Neurology
Brain
Stroke
- H&P: Ischemic stroke risk factors parallel ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent focal neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer. Different brain areas cause different stroke syndromes, such as thalamic strokes (pure sensory), insular strokes (pure motor), left MCA (dysphasia), right MCA (left arm and face), cerebellar (ataxia, poor coordination), posterior cerebral artery (homonymous hemianopsia), ACA (personality changes, leg weakness)
- Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
- Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. Prevention includes aspirin, statin, clopidogrel, blood pressure control, rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).
Hematoma
Vessel affected | History | Imaging | |
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Epidural | Middle meningeal artery | High energy impact (e.g. MVA), Lucid interval | Lens shaped (high pressure arterial bleed compresses brain); doesn't cross suture lines (due to tethering of the dura to skull) |
Subdural | Bridging veins | Old person or alcoholic with a fall (low energy) | Crescent shaped (low pressure venous bleed doesn't compress); may cross suture lines |
Headache
H&P | Treatment | Prophylaxis | |
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Migraine | F > M, throbbing, unilateral, aura, nausea, vomiting, photophobia, phonophobia, visual disturbances, family history, hours to days | NSAIDs, SQ triptans, CGRPs | AEDs (topiramate, valproate), Beta blockers (propranolol), Verapamil, low-dose TCAs (amitryptaline), zonisamide, botox, CGRPs |
Cluster | M > F, sharp/stabbing, unilateral, retro-orbital, occurs at the same time each day, resolves quickly; exam reveals Horner syndrome, ipsilateral nasal congestion, conjunctival injection, lacrimation | 100% O2, SQ triptans | AEDs (topiramate, valproate), Verapamil, lithium, steroids |
Tension | dull/tight/pressure, bilateral, band-like, can extend into the neck and shoulders, triggered by stress, lasts up to 7 days | NSAIDs/APAP, massage, heat, relaxation | Avoid triggers |
Seizure
- H&P: Aura, can have a guttural cry at onset, symmetrical rhythmic convulsions, eyes remain open and deviate towards contralateral side during focal phase, lateral tongue lacerations, bowel/bladder incontinence, post-ictal state, post-seizure myalgias, can have transient weakness that mimics stroke (Todd paralysis)
- Dx: EEG. Differentiate between focal (simple and complex) and generalized (grand mal, petit mal, myoclonic, atonic). Differential includes metabolic (hepatic encephalopathy, hyponatremia, hypomagnesemia, hypercalcemia, hypoglycemia), infectious (meningitis), intoxication (e.g. INH, Bupropion), EtOH withdrawal, neoplastic (brain tumor), vascular (aneurysm, stroke, hemorrhage, dissection). To evaluate for secondary causes, get CBC, BMP, LFTs, EtOH level, urine tox screen, AED levels, consider MRI in an adult with first-time seizure.
- Tx: AEDs (no first line agent, decide on a case-by-case basis). For status epilepticus, ABCs, give IV lorazepam, fosphenytoin if seizure persists, consider induced coma if all else fails.
Drug | Spectrum/Indications | Side effects |
---|---|---|
Levetiracetam (Keppra) | Broad | Suicidality |
Lamotrigine | Broad (also mood stabilizer) | SJS |
Valproate | Broad | Teratogenic, weight gain, hair loss, tremor, liver failure |
Topiramate | Broad (also migraine ppx) | Cognitive impairment, weight loss, kidney stones |
Carbamazepine | Narrow (focal, also trigeminal neuralgia) | Hyponatremia, pancytopenia |
Phenytoin | Narrow (focal) | Gingival hyperplasia, bone demineralization, drug-induced lupus |
Ethosuximide | Narrow (Abscence) | Sedation |
Brain Death
- Dx: Must have SBP > 100, temp > 36°C, PaCO2 35-45, euvolemia, off all sedatives. If these conditions are met, test for brainstem reflexes: pupillary reflex (II, III), corneal reflex (V, VII), doll's eye reflex (III, IV, VI, VIII), and gag reflex (IX, X). If no brainstem reflexes, do apnea test: positive if no breathing when PaCO2 is 60 mmHg or 20 mmHg higher than patient's baseline. If apnea test is equivocal, can do four vessel angiography, EEG, or duplex US. Rule out secondary causes of coma (e.g. test for severe hypoglycemia)
- Tx: If two physicians agree on diagnosis, withdraw care (even in absence of family agreement)
Vertigo
- H&P: Differentiate between dizziness and lightheadedness. Peripheral and central vertigo present differently. Peripheral is positional, improves with eye fixation or closure, and central is more likely to have focal neural deficit.
