EM E2: Neuro

What does loss/alteration of half-body sensory suggest?

cortical or subcortical lesion

What does a localized problem suggest?

peripheral nerve/nerve root

What is Broca’s aphasia?

expressive/language production - no issue understanding speech, but struggles to form complete sentences; pt is aware

What is Wernicke’s aphasia?

receptive/language comprehension - difficulty understanding speech

What is the role of the ED for cc: HA?

identify & tx life-threatening secondary causes; tx & dc primary HA

What makes up the majority of HA complaints in the ER?

migraine HA w/o aura

What does a “thunder clap” HA (worst HA, sudden onset) indicate?

SAH

What does a HA in the occiptonuchal location indicate?

intracranial pathology

What does a HA + fever indicate?

infection (meningitis, sinusitis) or SAH

What does a HA + HTN?

HTN urgency or emergency

What is the presentation of a SAH?

severe HA, normal neuro exam, progresses to radiation of pain down cervical spine, neck pain, AMS

*neuro consult ASAP

What is the presentation of meningitis?

usually w/ fever and meningismus (stiff neck, HA, photophobia), + Kernig, + Brudzinski

*if bacterial suspected → abx tx ASAP

What causes the sx of a migraine?

vasoconstriction → aura, rebound vasodilation → pounding HA

What is the tx for migraines in pregnant women?

*migraines generally improve during pregnancy

rest, ice, NSAIDs (class B), triptans (but NOT in 3rd trimester); prevention

What are systemic manifestations of a migraine?

N/V, photophobia, phonophobia, lightheadedness

What is the key of ED care for migraines?

migraine-specific meds & analgesia: Toradol, Bendaryl, Reglan, OR zofran IV, NaCl

How do tension HA present?

B/L non-pulsating, not worsened by exertion, no N/V

*tx: analgesics, NSAIDs

How do cluster HA present?

M > F, severe U/L orbital or temporal pain x 15-180 min w/ at least one of the following: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial swelling, miosis, ptosis

*tx: high-flow O2

How does temporal arteritis present?

severe HA over frontotemporal region

How does temporomandibular disorder present?

pain on movement, dec ROM, bruxism, tongue/lip/cheek biting, ± HA

*tx: simple analgesics or NSAIDs

How does trigeminal neuralgia present?

severe U/L pain in trigeminal nerve, lasting only seconds, chronic can be constant; neuro exam normal

*tx: Carbamazepine, fail → neuro

What is a TIA?

neuro deficit that resolves w/in 24 hrs

*new onset → admit/evaluate cardiac sources

When should you consider giving Heparin for a TIA?

high risk of recurrence: known high-grade stenosis, cardioembolic source, inc frequency of TIAs, TIA despite antiplt therapy

What has been shown to reduce risk of future strokes for pts presenting w/ TIA?

endarterectomy

What are the 7 D’s of stroke care?

Detection of onset of stroke s/sx

Dispatch EMS

Delivery w/ pre-arrival notification to stroke hospital

Door of ED, urgent triage

Data, -CT & interpretation

Decision regarding tx

Drug administration & monitoring

What is used to asses the severity of a stroke?

NIHSS

0 = no sx; 1-4 minor; 5-15 moderate; 16-20 mod/sever; 21-42 severe

What test is needed for a stroke?

CT w/o contrast

What is the tx for a stroke?

tPA

What are the recommended stroke evaluation targets?

door to doctor: 10 mins

door to CT: 25 min

door to CT read: 45 min

door to tx (tPA < 3hr sx onset): 60 minutes

door to admission: 3 hours

*access to neuro w/in 15 min, neurosurg w/in 2 hrs

What makes up the emergency neuro assessment?

LOC (use GCS), stroke type, stroke location, severity

What might a LP be done for a stroke?

SAH suspected

What labs should be drawn for a stroke?

Plt, PT/PTT

*used to asses for hematologic causes of CVA

What is the 1st sign of brain stem dysfunction?

