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ITE Review: Must Know NeuroStroke:-ischemic vs. embolic vs hemorrhagic-Hx of TIA (30-50% will have stroke in 5 years)-Carotid Bruit- greater than 70% increases incidenceMimic strokes-seizure (todd’s paralysis), migraine, tox/metabolicIschemic stroke-MCA: most common site, aphasia if left sided, upper ext. more severe-Anterior: sensorimotor greater in LE, loss of frontal lobe control-Posterior: CN III, memory, supplies occipital cortex-Vertebrobasilar: cerebellar signs, pain and temp deficits-Basilar: locked in syndrome-Lacunar: can affect both ACA and PCA, can be….-pure motor-pure sensory-clumsy hand-dysarthria-leg paresis and ataxiaHemorrhagic SyndromesSAH- nontraumatic-35-65 women (<40 male predominance)-from rupture of saccular (berry) aneurysm-sudden onset HA (unusual or thunderclap)-CT most sensitive in the 1st 12 hours, 5% have neg head CT (ie do LP)-LP findings: RBC count that does not decrease, xanthochromia (can take 12 hrs to develop)-angiography (CTA) not routineHTN ICH-Putamen most common: looks like MCA with decreased consciousness-Cerebellar: catch it early as treatable with surgical decompression-Thalamic: sensory > motor-Pontine: occipital HA with rapid progression to coma (poor prognosis)Treatment of Stroke:-time sensitive TPA, know it!-no TPA, give ASA within 48 hours-HTN in ischemia, don’t treat unless SBP >185 or DBP >110-labetalol (or nicardipine)-no Nitroprusside (or hydralazine), increase ischemia-HTN in hemorrhage- unclear goal BP, but treatSeizures:-incidence 1-2% population-etiology: primary vs secondary-primary: epilepsy (usual onset 10-20 years)-secondary: intracranial (mass, abscess, trauma) extracranial (tox, uremic)Partial -simple: focal and no loss of consciousness-complex: focal with impaired consciousnessGeneralized-non-convulsive: absence (brief, think school aged child)-convulsive: tonic-clonic, grand malTodd’s Paralysis-focal paralysis following seizure-usually lasts 1-2 hours (can last 1-2 days)Seizure vs. Syncope-no warning vs prodrome of darkened vision/nausea-tonic-clonic activity vs. brief clonic movements-prolonged postictal vs no postictal Work up First Time Seizure-glucose and NA-possible tox/ETOH, LP, CXR (aspiration)-CT head if…..-focal deficit, HA, head injury, status, prolonged postictal-high risk for mass lesion (HIV)Status Epilepticus-persist greater than 5 minutes or repetitive without return to baseline-mortality can be as high as 30%Adult Treatment-thiamine and glucose (if low or suspect ETOH abuse)-magnesium for ecclampsia-pyridoxine for INH OD (refractory to all other treatment)-Benzos -> phenytoin/fosphenytoin -> phenobarb -> barb coma (clinically keppra in there with Dilantin)Pediatric Treatment-glucose, calcium for neonates-benzos -> fosphenytoin -> phenobarb-rapid Dilantin infusion: hypotension and dysrhythmiasPeripheral Neuropathies-both motor and sensory deficit-impairment symmetrical and greater distal than proximal-Diphtheria: acutely ill, membrane pharyngitis, motor-Tetanus: trismus, tetany, twitching, tightness with increased sympathetic -Guillain-Barre – preceding viral illness, increased CSF protein-Tick Paralysis- looks like GB, search for tickDisorders of the Neuromuscular JunctionMyasthenia Gravis-autoimmune that destroys acetylcholine receptors-proximal muscle weakness-exacerbated by activity-ptosis, diplopia and blurred vision, most common initial symptoms-diagnose with edrophonium test or electromyogram-Myasthenic crisis-undiagnosed or untreated-severe weakness, respiratory compromise-edrophonium 1-2 mg IV test, then more if improved-Cholinergic Crisis-too much acetylcholinesterase inhibitor-edrophonium test increases weakness then give atropineEaton-Lambert Syndrome-disorder of neuromuscular transmission-oat cell CA of lung-CN spared, grip strength increases with repetitionBotulism (food-borne)-preformed toxin-prevents release of acetylcholine-symptoms in 24-48 hours-earliest and most common blurred vision, diplopia-floppy baby – raw honeyMyopathies-proximal weakness (getting up from chair, climbing stairs)-sensory symptoms absent-DTR intact-abnormal lab test- increased WBC, sed rate, muscle enzymes-polymysitis, steroid, alcoholic, hypokalemicVolkmann’s Ischemic Paralysis-complication of compartment syndrome-treat compartment syndrome to prevent-paralysis with eventual contractureIsolated Peripheral NeuropathiesTrigeminal Neuraliga (Tic douloureux)-excruciating, lancinating pain-CN V distribution, right side of face most common-elicited by tapping trigger zones-tx is carbamazepineBell’s Palsy-unilateral facial nerve paralysis (CN VII)-Ramsay-Hunt: herpes zoster, look in ear!