neuro Flashcards
(29 cards)
stroke evaluation: door to needle time when they come in at 0 min tilll tx
-0 mins= arrive
-<10mins= ABCs and POC glucose, last well known, exam
-supplement O2 if <94%
-NIH stroke scale
-<15mins= notify stroke team
-<25mins= Head CT or MRI -tells us if hemorrhagic or ischemic -> helps guide BP management
-get CTA immediately if ischemic/negative CT head to see where occlusion is
- MRI for POSTERIOR
-<45mins- Interpretation of scan, decide tPA
-<60mins- IV alteplase within 3-4.5hrs from sx onset
-Labs: Coagulation, CBC, BMP, lipids, A1C, T&S
-ECG- Afib, large strokes you can see deep TWI and prolonged QT (ICP)
- notify pharmacy that tPA might be needed
Vascular territories for stroke based on signs and symptoms:
MCA
ACA
PCA
Lacunar strokes
basilar
vertebral artery
MCA: MC - 70%
- contralateral weakness in ARMS/FACE > leg
- dominant side (MC left) = aphasia
- non-dominant side = hemineglect
ACA: (3%)
- contralateral weakness in LEGS (fall then stroke)
- if frontal lobe: abulia, personality change, incontinence
PCA:
- contralateral homonymous hemianopsia macular sparing
- dizziness, vertigo, nystagmus, ataxia, N/V, ocular palsies
basilar:
- incompatible with life
- locked in syndrome
vertebral artery: supplies brainstem and cerebellum
-PICA = wallenberg (crossed finding, ipsilateral horner syndrome, ataxia, facial numbness with contralateral loss of pain and temp sensation)
- think dissections if vertebral involvement
- 5 D’s: dizziness, dysarthria, dystaxia, diplopia, dysphagia
- need MRI for dx
lacunar stroke (small deep penetrating arteries): Pure motor or sensory, dysarthria-clumsy hand
whats up with this ekg - sign of what?
deeply inverted T waves = sign of increased ICP!!!
- acute ischemic stroke and edema
- intercerebral hemorrhage
stroke tx plan: when do you do tPA, indications vs CI
-tPA: indications
- * < 3hrs since onset of sx (<4.5 in select individuals)
-≥ 18yo
-if tPA causes head bleed complication -> 10u cryoprecipitate + 6U platelets
Absolute CI:
-!ICH on CT
-Presentation- sus of SAH
-!Neurosurgery, head trauma, or stroke in previous 3mo
-Uncontrolled HTN (>185/>110)!
-!Hx of ICH
-Known intracranial arteriovenous malformation, neoplasm, or intracranial aneurysm
-!Active internal bleeding
-Suspected or confirmed endocarditis
-Known bleeding diathesis with platelet count < 100,000/μL -Elevated PTT with heparin administered in last 48hrs or oral anticoagulants -Glucose < 50 mg/dL or >400mg/dL
Relative CI:
-Recent GI or urinary tract bleeding (past 21 days)
-Minor or rapidly improving stroke sx
-Major surgery or serious nonhead trauma in past 14 days
-Seizure at stroke onset
-Recent arterial puncture at a noncompressible site
-Recent LP
-Post-MI pericarditis
-Pregnancy
DAPT and mechanical thromboectomy indications for stroke
Dual anti-platelet therapy:
-for Minor strokes (NIHSS ≤5) who do not always receive tPA
-Initiate DAPT within 24hrs of sx onset
-ASA + clopidrogel/ticagrelor
-Endovascular therapy (EVT)/ Intra-arterial thrombectomy
-Embolectomy or angioplasty with catheters
-Indicated in LARGE VESSEL OCCLUSIONS! (LVO) in the ANTERIOR CIRCULATION!
-done up to 24 hours! after sx onset
-even if patient received tPA
-Indications:
-<6hrs from sx onset (but up to 24 hrs) -High baseline function prior to sx onset -Minimal tissue damage on CT -NIHSS score > 6
tPA indications and BP goals; complications
indications:
- * < 3hrs since onset of sx (<4.5 in select individuals)
-≥ 18yo
BP goal:
- <185/110** (if too high give IV labetolol and nicardipine)
- target during and after tx: 180/105
complications:
- hemorrhage: stop infusion, stat CT, give 10 U CRYOPRECIPITATE AND 6U platelets
- seizure
- angioedema
Endovascular therapy (EVT)/ Intra-arterial thrombectomy what is it and indications
-Embolectomy or angioplasty with catheters
-Indicated in LARGE VESSEL OCCLUSIONS! (LVO) in the ANTERIOR CIRCULATION!
