ITE Review: Must Know Neuro
Stroke:
-ischemic vs. embolic vs hemorrhagic
-Hx of TIA (30-50% will have stroke in 5 years)
-Carotid Bruit- greater than 70% increases incidence
Mimic strokes
-seizure (todd’s paralysis), migraine, tox/metabolic
Ischemic stroke
-MCA: most common site, aphasia if left sided, upper ext. more severe
-Anterior: sensorimotor greater in LE, loss of frontal lobe control
-Posterior: CN III, memory, supplies occipital cortex
-Vertebrobasilar: cerebellar signs, pain and temp deficits
-Basilar: locked in syndrome
-Lacunar: can affect both ACA and PCA, can be….
-pure motor
-pure sensory
-clumsy hand-dysarthria
-leg paresis and ataxia
Hemorrhagic Syndromes
SAH- nontraumatic
-35-65 women (<40 male predominance)
-from rupture of saccular (berry) aneurysm
-sudden onset HA (unusual or thunderclap)
-CT most sensitive in the 1st 12 hours, 5% have neg head CT (ie do LP)
-LP findings: RBC count that does not decrease, xanthochromia (can take 12
hrs to develop)
-angiography (CTA) not routine
HTN ICH
-Putamen most common: looks like MCA with decreased consciousness
-Cerebellar: catch it early as treatable with surgical decompression
-Thalamic: sensory > motor
-Pontine: occipital HA with rapid progression to coma (poor prognosis)
Treatment of Stroke:
-time sensitive TPA, know it!
-no TPA, give ASA within 48 hours
-HTN in ischemia, don’t treat unless SBP >185 or DBP >110
-labetalol (or nicardipine)
-no Nitroprusside (or hydralazine), increase ischemia
-HTN in hemorrhage- unclear goal BP, but treat
Seizures:
-incidence 1-2% population
-etiology: primary vs secondary
-primary: epilepsy (usual onset 10-20 years)
-secondary: intracranial (mass, abscess, trauma) extracranial (tox, uremic)
Partial
-simple: focal and no loss of consciousness
-complex: focal with impaired consciousness
Generalized
-non-convulsive: absence (brief, think school aged child)
-convulsive: tonic-clonic, grand mal
Todd’s Paralysis
-focal paralysis following seizure
-usually lasts 1-2 hours (can last 1-2 days)
Seizure vs. Syncope
-no warning vs prodrome of darkened vision/nausea
-tonic-clonic activity vs. brief clonic movements
-prolonged postictal vs no postictal
Work up First Time Seizure
-glucose and NA
-possible tox/ETOH, LP, CXR (aspiration)
-CT head if…..
-focal deficit, HA, head injury, status, prolonged postictal
-high risk for mass lesion (HIV)
Status Epilepticus
-persist greater than 5 minutes or repetitive without return to baseline
-mortality can be as high as 30%
Adult Treatment
-thiamine and glucose (if low or suspect ETOH abuse)
-magnesium for ecclampsia
-pyridoxine for INH OD (refractory to all other treatment)
-Benzos -> phenytoin/fosphenytoin -> phenobarb -> barb coma
(clinically keppra in there with Dilantin)
Pediatric Treatment
-glucose, calcium for neonates
-benzos -> fosphenytoin -> phenobarb
-rapid Dilantin infusion: hypotension and dysrhythmias
Peripheral Neuropathies
-both motor and sensory deficit
-impairment symmetrical and greater distal than proximal
-Diphtheria: acutely ill, membrane pharyngitis, motor
-Tetanus: trismus, tetany, twitching, tightness with increased sympathetic
-Guillain-Barre – preceding viral illness, increased CSF protein
-Tick Paralysis- looks like GB, search for tick
Disorders of the Neuromuscular Junction
Myasthenia Gravis
-autoimmune that destroys acetylcholine receptors
-proximal muscle weakness
-exacerbated by activity
-ptosis, diplopia and blurred vision, most common initial symptoms
-diagnose with edrophonium test or electromyogram
-Myasthenic crisis
-undiagnosed or untreated
-severe weakness, respiratory compromise
-edrophonium 1-2 mg IV test, then more if improved
-Cholinergic Crisis
-too much acetylcholinesterase inhibitor
-edrophonium test increases weakness then give atropine
Eaton-Lambert Syndrome
-disorder of neuromuscular transmission
-oat cell CA of lung
-CN spared, grip strength increases with repetition
Botulism (food-borne)
-preformed toxin
-prevents release of acetylcholine
-symptoms in 24-48 hours
-earliest and most common blurred vision, diplopia
-floppy baby – raw honey
Myopathies
-proximal weakness (getting up from chair, climbing stairs)
-sensory symptoms absent
-DTR intact
-abnormal lab test- increased WBC, sed rate, muscle enzymes
-polymysitis, steroid, alcoholic, hypokalemic
Volkmann’s Ischemic Paralysis
-complication of compartment syndrome
-treat compartment syndrome to prevent
-paralysis with eventual contracture
Isolated Peripheral Neuropathies
Trigeminal Neuraliga (Tic douloureux)
-excruciating, lancinating pain
-CN V distribution, right side of face most common
-elicited by tapping trigger zones
-tx is carbamazepine
Bell’s Palsy
-unilateral facial nerve paralysis (CN VII)
-Ramsay-Hunt: herpes zoster, look in ear!
