Neuro Flashcards
(233 cards)
1
Q
how much CSF is present in spinal canal
A
30 ML
2
Q
where is CSF produced
A
ventricular choroid plexus
3
Q
where is CSF absorbed
A
arachnoid villi
4
Q
LP indications
A
suspected meningitis. SAH, CNS syphilis, IIH
5
Q
absolute contraindications for LP
A
presence of infection near puncture site, increased ICP
6
Q
relative contraindications for LP
A
unstable patient, coagulopathy, brain abscess, epidural/subdural fluid collection, spinal cord tumor, severe thrombocytopenia
7
Q
usual volume of CSF removed at LP
A
15-20 mL
8
Q
rate of CSF production
A
0.35 mL/min
9
Q
how long does it take the CSF to regenerate that is extracted via LP
A
about an hour
10
Q
net flow of CSF out of ventricles per day
A
50-100 mL
11
Q
what meningitis patients may not show meningeal signs
A
elderly, debilitated, immunocompromised, receiving anti-inflammatories, partial abx tx
12
Q
signs of meningitis in an infant
A
bulging fontanelle, toxic appearance, +/-nuchal rigidity, +/-positive blood cultures
13
Q
most common signs of meningitis in peds 1-3 y/o
A
fever, irritability, vomiting
14
Q
what is jolt accentuation test
A
patient’s pain is exacerbated by lateral rotation of the head to either side
15
Q
petechial rash in febrile patient raises suspicion for ____
A
neisseria meningitis
16
Q
ssx of SAH
A
thunderclap HA, N/V, AMS, meningeal signs (may occur later), fever
17
Q
IIH ssx
A
chronic headaches that worsen with maneuvers that increase ICP, papilledema, 6th CN palsies, visual loss
18
Q
IIH diagnosis
A
LP after neuroimaging while measuring opening pressure
19
Q
IIH management via LP
A
remove 5-10 mL at a time of CSF and recheck opening pressure until ICP is normal
20
Q
IH drug therapy
A
acetazolamide, other diuretics
21
Q
what ssx warrant caution before LP
A
lateralizing signs (hemiparesis), uncal herniation (unilateral 3rd nerve palsy with AMS)
22
Q
ssx of brain abscess (high risk of herniation with LP)
A
HA, AMS, focal signs. (-)meningeal signs
23
Q
who is at risk for spinal epidural hematoma after LP
A
bleeding diathesis, anticoagulant Pts, thrombocytopenia
24
Q
how to correct warfarin-induced coagulopathy prior to LP
A
FFP or prothrombin complex concentrate together with vitamin K (only if time permits)
25
where to do LP and how to find this spot
line connecting posterior superior iliac crests intersecting the midline at the L4 spinous process (use adjacent interspace above or below). Can be performed from L2-L3 interspace to L5-S1 interspace
26
where to perform LP in infants
L4-L5 or L5-S1 interspace
27
needle sizes used for adults and peds in LP
adults: 3.5 inch 20 gauge. Peds: 2.5 inch 22 gauge
28
how to insert LP needle
bevel toward ceiling in a patient on their side. (bevel pointed towards patient's right regardless of position) Start with needle parallel to bed, then angle toward umbilicus once subq tissue has been penetrated
29
when will dura be penetrated in normal patients
when the needle is advanced approx 1/2-3/4 of its length
30
how to withdraw LP needle
replace stylet into needle before withdrawing it
31
which CSF tubes have cell counts performed
1st and 3rd
32
post-LP HA onset
usually within first 48 hours after LP
33
post LP HA ssx
worse on standing and better lying down, cervical/suboccipital location, +/-N/V
34
suspected mechanism of post-LP HA
leading of CSF through dural hole
35
post LP HA tx
caffeine (300 mg PO or 500 mg IV), . Epidural blood patch for refractory cases. aminophylline (5-6 mg/kg IV), +/-lying flat/sumatriptan: Article yes, Terry says no
36
when to perform CT before LP
trauma, age>60, severely altered mental status, focal neuro deficits, HIV positive/immunocompromised, papilledema, suspected intracranial mass lesion, progressively worsening HA, seizure
37
position of Pt in order to measure opening pressure
lateral decubitus
38
normal CSF pressure
6-25 cm H2O
39
elevated opening pressure for most children
>28 cm H20
40
how much blood must be in CSF for it to appear grossly bloody
>6000 RBCs/microliter
41
what is xanthochromia
yellow-orange discoloration of the supernate of centrifuged CSF produced by red cell lysis indicative of SAH of at least a few hours' duration
42
WBC greater than ___ indicates pathological CSF
5 cells/microliter
43
neutrophilic pleocytosis in CSF is associated with _____
