Neuro Quick Management

Alcohol Withdrawal

• Treatment:
  • Delirium Tremens (48 hours)3 B’s:
    • Benzodiazepines
    • Beta-Blocker
    • Banana Bag (thiamine/folate)

Benign positional paroxysmal vertigo

• Presentation:
  • spinning with the head still
  • worsening with change positions
• Diagnosis:
  • Dix-hallpike maneuver
• Management:
  • Epley maneuver

Cerebrovascular Accident (stroke)

• Types:
  • TIA
  • Ischemia
    • Thrombus
    • Embolus
  • Hemorrhage
    • Intracerebral hemorrhage
    • Subarachnoid hemorrhage
• Diagnosis:
  • EKG – look for atrial fib or atrial flutter
  • 24-hour monitoring
  • CBC, Hgb, Hct WBC
  • Platelet count
  • PT, PTT, and INR
  • Serum lipids, Total, HDL, LDL, and Triglycerides
  • Blood glucose
  • Thrombin time and/or ecarin clotting time if patient is taking a direct thrombin inhibitor or a direct factor Xa inhibitor
• Confirmatory: 
  • duplex ultrasound of the neck and transcranial Doppler (TCD) of the intracranial arteries
  • CT angiography (CTA) or MR angiography (MRA) of the neck and head arteries
  • transthoracic echocardiography (TTE) then transesophageal echocardiography (TEE) – a source of embolism
• Steps:
  • Assess vital signs and stabilize airway, breathing, and circulation
  • CT, MRI, CT angiography or MRA
  • Managing volume depletion and electrolyte disturbances
  • Checking serum glucose.
    • Low serum glucose <60 mg/dL – corrected rapidly.
    • High serum glucose level >180 mg/dL – a goal of keeping serum glucose levels within a range of 140 to 180 mg/dL 
  • Assess swallowing and preventing aspiration
  • Optimizing head of bed position.
• Management:
  • tPA (alteplase)
  • aspirin within 48 hours
  • pharmacologic VTE prophylaxis – subcutaneous low molecular weight (LMW) heparin – Enoxaparin 40 mg daily

Creutzfeldt Jacob Disease

• Diagnosis:
  • MRI of brain
  • Brain biopsy (definitive)

Epilepsy

• Differential Diagnosis:
  • Migraine HA
  • Stoke
  • Febrile seizure
  • Syncope
  • Psychogenic non-epileptic syndrome
• Diagnosis:
  • EEG
    • absence seizures: 3 Hz spike and wave pattern
  • CT r/o tumor
  • MRI – focal abnormalities in the brain
  • CMP – r/o electrolyte abnormalities
  • CBC, Toxicology, AED levels
• Management:
  • antiepileptic drugs not started if first seizure
  • EEG before starting a regimen
  • 5-7 day continuous video EEG
  • Absence seizures:
    • Ethosuximide
  • Simple or secondary generalized: 
    • Carbamazepine (best for prego pts)
    • Oxcarbazepine
    • Lamotrigine (steven johnson syndrome)
    • Topiramate
  • Generalized Epilepsy or Unclassified Epilepsy:
    • Valproate (teratogenic)

Guillain-Barre Syndrome

• Path:
  • recent infection, diarrheal, URI or herpetic
• Presentation:
  • ascending weakness/neuropathic sx. 
  • pain
  • weakness or paresthesias in the feet or weakness of the legs
  • loss of DTRs
• Diagnosis:
  • routine labs normal
  • LP/CSF analysis – initial 
  • CSF – elevated protein, but no cells
  • EMG/ nerve conduction studies – most accurate test
• Management:
  • admit to the hospital for observation and treatment
    • monitor vital capacity in pulmonary function test to check his respiratory diaphragm
  • plasma exchange or IVIG

Headache

Multiple Sclerosis

• Presentation:
  • Optic Neuritis
  • Space and Time
• Diagnosis:
  • MRI w and w/o contrast – white matter lesion
  • CSF – Oligoclonal bands
  • McDonald criteria
• Management:
  • Short term:
    • IV methylprednisolone for 2-3 days followed by a taper of PO prednisone for 3-4 weeks.
  • Long term:
    • Injection therapy Interferon 1a, Interferon 1b, or glatiramer (safe during pregnancy)
    • Oral therapy with dimethyl fumarate, teriflunomide, fingolimod
    • Infusion monotherapy with natalizumab or ocrelizumab
  • Monitor outpatient disease-modifying therapy (DMT)
• Manage various sxs:
  • Muscle spasticity:
    • Baclofen
    • Dantrolene
    • Diazepam (for PM use)
  • Fatigue and narcolepsy:
    • Amantadine
    • Modafinil
    • Methylphenidate
  • Pain:
    • Phenytoin
    • Carbamazepine
    • Pregabalin
  • Urinary Urgency:
    • Tolterodine
    • Oxybutinin

Myasthenia Gravis

• Differentials:
  • Generalized fatigue
  • Amyotrophic lateral sclerosis (ALS)
  • Lambert-Eaton myasthenic syndrome
  • Miller Fisher
  • Guillain-Barré syndrome
  • Botulism
  • Autoimmune disorders
• Diagnosis:
  • Ice Pact Test
  • AChR-Ab
  • or against a receptor-associated protein, muscle-specific tyrosine kinase (MuSK-Ab) 
  • or low-density lipoprotein receptor-related protein 4 (LRP4)
• Confirmatory:
  • Repetitive nerve stimulation
  • Single-fiber electromyography 
• Associated Conditions:
  • Thymoma
    • Imaging mediastinum with CT or MRI
• Workup:
  • CBC
  • Thyroid function test
  • ANA 
  • RF
• Management:
  • Pyridostigmine
    • Adults and older adolescents: 30 mg TID.
    • Children and younger adolescents: initial dose is 0.5 to 1 mg/kg every 4-6 hrs.
  • Plasma exchange
  • IVIG
  • Thymectomy

