Neurology - Details

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Damage to multiple nerves. Mostly distal and symmetrical

Symmetric Polyneuropathy Definition

Diabetes, Alcoholism, Hypothyroid, B12 def, HIV, Lyme, Multiple Myeloma, Celiac, Sarcoid, Meds: Hydralazine, INH,Vit B6, arsenic and lead

What are the causes of Polyneuropathy?

First level test: B12, A1c, SPEP with immunifixation electrophoresis initially, TSH, CBC, and CMP. Extensive testing not necessary if known DM or ETOH Second level test: EMG/NCS: EMG will differentiate between nerve or muscle disorder, NCS differentiates bw axonal or demyelinating neuropathy. consider Lyme titer in Endemic area CXR if suspect sarcoid

What is the work up of Polyneuropathy?

Radial neuropathy: Compression, DM or Lead toxicity

Acute Wrist Drop - Cause

Median N. Check TSH and Glucose Treat: Splint, Steroid injection and Surgery

Carpel Tunnel : W/U and Tx

Weakness in leg, can't stand on toes, decrease sensation lower leg and absent ankle reflexes. MRI

Sciatic N radiculopathy sx and w/u

Foot drop and inability to evert foot

Peroneal N sx

7th CN ipsilateral paralysis half of face, loss of test, lacrimation and hyperacusis) Associated with viral illness and Lyme disease. 80% recover Treat : Predinosine 60 mg taper for 7 days combined with Valacyclovir

Bell's palsy cause and treatment

CN 3 and 6 palsy( diplopia and ptosis/painful), foot drop, wrist drop, sensory polyneuropathy of distal LE

Neuropathy associated with DM

Pain and numbness in feet stocking distribution . Recovery with abstinence and MVI

Alcoholic Neuropathy sx

Chemotherapy, H2 blockers, PPI, Metformin because lowers B12 absorption, Fluoroquinolones.

Which drugs are associated with neuropathy?

Treat underlying disease First line: Amitriptyline or Duloxetine (less anticholinergic) follows by Venlafaxine Gabapentin 100-300 mg tid Alpha lipoid acid 600 mg/d as antioxidant Topical lidocaine Capsasin

What is the treatment of neuropathy?

POUND: 4/5 Pulsatile, phonophobia and photophobia One day- can last up to 72 hours if untreated Unilateral Nausea Disabling

Migraine Headache Dx

Tylenol 1000 mg Asprin 900 mg NSAIDS Ibuprofen 400 mg Midrin ( isometheptne( sympathomimetic/ muscle relaxant)

Migraine Acute treatment mild to moderate

Sumatriptin 50-100 mg (max 200 mg) with Naproxen 500 mg Dihydroergotamine nasal spray ( Migrant) Midrin Dexamethasone with Opiates and IV Reglan

Migraine Acute treatment : Severs Sx

Pregnancy,CAD, PAD, CVD, uncontrolled HTN, hemiplegic migraine, liver disease, SSRI No not use more than 2x/wk due to rebound headache.

Whe to avoid Triptans

If having , > 2x wk, > 3 headaches/mo or using analgesics > 10x / mo BB ( Propanolol) TCA ( Amitriptyline) SSRI (Fluoxetine, Mirtazapine and Venlafaxine) - caution with Tripan Anticonvulsants ( Topomax, Gabapentin) CaB ( Verapamil) NSAIDS Magnesium 400 mg/d and B2 and acupuncture and Botox

When do you use prophylactic medication for migraine?

MRI with and without contrast Autonomic cephalgia: Severe supraorbital pain with lacrimation and nasal congestion. Focal sign Immunocompromised or over 50 Worst headache - R/O SAH with CT Trauma Cancer Coumadin, Meth or Cocaine use

Red Flags for imaging Headaches

Tylenol, Aspirin, NSAID For chronic: Amitriptyline or gabapentin or Botox

Treatment of Tension Headache

O2 7-12 L / 15 min Sumatriptan 6 mg SQ Zolmitripatan 5 mg intranasal For chronic Rx Verapamil 240 mg/d or Prednisone 60 mg for 10 d.

