Neuro

#Syncope:

Patient experienced sudden transient loss of consciousness due to global cerebral hypoperfusion. No evidence of seizure (no bowel/bladder incontinence, tongue laceration, or post-ictal state), hypoglycemia, hypoxia, narcolepsy.

Differential: neurocardiogenic (vasovagal), orthostatic hypotension, cardiovascular, neurologic

History most consistent with ***.

Witnessed? History of syncope?

Possible vasovagal given *** vs orthostatic etiology given *** vs situational given ***.

-Neurocardiogenic (vasovagal)

-Presyncope present? Preceding trigger (cough, micturition, defecation)?

-Orthostatic

-vitals, diuretic, medications, dysautonomia

-Cardiogenic (arrhythmia vs mechanical)

-history of cardiovascular disease?

-EKG. ROMEO score/San Francisco syncope rule. TTE needed?

-Neurologic (vertebrobasilar insufficiency, cerebrovascular dissection, SAH, TIA/CVA, migraine)  

-CNS imaging: Unnecessary unless head trauma, or new focal neurodeficit.

-Carotid ultrasound: Unnecessary. Carotid CVA/TIA almost never causes LOC.

-continuous telemetry (Yield is 18% during 3-5 days in hospital)

-orthostatic VS 

-q4 vitals

-CBC, coags, RFP, hepatic function panel; troponin, D-dimer

-TTE

Further workup to consider? Ambulatory ECG, exercise stress test, CCTA, cath, EP studies

-Continue with fall for precautions while inpatient. 

-Per Texas state law, patient will need to avoid driving for at least 6 months in the setting of syncope/LOC with unclear etiology - primary team to reinforce this with the patient.  

 -PESIT study, rule out PE

#dizziness

Vertigo vs presyncope vs disequilibrium

Acute vestibular syndrome vs spontaneous episodic vestibular syndrome vs triggered episodic vestibular syndrome

ATTEST: associated symptoms, timing and triggers, bedside examination signs, and additional testing as needed

4 categories: vertigo, presyncope, disequilibrium, nonspecific

Vertigo: peripheral = BPPV, vestibular neuronitis, labyrinthitis, meniere, medication effects, ramsay hunt, vestibular schwannoma

BPPV: spinning sensation with head movement lasting less than 3 minutes

Recent viral infection? (vestibular neuronitis vs labyrinthitis (also has hearing loss)

Hx of migraine? -> vestibular migraine

Hearing loss or ear fullness? Tinnitus?

Ear pain, vesicles, facial paralysis, taste loss, hearing changes (hyperacusis)

PMID: 29395695

#Migraine

Unilateral, throbbing headache accompanied by photophobia, phonophobia, nausea, and disability

Accompanied by aura (FND) in 30% of cases (visual, hemisensory, or language abnormalities)

Prodrome: mood, irritability, fatigue, food cravings, increased need to urinate, difficulty concentrating, neck pain, and difficulty with sleep

Postdrome: (80% of patients) fatigue, difficulty concentrating, light sensitivity, body aches

Rule out secondary causes of headache: new onset headache, jaw claudication, nodular or tender temporal arteries; worsened with exertion, transient loss of binocular vision, double vision, pulsatile tinnitus (IIH); orthostatic sx (spontaneous intracranial hypotension); no trauma or AMS; no s/sx of infection

Indications for MRI with contrast: neuro exam abnormality, worse with valsalva or waking up, new headache in an older person, progressively worsening headache

MRI with and without + vascular imaging if associated with cough, exertion, or sexual activity

Refer to neurology if atypical symptoms leading to diagnositic uncertainty, failure to respond to medication, or comorbidities that require a more complex treatment approach

Treatment for acute attacks: over the counter anagesic, if no vomiting or severe nausea, acetaminophen, aspirin, and/or caffeine are effective. NSAIDs are effective. If severe and no vascular history: triptans. If severe and vascular history or if 2 separate triptans have been ineffective: gepants (CGRP antagonists)

Consider addition of preventive medications when >2 days/week for multiple weeks, patient preference, adverse events from frequent therapy, uncommon migraine type (hemiplegic or brainstem aura), of substantial disability >2x/month

Medication options include propranolol (60 to 240mg/d), timolol (5 to 30mg/d), divalproex sodium (500 to 2000mg/d), topiramate (100md/d). Can also consider candesartan and venlafaxine. Uptitrate for a few weeks and maintain for >8 weeks. 

Consider new preventive med when >2 meds above have been ineffective

Erenumab has black box warning for constipation

Women planning to become pregnant should avoid antiCGRP monoclonal antibody medications at least 5 months prior to becoming pregnant 

#status migranosus: 

Migraine >72 hours

IV compazine or reglan + benadryl +subq sumatriptan

IV ketorolac + IV dexamethasone

Opioids are generally ineffective

"Inpatient treatment typically consists of repeated IV dihydroergotamine ofen with reglan or other antiemetic, with toradol, steroids, valproic acid, and other parenteral medications. Improvement may not be seen for several weeks after discharge, typically in conjunction with preventive therapy

#Medication overuse headache

50% of patients with chronic migraine and 15% with migraine who use symptomatic medications meet criteria for medication-overuse headache

Frequency is more important than the quantity of drug

Suspect in patients who have a headache on 15 or more days per month for more than 3 months and have taken ergots, triptans, opioids, combined analgesic medications, or any combination on 10 of more days per month or simple analgesics on 15 of more days per month

#Encephalopathy:

Patient with acute onset of altered mental status on ***. No systemic signs of infection. No structural or vascular abnormalities on imaging and no hx of trauma. Electrolyte wnl decreasing suspicion for metabolic etiology. Tox screen **. TSH **. Ethanol **.  

