - 3mm down from the retina and >5mm across the optic nerve sheath indicates papilledema, or crescent sign

INVESTIGATIO]
L(H)/Haim] WBC (meningitis), COHb level (CO poisoning)
L(H)/Meta] SMA7
L(H)/Infla] ESR (temporal arteritis), CRP

L(I)/Haim] Blood C&S (meningitis)
L(I)/CSF]
SAH
<12h Xanthochromia may/may not be present, large RBC should be present
>12h Xanthochromia is HIGHLY suggestive, large RBC +/- present
12h-2w Xanthochromia or RBC may be absent

Meningitis
Tube 1&4 - cell count and differential
Tube 2 - glucose and protein
Tube 3 - gram stain, culture, HSV, PCR
Other – india ink (cryptococcus), acid fast for mycobacteria
Bacteria meningitis (protein high, glucose low) – gram stain positive , WBC>2000, neutrophils>80%, protein>200 (high), glucose<40 (reference or low)

IIH
Increased opening pressure otherwise normal

I]

• *CT wo contrast (SAH)** - within 6hours 100% sensitivity and 100% specificitiy (misses 2% within 12 hours and 7% within 24hours) CT scan within 6 hours should NOT need an LP to rule out SAH
• *CT wo contrast (CVT)** - normal in 30% of cases, dense triangle sign (thrombosed sup sag sinus posteriorly), cord sign (thrombosed cortical vein), bilateral edema/ICH
• *CT w contrast (brain mass/lesion, IIH, HIV with new HA)** - normal in IIH
• *CT w contrast venogram (CVT)** – empty delta sign (flow defect in sup sag sinus)
• *CT angiography (CAD)**
• *MRI w venogram (CVT)** – study of choice for CVT
• *MRI/MRA (CAD, IIH)**
• *Angiography (CAD)**

B]
Temporal artery (TA)

RECIPERE]
PRIMARY
Tension
P/Poin] Tylenol 975mg PO x1 (max 3000mg) OR Toradol 30mg IM x1

Migraine
NP/C] PIV, NS Bolus
P/Poin] {Toradol} Ketorolac 30mg IV/IM x1
P/Poin,N,V] {Maxeran} Metoclopramide 10mg IV/IM x1
Note: Dopamine antagonists have 80-90% effectiveness when given IV, 60-80% when given IM, and 40% when given PO.
P/Org(Neuros)] Sumatriptan 50mg PO x1 (early in migraine when aura is present)
P/Infla] {Decadron} Dexamethasone 10mg IV/IM x1 (if migraine >72hours)

Cluster
NP/A,B] High flow O2 3-10L NP
Intranasal lidocaine

SECONDARY – NEW ONSET
CVT
P/Haim] Heparin 10,000U IV now, 50-70U/kg (5000-10000U) IV q4-6h
Consult] Neurosurgery

CO Poinsoning
NP/A,B] 100% NRM

IIH
P/Org(Cephalos)] {Diamox} Acetazolamide 1-4g/day divided q8-12h
Surg/Consult] Neurology Consult
If vision loss then ONSF (Optic Nerve Sheath Fenestration) and VP shunt

Acute Glaucoma
P/Ophthalamos]
0.5% timolol maleate {Timoptic} one drop
1% apraclonidine {Lopidine} one drop
2% pilocarpine {Isopto Carpine}
{Diamox} Acetazolamide 500mg IV then 500mg PO

SAH (for increased ICP)
NP/A,B] SpO2>94%
NP/C] PIV, NS fluids for maintanence
NP/Mon] cardiac monitor, BP, SpO2
NP/Nut] NPO
NP/Pro]
Elevate the head of the bed 30 degrees
Hyperventilation to PaCO2 25-30mmHg

P/Poin] Morphine 4-8mg IV q5-15min
P/N,V] {Zofran} 4mg IV/SL
P/Haim]
Vitamin K 10mg slow influsion if anticoagulation of Warfarin
Protamine sulfate if anticoagulation on Heparin
P/Meta] Insulin for hyperglycemia
P/Neuros]
Propofol, Etomidate, Midazolam (sedation if unstable)
{Dilantin} Phenytoin (for seizures)
P/Org(Cephalos)] Mannitol 1g/kg IV bolus, then 0.25 to 0.5 g/kg q6h to plasma Osm 300-310
P/Org(Vasculos)] IF SBP>200 or MAP>150 DO NOT overcorrect ​BP
Labetalol 10-20mg IV, over 1-2 min THEN 2mg/min influsion titrated to MAP reduction of 10% to 20%
{Nimotop} Nimodipine 60mg PO q4h (CCB for vasospasm)
P/Consult] Neurosurg consult

SDH
I] Follow up CT 6-8 hours
Surg/Consult] Burr hole, craniotomy (hemotoma thickness ≥10 mm or midline shift ≥5 mm on initial brain scan)

CAD
P/Haim] Aspirin 325mg PO
P/Consult] Neurosurgery/Vascular consult

Temporal giant cell arteritis
P/Infla]
Prednisone 50mg PO with no vision loss OR if vision loss
{Salu-Medrol} Methylprednisolone 1000mg IV OD x days
P/Consult] Vascular surgery

Brain mass/lesion
P/Poin] {Tylenol} 625mg PO x1
P/N,V] {Zofran} 4mg SL/IV
P/Infla] {Decadron} Dexamethasone 10mg IV x1 then 4mg IV/IM q6h

Meningitis
P/Infect]
Vancomycin 1gm IV AND
Ceftriaxone 2gm IV AND
Ampicillin 2gm IV (age>50) for H. influenza and Listeria monocytogenes
P/Infla] Dexamethasone 10mg IV, 15 min before Abx has proven to be helpful in adults

Question 3

Stroke/TIA

Question 4

Status Epilepticus

Answer 4

• *Etiology]**
• *Generalized** – whole brain – LOC
  1. Tonic-clonic (grand mal)
  2. Absence (petit mal)
• *Partial** – localized but can generalize
  1. Simple partial (no LOC)
  2. Complex partial (impaired consciousness)
  3. Partial with secondary generalization

HPI]
Generalized
Tonic-clonic – abrupt LOC, tonus/clonus,lasting 60-90 seconds,post-ictal confusion and fatigue that can last for several hours, apnea, cyanosis, urinary incontinence, vomiting, followed by faccidity,
Absence – brief lasting a few second with apparent LOC, patients appear confused and withdrawn and do not respond to voice or stimulation, NO post-ictal
Partial
Simple partial– remain localized withno LOC
Complex partial – automatisms - repetitive purposelss movements like lip smacking

Status epilepticus – continuous seizure >5min
RECIPERE]
NP/A,B] O2, maintain airway protection
NP/C] 2 PIV
NP/Mon] cardiac, BP, SpO2

P/Meta]
D50W 50mL (50% dextrose in Water) IV, IF BG<3.3
Thiamine 100mg IV
P/Org(Neuros)]
Lorazepam 0.1mg/kg or 4mg IV at 2mg/min repeat x1 if necessary
Note: If no IV access use Lorazepam IM
If still seizing THEN {Dilantin} Phenytoin 20mg/kg at 25mg/min
If still seizing THEN Propofol or Midazolam
Note: If no IV access use Midazolam 10mg (>40kg) IM