different types of strokes
thrombotic
embolic
hemorrhagic
basics on thrombotic stroke
“stem” - distal of clogged vessel affected
risk factors for thrombotic stroke
HTN HLD DM Obesity Age Smoking Family hx
embolic stroke basics
clot from the heart due to afib
valve issue
dissection
carotid artery stenosis
MCA supplies
Face
Arms and Hands
Speech
ACA supplies
legs and feet
PCA supplies
visual cortex
basilar Artery compromise leads to
locked in
vertebral artery compromise leads to
syncope
cerebellum issues lead to
ataxia
cushing reflex basics and causes
bradycardia along with hypertension
seen in intracerebral hemorrhage
blood in the parenchyma =
intracerebral hemorrhage
blood around the brain =
Subarachnoid hemorrhage
next step after seeing a hemorrhagic stroke on non con CT head
decrease BP
send to ICU
if INR up —> give FFP
contact neurosurg
—> coil (SAH, clip or craniotomy
work up after ischemic stroke is dx on CT head noncon
EKG –> afib/a flutter - tx - warfarin or NOAC (no bridge)
2D Echo –> thrombus - tx - warfarin or NOA with bridge
Carotid US - carotid artery stenosis
- –> <70% and no symptoms - tx - medically
- –> >80 or >70 with symptoms - tx - endocardectomy or stent with 2weeks
contraindications to TPA
prior ICH
recent GI bleed or other major bleed
recent surgery
when can you give TPA
< 3 hrs
< 4 hrs if non diabetic
acute stroke tx
TPA if they meet requirements
ASA 325m
control DM
BP - permissive HTN (220/120)
chronic stroke tx
LMWH - if at risk for DVT
anticoagulate - if afib/flutter or valve
ASA 81 mg +/- dyprimadol or clopridogrel if resistant
HgbA1c < 8%
control BP with ACE-I or diuretics
def of generalized seizure vs partial
generalized - whole body is involved
partial - part of the body is involved
complex seizures vs simple seizure
complex - LOC
simple - no LOC
1st time seizure causes
V - vascular - CVA I - infection - meningitis/encephalitis T - Trauma - brain bleed A - autoimmune - SLE M - metabolic - BG, O2, Ca, Na, Mg I - ingestion/withdrawal ( etoh/benzos) N - neoplasm S - pSych, pSeudoseizures
signs and symptoms of a seizure
LOC with limb jerking
bowel and bladder incontinence
tongue biting
post ictal confusion
Most important signs of a seizure
post ictal state
work up of a seizure
hx of epilepsy?
—> yes –> check med levels –> make adjustments
—-> No –> currently seizing —>
Yes - >5min and/or >30min no return to baseline = status epilepticus –>
NO —> EEG, MRI> CT –> check VITAMINS
tx of status epilepticus
benzo benzo benzo no good fosphenytoin (IV) no good midozalam + propofol no good phenobarbital
antiepileptic drugs
valproate (#1 since its cheap)
lamotrigine
levetiracetam (keppra)
types of seizures
atonic
myoclonic
absence
trigimenal neuralgia
atonic seizures
No LOC
(+) loss of tone - collapse helmet kids
tx - valproate
myoclonic seizures
No LOC
Unnecessary tone present
tx - valproate
absensce seizures
kids
+ LOC
No loss of tone
tx - ethosuximde
trigimenal neuralgia
CN V issues
Tx - carbamezapine
path of parkinsons disease
loss of dopaminergic neurons in substantia niagra
presentation of parkinsons disease
1) bradykinesia - masked face, trouble getting started
2) cogwheel rigidity - no fluid
3) resting tremor - pill rolling
4) gait/postural instability - shuffling steps
tx of parkinsons disease
<70 and function –> dopamine agonist such as ropinerol, promipraxole (bromocriptine)
> 70 or non function –> levodopa + carbodopa –> add COMT-I and/or MAO B-I –> deep brain stim
carbadopa MOA
prevents the conversion of levodopa into dopamine in the periphery
essential tremor
familial
Male 40-60s
Tremor occurs with movement
No tremor at rest
Tx - propranolol
intention tremor
path - Cerebellar dysfunction (CVA) or etoh
No tremor at rest
Tremor with movement that gets worse in amplitude the closer they get to the target
tx - none
huntington disease path
anticipation- trinucleotide repeats that get worse each generation
AD
Chr 4
Huntington disease presentation
Chorea
- purposeless, ballistic, uncontrolled movement
tx - none - psychosis, depression, suicide
red flags symptoms for a headache
FND progressive N/V especially in AM = tumor Fever Thunderclap New onset >50y/o
tension headache
path - muscular
pt - F>M under stress,
band like pattern around the head (bilateral) - vice like pain can radiate to neck
tx of tension headaches
NSAIDs or Acetaminophen
analgeseic rebound
path - withdrawal