-done up to 24 hours! after sx onset
-even if patient received tPA
Indications:
-<6hrs from sx onset (but up to 24 hrs)
-High baseline function prior to sx onset
-Minimal tissue damage on CT
-NIHSS score > 6 (large stroke)
stroke: posterior vascular territory
-Vertebral artery supplies brain stem and cerebellum
-Branches of vertebral artery: AICA, Basilar artery, PCA, PICA
-Crossed-findings are classic = Ipsilateral CN palsy + contralateral hemiplegia
-!5 D’s: dizziness (vertigo), dysarthria, dystaxia, diplopia, dysphagia
-!LOC, N/V, ataxia, nystagmus
-Require MRI for dx!!!!
-“Locked in syndrome”
-Basilar artery infarction
-Quadriplegia, can’t speak or swallow. Eyes are spared, and patients are awake and cognitively ware.
-Posterior inferior cerebellar artery (PICA) = Wallenberg’s syndrome
-Dysphagia, dysphonia
-hiccups
-Ipsilateral CN deficits with contralateral pain/temp loss
-ipsilateral Horner syndrome
-ipsilateral gait Ataxia with a tendency to fall to affected side, nystagmus, vertigo
-dysmetria- failure of finger to nose
cervical artery dissection and how it pertains to stroke - MCC stroke in what population, RFs, sxs depending on carotid vs vertebral
-MCC of stroke in <50yo
-RF- any trauma especially rotary, chiropracter, connective tissue disorder, migraines, infection, OCP, smoking, post partum
-!can cause intramural hematomas and emboli -> TIA/CVA sx
presentation:
- minor trauma: rotational or hyperextension injury
-sudden
-!Head/face/jaw pain (74%)
-!HA and/or neck pain (57-90%)
-Horner’s syndrome (25%) (just miosis/ptosis)
-CN palsy (8-16%) (mostly CN 12,9)- rare
-Sx of ischemic stroke (weakness, numbness, vision changes)
-Pulsatile tinnitus (16-27%)
Carotid artery dissection vs vertebral artery dissection:
Carotid = MCA/ACA
- sx of MCA/CA: aphasia, contralateral weakness
-Anterolateral aspect of neck
-Radiates to jaw/face/head
-Neuro sx- often CONTRALATERAL
-Partial Horner’s syndrome
-CN deficit 9 +12 (contralateral)
-Transient monocular blindness (amaurosis fugax)**
-Retinal artery occlusion
Vertebral = PCA
-Unilateral, posterolateral neck and occiput
-Neuro sx- contralateral or b/l
-Posterior circulation stroke sxs: Vertigo, diplopia, ataxia, nystagmus, Wallenberg signs
Wallenberg syndrome- PICA off vertebral:
- Dysmetria, ataxia, IPSILATERAL hemiplegia, contralateral loss of pain and temp sensation
🧠 Cervical Artery Dissection & Stroke
⚡ Why It Matters
#1 cause of ischemic stroke in patients <50 years old
Can lead to intramural hematoma or arterial emboli → TIA or stroke
🧬 Risk Factors
Trauma, especially rotational (rollercoaster, yoga, chiropractor)
Connective tissue disorders (e.g. Marfan, Ehlers-Danlos)
Migraines, infections
Oral contraceptives
Smoking
Postpartum period
📋 Common Symptoms (Dissection in General)
Symptom Frequency
Head/face/jaw pain 74%
Neck pain / headache 57–90%
Horner’s syndrome 25% (ptosis + miosis)
Cranial nerve palsies 8–16% (mainly CN IX, XII)
TIA/CVA symptoms Variable
Pulsatile tinnitus 16–27%
🔍 Carotid vs. Vertebral Artery Dissection
Feature Carotid Artery Vertebral Artery
Location Anterolateral neck Posterolateral neck and occiput
Radiation Jaw, face, head Occiput
Neuro Deficits Contralateral Contralateral or bilateral
Classic Stroke Syndrome MCA / ACA (anterior circulation) Posterior circulation (PICA, brainstem)
Visual Sign Amaurosis fugax (transient monocular vision loss), retinal artery occlusion Visual field cuts, diplopia
CN Involvement CN IX, XII (rare, contralateral) CN V, IX, X (if Wallenberg)
Horner’s Syndrome Partial, often isolated Full or partial
🌪️ Posterior Circulation Complication: Wallenberg Syndrome
Often from PICA dissection off vertebral artery
Ipsilateral: Ataxia, Horner’s, facial numbness
Contralateral: Loss of pain/temp in limbs
🧪 Diagnosis
Initial: Non-contrast CT head
Confirmatory: CTA neck ± MRA neck
Gold standard (rarely done): Digital subtraction angiography
💊 Management
Extracranial dissection: Antiplatelet (ASA) or anticoagulation (LMWH)
Intracranial dissection: No anticoagulation due to SAH risk → use antiplatelets
Consider stenting in select cases
cervical artery dissection: carotid vs vertebral sx
Carotid = MCA/ACA
- sx of MCA/CA: aphasia, contralateral weakness