Treatment of Cluster Headache

Unilateral periorbital with conjunctival injection and lacrimation Occurs in clusters several times a day lasting minutes and for a few days. Affects mostly men who smoke Triggers: vasodilators, ETOH, NTG and histamine

Define Cluster Headache ( Trigeminal Autonomic Cephalgia)

Tender temporal a. with headache in pt > 55 y.o. May be ass with PMR , Elevated sed rate Treat Prednisone 60 mg taper 4 wk while awaiting bx. Can lead to blindness

Temporal Arteritis Sx and treatment and complication

Worse headache of life associated with stiff neck. Ass: LOC, sentinel headache 3 wk before W/U: CT and if - , LP Cause : Saccular aneurysm in circle of willis

SAH Sx

Headache > 15 day/mo

Definition of Medication Overuse Headache

Chroni pain, Obesity, DM, and Arthritis

What are the risk factors for Medication overuse headache?

Central sensitization and neuronal dysfunction causing inappropriate response to stimuli. Lowers threshold for pain. Pain lingers after removal of trigger.

What is the pathofiz of medication overuse headache?

Topiramate, Amitriptyline and Steroids 60 mg taper for withdrawal Slowly withdrawal the medication while starting prophylactic Acute Rx during taper: Hydroxyzine, Reglan or Gabapentin

What is the treatment of overuse headache?

Pregnancy, CAD, PVD, uncontrolled HTN, SSRI, MOI, liver disease and hemiplegic migraine Avoid taking > 2x/wk due to rebound headache.

When do you avoid Triptans?

Avoid estrogen contains contraceptives,. Doubles the risk of stroke.

Migraine with Aura - Contraceptive

Functional impairment with normal CT. Affects physical, cognitive, emotional and behavioral domains.

Concussion Definition

Glasgow Coma Scale : Eye opening4, Verbal response5 and motor response6. 15 best.

Concussion - classification

May be delayed: Headache, confusion, amnesia, dizziness, N/V, balance, confusion, disorientation. Later: mood and cognitive disturbance, sensitivity to light and noise seep.

Concussion sx:

Most sx resolve in 2 wk. Children have delayed recovery up to 3 mo.

Concussion prognosis:

Seizure < 5% if mild, Epidural hematoma with bleed, second impact syndrome 50% mortality, post concussion syndrome ( prolonged sx) If sx > 1 mo refero out

Complication of concussion.

SCATS 5

Tool for concussion assessment in athletes

Neck pain or tenderness Double vision Weakness or tingling in extremities Severe or worsening headache LOC Seizure Deteriorating conciousness Vomiting and Agitation.

Red Flags for Concussion

LOC, amnesia, disorientation severe headache, MS change, abnormal neurological, seizure, GCS < 15, suspect fx, vomiting, over 65, retrograde amnesia > 30 min, MVA, fall > 3 ft.

When do you image for concussion with CT?

48 hours physical and cognitive rest, sunglasses for photophobia and ear plugs for photophobia Tylenol for pain. NO NSAIDS ED precautions Monitor for ups to 3 mo.

Management of Concussion

Neuro: Balance with Romberg and gait CN, DTR, muscle strength, finger to nose and MS exam.

Concussion Eval

Head trauma, Drug withdrawal ( ETOH) or use ( Tramadol, amphetamine) , sleep deprivation, Elyte abnormality ( hypoglycemia, Mg, CA, Na) Anoxia, infection, stroke 22% in elderly.

Seizure: Causes

Labs: CMP, Mg, CBC, Tox screen, CPK EEG: if abnormal increase risk of subsequent seizure 50% MIR to r/o structural brain lesion.

Seizure Eval

Not needed if first seizure with provoking factors Antiepileptic drugs: Topomax, Lamotrigine, Valproate Avoid TRamadol, Wellbutrin, TCA, Sympathomimetics, and some antipsychotics.

Seizure treatment:

2-4 years if seizure free and normal EEG Risk of seizure recurrence off ACE 25% Driving: need at least 12 mo seizure free interval

The can you stop AED ( Antiepileptic Drugs)

Artharitis, and disc disease

Spinal Stenosis causes

Bilateral pain LE brought on by walking and standing upright. Relieved by bending forward Exam can be normal.

Spinal Stenosis symptoms

Weakness in arms and legs, sensory loss, urine and rectal sphincter dysfunction with incontinence, Lhermitte's sign (electric shock sensation with neck flexion. )

Sx of myelopathy

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