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?
What is the DSMV criteria for delirium?
What are the choices of Ix for delirium according to clinical presentation?
What is management of patients with delirium?
What is general features of delirum tremens?
How to make a dx?
What is management of delirium tremens?
What is the cause of wernickes encephalopathy?
What is the complication?
What is classical triad?
What is criteria for wernickes encephalopathy in alcoholics?
What are predisposing factors?
What is the management of wernickes encephalopathy:?
What is supportive management of acute stroke?
What is specific therapy for ischemic stroke?
What is specific therapy for intracerebral hemorrhage?
What is secondary prevention of acute stroke?
What are Ix for subarachnoid hemorrhage?
What is Ix of subarachnoid hemorrhage?
What is general management of tonic clonic status epilepticus?
What is management of stage 1 tonic clonic status epilepticus: stage of early status (if seizure ongoing for 5-10mins)?
What is management of stage 2 tonic clonic status epilepticus: stage of established status (if seizure persists for 10-30mins)?
What is management of stage 3 tonic clonic status epilepticus: stage of refractory status (seizure desite BDZ and 1 AED treatment)?
What is management of stage 4 tonic clonic status epilepticus: stage of super refractory status epilepticus (SE which has been continued or recurred despite therapy with GA for 24 hours or more)?