bacterial meningitis, or early stages of viral/TB meningitis
44
eosinophils in CSF are associated with
parasitic CNS infection
45
normal RBC count for CSF
less than 10 cells/microliter
46
normal range of CSF glucose
50-80 mg/dl
47
normal range of CSF protein
15-45 mg/dl
48
bacterial meningitis CSF findings
elevated WBC, polymorphonuclear predominance on differential, glucose <40, protein >50
49
viral meningitis CSF findings
elevated WBC (but not as elevated as bacterial), lymphocytic/mononuclear predominance on differential, normal glucose, normal to slightly elevated protein
50
most commonly identified organism in viral meningitis
enteroviruses (coxsackievirus, echoviruses, etc)
51
cryptococcus CSF findings
slightly elevated WBC, lymphocytic pleocytosis, low glucose, high protein
52
CSF findings in Guillain-Barre
elevated protein
53
CSF findings in MS
oligoclonal bands, elevated protein
54
CSF findings in SLE
elevated WBC, protein, IgG
55
common pathogens of bacterial meningitis
strep pneumo, group b strep, neisseria meningitidis
56
common cause of amebic meningitis
naegleri fowleri
57
causes of non-infectious meningitis
cancer, SLE, head injury, etc
58
what is kernig sign
painful knee extension when hip is flexed
59
what is brudzinski sign
passive flexion of neck elicits flexion of knee and hip
60
who is most likely to get group B strep meningitis
infants< 2 months old
61
most common cause of bacterial meningitis overall
strep pneumo
62
who gets neisseria meningitidis
11-17 y/o
63
who gets h. flu meningitis
unvaccinated
64
who gets listeria meningitis
immunocompromised (including liver disease), newborns, elderly
65
what is true of the diagnosis of traumatic SAH
usually found on CT, not LP
66
what is most sensitive (or specific?) ssx for SAH
"worst headache" followed by thunderclap onset
67
ottowa SAH rule population
for alert patients older than 15 y/o with new, severe, nontraumatic HA reaching maximum intensity within 1 hour
68
ottowa SAH rule excluded populations
new neuro deficits, previous aneurysms or SAH, brain tumors. hx of recurrent HA
69
ottowa SAH rules when to investigate
if at least 1 of these variables present: Age at least 40, neck pain/stiffness, witnessed LOC, onset during exertion, thunderclap, limited neck flexion on exam
70
cerebral edema CT findings
effaced basilar cistern and loss of "smile sign," slit-like lateral ventricles, effaced sulci
71
what to do before LP if thrombocytopenia and at what severity of thrombocytopenia
FFP if platelets<20,000
72
what to do after LP if thrombocytopenia
monitor for neuro signs (spinal epidural hematoma)
73
common complications of LP
spinal headache, low back pain, dry tap
74
uncommon complications of LP
localized cellulitis, dural abscess, discitis, localized bleeding, cerebral herniation
75
how much autologous blood goes in blood patch
10-20mL
76
quincke vs whitacre needle
Quincke is more blunt, Whitacre is super pointy. Quincke is used most commonly
77
pre-treatment for LP
IV fluids, pain meds (50 mcg fentanyl), anti-emetics (4 mg zofran), anxiolytics (midazolam 1 mg)
78
needle size for adults
22g or larger
79
causes of high opening pressure
IIH, SAH, meningitis, encephalitis, Guillain-Barre, brain abscess, venous sinus thrombosis, intracranial mass/vasculitis
80
CSF orders
cell count with diff, gram stain/culture, protein, glucose, xanthochromia
81
methods of assessing xanthochromia
spectrophotometry, visual comparison
82
how to assess for SAH vs traumatic tap
in a traumatic tap there should be a 30% decrease in RBCs between tubes 1 and 4, less than 500 RBCs in tube 4
83
tx for bacterial meningitis
steroids, abx (ceftriaxone, vanc, ampicillin)
84
tx for viral meningitis
antivirals (acyclovir, valcyclovir)
85
emergent causes of HA
SAH, epidural, subdural, intracerebral hemorrhage, stroke, CNS infection, CNS mass, CO poisoning, acute angle closure glaucoma
86
dizziness plus headache is concerning for
cerebellar bleed
87
HA red flags
new onset, neuro findings, thunderclap, fever, immunocompromise, elderly, jaw claudication, multiple Pts, pregnancy, clotting disorder, eye pain, cervical manipulation, age >50, exertional
88
what is true of headaches in the ED
most are benign and do not require immediate intervention
89
physical exam components for HA
