Kritsanapak Seekoongosum

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Clinical Method Neurology

Acute: NSIAD, Para, triptans

Prophylaxis miagraine: ABC TV

Advice: sleep, meal, caffeine, stress, beware analgesia overuse headache

Emergency Neurology

Approach to common problems

Headache
- Prove
- Migraine criteria
- GP Tx
- How to R/O secondary causes

Movement disorder
a. 6 types
i. BRADY/AKINESIA
 1. Dec dopamine in Pakinsonism
ii. DYSKINESIA
1. Tremors (rhythimic, sinusoidal move gmjkdyo-k-
7hoc]t])
2. Tics, Tourettes syndrome (jerky, want to do to
release stress)
3. Dystonia (increased tone of both agonist and
antagonist dystonic posture)
4. Flapping tremors (
)
5. Myoclonus (jerk, repeat, same, )
6. Chorea, Athetosis, Hmiballism, TD

Tremor

- Resting
o 4-6/sec
o
o Roll pilling in PD (Dx PDism Wilsons)
o FtoN negative
- Postural
o

o Familial-essential tremor Propanolol, self alcohol
o Dx
Thyrotoxicosis (polyuria but rare not fever with chills)
B-anonist bronchodilator, Theophylline

o High fq: 9-10 /sec
- Intention
o
o Cerebellum or brain stem (MS, tumor, Benedicts)
o FtoN (also call ataxia)
o Low fq: 2-3/sec
o titubation
- PD and MS may +- postural tremor

Epilepsy

- DDx of 1t episode seizure

o TIA, Syncope, Basilar Migraine
o Others: metabolic, sudden IICP, Sleep ds, Panic
o Real:
 No lateralization, No
No conscious
Postictal phase:
Todds paralysis (hours to < 3days)
- Seziure vs Epilepsy
o Unprovoked >= 2 times
Episodic, recuurent, stereotype
o Acquired epilepsy
OB
Infection CNS/Trauma
Vascular
- Seizure
o Patial (Focal)
Simple
Complex
Evolving to generalized
o Generalized
Absence (petit mal seizures)
Myoclonus
Tonic-clonic (GRAND MAL)
Clonus
Tonic
Atonic
- Epilepticus
o 5 min: good conscious of inter-ictal
o 30 min
- R/O
o Papilledema
o Post-hypoxia (MR)
o Carpopedal spasm Hypocalcemia
o Chronic liver, Flapping tremor (Hepatic, Metabolic enceph)
o Neuro deficit (post-stroke, brain tumor, encephaliltis)
o SLE
o Neurocutaneous syndrome:
Caf au lait spot
Neonates who have multiple CALMs should be
evaluated carefully for stigmata of NF-1
as leaf - shagreen patch
TSC (tuberous sclerosis complex)
Port wein stain (PWS)
(Two syndromes associated with PWSs and
extracutaneous abnormalities are Sturge-Weber
syndrome (SWS) and Klippel-Trenaunay syndrome
(KTS))
http://www.ohsu.edu/xd/health/services/doernbecher/rese
arch-
education/education/residency/upload/res_lounge_significa
nt-birthmarks.pdf
o Cerebral cysticercosis
o Ecchymosis ICH ??
- Mx
o I/C initiate anti-epileptic drug
>= 2
Status Epilepticus ()
1st episode seizure with
Lesion in brain
Always Sleep deprivation
Neuro deficit
Pt want to
o General principle
Start slow, go slow
Clos monitoring
Drug level only as indicated
Suspected overdose
Check compliance
Pregnancy
Liver, Renal disease
o Goal: best QoL
o Initiation
Generalized valproate (400-500mg, 500-2500),

Ethosuximide ()
Partial Carbamazepne (100mg, 400-1600), Valproate,
Phenytoin
o I/C for new gen (Gabapenem, Lamotrigine, Levetiracetam,
Vigabatrin)
SJS, TEN
Liver failure, Renal failure
Fail to first drug
o
trauma jt dislocation

<4
CPS
aspirate

Motor weakness
- Localization
o UMN
Cortex (vascular, tumor, abscess, Herpes enphe, injury)
Subcortex/Internal capsule
Brainstem
Spinal cord (transverse myelitis, trauma, compression, TB,
Demyelination: MS, tumor)
 o LMN
AHC (Poliomyelitis, ALS both c ccst UMN)
Nerve root (herniated intervert disc, malignancy)
Motor nerve of peripheral nerve
Motor nerve of motor cranial brain stem
NMS: LE, MG, Botulinum toxin, , pesticide
poisoning
Muscle: Hypokalemic periodic paralysis, Polymyositis,
dermatomyositis, Endocrine myopathy: steroid,
Thyrotoxicosis, rhabdomyolysis, muscular dystrophy
- UMN vs LMN

UMN LMN
Hemiplegia, Quadriplegia, Paraplegia Quadriplegia (Proximal muscle
Monplegia weakness),
Monplegia
Local muscle
Cortical sign
Brainstem sign (pupil, CN)
Sacral sign
BK Fasciculation
Clonus Hyporeflexia
Hyperreflexia Flaccid
Spastiocity or Rigidity Early atrophy
No clonus
No BBK