Pseudotumor Cerebri

• Presentation:
  • Headache 
  • Papilledema
  • Diplopia
  • Obese and young childbearing age
• Differential Diagnosis:
  • Intracranial mass lesions (tumor, abscess)
  • Obstruction of venous outflow (venous sinus thrombosis, jugular vein compression, neck surgery)
  • Obstructive hydrocephalus
  • Decreased CSF absorption (infectious meningitis, subarachnoid hemorrhage)
  • Increased cerebrospinal fluid (CSF) production (choroid plexus papilloma)
  • Malignant HTN
• Diagnosis:
  • Papilledema
  • Normal neurologic examination, except for papilledema and cranial nerve abnormalities
  • MRI w and w/o contrast and postcontrast MR venography
  • Lumbar puncture > 250 mmH₂O = elevated intracranial pressure
  • Normal CSF composition
  • Ophthalmologic exam/Ophthalmologic consult
• Management:
  • Vision:
    •  Acetazolamide
      • Alternatives: Topiramate or other carbonic anhydrase inhibitors
      • add Furosemide
  • Progressing Vision Loss:
    • Surgical intervention with optic nerve sheath fenestration (ONSF) and/or a cerebrospinal fluid (CSF) shunting procedure
  • Headache:
    • Amitryptiline and naproxen

Status epilepticus

• Differential Diagnosis:
  • Delirium tremens
  • Neuroleptic malignant syndrome
  • Drug ingestion
• Diagnosis:
  • CMP (metabolic derangements)
  • CBC, cultures, LP (Infection)
  • CT, MRI (structural lesions)
  • CT (trauma)
  • Toxicology, hx (drugs)
• Management:
  • ABC
    • Vitals – monitor oxygen saturation
    • High flow oxygen
    • EKG monitoring
  • Establish IV access
  • CBC, CMP, toxicology, AED levels
  • Hypoglycemia
    • CANNOT check levels – assume hypoglycemia – administer 50mL of D50 with Thiamine
  • Administer 1st round of Benzos:
    • IV lorazepam (diazepam, midazolam) (T=5 mins)
    • IV lorazepam (T=10mins)
    • Fosphenytoin (watch for hypotension) (T=15 mins)
      • prepare for impending mechanical intubation
      • call anesthesia, intensivist
    • IV phenobarbital (T=20 mins)
      • Insert Foley catheter, IV fluids
      • prepare rapid sequence intubation and propofol (anesthesiologist)
• Post status epilepticus:
  • Rhabdomyolysis
  • Aspiration pneumonitis
  • Arrhythmia

Vertigo

Vestibular Neuronitis

• Path:
  • acute, peripheral vertigo associated with URI
• Presentation:
  • Vertigo, nausea, vomiting
• Diagnosis:
  • + Romberg’s test
  • abnormal caloric vestibular stimulation test
• Management:
  • Rehydration
  • Antiemetics: diphenhydramine, Phenergan, metoclopramide
  • Anticholinergics/vestibulosuppressants: meclizine, scopolamine

Labyrinthine Concussion

• Path:
  • acute, peripheral vertigo associated with head injury or trauma to the ear
• Presentation:
  • vertigo, nausea, and vomiting
• Diagnosis:
  • + Romberg’s sign
  • signs of head injury or ear injury on otoscopic exam
  • examine head and neck for injury
  • Trauma to head = Head CT (r/o cranial bleed)
• Management:
  • supportive
  • vestibulosuppressants: Meclizine
  • consult ENT if medical fails

Meniere’s disease

• Path:
  • Recurrent, peripheral vertigo associated with constant tinnitus and progressive hearing loss. 
  • unilateral increase in perilymphatic volume
• Presentation:
  • MC older adults
  • women > men
  • feeling of fullness in one ear
  • ringing
• Diagnosis:
  • Imaging to r/o acoustic neuroma (NF)
  • abnormality in hearing
  • unilateral conductive hearing loss
• Management:
  • Supportive (gentle diuretics)
  • ENT surgical therapy

Normal Pressure Hydrocephalus

• Treatment:
  • Ventriculoperitoneal or Ventriculoatrial shunt

Perilymphatic Fistula

• Path:
  • Recurrent, peripheral vertigo caused by rupture of the bony capsule in the inner ear, leakage of perilymph into the middle ear
• Presentation:
  • Pop associated with an increase in middle ear pressure (Valsalva maneuver, straining, coughing, sneezing)
• Diagnosis:
  • differential from Meniere’s disease
• Management:
  • Supportive
  • ENT surgery

Wallenberg’s Syndrome

• Path:
  • stroke of PICA
  • infarct of the lateral inferior medulla
• Presentation:
  • acute, central vertigo
  • n/v, facial hemianesthesia, contralateral body hemianesthesia, dysphagia, dysarthria
  • horner syndrome (ptosis, miosis, anhidrosis)
  • Medical emergency
• Diagnosis:
  • Non-contrast CT
• Management:
  • Stroke protocol (tPA if within 3 hours of sx)

Tumors of Nervous system