full neuro exam plus palpate temporal artery if suspicion of temporal arteritis
90
red flags on physical exam for HA
AMS, meningeal signs, focal deficits, rash
91
what could rash with HA signify
rocky mountain spotted fever or meningococcemia
92
most common HA in ED/primary care
tension
93
common migraine aka
migraine without aura
94
classic migraine aka
migraine with aura
95
what is a scotoma
"hole in vision"
96
what are soft neuro findings
confusion, lightheadedness, trouble focusing
97
what are hard neuro findings
things that can be explained by a specific lesion, focal deficits, ataxia
98
tension HA characteristics
constricting, bilateral, no associated ssx except pre-cranial muscle tenderness
99
migraine characteristics
4-72 hours, unilateral, +/-aura, severe, pulsatile, aggravated by exertion, with N/V, photophobia, phonophobia
100
cluster HA characteristics
nocturnal onset (awaken Pt), severe, unilateral, located around eye, clustered episodes, +/-autonomic ssx (lacrimation, congestion, miosis, ptosis)
101
cluster HA tx
high-low O2, +/-triptans
102
SAH tx in ED
confine to bed, advise against exertion or straining, ssx control, nimodipine, keep BP<140, Keppra x 7 days for seizure prophylaxis
103
if acute HA patient has any of the following, investigate further (Ottowa)
age >39, meningeal signs, witnessed LOC, exertional onset, thunderclap
104
how to differential traumatic tap vs SAH in LP (for testing purposes)
a positive LP for SAH is when RBCs do not completely clear to 0 in the final tube
105
what is true of kernigs and brudzinski sign
low sensitivity, high specificity
106
ssx of meningitis in peds
irritable, lethargic, poor feeding
107
ssx of neisseria meningitis
DIC, purpuric rash
108
what to do if high suspicion of bacterial meningitis
initiate tx before confirmation of diagnosis
109
tx for bacterial meningitis in 6-50 y/o
ceftriaxone + vanc
110
tx for bacterial meningitis in newborns, elderly
ceftriaxone, vanc, ampicillin
111
temporal arteritis ssx
fatigue, fever, proximal muscle weakness, jaw claudication, transient vision loss, tender/nonpulsatile temporal artery, HA
112
lab findings in temporal arteritis
elevated ESR/CRP, normochromic, normocytic anemia, thrombocytosis
113
temporal arteritis diagnostics
temporal artery biopsy, CT/MRI
114
temporal arteritis tx
prednisone
115
what opening pressure suggests IIH
>25
116
IIH diagnostics
CT to r/o intracranial mass, LP, ocular US
117
ssx of IIH
disabling HA, papilledema, vision loss, pulsatile tinnitus, N/V, diplopia
118
red flags for tumor as cause of HA
getting worse over time, history of malignancy, HA worse in the morning/with head down/with valsalva, HA awakening from sleep, seizures or acute mental status change
119
characteristics of CO poisoning
others in home are sick, worse in the morning, normal SpO2, myalgias, N/V, dizziness, AMS, focal deficit
120
how to assess for CO poisoning
carboxyhemoglobin level
121
indications for hyberbaric O2
neuro/cardiovascular signs, pregnancy
122
ssx of acute angle-closure glaucoma
red eye, mid-range/fixed pupil. cloudy cornea, decreased visual acuity
123
acute glaucoma etiology
obstruction of aqueous humor flow 2/2 narrow anterior chamber angle
124
peak age of onset of acute glaucoma
>70 y/o
125
acute glaucoma diagnostics
tonometry
126
what tonometry reading is indicative of acute glaucoma
>21 mmHg, but usually >30 mmHg
127
acute glaucoma tx
timolol, diamoz, pilocarpine, optho consult
128
cervical/vertebral artery dissection characteristics
young pt with HA +/-face/neck pain, sharp pain up the back/front of neck after low mechanism trauma
129
cervical/vertebral artery dissection diagnostics and treatment
CT or MR angiogram, tx with heparin
130
terry cocktail for HA
reglan 10 mg, benadryl 25-50 mg, decadron 10 mg
131
don't give triptans and ergotamines to:
Pts with CAD, severe HTN, or history of AMI
132
don't give ketorolac to _____
Pt's with PUD or renal insufficiency
133
nerve blocks for HA
occipital, spleno-palatine
134
ED tx for HA options
IV fluids, NSAIDs, APAP, dopamine antagonists, triptans, DHE, IV corticosteroids, caffeine, valproate, ketamine
135
route for HA meds in ED
NOT PO
136
most common location for epidural hematoma
temporoparietal
137
what limits expansion of subdural
falx cerebri, tentorium, falx cerebelli
138
