Emergency Medicine EOR: Neurology

Name the disorder: Progressive cognitive decline; most common older than age 65 years. Characterized by loss of brain cells, beta-amyloid plaques, and neurofibrillary tangles; abnormal clock drawing test on physical exam

Alzheimer dementia

What signs/symptoms are associated with carotid/ophthalmic stroke?

Amaurosis fugax (monocular blindness)

What classic triad of symptoms is associated with meningitis?

Headache, fever, nuchal rigidity

How is giant cell arteritis treated?

High dose prednisone (start ASAP to avoid blindness)

What signs/symptoms are associated with PCA stroke?

Homonymous hemianopsia (vision loss on the same side of the visual field in both eyes)

A 40-year-old woman comes to the office because of involuntary movements of her body that have progressed insidiously and are now interfering with her walking. Her father had similar symptoms when he was 50, with rapid cognitive decline. The patient is found to have the same trinucleotide repeat expansion as her father. What is the most likely diagnosis?

Huntington's Disease

Name the disorder: Autosomal dominant, incurable neurodegenerative DZ ⇒ progressive motor/psychiatric dysfunction, dementia, chorea

Huntington's Disease

How is encephalitis diagnosed?

LP (PCR for viruses) and MRI

How is Guillain-Barre syndrome diagnosed?

LP: elevated CSF protein with normal CSF WBC

What is the etiology of Bell's Palsy?

Largely unknown but may be due to viral infection/URI

What signs/symptoms are associated with ACA stroke?

Leg paresis, hemiplegia, urinary incontinence

Name the disorder: Parkinsonian symptoms; gradual, progressive decline in cognitive abilities, hallucinations and delusions, gait difficulties, and falls

Lewy body dementia

What are the most common sources of intracranial metastasis?

Lung, breast, kidney, GI tract

How is giant cell arteritis diagnosed?

Biopsy of affected temporal arteries reveals thickened, nonpulsatile arteries as well as dilated and tender arteries + ESR >100

How is vascular dementia treated?

Blood pressure control

How is Alzheimer's treated?

Cholinesterase inhibitors (Tacrine, Donepezil)

How do you differentiate Bell's Palsy from stoke?

Stroke does not affect upper face, Bell's palsy does

What is amaurosis fugax?

Sudden onset temporary monocular blindness

How is a ruptured aneurysm managed?

Surgical clipping, endovascular coiling within first 24 hours; restore respiration

In what case should steroids not be used in the treatment of Bell's palsy?

Suspected Lyme disease

Name the disorder: Associated with arteriosclerotic small vessel disease - multi-infarct, usually correlated with a cerebrovascular event and/or cerebrovascular disease. Stepwise deterioration with periods of clinical plateaus; may cause a sudden decline

Vascular dementia

What is the most common cause of meningitis?

Viral infection

What usually causes encephalitis?

Viruses (HSV, CMV if immunocompromised)

How is essential tremor treated?

Propranolol, primidone, alprazolam, small amounts of alcohol, gabapentin, topiramate, or nimodipine

How is Bell's palsy managed?

- Usually none, prednisone if necessary - Eye patch at night to prevent corneal abrasion - Surgical decompression if it progresses/deteriorates

What symptoms characterize a Grade 2 concussion? What is the recommendation for return to activity?

+ LOC , 1 minute or post-traumatic amnesia and other symptoms last > 30 minutes but < 1 week Athlete may return to sports in 2 weeks if asymptomatic at rest and exertion for at least 7 days

What symptoms characterize a Grade 3 concussion? What is the recommendation for return to activity?

+ LOC > 1 minute or post-traumatic amnesia and other symptoms last > 1 week Athlete may return to sports in 1 month if asymptomatic at rest and exertion for 7 days

What signs and symptoms are characteristic of delirium?

- Acute and rapid deterioration of mental status - Symptoms fluctuate throughout the day - Visual hallucinations and more frequent falls

How is Huntington's disease diagnosed?

- Clinical symptoms - Family history, genetic testing (40+ CAG repeats) - MRI = cerebral atrophy and atrophy of the caudate nucleus

How are intracranial tumors evaluated?

- Head CT or MRI: location, size, effect on normal tissue - EEG: may demonstrate a focal disturbance resulting from the neoplasm or a more diffuse change reflecting altered mental status - Arteriography: may demonstrate stretching or displacement of normal cerebral vessels as well as the presence of tumor vascularity

When is neuroimaging indicated in the evaluation for possible concussion?