-Delirium precautions: reorientation, sitter, avoid nighttime awakenings, avoid deliriogenic medications 

-MRI brain 

-obtain EKG to eval QTc if using antipsychotics for agitation 

-re-evaluate in AM for repeat examination 

#Delirium

Haldol if needed for patient or staff safety

Andersen-Ranberg NC, Poulsen LM, Perner A, Wetterslev J, Estrup S, Hästbacka J, Morgan M, Citerio G, Caballero J, Lange T, Kjær MN, Ebdrup BH, Engstrøm J, Olsen MH, Oxenbøll Collet M, Mortensen CB, Weber SO, Andreasen AS, Bestle MH, Uslu B, Scharling Pedersen H, Gramstrup Nielsen L, Toft Boesen HC, Jensen JV, Nebrich L, La Cour K, Laigaard J, Haurum C, Olesen MW, Overgaard-Steensen C, Westergaard B, Brand BA, Kingo Vesterlund G, Thornberg Kyhnauv P, Mikkelsen VS, Hyttel-Sørensen S, de Haas I, Aagaard SR, Nielsen LO, Eriksen AS, Rasmussen BS, Brix H, Hildebrandt T, Schønemann-Lund M, Fjeldsøe-Nielsen H, Kuivalainen AM, Mathiesen O; AID-ICU Trial Group. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. 2022 Oct 26. doi: 10.1056/NEJMoa2211868. Epub ahead of print. PMID: 36286254.

#Possible TIA:

ABCD2 score to risk stratify as it affects mgmt 

-If ABCD2 score high risk (>4), consider initiating DAPT for 21 days after high risk TIA or minor stroke 

-TTE to eval for cardioembolic source 

-A1c and lipid profile if not recent 

-initiate statin and aspirin therapy 

Lumbar puncture findings:

#Elevated CSF protein 

#Elevated CSF opening pressure 

>25cm H2O 

Ddx: meningitis, IIH, SAH, brain abscess, intracranial vasculitis, encephalitis, meiningeal carcinomatosis, GBS, intracranial mass, venous sinus thrombosis, jugular vein compression, cerebral edema, choroid plexus papilloma 

Need CT prior to LP 

Trauma, age>60, papilledema (or increased ICP), AMS, seizure, immunocompromised, FND 

Elevated protein s/p spinal cord injury will result in false elevation (Travlos et al, 1994) 

#Lumbar puncture 

Contraindications: Focal neurological defect, altered mental status, immunosuppression, lesion, seizure; increased bleeding risk ie patient on Eliquis, plt <100k (plt <50k with IR) 

#Optic neuritis 

Patient presenting with rapid onset eye pain, worse with movement, decreased vision, relative afferent pupillary dilation on exam 

Ddx: Autoimmune disease: central demyelinating diseases such as Multiple Sclerosis, Neuromyelitis Optica, Myelin Oligodendrocyte Glycoprotein (MOG) immunoglobulin IgG; Sjogren syndrome, Sarcoidosis 

Infection: Lyme, syphilis 

Metabolic: B12 deficiency 

Will order TSH, RPR, B12/MMA, CRP/ESR 

LP to be performed 

- MS profile ordered on Essentris (serum red top + CSF) 

-will consult neurology, recs appreciated 

-will order 1g salumedrol for 3 days, followed by 11 days of 1mg/kg prednisone

#Guillian Barre 

Patient presenting with progressive ascending weakness 

No respiratory symptoms at this time 

Neurology consulted, recs appreciated 

Negative inspiratory force ordered via RT 

IVIG ordered 

#Headache 

Positional? Time of day? Triggers? Hx of OSA? Papilledema on exam? Imaging? CT non con ordered/performed; MRI w/wo and MRV ordered to rule out Central Venous Thrombosis 

#Increased intracranial pressure 

Ddx:  

Arterial: hemorrhage, stroke, aneurysm 

Vein: central venous thrombosis 

CSF: decreased choroid plexus re-absorption, choroid plexus papilloma, subarachnoid hemorrhage 

Brain tissue: mass 

#Seizure 

Per the Epilepsy Foundation (epilepsy.com) 

-patient counseled on required seizure free period of ___ months prior to driving again in state of ___ 

-Physician is/is not required to report to the state's DMV 

#AMS 

MIST 

METABOLIC: electrolytes, organ dysfunction, vitamin b1/b12 

Infection:  

Structural: 

Toxin 

Low glucose, opiate, GCS 

Dementia/delirium 

Psychiatric 

Stroke 

Pupils? Sweat/salivate? Bowel movements? 

Normal lithium level 0.8-1.2 

CBC, CMP, LFTS, UDS, EKG, CT head 

#lithium toxicity 

Chronic equals lethargy slurred speech somnolence 

Give IVF, check li on admission and q4 hours 

Consider dialysis if uptrending