U/L pupil dilation

What are signs of brain stem dysfunction?

absent doll’s eye reflex, corneal & gag reflex

What do Cheyne-Stokes respirations indicate?

cortical damage

What does hyperventilation or ataxic respiration indicate?

brain stem damage

What makes up the majority of strokes?

Ischemic: blood clots

*tx w/ fibrinolytics < 3hrs

What are sx of a CVA in the brain stem?

crossed deficits (1 sided motor weakness & C/L sensory); bilateral neuro signs

What are signs of a subcortical or lacunar infarct (caused by small vessel dz)?

pure sensory stroke, dysarthria (slurred speech) w/ clumsy hand

*pure motor deficit is rare

What 5 areas does the NIHSS assess?

*this should be performed in < 7 minutes and prior to tPA

LOC, visual assessment, motor function, sensation & neglect, cerebellar function

Who is not a fibrinolytic candidate based on NIHSS?

severe deficits (>22) -probably large area infarcted

mild or improving sx (< 4)

exceptions: isolated severe aphasia (3), hemianopsia (2 or 3)

What is used to grade SAH severity, survival, and complications?

Hunt & Hess scale

What grade SAH:

asx, minimal HA, mild nuchal rigidity; 15% normal CT

grade 1

What grade SAH:

mod/severe HA, nuchal rigidity, CN deficits only; 7% normal CT

grade 2

What grade SAH:

drowsy, confused or mild focal deficit; 4% normal CT

grade 3

What grade SAH:

stupor, hemiparesis, early decerebrate; 1% normal CT

grade 4

What grade SAH:

deep coma, decerebrate rigidity, moribund; 0% normal CT

grade 5

What is the most important dx test for CVA?

CT w/o contrast

What does hemorrhage show up as on a CT?

white density

How does ischemia show up on a CT?

appears normal for a few hours, > 6-12 hrs edema appears hypodense

How does a subdural hematoma present on CT scan?

crescent-shaped between dura & brain

How does an epidural hemorrhage present on CT scan?

lens-shaped, between skull & brain; biconvex

How does a subarachnoid hemorrhage appear on CT?

diffusely spread over brain surface

What is the MCC of SAH?

saccular (berry) aneurysm

What causes the majority of Epidural hematomas?

head trauma w/ skull fx that crosses middle meningeal artery/vein (torn in 60% cases)

Why should you get a UA or blood tox screen when working up a CVA?

check for drug/alcohol causes (cocaine, amphetamines, opiates, alcohol)

What additional studies can be ordered for CVA (mostly just r/o other causes)?

EKG: r/o MI, afib

CXR: r/o cardiomegaly, pulm edema, aspiration

lat C-spine XR: r/o fx or dislocation

What testing can be done to assess and tx SAH?

cerebral angiography: plan for aneurysm clipping, coiling, angioplasty

What is the best head positioning for stroke pts to maximize cerebral perfusion?

supine

*may inc ICP → do NOT do for ICH

When should you lower BP in stroke pts?

>220/120

What is the window for recombinant tPA?

4.5 hours

What are sx of intracerebral hemorrhage?

HA, N/V, elevate BP, neuro deficit, quick deterioration

What are sx of cerebellar hemorrhage?

sudden onset dizziness, vomiting, marked truncal ataxia, inability to walk

What is the tx for hemorrhagic stroke?

control HTN, elevate head (30*), mannitol or furosemide for ICP, monitor ICP, seizure prophylaxis: Phenytoin, acute surgical intervention (decompression and hematoma evacuation)

What is delirium?

transient, abrubpt onset of impaired attention and cognition: hallucination, delusions, difficulty focusing, disturbed wake-sleep cycles

Delirium always has an organic cause. What are some examples?

primary intracranial disease, systemic disease secondarily affecting CNS, exogenous toxins, drug withdrawal

*tx underlying cause

What is dementia?