- LOC - GCS <15 - Focal neuro deficit - Persistent AMS - Clinical deterioration

How is cluster headache managed?

100% O2 at 6-12 L/min for 15 minutes via nonrebreathing mask + Imitrex

What is the GSW score range associated with concussion and when is it seen?

13-15 thirty minutes after injury

What is a normal GCS score?

15

How is the Eye Opening component of the Glasgow Coma Scale scored?

4= spontaneous 3= to voice 2= to pain 1= none

How is the Verbal Response component of the Glasgow Coma Scale scored?

5= normal conversation 4= disoriented conversation 3= words, but not coherent 2= no words, only sounds 1= none

How is the Motor Response component of the Glasgow Coma Scale scored?

6= normal 5= localizes to pain 4= withdraws to pain 3= decorticate posture 2= decerebrate posture 1= none

What GSW score means coma?

9 or less

How is encephalitis differentiated from meningitis?

AMS

What endocrine crisis has delirium as an associated symptom?

Acute hyperthyroidism (thyroid storm)

How is encephalitis treated?

Acyclovir until HSV and Zoster are ruled out, empiric antibiotics are often given until bacterial meningitis is excluded

What is the most common cause of delirium?

Alcohol withdrawal (delirium tremens)

A 16-year-old male briefly lost consciousness following a football collision and after regaining consciousness had an episode of nausea and vomiting. What is the most likely diagnosis?

Concussion

What signs/symptoms are associated with MCA stroke?

Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia

What are the Budapest consensus criteria for complex regional pain syndrome?

At least one symptom in 3/4 categories: - Sensory: hyperalgesia and/or allodynia ⇒ evidence of hyperalgesia to pinprick/allodynia to light touch/temperature - Vasomotor: temperature asymmetry >1 degree C and/or skin color changes - Sudomotor/edema: edema, sweating changes, sweating asymmetry - Motor/trophic: decreased ROM or motor dysfunction and/or trophic changes (hair, nail, skin) ⇒ weakness, tremor, dystonia, changes in skin/nail/hair growth

when is endarterectomy indicated for carotid stenosis?

At or above 70% stenosed

What chronic conditions are associated with lacunar infarct?

Atherosclerosis, hypertension, and diabetes

Name the disorder: a mild traumatic brain injury (TBI) due to contact or acceleration/deceleration injury

Concussion

What etiology of meningitis is suggested by these CSF results? ↑ Protein ↓ Glucose

Bacterial

A 47-year-old man who comes to the emergency department because of the sudden onset of left facial paralysis. He has a 10-year history of hypertension and hyperlipidemia treated with lisinopril and atorvastatin. Physical examination shows drooping of the left side of the face, lack of wrinkling of the left forehead when asked to raise both eyebrows, and absence of left nasolabial fold. What is the most likely diagnosis?

Bell's palsy

Name the disorder: Hemifacial weakness/paralysis of muscles innervated by CN VII due to swelling of the cranial nerve

Bell's palsy

A 69-year-old woman who is brought into the emergency department by ambulance after her husband noticed that she began slurring her speech and had developed facial asymmetry during dinner approximately 30 minutes ago. Her past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. She is noted to have a distinct right facial paralysis. Non-contrast head CT is performed, which is negative for blood. What is the most likely diagnosis?

CVA/stroke

Name the disorder: Weak bulging spot on the wall of brain artery like thin balloon/weak spot of inner tube; usually there's a genetic predisposition

Cerebral aneurysm

How is ruptured aneurysm diagnosed?

Cerebral angiogram is gold standard; non-contract CT head

What should always be done before performing an LP in a patient with suspected meningitis?

Check for increased ICP - papilledema, CT head

A 45-year-old man comes to your office with a 4-week history of recurrent headaches that wake him up in the middle of the night. The headaches have been occurring every night and have been lasting approximately 1 hour. The headaches are described as a deep burning sensation centered behind the left eye. The headaches are excruciating (he rates them as a 15 on a 10-point scale) and are associated with watery eyes, "a sensation of heat and warmth in my face," nasal discharge, and redness of the left eye. What is the most likely diagnosis?

Cluster headache

Name the disorder: Unilateral, excruciating, sharp, searing, or piercing pain (often at night), lacrimation, and nasal congestion

Cluster headache

What signs/symptoms are associated with basilar artery stroke?

