Week 3: Neuro Flashcards
Migraine: Presentation
Pulsatile, unilateral
With or without aura
N/V, visual changes, photophobia, phonophobia
repeated attacks lasting 4-72 hours
Tension headaches: Presentation
Persistent for weeks- months
Band squeezing
Cluster headaches: Presentation
pain behind the eye
Sinus headaches: Clinical presentation
Worsens with changes in atmospheric pressure
Pain behind the forehead/cheekbones
Headache red flags
Interrupts sleep Awakens patient New onset > 50 y.o or < 5 y.o Thunderclap Focal neuro signs Fever and headache (meningitis) First/worst headache of life Change in mental status Papilledema Neck stiffness Retractable vomiting Headache that increases in frequency and severity over a period of several weeks
What are the headache screening questions?
How often do you get severe HA (difficulty to function)
How often do you get mild HA?
How often do you take pain relievers for HA?
Has there been any recent change in your HA?
Imaging criteria for headaches
Worst headache of their life
Unexplained abnormal exam finding w/ non-acute HA pattern
Recent change in pattern, frequency, severity
Progressive worsening despite appropriate tx
Onset w/ exertion, cough or sexual activity
Onset after age 40
Thunderclap headache
What is abortive vs. preventative treatment for migraines?
Preventative - Anticonvulsants (Topamax) - Ca channel blocker/Beta Blocker - TCA or SSRI (if sleep interrupted) Abortive - Tylenol, Excedrin, NSAIDS - Triptans
What are the types of concussions?
Simple: sx resolve in 7-10 days w/o complication
Complex: prolonged healing beyond 10 days; sx may include those that recur w/ exertion; may have prolonged impairment of cognitive function, more common in repeat concussions
Second-impact syndrome: pt sustains second head injury before sx from the first are resolved; can cause cerebral edema and herniation, possibly death
Repetitive injury syndrome: sustains multiple concussions even when sx of prior concussions have resolved - may lead to long term neuro and functional
deficits
Post-concussive syndrome: sequela of minor head injury
Concussion red flags for ED referral
Weakness, numbness, decreased coordination Worsening HA Repeated N/V Slurred speech Anisocoria Seizures Inability to wake or seem very drowsy Increasing confusion, agitation, restlessness Focal neuro signs Can't recognize people or places Neck pain/nuchal rigidity Unusual behavior changes Any LOC esp if for 30 seconds +
When is it ok to dc a child w/ head injury home?
No loss of consciousness
OR
Loss of consciousness < 5 minutes and normal neuro exam, no s/s basilar fracture or increased ICP, AND NORMAL CT
Immediate referral for head injuries + ___
alteration in LOC, paralysis, paresthesia, rhinorrhea (glucose + on dipstick), racoon sign, battle sign, otorrhea,
Bell’s Palsy: Patho & causative agent
P: Acute paralysis of the 7th CN
C: Most commonly caused by HSV; other: CMV, EBV, adenovirus, rubella, HiB, coxsackie, pregnancy
Bell’s Palsy: Presentation
Acute unilateral upper and lower facial weakness or paralysis of CNVII with onset less than 72 hours and unknown etiology o Weakness of the facial muscles o Hyperacusis o Posterior auricular pain o Decreased tearing o Incomplete eyelid closure o Taste disturbances o Otalgia
What is the grading system for Bell’s Palsy?
House & Brackmann (Grade I no paralysis - VI full paralysis)
What is a distinguishing feature of Ramsey Hunt Syndrome?
Rash/vesicles present
What is crucial to r/o when assessing for Bell’s Palsy?
STROKE
What else might be important to consider in dx for Bell’s Palsy?
Lyme titer
MRI
EEG
Bell’s Palsy: Management
Protect eye due to incomplete lid closure, keep moist
Corticosteroids w/in 72 hours of onset
Antivirals can be considered (acyclovir, valacyclovir)
What are characteristics of an epileptic seizure?
LOC w/ generalized motor activity Eyes open Mouth open Tongue bite on the lateral edges No response to painful stimuli Episode short lived
What are characteristics of a NON-epileptic seizure?
Preservation of consciousness eyes closed mouth closed tongue bite on the tip of the tongue normal response to painful stimuli wax and wane for hours
What are the characteristics of West’s Syndrome?
Dramatic rapid tonic contract of the trunk and limbs
Appears in 1st yr of life and diminish and disappear by 4-5
Infantile spasms + EEG pattern of hypoarrhythmia and developmental delay
What are other seizure disorders that can occur in neonates?
Benign familial neonatal seizures
Early myoclonic encephalopathy
Ohtahara syndrome
Migrating partial seizures of infancy
What are some seizure disorders that can occur in infants?
Aicardi's syndrome Benign myoclonic epilepsy of infancy Benign infantile seizures Dravet syndrome West's syndrome
What are some seizure disorders that can occur in children?
Benign Rolandic epilepsy Lennox-gastaut syndrome Landau-kleffner syndrome Childhood absence epilepsy Progressive myoclonic
What are some seizure disorders that can occur in adolescents?
Idiopathic generalized epilepsies
Juvenile myoclonic epilepsy
Reflex epilepsies
What are characteristics of Lennox-gastaut syndrome?
Multiple seizure types: tonic and atonic seizures, may also include absence and myoclonic seizures and non-convulsive SE
Developmental delay or regression w/ or w/o other neuro abnormalities
What are the characteristics of childhood absence epilepsy?
- 8% of epilepsy in school aged children
- Girls are 60-78%
- Peak incidence 6-7 yo
- Occurs in developmentally normal children
- Brief seizures; misdiagnosed with ADHD
- Occurs frequently - 10-100 times per day
- May see eye fluttering, eyes rolling upwards, lip smacking, autonomic sx (flushing, tachycardia)
What is the general approach to management of new-onset seizure disorder?
Referral to neurology and can monitor once treatment initiated
What is an important consideration for female patients with seizure disorders?
- OCP needs to contain at least 50mcg of estrogen to overcome the interaction with AEDs
- Decreased efficacy of morning after pill
- Folate may need to be increased as AED can effect absorption
- Refer any woman who is considering pregnancy on AEDs
MS: clinical presentation
visual disturbances, weakness of the limbs, facial paralysis, vertigo, coordination issues, tremors, pain w/ movement, bowel & bladder dysfunction
MS: what patient population does it more frequently affect?
women between 20-50 yo
MS: management?
MRI - neuro and MS specialist referral for initial evaluation and can manage treatment plan from there