-Anterolateral aspect of neck
-Radiates to jaw/face/head
-Neuro sx- often CONTRALATERAL
-Partial Horner’s syndrome
-CN deficit 9 +12 (contralateral)
-Transient monocular blindness (amaurosis fugax)**
-Retinal artery occlusion
Vertebral = PCA
-Unilateral, posterolateral neck and occiput
- radiation to the occiput
-Neuro sx- contralateral or b/l
-Posterior circulation stroke sxs: Vertigo, diplopia, ataxia, nystagmus, Wallenberg signs
Wallenberg syndrome- PICA off vertebral:
- Dysmetria, ataxia, IPSILATERAL hemiplegia, contralateral loss of pain and temp sensation
cervical artery dissection dx and tx (extracranial vs intracranial)
-Gold standard for imaging = digital subtraction angiography (rarely used)
BECAUSE IT tends to present as stroke: order
-!non contrast CT head 1st
-!then -> CTA neck ± MRA neck to determine involved vessel
- if sx are posterior: MRI brain + MRA head/neck
tx for EXTRACRANIAL dissection: (before artery enters the neck)
-Antiplatelet (ASA) or anticoagulation (LMWH)
-Consider endovascular stenting
tx for INTRACRANIAL dissections:
- NO anticoagulation (no heparin/warfarin) due to risk of SAH
- Anti-platelets ONLY
primary headaches: migraines vs cluster vs tension quick summary and other types of primary
migraines:
-F-10-30yo, family hx
-Unilateral throbbing pain with photo/phono-phobia, n/v
- tx: NSAIDs are first line; consider greater occipital nerve block, Triptans - outpt tx
- triptans: ❌ Contraindicated in: CV disease, uncontrolled HTN, pregnancy
cluster:
-Unilateral lasting 30-90mins
-Multiple HA daily over several weeks (clustered)
-No prodrome or aura, no N/V, no photo/phono-phobia
-Signs: Ptosis, miosis, ipsilateral conjunctival injection, lacrimation, rhinorrhea
-Tx: 100% O2 non-rebreather for 15 mins (first line); triptans; consider greater occipital nerve block
Tension:
-B/l vice-like pain
-No n/v, photo/phono-phobia
-Tx = Analgesics like Tylenol or NSAIDs
- others: stress reduction, hydration, rest
Other common causes:
-Fever associated HA
-Sinusitis
-TMJ disease
-Trigeminal neuralgia
PE: HEENT, neuro
imaging: primary doesn’t need lab testing
primary headache ED managment
-1st line: IV antidopaminergics! as monotherapy***
-(!Metoclopramide IV up to 3 doses
-!Prochlorperazine IV
-!Droperidol IV
-MC SE: Akathisia! (restless), administer diphenhydramine if occurs)
-Acetaminophen IV or PO, 325-1000 mg
-Ketorolac IV or IM
-Triptans: outpatient, less effective than IV antidopaminergics
-Sumatriptan 6mg SQ once
-CI- CV ds, uncontrolled HTN, pregnancy
-Consider dexamethasone! IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if hx of recurrent headache
-Consider greater occipital nerve blocks for migraines and cluster HA
✅ First-Line in ED: IV Antidopaminergics
Metoclopramide 10 mg IV (can repeat up to 3 doses)
Prochlorperazine 10 mg IV
Droperidol 5 mg IV
⚠️ Common side effect: Akathisia (restlessness)
Manage with diphenhydramine
➕ Adjuncts:
IV/PO Acetaminophen: 325–1000 mg
Ketorolac: 10–30 mg IV or 30–60 mg IM
Dexamethasone 10 mg IV: Prevents recurrence at 48–72 hrs; do if hx of recurrent headaches
⚠️ Imaging & Labs
Not needed for typical primary headaches with no red flags
Always assess with a good HEENT + neuro exam
2ndary headache
-Meningitis:
-CSF
-cerebral venous thrombosis (CVT):
-DVT of brain
-F>M, 39yo
-RF- hypercoag, infection
-gradual, progressive HA
-focal neuro deficits, seizures, dec LOC
-Dx-
-CT head- 1st test, 30% WNL, small hemorhagic lesions, vasogenic edema, venous infarction -> dense triangle sign, empty delta sign, cord sign
-!!!!MRI with MRVenography (or CT venography)
-Tx- heparin (LMWH)
-Cervical artery dissection (carotid, vertebral)- horners (miosis+ptosis)
-CO poisoning:
-carboxyhemoglobin level
-Giant cell arteritis:
-ESR >50
-gradual onset (weeks/months)
-low grade fever
-polymyalgia rheumatica- symmetric aching and stiffness of shoulders, hip, neck, torse, worse in AM
-Tx- steroids -> dont wait for Bx
-Idiopathic intracranial HTN:
-young, obese, female, irregular menses
-hypervitaminosis A
-diffuse HA over days/week
-worse lying supine, walking in morning, valsalva
-N/V, visual dx, pulsatile tinnitus
-cushing reflex- HTN, brady, respiratory effort dec
-B/L papilledema!!!