Coma, cranial nerve palsies, apnea, drop attach, vertigo

How are intracranial tumors treated?

Complete superficial removal of the tumor with radiation/chemotherapy Steroids to help reduce cerebral edema, anticonvulsants

Name the disorder: A pain syndrome disproportionate to injury with continuing pain that is disproportionate to any inciting event

Complex regional pain disorder

A 36-year-old who sustained minor trauma to his left lower leg, now months later presents with chronic pain that is greater than would be expected given his injury. You notice swelling of the affected extremity, change in skin color from red to cyanotic, temperature changes, and increased hair and nail growth. On palpation, the patient has significant pain to light touch. What is the most likely diagnosis?

Complex regional pain syndrome

What is/are the most common causes of meningitis in immunocompromised patients?

Cryptococcus neoformans

Name the disorder: acute cognitive dysfunction secondary to some underlying medical condition and is usually reversible

Delirium

You see a 77-year-old female who for the past 4 days has been crying easily, confused, and rambling incoherently. Her medical history is remarkable for mild dementia and well-controlled hypertension. She has never had anything like this in the past and she has not had any recent changes to her medications. When questioned, she has no difficulty articulating a sentence but difficulty remembering what she was asked. Laboratory testing is significant for leukocytosis. What is the most likely diagnosis?

Delirium

What signs/symptoms are characteristic of Huntington's disease?

Dementia, mutism, dysphagia, chorea (nonrepeating, complex, involuntary rhythmic movements that may appear purposeful)

How is bacterial meningitis treated?

Dexamethasone + Empiric IV antibiotics (Cephalosporin, Vancomycin, Penicillins

What signs/symptoms are associated with vertebral/basilar artery stroke?

Dysarthria and dysphagia; vertigo, nausea, and vomiting; disorientation; ataxic gait (ipsilateral cerebellar ataxia); visual symptoms (double vision and blurred vision); dysphagia; ocular signs (nystagmus, conjugate gaze paralysis, and ophthalmoplegia); akinetic mutism (locked¬in syndrome when basilar artery occlusion occurs); numbness of lips and face; facial weakness, alternating motor paresis; and drop attacks, syncope

What is/are the most common bacterial causes of meningitis in neonates?

E. coli and S. agalactiae

What testing should be considered if Bell's palsy does not resolve within 10 days?

EMG

What findings are characteristic of ruptured aneurysm on LP?

Elevated opening pressure, bloody fluid (xanthochromia, RBC)

A 34-year-old male is brought to the emergency department by his wife due to a seizure event. She reports that prior to the event, he complained of headache, fever, and nausea. She also reports her husband appeared confused. On exam, the patient cannot clearly answer questions. A CT of the head shows no evidence of hemorrhage or a space-occupying lesion. A lumbar puncture is performed, and cerebrospinal fluid analysis shows a normal opening pressure, a lymphocytic pleocytosis, normal glucose, and elevated protein. PCR is positive for herpes simplex virus-1. What is the most likely diagnosis?

Encephalitis

Name the disorder: an acute inflammation of the brain; the infection may be bacterial or viral. In some cases, may be the result of an immune system disorder

Encephalitis

What is/are common causes of aseptic meningitis?

Enterovirus, HSV, TB, fungus

A 65-year-old patient presents with shaking that occurs with simple tasks such as tying his shoelaces, writing, or shaving. According to his wife, the symptoms are aggravated by stress, fatigue, caffeine, and changes in temperature. The patient reports his dad had the same symptoms. On physical examination, there is a 4-10 Hz tremor elicited when both of his arms are outstretched forward. There is no tremor at rest. What is the most likely diagnosis?

Essential tremor

What symptoms are characteristic of encephalitis?

Fever, headaches, altered mental status, seizures, personality changes, exanthema

Name the disorder: Language difficulties, personality changes, and behavioral disturbances (personality changes precede memory changes)

Frontotemporal lobar degeneration

A 67-year-old female with a severe throbbing headache and visual impairment in the left eye. The patient describes worsening of pain with chewing or combing her hair. Lately, she reports feeling very weak and tired especially in the mornings. At times she cannot even raise her arms to reach the cabinets in her kitchen. On physical exam, she has decreased visual acuity of the left eye, scalp tenderness on the left, and an absent pulse in the left temporal area. Laboratory testing is significant for an elevated ESR. What is the most likely diagnosis?