-Lyme disease: bilateral Bell’s-steroids, eye protection, +/- antiviral, ENT referralMyelopathiesSyringomyelia-fluid filled cavity in the spinal cord-dissociated sensory loss, pain and temp, ‘capelike’MS-demyelinating disorder-think subtle vision problems-can be episodic-UMN weakness, hyperreflexia, LMN sensory/bladder/bowelTransverse Myelitis-post viral or toxic inflammation of the cord-think distinct level of cord and below (no pain and temp, paralysis)Epidural Mass Lesions-hematoma, abscess, disc herniation, mass lesion-acute pain, radiating electrical sensation, progressing cord compression-watch out for cauda equinaDorsal Column Disorders-syphilis, vitamin B12-loss of position, vibration and light touchTraumatic Brain InjuryCerebral Contusion-focal hemorrhage and edema (coup/countercoup)-commonly frontal, sub-frontal and anterior temporal-non contrast CT-temporal lobe high risk expanding and dangerous edema, ICU monitoring-Concussion: know when to image/ esp kidsSubdural Hematoma-tearing of the bridging veins-collect under dura-‘half moon’, crossing suture lines-think elderly and ETOH-acute vs subacute vs chronicEpidural Hematoma-‘coup injury’ from trauma-tear of middle meningeal artery-classic lucid interval (may have no initial LOC)-with herniation ipsilateral pupil dilatation-convex or ‘lens shape’ICH-delayed, hours or days after injury, usually from contusionCerebral Edema-from head trauma causing increased ICP-CPP = MAP – ICP-CO2 regulates cerebral blood flow, increased means increased flow (ICP)-controversial hyperventilation, don’t go too far (goal 30-35)-remember cushing reflex (HTN, brady)-watch for herniation (blown pupil, decreased LOC, posturing, doll’s eye)-RAISE THE HEAD, oxygenate, get neurosurg, CO2 35CSF Leak-usually from ear or nose, look for intracranial air-clear halo ring-infection is the complication-most resolve spontaneously-consult NSHerniation Syndromes-mass, edema, ICP can displace tissue-Uncal: temporal, ipsilateral pupil, cheynes-stokes, coma/death-Central: compresses brainstem, fixed mid pupils, eventual respiratory-Cerebellar tonsillar: medullary compression, flaccid quad, CVCSkull Fractures-routine xrays not indicated, get CT-NS consult-Basilar: raccoon eyes, battle sign, hemotympanum, CT might miss, blood-air interface in the sphenoidTBI Complications-Immediate (48hrs): SZ, ‘talk and deteriorate’-Early (one week): SZ, DI, DIC, CSF leak, dysrhythmias, pulmonary edema-Late (after one week): SZ-Post concussive syndrome: HA, memory, concentration, organic brain damageVertigoCentral-ominous prognosis-brainstem or cerebellar lesions-mild continuous last longer than one minute-nystagmus increased by visual fixation-look for dysmetria, ataxia-DON’T SEND THESE PATIENTS HOMEPeripheral-85% self limited-ear or CN VIII-sudden, intense, intermittent-nystagmus suppressed by visual fixation, never vertical-NO NEURO FINDINGS-Meniere’s- 40-60, vertigo with tinnitus, sensorineural deafnessabrupt onset last minutes to hours-Tx: antihistamines, anticholinergicsCOMA-TIPS – AEIOU-find underlying cause-know how to support and treat-Coma Cocktail: narcan, glucose, thiamine, O2HeadacheMigraine-usually have aura-know treatment (NSAID, triptan, reglan, steroids for status, opiates)Cluster-25 or so MALE, burning HA one sided-give 100% O2, tapering course of steroidsTemporal arteritis-inflammation of one or more branches of the external carotid-FEMALE, 50 years, throbbing, burning one side (think forehead)-Sed rate usually greater than 50-Blindness is the complication-steroids large doses-ophtho/neuro consultTension-tight bandPseudotumor Cerebri-young, obese female-blurred vision and papilledema-LP with increased pressureCervical Spine InjuriesKnow stable vs. unstable fractures-Stable: simple wedge, clay-shovelers, pillar fxCentral Cord Syndrome-elderly, forced hyperextension (you intubating)-weakness greater in the arms than legsAnterior Cord Syndrome-flexion injuries-complete motor and loss of pain and temp-dorsal column intact, normal light touch, vibration, positionBrown-Sequard-penetrating usually-hemisection: ipsilateral motor with loss of position and vibration withcontralateral pain and tempSpinal Shock-hypotensive and stable brady-warm pink skin, normal urine output-loss of sympathetic toneMeningitis General-don’t delay antibiotics-CT before LP with AMS or focal deficit-know CSF analysisEtiology-0-4 weeks: e. coli, GBS, think listeria-3 months to 18yrs: strep pneumo-18-50: neisseria, strep pneumo->50/ETOH: think listeria againAntibiotic-neonate: cefotaxime and amp (gent and amp)-infants: ceftriaxone and amp (possible vanc)-adults: ceftriaxone (vanc)-greater than 50: ceftriaxone and ampSteroids-some controversy-before antibiotics-adults with suspected pneumococcal ................
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