subdural locations in adults vs infants
usually unilateral in adults, bilateral in infants
139
temporal arteritis is associated with ____
polymyalgia rheumatica
140
facial pain indicates dissection of _____ artery
carotid
141
neck pain indicates dissection of _____ artery
vertebral
142
what is a seizure
sudden, uncontrolled electrical discharge in brain, usually bursts of action potentials
143
do patients remain conscious during atonic seizure
yes
144
what type of seizure often occurs during sleep
tonic
145
what is a focal seizure
generally confined to one hemisphere and may look very different depending on what part of the brain is affected
146
types of generalized seizures
tonic-clonic, absence, myoclonic, atonic
147
simple partial seizure aka
focal-aware
148
focal aware seizures affecting temporal/parietal region ssx
affect movement and speech
149
focal aware seizures affecting frontal lobe ssx
confusion, behavior disturbance
150
focal aware seizures affecting occipital lobe ssx
changes in coordination/vision
151
what is more indicative of psychogenic non-epileptic seizures
forced eye closure, responsiveness to toxic stimuli, pelvic thrusting, side-to-side motion and out-of-phase movement of limbs, recall of events with generalized-appearing seizures, no intra-oral bruising or lacs, no elevation of lactate or procalcitonin, optokinetic nystagmus
152
tx for psychogenic non-epileptic seizures
CBT
153
6 broad categories of seizure causes
vital sign abnormalities, tox, trauma/mass, infection, epilepsy, pregnancy
154
vital signs causes of seizures
hypoglycemia, hypoxia, AMI, hypertensive emergency, febrile, electrolytes
155
simple febrile seizure age
6 months-5 y/o
156
simple febrile seizure characteristics
generalized, lasts <15 minutes, returns to baseline after brief postictal period
157
workup for febrile seizure
only for ssx of meningitis or 6-12 month olds that aren't fully immunized. No further workup needed for simple febrile seizures
158
electrolytes as cause of seizure
sodium, calcium, potassium, magnesium
159
mortality rate of delirium tremens
30%
160
what meds can cause seizures
antihistamines, local anesthestics, wellbutrin, clozapine, abx, tramadol, TCA OD, antiseizure drug OD
161
TCA OD mortality rate and tx
50%, sodium bicarb
162
what is the final common pathway
seizure coma death
163
what % of pts with penetrating brain injury end up with epilepsy
30-40%
164
why dies intracranial bleeding cause seizures
blood is irritating, and compression from blood buildup can cause ischemia
165
what is purpura fulminans
bad purpural rash associated with meningococcal meningitis
166
every hour of delay in starting abx in bacterial meningitis leads to ____
30% increase in mortality
167
causes of breakthrough seizures
stress, infection, insomnia, menstrual cycle, med noncompliance
168
what is status epilepticus
any seizure >5 minutes or 2+seizures without a return to baseline in between
169
what to do about someone who has a first time seizure and no other abnormal findings
refer to outpatient neuro follow up
170
indications for admission for seizures
multiple seizures, recurrent seizure without inciting factor/different from past seizures, other abnormalities on labs/VS
171
initial treatment for status epilepticus
Lorazepam: 0.1 mg/kg up to 4 mg IV
Midazolam: 0.2-0.3 mg/kg up to 10 mg IM (do this if no IV access already)
172
2nd line treatments for status epilepticus
another benzo dose, followed by (if needed) antiepileptic
173
antiepileptic choices for status epilepticus
levetiracetam (60 mg/kg), fosphenytoin (20 mg/kg), valproate (40 mg/kg)
174
3rd line meds for status epilepticus
massive dose of: propofol, ketamine, midazolam, phenobarbital followed by intubation
175
caution with intubating status epilepticus
paralytic won't stop them from seizing, but they won't appear to be seizing outwardly/ So continuous EEG is necessary
176
tx for eclampsia
magnesium: 4-6 gram bolus over 15-20 minutes, then 2 g/hour infusion
177
1st line antihypertensives in pregnancy
nefedipine, methyldopa, labetalol, hydralazine
178
BP goal in pregnancy
140/90
179
definitive treatment for eclampsia
delivery
180
cause and tx for seizures in the setting of TB infection
INH toxicity, administer pyroxidine (B6)
181
at what sodium level do seizures become a possibility?