pt - typically takes meds for HA >10/month
gets HA when they stop
tx - let them withdraw from meds
Cluster headaches
M>F, path = vascular wakes pt up from sleep unilateral behind one eye 8-10/day after being asymptomatic for a while associated with horners syndrome
dx workup should include a CT or MRI
tx of cluster headaches
O2 therapy –> triptans
prophylaxis with CCB such as verapamil
migraine headache
F>M, with family history, path = vascular
pulsatile and throbbing
debilitating, photophobia, phonophobia, N/V aura
4-72hrs
HAS A TRIGGER
tx of migraine headache
sleep will abort it
tx - mild = NSAIDs
moderate to severe - triptans, ergots (watch out for ADR of vasospasm)
prophylaxis with beta blocker such as propranolol or valproic acid topiramate
idiopathic intracranial hypertension
pseudotumor cerebri
path - increased ICP
female, obese taking OCPs
pt - papilledema, FND, N/V
dx - negative CT, LP will be diagnostic showing increased opening pressure >25
tx of idiopathic intracranial hypertension
pseudotumor cerebri
LP makes it better
tx - acetazolamide –> still there –> serial LPs –> still there –> VP shunt
musculoskeletal back pain
muscle spasms
young male recently lifting heavy things
belt like = dx
dx - clinical
tx - NSAIDs and exercise recheck in 4wks
alarm symptoms in back pain that require further workup
bowel/ bladder incontinence
saddle anesthesia
FND that are new or rapidly progressing
workup of back pain + alarm symptoms
thinking cord compression –> give steroids –> x-ray –> MRI
hematoma - drain it
abscess - I&D and abx
cancer - radiation
fracture - surgery fix t
disc herniation
path - nucleus pulposis pinching the nerve
pt - male 30-50s, recent heavy lifting
(+) sciatica and (+) straight leg test
dx and tx of disc herniation
dx - xray but MRI better
tx - neuro sx > conservative therapy at 6months
—-> neuro sx = conservative therapy at 1 yr
Osteophyte
older male
no heavy lifting
(+) sciatica (+) straight leg test
path of osteophye
bony spur that grows into a nerve canal pinching that nerve
dx and tx of osteophyte
dx - xray –> MRI
tx - surgery
compression fracture
path - osteoporosis pt - old person, female who fell on her butt (-) straight leg test (+) vertebral step offs (+) pinpoint tenderness on mid spine
dx and tx of compression fracture
dx - xray (MRI if you need it)
tx - surgery
f/u dexa scan to fix osteoporosis which you could see on xray as osteopenia
spinal stenosis
path - narrowing of canal pinching Nerve
pt - old, pseudocladuciation that is positional - worse when upright and walking around
dx and tx of spinal stenosis
dx - xray –> MRI
tx - laminectomy
Amnesia basics
memory loss
no cognitive impairment
delirium basics
AMS that is acute, overt, waxes and wanes
cause = UTI typically
workup to see if reversible dementia
TSH, T4 vit B12 BMP - BUN/Cr LFTs RPR Depression CT > MRI
creutzfeld jacob dz
priors
undercooked meat or sporadic mutations
young dementia that progresses rapidly
myoclonus
Alzheimer basics
path - plaques and tangles, chr 21
memory loss goes 1st (short then long term memory)
down syndrome pts at risk
spares social graces
dx and tx of alzheimers
dx - clinical - CT may show diffuse cortical atrophy
tx - supportive, family counseling, tacrine, donepezil
Picks disease
frontotemporal degernation
personality goes frist - hypersexual, hyperaggresive
dx - clinical CT -may show frontotemporal degernation
tx - supportive
lewy body dementia
path - parkinsons disease
pt - dementia with parkinson symptoms
* visual hallucinations*
mri - loss of substantia nigra - dx = clinical tho
vascular dementia
path - CVA
stepwise decline with each stroke
normal pressure hydrocephalus
path - increased ICP
wet- incontinent
wobbly - ataxia
weird - personality/actions
dx and tx of normal pressure hydrocephalus
dx - CT - hydrocephalus + relief when LP performed
tx - VP shunt
central vertigo signs
+ brain lesion signs
+ FND
no hearing loss
no tinnitus
peripheral vertigo signs
+ tinnitus
+ hearing loss
No FND
No brain stem lesion signs
causes of central vertigo
posterior fossa insults seen on MRI
examples of posterior fossa insults
MS, CVA, Tumor
Abscess, migraines (complex), weird seizures
pt - FND present and cerebellar signs no ear issue
3 causes of peripheral vertigo
BPPV
Vestibular neuritis (labrynth neuritis)
Meineires Dz
BPPV
path - otolith (stone) hits a hair brain thinks body is in motion
pt - recurrent and reproducible vertigo <1min
