ITE Review Must Know Neuro Angela M. Pugliese MD Department of Emergency Medicine Henry Ford Hospital Outline Strokes Seizures Peripheral Neuropathies Disorders of the Neuromuscular Junction Myopathies Myelopathies Traumatic Brain Injury Coma Headaches Spinal Cord Injuries Vertigo Meningitis STROKE General Ischemic vs embolic vs hemorrhagic Hx of TIA (30-50% will have stroke in 5 years) Know what mimics strokes seizure (todds paralysis), migraine, tox/metabolic Treatment Know when to use TPA BP..when to treat?? use labetalol or nicardipine dont use nipride (or hydralazine) Presentations MCA most common, UE deficit more severe, aphasia if left Anterior LE deficit more severe, loss of frontal lobe control Posterior think visual, CN III, memory loss Vertebrobasilar look for cerebellar and CN findings Basilar locked in Lacunar affect both anterior and posterior circulation Hyperdense MCA sign Dont miss the stroke Know when to give TPA Dont forget about Bells Dont image Dont give TPA SEIZURES General Generalized Partial simple complex partial Seizure vs Syncope First time work up.. Status Epilepticus Definition Mortality can be up to 30% Treatment- Adult thiamine/glucose, mag, pyridoxine Pediatric glucose, calcium for neonates Status Treatment Benzos More Benzos Phenytoin vs. Fosphenytoin (Keppra) Phenobarb.barb coma Phenytoin vs Fosphenytoin Peripheral neuropathy Toxic Neuropathies Tetanus 4 Ts trismus, tetany, twitching and tightness Diptheria fever, ill membranous pharyngitis mononeuritis of eyes motor ETOH stocking-glove Metabolic Neuropathies Guillain-Barre preceding viral illness ascending paralysis increased protein in CSF Tick Paralysis looks like GB find and remove tick Disorders of the NM Junction Myasthenia Gravis Most common Destroys acetylcholine receptors leading to proximal weakness Muscle weakness exacerbated by activity Diagnose with Edrophonium Test Myasthenia Gravis Myasthenic Crisis undiagnosed/untreated not enough ACH Edrophonium improves Cholinergic Crisis too much anticholinesterase functional excess of ACH Edrophonium worsens Can treat with Atropine Eaton-Lambert Syndrome disorder of neuromuscular transmission associated with Oat Cell Lung CA CNs spared repetition improves grip strength unlike MG Botulism (food-borne) ingestion of preformed toxin think canned food and honey earliest and most common symptoms blurred vision, diplopia and photophobia Floppy baby ingestion of raw honey acute onset lethargy, poor feeding, weak cry and loss of head control Myopathies MYELOPATHIES Multiple Sclerosis demyelinating disorder UMN weakness, hyperreflexia think subtle vision problems pt presenting with optic neuritis should have work up Transverse Myelitis post-viral or toxic inflammation of the spinal cord remember below the level of cord involvement can have paralysis pain and temp sensation are diminished TRAUMATIC BRAIN INJURY Cerebral Edema head trauma resulting in increased ICP (>20) raise the head of the bed CO2 at 35 maintain oxygenation Consult Neurosurgery Watch for Cushing reflex COMA Coma = TIPS AEIOU T trauma I infection P psych S stroke A alcohol E endocrine (lytes) I ingestion/drugs- insulin O oxygen U - uremic COMA Cocktail Oxygen Narcan Glucose Thiamine Headaches SAH acute thunderclap worst headache of life Temporal Arteritis women, Sed rate > 50, start steroids Cluster men, bursts, tx with 100% O2 Cavernous sinus thrombosis facial infection, EOM not intact, needs MRV, high dose Abx CO exposure whole family presentation (even pets have symptoms) SPINAL CORD INJURIES Fractures Need to know stable vs unstable Stable Fractures Simple Wedge Clay-Shovelers Pillar Central Cord Syndrome elderly patients from forced extension (you intubating) weakness greater in arms than legs Anterior Cord Syndrome flexion injuries complete motor loss with pain and temp loss normal light touch, position and vibration Brown-Sequard usually from penetrating injury ipsilateral motor, vibration and position loss contralateral pain and temp loss Spinal Shock hypotension and steady bradycardia warm pink skin, normal urine output loss of sympathetic tone Vertigo Peripheral vs Central GOOD sudden, intense onset no neuro deficits nsystagmus suppressed by fixation, no vertical BAD mild continuous symptoms cerebellar or brainstem lesions DONT SEND HOME MENINGITIS General dont delay antibiotics CT before LP with AMS or neuro deficit know how to analyze the CSF 1.high pressure >300 and PMNs (low glucose) 2.low protein, high glucose and monos 3. 50 years e. coli, GBS, listeria strep pneumo strep pneumo, neisseria s. pneumo, listeria Treatment cefotaxime for neonates ceftriaxone for everyone else Add ampicillin for neonates and > 50 years THE END