-Lyme disease: bilateral Bell’s
-steroids, eye protection, +/- antiviral, ENT referral
Myelopathies
Syringomyelia
-fluid filled cavity in the spinal cord
-dissociated sensory loss, pain and temp, ‘capelike’
MS
-demyelinating disorder
-think subtle vision problems
-can be episodic
-UMN weakness, hyperreflexia, LMN sensory/bladder/bowel
Transverse Myelitis
-post viral or toxic inflammation of the cord
-think distinct level of cord and below (no pain and temp, paralysis)
Epidural Mass Lesions
-hematoma, abscess, disc herniation, mass lesion
-acute pain, radiating electrical sensation, progressing cord compression
-watch out for cauda equina
Dorsal Column Disorders
-syphilis, vitamin B12
-loss of position, vibration and light touch
Traumatic Brain Injury
Cerebral Contusion
-focal hemorrhage and edema (coup/countercoup)
-commonly frontal, sub-frontal and anterior temporal
-non contrast CT
-temporal lobe high risk expanding and dangerous edema, ICU monitoring
-Concussion: know when to image/ esp kids
Subdural Hematoma
-tearing of the bridging veins
-collect under dura
-‘half moon’, crossing suture lines
-think elderly and ETOH
-acute vs subacute vs chronic
Epidural Hematoma
-‘coup injury’ from trauma
-tear of middle meningeal artery
-classic lucid interval (may have no initial LOC)
-with herniation ipsilateral pupil dilatation
-convex or ‘lens shape’
ICH
-delayed, hours or days after injury, usually from contusion
Cerebral Edema
-from head trauma causing increased ICP
-CPP = MAP – ICP
-CO2 regulates cerebral blood flow, increased means increased flow (ICP)
-controversial hyperventilation, don’t go too far (goal 30-35)
-remember cushing reflex (HTN, brady)
-watch for herniation (blown pupil, decreased LOC, posturing, doll’s eye)
-RAISE THE HEAD, oxygenate, get neurosurg, CO2 35
CSF Leak
-usually from ear or nose, look for intracranial air
-clear halo ring
-infection is the complication
-most resolve spontaneously
-consult NS
Herniation Syndromes
-mass, edema, ICP can displace tissue
-Uncal: temporal, ipsilateral pupil, cheynes-stokes, coma/death
-Central: compresses brainstem, fixed mid pupils, eventual respiratory
-Cerebellar tonsillar: medullary compression, flaccid quad, CVC
Skull Fractures
-routine xrays not indicated, get CT
-NS consult
-Basilar: raccoon eyes, battle sign, hemotympanum, CT might miss, blood-air
interface in the sphenoid
TBI Complications
-Immediate (48hrs): SZ, ‘talk and deteriorate’
-Early (one week): SZ, DI, DIC, CSF leak, dysrhythmias, pulmonary edema
-Late (after one week): SZ
-Post concussive syndrome: HA, memory, concentration, organic brain
damage
Vertigo
Central
-ominous prognosis
-brainstem or cerebellar lesions
-mild continuous last longer than one minute
-nystagmus increased by visual fixation
-look for dysmetria, ataxia
-DON’T SEND THESE PATIENTS HOME
Peripheral
-85% self limited
-ear or CN VIII
-sudden, intense, intermittent
-nystagmus suppressed by visual fixation, never vertical
-NO NEURO FINDINGS
-Meniere’s- 40-60, vertigo with tinnitus, sensorineural deafness
abrupt onset last minutes to hours
-Tx: antihistamines, anticholinergics
COMA
-TIPS – AEIOU
-find underlying cause
-know how to support and treat
-Coma Cocktail: narcan, glucose, thiamine, O2
Headache
Migraine
-usually have aura
-know treatment (NSAID, triptan, reglan, steroids for status, opiates)
Cluster
-25 or so MALE, burning HA one sided
-give 100% O2, tapering course of steroids
Temporal arteritis
-inflammation of one or more branches of the external carotid
-FEMALE, 50 years, throbbing, burning one side (think forehead)
-Sed rate usually greater than 50
-Blindness is the complication
-steroids large doses
-ophtho/neuro consult
Tension
-tight band
Pseudotumor Cerebri
-young, obese female
-blurred vision and papilledema
-LP with increased pressure
Cervical Spine Injuries
Know stable vs. unstable fractures
-Stable: simple wedge, clay-shovelers, pillar fx
Central Cord Syndrome
-elderly, forced hyperextension (you intubating)
-weakness greater in the arms than legs
Anterior Cord Syndrome
-flexion injuries
-complete motor and loss of pain and temp
-dorsal column intact, normal light touch, vibration, position
Brown-Sequard
-penetrating usually
-hemisection: ipsilateral motor with loss of position and vibration with
contralateral pain and temp
Spinal Shock
-hypotensive and stable brady
-warm pink skin, normal urine output
-loss of sympathetic tone
Meningitis
General
-don’t delay antibiotics
-CT before LP with AMS or focal deficit
-know CSF analysis
Etiology
-0-4 weeks: e. coli, GBS, think listeria
-3 months to 18yrs: strep pneumo
-18-50: neisseria, strep pneumo
->50/ETOH: think listeria again
Antibiotic
-neonate: cefotaxime and amp (gent and amp)
-infants: ceftriaxone and amp (possible vanc)
-adults: ceftriaxone (vanc)
-greater than 50: ceftriaxone and amp
Steroids
-some controversy
-before antibiotics
-adults with suspected pneumococcal