dx and tx of BPPV
dx - Dix hallpike - quick turn of head induces vertigo
tx - epley maunvear - get the stone out
vestibular neuritis
labrinyth neuritis is the same + hearing loss
path - post viral
pt - 4wks post URI
vertigo 1-10 min
+/- hearing loss
+/- N/V
tx of vestibular neuritis
steroids - shortens duration
meclizine - reduces symptoms
Meineres Dz
triad
1) hearing loss
2) tinnitus
3) vertigo
tx of Meineres Dz
salt restriction
HCTZ
Meclizine
Coma pt basisc
Cerebral function = depression
Brainstem reflexes = (+)
Heart =(+)
Motor = (+)
Persistent vegetative stage
cerebral function = absent
Brainstem reflexes = (+)
Heart =(+)
Motor = (+)
Brain death basics = real death
cerebral function = absent
Brainstem reflexes = absent
Heart =(+)
Motor = absent
Locked in basics
cerebral function = (+)
Brainstem reflexes = (+)
Heart =(+)
Motor = absent - except for eye blinks
types of brain stem reflexes
corneal reflex
cold water calorics
dolls eyes
corneal reflex
take a q tip touch eyeball nothing happens = brain death
cold water calorics nml person
poor cold water in right ear - eyes look right and then have nystagmus to the left and vice versa
cold water calorics in PVS
cold water in right ear - eyes look right - but no nystagmus to the left
cold water calorics in brain death
cold water in right ear - eyes dont move
warm water calorics in brain death =
opposite of cold water calorics
dolls eyes reflex
move head - eyes stay fixed
Multiple sclerosis path and pt presentation
autoimmune demyelinating disorder
women 20-40
any neuro symptoms separated by time and space
- optic neuritis *
- blurry vision
- pain with eye movements
MS dx
MRI - perventricular white matter lesions
LP - oligoclonal bands IgG
evoked potentions - demyelination
tx of MS
Flare up = steroids
Chronic = interferon, glatirauna, fingolaud
urinary retention - bethanecol
urinary incontince - amitryptilline
spasms - baclofen
neuropathic pain - gabapentin, pregabalin
Guillan barre path
autoimmune demyelination
Flu shot
recent URI
diarrhea - camplobacter jejuni
guillan barre pt presentation dx
ascending paralysis
hyperreflexia
dx - LP - lots of proteins but very few cells
tx of guillan barre
intubate
IVIG = plasmaphoresis
never give steroids - makes it worse
myasthenia gravis path
auto immune - antibodies against the Ach-receptor
blocks the receptor
pt presentation of MG
>50 y/o fatigability in most commonly used muscles - eyes - blurry vision - throat - trouble swallowing - distal extremities - coordination off
worse in evening
tx of MG
Acetylcholinesterase inhibitors to increase Ach
steroids decrease autoimmune factor in resistant disease
tx of myasthenic gravis crisis
pt having difficulty breathing
IVIG = plasmaphoresis
eaton lambert syndrome path
typically a paraneoplatic syndrome from small cell lung cancer
abs to presynaptic calcium channels
dx of MG
anti Ach- receptor antibodies
EMG
GET CT SCAN THymoma – resect = curable sometimes
pt presentation in lambert eaton syndrome
> 50 y/o,
improvement with use
so muscles not used affected the most - such as proximal weakness - getting up from chair, combing hair
dx and tx of eaton lambert syndrome
antibodies to presynaptic calcium channels
EMG
CT scan for small cell lung cancer
tx - treat lung cancer
ALS
sporadic mutations
UMN lesions + LMN lesions (sensation intact)
dx - EMG
tx - Riluzole
UMN lesion signs
hyperreflexia
weakness chronic
LMN lesion signs
fasciculations
areflexia
weakness
risk factors for ischemic stroke in a younger patient
OCPs
hypercoagulable states (antiphospholipid syndrome, protein c and s def)
Cocaine and amphetamines
sickle cell disease
peripheral vascular disease
amaurosis fuga
transient, curtain like loss of sight in the ipsilateral eye due to microembolic of retina
vertebrobasilar TIA
Dizziness, double vision, vertigo,
Numbness of ipsy face and contralateral limb
projectile vomiting
drop attacks (aka syncopal episodes)
main predisposing risk factor for lacunar strokes (aka small vessel thrombotic dz)
HTN
lacunar stroke - affects subcortical structures (basal ganglia - putamen, thalamus, internal capsule, brain stem)
pure motor lacunar stroke affects the
internal capsule affected
pure sensory lacunar stroke affects the
thalamus
subclavian steal syndrome
decreased cerebral blood flow
BP in L arm < BP in R arm (same with pulse)
upper extremity claudication
tx - surgical bypass
