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Neurology

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What should you consider in your differential for AMS?

  • Neuro (CVA/Seizure), Metabolic (sugar, uremia, Ca/Na, hepatic), Drugs/Alcohol, Infx, resp (hypoxia, hypercapnia), constipation/urinary retention

 

What should your work-up for AMS include?

  • Accucheck, ABG, CBC, CMP, CT head if concerned, infection workup, KUB/bladder scan, evaluate for any recent opiates (consider naloxone)

  • Additional work up - UDS, UA, B12, and TSH

  • Consider LP if concerned for meningitis and EEG if it is a fluctuating mental status or associated with seizure like activity

 

What medications should be ruled out as the cause of AMS?

  • Sedatives including anticholinergics and benzodiazepines

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Most common type?

  • Tension: generally bilateral, pressure/ tightness, mild-moderate, no significant photophobia/ phonophobia/ nausea


First line for tension HA?

  • Acetaminophen, TCAs, SNRIs

 

Dx for migraine? 

  • Recurrent head pain 4-72 hrs, must have 2/4 (unilateral, throbbing, mod-severe intensity, worse with physical activity) and association with N/V or photophobia+phonophobia

 

First-line for episodic migraine? 

  • NSAIDs 

Second-line? 

  • Triptans

Preventative?

  • TCAs, propranolol, topiramate, VPA

 

How can you distinguish migraines from cluster headaches? 

  • Cluster headache pain is unilateral and pain <3 hours, often with lacrimation, rhinorrhea, sweating, swelling of face, visual changes

 

Acute therapy for cluster HAs?

  • Supplemental O2, triptans, indomethacin

 

What is defined as a medication overuse HA?

  • HA at least ½ the days of the month, with medication intake at least ½ the days of the month. HA worsens despite increased intake of medication.

  • Treat by stopping offending medication, typically with taper. Can give daily ppx med.

 

Headache red flags?

  • Neurologic symptoms, thunderclap headache, systemic symptoms, postural component, age>40, progression or evolution in previous HAs, preceding trauma, HA awakening pt from sleep, no HA-free intervals

  • Imaging and further w/u necessary if red flags present

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What are the hallmarks of each dementia diagnosis?

  • Alzheimer’s: impaired memory, minimal motor/hallucinations/delusion sxs

  • Dementia with Lewy bodies: 1) Parkinsonism 2) Hallucinations 3) Rapid eye movement sleep behavior d/o 4) Attention fluctuation

  • Parkinson’s: Motor sxs must precede cognitive impairment by >2 years

  • Frontotemporal: Behavioral/personality/language sxs, poor insight

  • NPH: 1) Gait changes, 2) urinary incontinence, 3) cognitive impairment

  • Vascular dementia: Early gait impairment (stepwise), personality/mood changes

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Causes of provoked seizures?

  • Electrolyte abnormalities, hypo/ hyperglycemia, medications, CNS infections

 

What is status epilepticus?

  • Either single seizure >5 min or >/=2 seizures without return to baseline in between

 

Treatment for convulsive status epilepticus? 

  • IV benzo (e.g., lorazepam 2mg IV q1-3 min up to 0.1 mg/kg)

  • After 2 rounds of benzos, antiepileptics if still in status (e.g., levetiracetam 30-60 mg/kg)

  • If still seizing, will need intubation and EEG when paralyzed/ sedated

 

What is the positive predictive value (PPV) and negative predictive value (NPV) for tongue biting in a seizure? 

  • High PPV, low NPV

 

What is the first-line anti-epileptic medication with the best safety and efficacy profile?

  • Lamotrigine

 

How is drug-resistant epilepsy managed? 

  • Defined as ongoing seizures despite trials of two tolerate, adequately dosed anti-epileptic medications; obtain MRI brain and continuous video EEG to confirm diagnosis of temporal lobe epilepsy and evaluate for temporal lobe resection

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What kinds of strokes are there?

  • Ischemic stroke (~70%) = most common, arterial occlusion leading to ischemia

    • Large artery atherosclerosis = plaque rupture

    • Cardioembolic = infarcts in multiple territories from embolic “shower”

    • Lacunar infarct = isolated sensory/motor sxs

  • Hemorrhagic stroke (15-30%) = ICH or SAH

  • TIA = sxs <24 hrs

  • Obtain stat CTH for any suspected stroke, as this will guide your management

 

Indications and contraindications for alteplase (TPA)?

  • Indication: Acute ischemic stroke with symptom onset <4.5 hours

  • Contraindications: head trauma in last 3 months, suspicion of SAH or recent intracranial/spinal surgery, active internal bleeding, platelets <100,000, on home AC, glucose <50 tPA Contraindications for Ischemic Stroke - MDCalc

  • BP must be <185/1110 for TPA → use nicardipine or labetalol to bring BP within range before administering

 

Indications for endovascular therapy?

 

Work-up after a stroke?