- Dx: Nystagmus is rotary, unilateral, and fatigable in peripheral vertigo. In central vertigo, nystagmus is bilateral, sometimes vertical (highly specific). No headache, no CNS findings, mild ataxia, that lasts seconds (BPPV), minutes to hours (Ménière disease), more than a day (acute vestibular neuritis or labyrinthitis) or is variable duration (MS, chronic otitis media, acoustic neuroma). No headache, no CNS findings, moderate-severe ataxia with (VBI-vertebrobasilar insufficiency) or without (acute vestibular neuritis or labyrinthitis) falling.
- Tx: Treat underlying cause. For BPPV, the Epley maneuver, PT, antihistamines, benzos, and scopolamine can all help.
Spinal Cord
Spinal Cord Compression
- H&P: Low back or neck pain associated with limb weakness, sensory changes
- Dx: Sensory level, pain, weakness, numbness, or hyperreflexia below the level of compression, bowel/bladder incontinence and saddle anesthesia with cauda equina. Stat MRI. Differential includes tumor, disc herniation, osteomyelitis, epidural abscess, aneurysm, epidural/subdural hematoma, fracture
- Tx: Based on etiology. Don't give steroids for infection. May need neurosurgical decompression.
Spinal Stenosis
- H&P: Neurogenic claudication-low back pain that radiates to the buttock that is worse with spinal extension, walking downhill, and standing, better with walking downhill and leaning forward. Negative SLR.
- Dx: Degenerative changes and neuroforaminal narrowing on xray or MRI.
- Tx: NSAIDs, PT; multimodal, MNB, MND, ESI, laminectomy
Transverse Myelitis
- H&P: Inflammatory spinal cord process without compression but with weakness, numbness, and autonomic dysfunction below the level of the lesion.
- Dx: Bright area on MRI. Test CSF to rule out HSV, VZV, Lyme, MS.
- Tx: IV glucocorticoids. Plasma exchange.
Cord Syndromes
Syndrome | Spinal Tracts Involved | Presentation |
---|---|---|
Syrinx | Spinothalamic decussation at ventral commissure, then corticospinal tracts | Loss of pain and temperature bilaterally at the level of the lesion, followed by weakness |
Brown-Sequard | Hemi-cord dissection | Contralateral loss of pain and temperature, ipsilateral weakness and loss of light touch, vibration, and proprioception |
Anterior | Spinothalamic, Corticospinal | UMN syndrome at the level of the lesion, loss of pain and temperature below the lesion |
Posterior | Dorsal columns | Loss of light touch, vibration, and proprioception bilaterally below the level of the lesion |
Anterior Horn Cells
Amyotrophic Lateral Sclerosis
- H&P: Idiopathic progressive destruction of upper and lower neurons with pure motor symptoms
- Dx: Combined UMN and LMN symptoms. EMG shows denervation and re-innervation, fasciculations.
- Tx: Riluzole, Edavarone
Nerve Roots
Radiculopathy
- H&P: Lower back or neck pain that radiates down the arms or legs.
- Dx: Acute onset pain is usually due to herniated disc. Chronic pain is usually due to spondylosis. Straight leg raise is positive in lumbar radiculopathy. Spurling maneuver (extend the neck and rotate to the side of the pain, then apply downward pressure) is positive in cervical radiculopathy.
- Tx: NSAIDs, PT, ESI, discectomy
Peripheral Nerves
Bell Palsy
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Carpal Tunnel Syndrome
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Neuromuscular Junction
Myasthenia Gravis
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Lambert Eaton Myasthenia
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Muscle
Muscular Dystrophy
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Movement Disorders
Parkinson Disease
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Huntington Disease
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Autoimmune Disorders
Guillain-Barré syndrome
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Multiple Sclerosis
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Neuropsychiatric Disorders
Dementia
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Wernicke-Korsakoff Syndrome
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