Neurology handbook Flashcards
What are Ix for acute stroke?
- Ix:Urgentnon-contrastCTbrain,CBP,R/LFT,PT,aPTT,blood glucose, lipid, CXR, ECG.
- Special Ix (in selected cases): Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), computer tomography angiography (CTA), Echocardiography, Duplex study of carotid arteries, Transcranial Doppler (TCD), cerebral angiography, VDRL, thrombophilia assessment and autoimmune screening.
What is clinical presentation of GBS?
- Subacute progressive ascending type of sensory/motor polyneuropathy
- ±involvement of respiratory/bulbar muscles
- Generalized areflexia or hyporeflexia
- Autonomic dysfunction (eg: arrhythmias, swings in blood pressure, urinary retention, paralytic ileus and hyperhydriasis)
- Monophasic illness pattern; clinical plateau by about 4 weeks
- Miller Fisher syndrome: bilateral ophthalmoparesis, ataxia,
areflexia - Look for preceding infection e.g. Campylobacter jejuni,
Mycoplasma pneumonia, CMV/ EBV/ VZV; recent vaccination
What is dx of GBS?
- Should NOT have new-onset upper motor neuron signs or sensory level.
- Consider paralysis due to other acute neuropathies e.g. toxic neuropathy (alcohol, heavy metals, insecticides, solvents, drugs like cytotoxic agents), vasculitis, lymphomatous infiltration, porphyria, critical illness polyneuropathy; or neuromuscular junction disorders (e.g. myasthenic crisis, botulism)
- Arrange nerve conduction study (may be normal in 1st week): Findings depends on subtype of GBS, majority show demyelinating pattern
- Perform lumbar puncture: look for cytoalbuminologic dissociation [Raised CSF protein (may be normal in 1st week, ~80% abnormal in 2nd week, peak in 3rd to 4th week) and CSF total white cell count < 50 cells/uL]
- Anti-ganglioside antibodies:
- GQ1b is closely associated with Miller-Fisher Syndrome
- GM1 and GD1a are associated with acute motor or motor-
sensory axonal neuropathy.
What is management of GBS?
- Monitor pulmonary dysfunction (Vital capacity); consider mechanical ventilation if:
- hypercarbia and/or hypoxaemia
- FVC <15 ml per kg of BW
- bulbar weakness, impaired swallowing, insufficient cough, tachypnoea - Watch for autonomic dysfunction (potentially fatal):
- cardiac monitoring (for arrhythmia and severe bradycardia) - BP monitoring (fluctuate between severe hypertension and
hypotension) - Gastrointestinal
Susceptible to the development of paralytic ileus
Monitor swallowing ±temporary non-oral feeding - Other supportive measures:
- DVT prevention
- urinary retention, constipation
- clear secretion
- early mobilization
- medical treatment for pain and paraesthesia - Immunotherapy (in severe cases):
- give intravenous immunoglobulin (IVIg) 0.4g/kg/day for 5 days - alternatively start plasma exchange 50 ml/kg/session of plasma
for 5 exchanges over 2 weeks - Combination of IVIg and PE is not better than PE or IVIg alone.
Steroid treatment has no benefit.
Define myasthenic crisis
Ix done
All MG patients with autoimmune or acquired form showing respiratory failure or muscle weakness and requiring ventilator assistance
Tensilon test - diagnostic test in untreated disease; not reliable in differentiating myasthenic and cholinergic crisis and not without risk, hence not recommended.
Ix
Respiratory distress (Dyspnoea, tachypnoea, use of accessory muscles of respiration)
FVC, ABG, ECG, Chest X ray
What is management of myasthenic crisis?
What is Ix to delinate level and nature of acute spinal cord syndrome?
- XR spine
- MRI spine of relevant level if immediately available; otherwise myelogram and CT myelogram
- Lumbar puncture if transverse myelitis is suspected; send CSF for microscopy and cell counts, culture, AFB culture, biochemistry, viral study and cytology; VDRL and oligoclonal band in selected cases
What is management of acute spinal cord syndrome?
What are conditions that have high risk of peri operative pulmonary complications?
Parkinsonism, myasthenia gravis, other neuro-muscular disorders affecting respiratory muscles and any neurological deficits compromising respiratory effort.
What is the perioperative management in patients with neurological diseases?
What are the risks of peri operative stroke in neurological diseased patients and how are they managed preop?
Define coma
What are the mechsnisms of coma?
A medical emergency characterized by the absence of arousal and awareness.
Mechanisms: structural brain lesion, diffuse neuronal dysfunction, psychiatric (rare)
What is initial approach to coma?
Assess responsiveness
Initial stabilization
History taking
What is initial approach to coma?
General exam
Neurological exam
What Ix done for coma?