<124
182
causes of hyponatremia leading to seizures
polydipsia, SIADH, MDMA, tea and toast
183
consideration in correcting hyponatremia
correct it slowly
184
definition of thrombotic stroke
narrowing of a damaged vascular lumen by an in situ process
185
which type of stroke is also a common cause of TIA
thrombotic
186
causes of thrombotic stroke
atherosclerosis, vasculitis, dissection, polycythemia, hypercoagulable state, infection
187
what is an embolic stroke
obstruction of a normal vascular lumen by intravascular material from a remote source
188
causes of embolic strokes
valvular vegetations, thromboembolism, paradoxical emboli, myxomas, fat/particulate/septic emboli
189
level 1 stroke alert
LKW < 6 hours
190
level 2 stroke alert
LKW 6-24 hours
191
level 3 stroke alert
negative BE FAST, but clinical suspicion and LKW<24 hours
192
BE FAST
balance, eyes, face, arm drift, speech, time
193
internal carotid occlusion ssx
progressive or stuttering onset of MCA syndrome
194
vertebrobasilar stroke ssx
crossed sensory deficits, CN palsies, diplopia, dizziness, N/V, ataxia, motor deficits, coma
195
lacunar stroke ssx
pure motor or pure sensory deficits, hemiparesis, dysarthria
196
PCA stroke ssx
ataxia, nystagmus, AMS, vertigo, homonymous hemianopsia, can't read but can still write, hallucinations, 3rd nerve palsy
197
BP goal for stroke without tPA
<220/120
198
BP goal for stroke with tPA
<185/110
199
BP goal for intracerebral hemmorhage
<180/90
200
BP goal for subarachnoid hemorrhage
<160/90
201
most important initial lab test in CVA
BGL
202
otherstudies in CVA
CBC, electrolytes, coags, troponin, ECG, CXR
203
only mandatory initial imaging for CVA
non contrast head CT
204
additional imaging for CVA
consider CT angiogram to look for large vessel occlusion, consider CT perfusion to evaluate penumbra to assist with thrombolytic decision in unknown LKW
205
risk of intracerebral hemorrhage with tPA
5-8%
206
CVA tx if not a tPA candidate
325 mg ASA, NPO, CTA, +/- mechanical thrombectomy if LVO found, admit to ICU
207
tPA aka
alteplase
208
exclusion criteria for tPA
non-ischemic stroke, age<18, LKW>4.5 hours, neurosurgery/head trauma/stroke within the last 3 months, BP>185/110, history of intracerebral hemorrhage, AVM/neoplasm/aneurysm, active internal bleeding, endocarditis, thrombocytopenia, INR>1.7, BGL<50
209
hemorrhage stroke seen on CT interventions
CTA, elevate head of bed 30%, goal BP <160/90, nimodipine, reverse anticoagulants, antiepileptics, neurosurgical consultation
210
what sound you not give for hemorrhagic stroke
platelets
211
risk stratification tool for risk of stroke after TIA
abcd2
212
anterior fossa houses
frontal lobe
213
middle fossa houses
temporal lobes
214
posterior fossa houses
lower brainstem and cerebellum
215
ICP greater than ___ associated with poor outcome
20 mmHg
216
what is the monro-kellie doctrine
total volume of intracranial content must remain constant
217
intra-axial means
within the brain parenchyma
218
extra-axial means
above the brain parenchyma, including epidural, subdural, and SAH
219
normal intracranial pressure is approximately
10 mmHg
220
at what MAPs can brain autoregulate
50-150 mmHg
221
MAP =
(pulse pressure)/3 *diastolic
222
always consider what other injury when head injury is present
c-spine
223
when to get a CT after head trauma
suspected skull fracture, age>65, anticoagulants, focal neuro findings, acute MOI, loss of consciousness
224
mild brain injury GCS
13-15
225
Moderate brain injury GCS
9-12
226
disposition for moderate brain injury
CT then admission with serial neruo exams
227
management of mild brain injury
serial neuros followed by discharge if appropriate
228
severe brain injury GCS
3-8
229
severe brain injury management
neurosurgery consult, treat hypotension, hypovolemia, hypoxia, get CT, type/cross, coags, keep PCO2 around 35. Mannitol, anticonvulsants
230
what is chronic traumatic encephalopathy
deposition of tau proteins in the brain due to repeated trauma
231
chronic traumatic encephalopathy ssx
early onset memory loss, depression, dysarthric speech, shuffling gait, ataxia
232
chronic traumatic encephalopathy imaging
ventricular dilation, sulcal widening, widening of septum pellucidum
233
what is second impact syndrome
rapid cerebral edema with high mortality rate, usually in young athletes
