neurology

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goal of the neuro exam?
to identify a dysfunction that gives insight into the anatomical abnormality
stroke defined
-sudden loss of blood circulation to an area of the brain resulting in a corresponding loss of neurologic function
-clinical syndrome consisting of the sudden or rapid onset of a constellation of neurologic findings that persist more than 24 hours
what is the most common disabiling neurologic disease of adults
stroke
stroke is what number leading cause of death?
4th
risk factors of stroke
htn, smoking, dm, cardiac dx, prior stroke, sickle cell, age, male, aa, a fib, hyperlipidemia, etoh salt, obesity
why is stroke increasing in children and young adults
increase in obesity, dm, and htn (uncontrolled)
what are the common signs of a stroke?
-acute hemiparesis or hemiplagia
-acute hemisensory loss
-visual disturbances
-dyarthria or aphasia
-ataxia, vertigo, nystagmus
-sudden decrease in conciousness
DD for stroke, important things to ask family, patient?
hypoglycemia, drug OD, seizures, recent trauma
signs and symptoms of internal carotid circulation stroke
hemiplegia, aphasia, visual field defects, less often headache, seizures, confusions (atherothrombotic>embolic)
signs and symptoms of vertebrobasilar stroke
diplopia, vertigo, ataxia, n/v, hiccup, facia paresis, limp or gait ataxia, motor deficit, coma, embolic and atherothrombotic equal
signs and symptoms of cerebral arteries
motors and or sensory deficit, aphasia, visual hallucinations, paresis of vertical eye movement
unequal pulses or blood pressure in extremities may indicate?
presence of aortic dissections
2 key questions for stroke patients?
1. are the patients symptoms due to brain ischemia?
2. what is the patient's risk for major permanent functional deficit from the ischemic insult?
ischemic stroke defined
caused by thrombosis or embolism, results in vascular occlusion
hemorrhagic stroke defined
usually related to htn
subarachnoid stroke defined
young adults, rarely in elderly, cause is usually a ruptured congenital aneurysm
atherothrombotic stroke defined
progressive stenosis with eventual occlusion due to atherosclerotic plaque formation
score measures risk of stroke on british scale
-estimate of who is at risk of having a stroke in the dates after a TIA
-score of 6 had a 30% change of having a stroke within 1 week
lab studies for stroke
1. CT- most common for acute symptoms
2. MRI- impaired metabolism and structural details
3. glucose
4. O2 saturation
5. ECHO
6. CBC, cardiac enzymes, electrolytes, nitrogen, creatinine, prothrombin, PT/PTT, INR
7. blood alcohol
8. pregnancy test
carotid duplex scanning and stroke work up
one of the the most useful tests in evaluation patients with stroke, intervention if they have carotid stenoses
digital subtraction angiography and stroke work up
considered the definitive method for demonstrating vascular lesions, including occlusions, stenoses, dissections, and aneurysms
bell's palsy defined
-isolated, sudden, unilateral peripheral facial paralysis of unknown etiology (CN VII)
-most common cause of facial paralysis
-acute inflammatory response results in swelling of the facial nerve within the myelin sheath, causing ischemia of the axon
bell's palsy and those patient's at risk
-DM in 10% of bell's palsy patients
-greater than 65 years old
-right side more than left side
-very few cases in summer months
-immunocompromised patients
when is the onset for bell's palsy?
-typically sudden, symptoms peak in less than 48 hours
when does nerve conduction become altered in bell's palsy patients?
-not until about 3 days after degeneration has begun
early symptoms of bell's palsy
-aching of the ear or mastoid
-alterations of taste
-hyperacusis
bell's phenomenon
funky eye movement, lateral and superior eye movement as they close eye on affected side
signs and symptoms of bell's palsy
-acute onset (maximal unilateral motor deficits occurring over a few hours)
-voluntary and involuntary muscle movements of the face are affected
bell's palsy and lymes disease
bell's palsy can be a complication of lymes disease
course of bell's palsy
-onset is acute over 1-2 days, the course is progressive, reaching a maximal clinical weakness/paralysis within 3 weeks or less from the first day of visible weakness
-recovery in 6 months of sooner
labs/tests for bell's palsy
-CBC
-ESR
-CSF
-Electromyography
-MRI
-Nerve conduction studies
Prognosis of Bell's Palsy
-approx 80% recover without noticeable disfigurement in 6 weeks to 3 months
Management of Bell's Palsy
-meds at time of onset ASAP to prevent further nerve damage
-steroids for acute bell's
-antiviral treatment has been used but studies aren't showing positive effects anymore
most important part in work up of headache?
history taking
Red flags for secondary disorders and headaches?
-new severe headache in patients under 5 or over 35
-first of new type of "worst headache ever"- post popping or snapping feeling in the head
-signs and symptoms of systemic illness
-anticoagulation therapy
-history of trauma
htn headaches
usually upon awakening in the am
4 questions by AAN to ask regarding headache
1. how often do you get severe headache (without treatment is it difficult to function?
2. how often to you get other headaches
3. how often do you take headache pain relievers
4. has there been any changes in your headaches
rebound headaches
due to overuse of pain medications for headache
migraines defined
neurochemical or neurocirculatory
-unilateral/temporal
-emotion/stress
-foods/etoh
-menstrual associated
-progressive symptoms
-dull/boring/throbbing
-n/v
-photophobia