-Dx- LP high opening pressure >250!!!
-CT- slight like ventricles!
-Tx- wt loss, acetazolamide, diuretics, therapeutic LP, corticosteroids, shunt, neuro
-can cause blindness
-Normal pressure hydrocephalus:
-dementia, ataxia, urinary incontinence -> wet, wacky, wobbly
-Dx- CT- enlarged ventricles
-MRI
-!!!LP is definitive- normal pressure!!!
-Tx- shunt
-Trigeminal neuralgia:
-spontaneous remission
-R>L, M>F, 50-60yo
-Tx- carbamazepine!!, baclofen, surgical decompression, neuro referral for MRI
-VP shunt HA:
-kinking, obstruction, disconnection, infection
-Dx- xray to look for kinking
-shunt tap to look for infection/obstruction
-Dx-
-CT head if worst HA, different HA, meingeal sx, intractable vomiting, new onset >50yo, HIV, neuro sx
-MRI if CT neg and red flags
- Meningitis
HA + fever, neck stiffness, photophobia
Dx: LP with CSF analysis (after CT if needed)
- Cerebral Venous Thrombosis (CVT)
“DVT of the brain”
Demographics: F > M, avg age ~39
RFs: Hypercoagulability, pregnancy, infection
Sx: Gradual HA, seizures, ↓LOC, focal deficits
Dx:
CT head first → may show hemorrhage, edema
MRI with MRV or CT venography = diagnostic
Tx: LMWH/heparin, even if hemorrhagic
- Cervical Artery Dissection
Carotid or vertebral artery tear → stroke
Sx: Neck/face pain, Horner’s syndrome (ptosis + miosis), stroke signs
Dx: CTA neck ± MRA
- Carbon Monoxide (CO) Poisoning
Multiple symptomatic people in same area
Sx: HA, confusion, cherry-red skin (rare), N/V
Dx: Carboxyhemoglobin level
Tx: 100% oxygen or hyperbaric O2
- Giant Cell Arteritis (Temporal Arteritis)
Age >50, gradual onset HA
Sx: Jaw claudication, low-grade fever, vision loss, PMR (proximal stiffness worse in AM)
Dx: ESR >50, temporal artery biopsy (don’t delay tx)
Tx: Steroids immediately to prevent blindness
- Idiopathic Intracranial Hypertension (IIH)
Young, obese females
Triggers: Hypervitaminosis A, tetracyclines
Sx: Diffuse HA, worse lying down, AM, Valsalva; N/V, pulsatile tinnitus, bilateral papilledema
Dx:
CT: Small/slit ventricles
LP: Opening pressure >250 mmH₂O
Tx: Weight loss, acetazolamide, therapeutic LP, diuretics, corticosteroids, surgery/shunt (prevent blindness)
- Normal Pressure Hydrocephalus (NPH)
Triad = “Wet, Wacky, Wobbly”
Urinary incontinence, cognitive decline, gait ataxia
Dx:
CT/MRI: Enlarged ventricles
LP: Normal opening pressure
Tx: Ventriculoperitoneal (VP) shunt
- Trigeminal Neuralgia
Sx: Unilateral, electric shock–like pain in V2/V3
R > L, M > F, age 50–60
Tx: Carbamazepine, baclofen, surgical decompression
MRI: Rule out tumor or MS
- VP Shunt Malfunction Headache
Causes: Kinking, obstruction, disconnection, infection
Dx:
Shunt series X-ray
Shunt tap (ICP, culture)
🧪 Imaging in Headache Evaluation
Scenario Imaging
Sudden severe (“worst ever”) CT head
Focal neuro signs, AMS, meningeal signs CT → then LP
Red flags + negative CT MRI
Suspect IIH CT to r/o mass → LP
CVT CT/MRI + venography
SSNOOP4 red flags in headaches
- systemic sx: fever, wt loss
- secondary risk factors
- neuro sx: confusion
- onset: progressive over 50 yrs, new onset
- previous headache: first time or change in pattern
- papilledema
- precipitated by exercise, position, valsalva: check for hx of aneurysms -> SAH
- pulsatile tinitus
get noncontrast CT in pts:
- thunderclap/worst headache of life
- different headache than usual
- meningeal signs
- headache + intractable vimit
- new onset headache
- if neg CT -> consider brain MRI for red flag sx
Describe the epidemiology and clinical presentation of subarachnoid hemorrhage (SAH), its diagnostic workup, and approach to management
epidemiology/presentation:
- ANEURYSM (80%); AVM, neoplasm
- onset during exertion (aneurysm)
- sentinel warning bleed precedes the rupture: worst HA of life + n/v
- rupture = thunderclap HA, LOC, neck pain and limited flexion, fever AMS, HTN
- PAIN MAY COMPLETELY RESOLVE WITH PAIN MEDS AND BY THE TIME THEY GET SEEN
dx:
- CT head within 6 hrs of sx
- LP if high sus and neg CT (more evidence now for MRA.CTA instead of LP)
- LP: increased opening pressure, xanthochromia, increased RBCs (make sure not traumatic lumbar tap and no declining RBCs in successive tubes)
managment:
- ABCs
- BP control to prevent bleeding from aneurysm: SBP < 160** (use labetalol, nicardipine)
- reverse coagulopathy: fix thrombocytopenia (< 100k platelets) with platelet transfusion, warfarin reversal with PCC and vit K
- prevent cerebral vasospasm with NIMODIPINE 60 mg
things that lower seizure threshold
MC trigger: subtherapeutic drug level of anticonvulsant -> Noncompliance with anti-epileptic meds
Alcohol withdrawal/intoxication
Certain drugs (e.g., bupropion, tramadol, isoniazid/INH)
Infection (meningitis, encephalitis)
Metabolic derangement (hypoglycemia, hyponatremia)
Drug use (stimulants like cocaine, meth)
Sleep deprivation
Hormonal changes (e.g., pregnancy)
🧪 Metabolic & Physiologic
Hypoglycemia
Hyponatremia / hypernatremia
Hypocalcemia
Hypoxia
Fever (esp. in kids: febrile seizures)
💊 Medications & Substances
Bupropion
Tramadol
Theophylline
Fluoroquinolones
Isoniazid (INH) — give vitamin B6 (pyridoxine) to treat seizures
Antidepressants (e.g., TCAs, SSRIs in overdose)
Antipsychotics
Withdrawal: Alcohol, benzos, barbiturates
Illicit drugs: Cocaine, amphetamines
🧠 Other Triggers
Sleep deprivation
Flashing lights (photosensitivity)
Missed anti-epileptic meds
Order correct medications for an active seizure
- POC glucose first: If hypoglycemia: Give 50% dextrose, If on INH: Give vitamin B6 (pyridoxine)
- 1st line: benzos - IV LORAZEPAM repeat in 5-10 mins if needed; RSI if non-responsive to first few doses of benzos
- 2nd line: anticonvulsants - PHENYTOIN, levitiracetam, valproic acid
- 3rd line: sedation - PROPOFOL 1.5 mg/kg IV
management of status epilepticus
management of patient presenting with a first time seizure vs a patient with a previous history of seizures + pregnancy w seizure
both: POC glucose, CBC, CMP, pregnancy test
first time:
- get a CT/MRI
- Consider LP: if febrile, immunocompromised, or meningeal signs
- Toxicology screen if suspicion for ingestion
- TB pt on INH with first time seizure: consider giving vit B6 - pyridoxine to stop convulsion
hx of epilepsy:
- get anti-epileptic drug level
- assess triggering factors: lack of sleep, change in meds, vomit. meds that lower threshold
- consider loading dose of anti-epileptic in pts who are subtherapeutic
- no routine imaging unless new features
if pregnant:
- give mag sulf 4-6 g IV bolus then infusion
- control BP with labetalol, hydralazine
- fetal monitoring