Common sensory deficit

- GBS, CIDP, diabetic neuropathy, toxic neuropathy (occupational, drug:

vincristine, cisplatin, colchicines, aminodarione, isoniazid), neuropathy
assc with CNT dz, HIV-related neuropathy, cryptogenic
- Nutritional isoniazid (B6)

- Syndromic approach
- AIDP: demyelinate php n
o dys/paresthesia +- painful along
o (areflexia early course, predominant motor finding)
- Sensory polyneuropathy
- Syryngomyelia: fluid-filled cavity expanding spinal cord dmg segmental
neurons and eventually white matter tracts - common in
cervicothoraccic - central cord syndrome
o Loss pain and temp at levels of lesion (capelike distribution;
suspended sensory loss)
 o Weakness at levels of lesion can, by motor n dmg spastic tone
eventually
- Thalamic infacrtion
o Contralateral body sensory loss and ataxia
o No aphasia or neglect (cortical signs)
o Eventually Thalamic pain syndrome
- Trigeminal neuralgia
o N root dysfunction
o Paroxysmal of lacinating electric shock0like neuropathic pain
o No other sensory, CN or motor deficits
- CTS
- Ulnar neuropathy
- Localization
- Intrinsic tumor of cord sacral sparing

Delirium

Dementia
 Some Pearls

Neurodegenerative ALS anterior horn cell (LMN) and also involve

corticospinal tct UMN and LMN signs
Poliomyeilis Ant horn cell asym weak LMN signs
GBS (acute AIDP) demyelination php isolated elevated protein, may

be normal or affect sensory, ascending weakness upper (distal

weakness proximal)
Multiple sclerosis autoimmune oligodrendocyte optic neuritis, RAPD+,
nystagmus
MG weak worse, ptosis, risk thymoma (type II A ) tx pyridostigmine

(long acting aches inhibitor) LE

Horner ptosis, anhidrosis, miosis, enopthalmos

Uncal (transtentorial herniation) CNIII fixed dilate, down and out,

ptosis

Argyll-Robertson pupil no papillary light but intact accommodation

Marcus Gunn pupil (RAPD)
Uncal herniation (lat transtentorial )-- > Ipsy 3 + contra weak

Alzheimer hydrocephalus ex vacuo not dilate but sulci atrophy no triad, no

IICP)
Hydropcephalus pressure Normal pressure hydrocephalus triad
wide based gait, urinary incontinence, wacky

Brown-Sequard
Contra pain temp (spino)
Ipsy cortico UMN, ipsy propio

INO
MLF lesion
o Ipsy Medial rectus palsy
Pure motor stroke (upper = lower grade) posterior limb of internal
capsule
Neurotoxin

- Bacterial producing Botulinum toxin (dec acetylcholine release

-
-

-
 Common Neurological Conditions

Bells palsy
Idiopathic + LMN CN II palsy
Ipsylateral weakness pf all hemifacial muscle not spare eyelid
Acute (hrs/days) onset + maximum within 1-2 days +- predomal
preauricular pain
May Report ipsilateral numbness but can have normal sensation upon
exam
Exclude otitis media, herpes zoster infection
EMG can show but only useful after >1wk
Mx
o High-dose corticosteroid (Prednisolne) benefit within 72 hrs given
after exclude Ramsey Hunts syndrome
o Little evidence of acyclovir
o Protect corne: artificial tears, protective patch/glasses
Complication
o Corneal ulcer, infection
o Aberant reinnervation eg blinking cases contraction of
mouth
Prognosis
o Most recovery within 2-12 wks c or without tx

Prednisolone 5 4 3 ,
Acyclovir 400 1 5 ,
Amitryptyline 1 7 ,
Patch ,

Alzheimers disease
 Primary + Chronic progressive + Neurodegenerative + Dementia
Extracellular depositon of B-amyloid protein and intracellular
neurofibrillary tangles
Mild cognitive impairment: affect some cognitive domains (memory,
language, visuospatial ) but not affect QoL
Cause unknown, RF age, FH, prior intellectual level
Neurion reduce in hippocampus, mesial temporal and precuneate cortex
Very common, >65 yo 5percent, 60-80percent of Dementia
History: anterograde amnesias initially, change personality, apathy, loss of
concentration, disorientation +- may have hallu/delusion
LAngauge spared until LATE, also myoclonus, seizure, incontinence and
loss of independence
Exam: MMSE to screen ()<27 score
Inv:
o Exclude hypothyroid
o Exclude tumors, infarction, sudural hematoma,
inflammatory
o Psychia: ddx psedo dementia from depression
o EEG: not dx, exclude non-convulsive status epilepticus
o LP: if subacutre onset -> exclude encephalitis
o Tau and B-42 peptide level can be meased
o Nuclear imaging: regional hypoperfusion
Mx:
o Multidisciplinary icd psychia, neuropsychia
o General rules
Intercurrent illness: avoid sedatives, antimuscarinic,
alcohol.
Environmental mx
Adaptation (memory aids: diaries, labels)
Meds: Anticholineaserase inhibitot (Rivastigminem
donepezil galantamine) only mild to moderate dz
(mod benefit)
Social support
Prog
o Av life expectancy 3-8 yr after dx

Acute UGIB

Asthmatic attack

Acute left MCA stroke, AF c RVR

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