slow loss of mental capacity: repetitive behavior, depression, delusions, hallucinations

How does Alzheimer’s present?

impaired memory, preserved motor/speech

How does vascular dementia present?

exaggerated or asymmetric DTRs, gait abnormalities, weakness of an extremity

*tx: antipsychotics

How does normal-pressure hydrocephalus present?

urinary incontinence, memory loss, ataxia

CT: large ventricles

What is a coma defined as?

reduced alertness and responsiveness from which pt cannot be aroused; both hemispheres or brainstem must be involved

What are sx of herniation causes of comas?

drowsiness followed by unresponsiveness, i/l pupil dilated and nonreactive, hemiparesis, loss of EOMs, loss of reflexes, irregular respirations, decorticate posturing

What is the tx for a coma?

stabilizaiton (ABCs), dx, identify and tx cause

What is vertigo?

perception of movement (rotational or otherwise) where no movement exists

*MUST persist for at least 24 hrs

What is syncope?

transient LOC accompanied by loss of postural tone w/ spontaneous recovery

What is near-syncope?

light-headedness raising concern for impending LOC

What is psychiatric dizziness?

dizziness not related to vestibular dysfunction that occurs exclusively in combo w/ other sx as part of a recognized psychiatric sx cluster

What is disequilibrium?

feeling of unsteadiness, imbalance, sensation of “floating” while walking

What causes peripheral vertigo?

disorders affecting vestibular apparatus and CN 8

*produces more distressing sx

What causes central vertigo?

disorders affecting central structures (brainstem or cerebellum)

*less distressing sx, but more serious

What are sx of peripheral vertigo?

sudden, intense spinning, paroxysmal, worsened by movement, nausea, rotatory-vertical or horizontal nystagmus, tinnitus

What are sx of central vertigo?

sudden or slow onset, less intense, constant, vertical nystagmus, no tinnitus, CNS sx, ± nausea, worsen w/ movement

What is the test for BPPV?

Dix-Hallpike

(+) = rotary nystagmus

What is the tx for vertigo?

pharm: reduce sx → scopolamine, meclizine

Epley maneuver

What causes BPPV?

otiliths

What is Meniere disease?

roaring tinnitus, diminished hearing, & fullness in one ear d/t endolymph in labyrinth

What is a perilymph fistula?

pneumatic changes in middle ear transmitted to vestibular apparatus, may cause hearing loss

*confirmed by nystagmus after pneumatic otoscopy (Henneburt sign)

What is vestibular neuronitis?

last several days, does not recur, usually w/ viral illness

What is Vestibular ganglionitis?

deafness, vertigo, facial nerve palsy d/t neurotrophic virus (VZV -Ramsay Hunt)

*confirmed via vesicles inside external canal

What is labyrinthitis?

infection of labyrinth → sudden hearing loss, middle ear findings

What causes ototoxicity?

aminoglycosides, loop diuretics, quinidine, antimalarials

*usually reversible

What tumors can cause peripheral vertigo?

meningiomas, acoustic neuroma

What is Wallenberg syndrome?

lateral medullary infarction of brainstem → central vertigo

What are disorders that can cause central vertigo?

cerebellar hemorrhage, Wallenburg syndrome, Vertebrobasilar insufficiency, Vertebral artery dissection, MS, migraines

What factors lower the seizure threshold?

medical noncompliance, fever, sleep deprivation, convulsant drugs, alcohol withdrawal, infection

What are generalized seizures?

nearly simultaneous activation of entire cerebral cortex; abrupt LOC

What are tonic-clonic (grand-mal) seizures?

consciousness returns gradually, postictal confusion and fatigue for several hours

What are absence seizures (petit mal)?

brief LOC w/o losing postural tone; appear confused, detached, withdrawn; usually school-aged

What are myoclonic seizures?

brief, shock-like muscle contractions

What are clonic seizures?

repetitive clonic jerks