two possible causes of a carotid bruit
1 - murmur referred from the heart
2 - turbulence in the internal carotid artery = serious stroke risk (>70% stenosis –> tx carotid endocardectomy
CT scan appearanes of ischemic vs hemorrhagic stroke
ischemic stroke - appears dark
hemorrhagic stroke - appears white
pts who should receive a carotid US duplex
those with a carotid bruit
pts with PVD
pts with CAD
complication of ischemic stroke
cerebral edema - occurs 1-2 days after stroke and can cause mass affects
management = hyperventilation and mannitol
if giving tpa what is the BP criteria
BP <185/110
two main categories of hemorrhagic stroke
ICH - bleeding into brain parenchyma
SAH - bleeding into CSF (outside of brain parenchyma)
ICH + pinpoint pupils =
ICH + poorly reactive pupils =
ICH + dilated pupils =
ICH + pinpoint pupils = pons
ICH + poorly reactive pupils = thalamus
ICH + dilated pupils = putamen (BG)
doc for decreasing BP in a hemorrhagic stroke
nitroprusside
hallmark finding of SAH
blood in the CSF called xanthrochromia (yellowish) meaning blood has bene there for a while and it is not due to a traumatic LP
complications of SAH
vasospasm - 50% - CCB
rerupture - 30%
hydrocephalus
seizures
SIADH
what is something that markedly decreases an essential tremor
alcohol
the most important risk factor for alzheimers disease
is increasing age
other risk factors = down syndrome and early onset alzheimers
tx of alzheimers
donepezil
rivastigmine
galantamine
if asymmetry is noted in a coma pt most likely due to
mass lesion
metabolic and systemic causes of coma do not cause asymemetric motor abnormalties
brain death cannot be established in the presence of
hypothermia
EEG of brain death =
isoelectric activity )electrical silence)
abnormal pupillary light reflex + coma =
structural intracranial lesions
or
drugs that affect the pupil
bilateral fixed dilated pupils
severe anoxia
unilateral fixed dilated pupils
herniation with CN III compression
pinpoint pupils
narcotics
or
ICH
locked in syndrome
mimicks coma
paralyzed except for (breathing and eye blinking)
can feel pain and are aware of their surroundings
cause by an infection or hemorrhage in the ventral pons
tx of acute attacks for MS
high dose IV corticosteroids
baclofen or dantrolene can be used for muscle spasticity
tx of guillan barre
IV IG or plasmphoresis if severe
–> never give steroids
one thing you should always do with a mysathenic gravis pt
CT scan to r/o thymoma
medications that can exacerbate MG
abx - aminoglycosides, tetracyclines
beta blockers
antiarrhthymics - quinidine, procainamide and lidocaine
complications of neurofibramatosis
scoliosis
pheochromocytomas
optic gliomas
renal artery stenosis
syringomyelia
associated with arnold chiari malformation
bilateral loss of pain and temperature in a caple like pattern
brown sequard syndorme
contralateral loss of pain and temperature
ipsy hemiparesisi
ipsy loss of position and vibration
peripheral vertigo vs central vertigo
hearing loss and tinnitus only occur in peripheral vertigo
central vertigo only has FND
ototoxic drugs
aminoglycosides
loop diuretics
dx test for vasovagal
tilt table test
pathophys of vasovagal
compensatory sympathetic response is instead replaced by parasympathetic response
orthostatic hypotensions
defect in vasomotor reflexes
common in elderly
posture is the main cause here
complex partial seizures
consciousness is impaired
postictal confusion
olfactory or gustatory hallucinations
purposeless involuntary movements
generalized seizures
+ LOC
disruption of electrical activity of entire brain
begins with sudden LOC
tonic phase - rigid
clonic phase - muscular jerking
tx of ALS
riluzole - glutamat blocking agent can prevent death for about 3-5 months
wernickes aphasia
fluent but makes no sense
no comprehension of spoken or written language
TEMPORAL LOBE
brocas aphasia
not fluent but words make sense
speech is slow and effortful
FRONTAL LOBE
comprehension of spoken and written language = intact
conduction aphasia
disturbance in repetition
involves arcuate fasciculus between wernicks and broacs
bells palsy
CN VII weakness/paralysis
affects both upper and lower face
tx - if lyme no steroids if not lyme steroids
eye patch to protect from corneal abrasion
DOC for trigeminal neuralgia =
carbamezapine
UMN signs
+ babinskin
spasticity
atrophy comes later
LMN signs
atrophy
flaccid paralysis
fasciculations
(-) DTRs