  • Obtain EKG and monitor on telemetry for afib

  • Obtain TTE to determine LA/LV thrombus, LA enlargement, atheroma, PFO

  • Obtain carotid u/s or CTA to determine carotid stenosis

  • If work-up unrevealing, consider loop recorder to diagnose subclinical AF https://www.nejm.org/doi/full/10.1056/nejmoa1313600

 

Management after a stroke?

 

How long should you continue DAPT after an ischemic stroke? 

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What is recrudescence?

  • Reemergence of prior stroke symptoms

 

What are some triggers for recrudescence?

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Mainstay of treatment? 

  • BP control to ~140 systolic

  • mannitol or hypertonic saline if significantly elevated ICP

  • surgery for cerebellar hemorrhage >3 cm

  • Reverse coagulopathies and keep platelets >100k

 

DVT ppx in cranial surgery? 

  • Mechanical prophylaxis >> no prophylaxis

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How is MG diagnosed? 

  • Acetylcholine receptor antibodies (AChR)

  • Muscle pecific tyrosine-kinase antibodies (MuSK)

  • Low-density lipoprotein receptor-related protein 4 abs (LRP4)

  • Seronegative (need electrodiagnostic testing to confirm diagnosis)

 

What are the exam findings of MG?

  • Ptosis, nasal speech, weak neck flexion/ extension, winded speech

 

Treatment?

  • Monitor NIF at baseline and q4h

  • IVIG or PLEX

  • Steroids (up-titrated slowly)

  • Pyridostigmine

  • Treat underlying cause of exacerbations and check to see if medications are the culprit (e.g., fluoroquinolones, aminoglycosides)

 

Indications for thymectomy? 

  • Thymoma or patients age <65 within 3 years of dx to minimize immunotherapy

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Diagnostic criteria for MS? 

  • Modified McDonald criteria: evidence of CNS damage disseminating in time (acute and chronic) and space (>/= 3 demyelinating lesions, 1cm, periventricular/ juxtacortical/ infratentorial) 

  • MRI with and without contrast can identify plaques and determine if they are more acute (active plaques can enhance for weeks)

  • LP with oligoclonal bands

 

What are the types of MS? 

  • 85% patients have relapsing-remitting course (develops age ~30)

  • 15% patients have primary progressive (develops at age ~50)

 

What are the most common clinical manifestations of MS? 

  • Optic neuritis, myelitis, brainstem/cerebellar syndromes (leading to nystagmus, INO, disconjugate eye movements, ataxia)

 

What is an MS relapse? 

  • New or worsening neuro sxs lasting >24 hrs

 

Treatment of an MS relapse? 

  • High-dose steroids - methylprednisolone 1 g/d x 3-5 days; studies have shown that oral glucocorticoids are equally effective

 

What is an MS pseudo relapse? 

 

Maintenance therapy for MS? 

  • Ocrelizumab for primary progressive and mitoxantrone, siponimod, and cladribine for secondary progressive

  • Dalfampridine can improve mobility

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Cardinal signs of Parkinson dz? 

  • Resting tremor (typically very early symptom, worse on one side) 

  • Bradykinesia (slowness with amplitude of repetitive movements) 

  • Cogwheel rigidity (resistance to motion) 

  • Gait/balance impairment - shuffling gait with reduced arm swings, stooped posture, imbalance with turning

 

How do you distinguish an essential tremor? 

  • Bilateral upper extremity that occurs with action; associated with +Family history, slow progression, starts in adolescence/middle age

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How do you treat Bell’s palsy? 

  • First-line treatment is Prednisone (60-80 mg/day for 1 week); can be given as 5 day course followed by short taper or a full week course. High-quality randomized studies demonstrate that steroids improve outcomes and reduce incomplete recovery 

  • https://pubmed.ncbi.nlm.nih.gov/27428352/ 

  • Consider anti-virals (valacyclovir or acyclovir) in severe Bell’s Palsy (defined as House-Brackmann grade IV or higher). Evidence is mixed and inconclusive

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How does GBS present?

  • Acute, ascending paralysis + paresthesias, decreased or absent deep tendon reflexes in arms/ legs in ~90% at presentation

  • Usually preceded by acute GI illness (ex. Campylobacter) or viral illness

 

What is the diagnosis/ management of suspected GBS?

  • Must do lumbar puncture → look for elevated protein and a normal cell count (albuminocytologic dissociation)

  • Consider NCS and EMG to support diagnosis and to provide prognostic info

  • Treat with IVIG (2000/mg/kg) x 2-5 days or plasma exchange

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What types of syncope are there?

  • Neurally mediated (vasovagal, situational): prodromal symptoms

  • Cardiovascular: arrhythmia, CAD, valvular disease, PE

  • Orthostatic: caused by hypovolemia, meds, alcohol use

  • Neurologic: TIA, seizures, strokes

 

What should your work-up for syncope include?

  • History of prodromal, postepisode symptoms (ex. Urinary incontinence)

  • Orthostatics

  • EKG, sometimes ambulatory monitor or loop recorder at discharge

  • TTE, if concerned for valvular issue

  • No recommendation for CTH or MRI if no focal deficit on exam

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