Giant cell arteritis

A 63-year-old man is brought to your office by his son due to progressively worsening headache and weakness. His headache began approximately 3 months prior to presentation and is described as diffuse but worse on the right side of the head. The headache worsens with coughing and lifting heavy objects and is associated with nausea, multiple episodes of vomiting, and left-sided weakness. He previously worked for the synthetic rubber industry for over 30 years. What is the most likely diagnosis?

Glioblastoma

Name the disorder: ascending paralysis that often presents after immunization or infection (campylobacter jejuni, CMV, EBV, HIV)

Guillain-Barre Syndrome

A 35-year-old paralegal arrives at the ED after hitting his head when he tripped while climbing the stairs to his office. He has noted his legs feeling heavy over the last 5 days and reported trouble pushing himself up after the fall. He experienced nausea, vomiting, and diarrhea 3 days ago (admits to eating discount sushi). Exam is remarkable for symmetric 3/5 lower and upper extremity weakness, absent ankle and patellar reflexes and 1+ biceps reflex. He is only able to count to 10 in one breath. Routine labs, chest x-ray, and head CT are unrevealing. What is the most likely diagnosis?

Guillain-Barre Syndrome

How is CVA due to occlusion/ischemia treated?

IV tPA if within 3-4.5 hours of symptom onset; give warfarin/aspirin once the hemorrhagic stroke has been ruled out

How is Huntington's disease treated?

Incurable, symptomatic/supportive - may treat chorea with risperidone, haloperidol - speech therapy and eventually nursing care - Tetrabenazine depletes dopamine ⇒ first drug to specifically treat chorea; neuroleptics also help Life expectancy 15-25 years after symptom onset; high-risk suicide

What are the two types of stroke?

Ischemic and hemorrhagic

A 34-year-old man is brought by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights. His temperature is 103.1° F, blood pressure is 134/82 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs. What is the most likely diagnosis?

Meningitis

If you suspect meningitis in a patient who also has a rash, what is the most likely cause?

N. meningitidis

What is/are the most common bacterial causes of meningitis in most people?

N. meningitidis, S. pneumoniae

Name the disorder: Substantial memory deficits, impaired executive functioning, poor attention and concentration, mental slowing, and apathy. Cerebral atrophy is typically evident on brain imaging

Neurocognitive disorder caused by HIV infection

What symptoms characterize a Grade 1 concussion? What is the recommendation for return to activity?

No LOC; post-traumatic amnesia and other symptoms resolve in < 30 minutes Athlete may return to sports if asymptomatic for one week

How is Guillain-Barre treated?

Plasma exchange (remove circulating antibodies) and IVIG Monitor PFTs for paralysis of chest muscle/diaphragm (respiratory failure)

What condition is associated with giant cell arteritis?

Polymyalgia rheumatica

How is concussion managed?

Rest and activity restriction (reduce sports, video games, TV, or too much socializing) Headache and nausea meds as needed

What medications can be used to treat household contacts of a person with confirmed bacterial meningitis?

Rifampin, Cipro, Levaquin, azithromycin, ceftriaxone

Smoking, hypertension, hypercholesterolemia, heavy alcohol use, polycystic kidney and coarctation of the aorta are all risk factors for:

Ruptured aneurysm

What assessment tool can be used to evaluate concussion?

SCAT 2 (sports concussion assessment tool 2)

What is the most common type of aneurysm?

Saccular (berry)

When would intra-arterial thrombolysis be indicated in a CVA patient?

Select patients (major MCA occlusion) up to 6 hours after onset of symptoms

What signs/symptoms are associated with lacunar infarct stroke?

Silent, pure motor or sensory stroke, "Dysarthria-Clumsy hand syndrome", ataxic hemiparesis

How is complex regional pain syndrome managed?

Stage 1: gabapentin, amitriptyline, and bisphosphonates Stage 2: Add steroids Stage 3: Include pain management specialist ⇒ regional nerve block / spinal cord stimulators

How does cerebral aneurysm usually present?

Usually asymptomatic unless ruptured; when ruptured ⇒ sudden, severe headache, stiff neck, photophobia, nausea and vomiting, AMS, elevated BP and temp

If a patient has multiple concussions in a short period of time, how should they be advised to return to activity?

if associated with either loss of consciousness or symptoms for more than 15 minutes they are NOT to return to play sports for that season