Neurologija skriptica
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Transcript of Neurologija skriptica
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neurologydis.
Inflammatoryds.
ADEM
dx
exam
LabCSF
Viralc/s
imaging
EEG
types
brainstem
spine
postencephalitis.
chronic
tumor
rheumatologic
abscess
Leukoodystrophy
Fulminate
Recurrent
steroidtaper
nontaper
steroiddependent
MS
dx
exam
Lab CSF
MRI
tx
fatigue
tonicspasms
INFreaction
encephalitisdx
clinical
lab
types Encephalomyeloradiculneuropathy
vasculitisdx clinical
tx
DDX
Autonomicneuropathy
signs
tmpcontrol
CVS
GI
GU
otherseye horner's
drymoth/eyes
etiology
CNS
PNS
DM glucoseintolerance
Amyloid
autoimmune
clinicaltypespureautonomic
sympathetic
parasympathetic
both
mixed
etiology
autoimmunediseases Sjogren
postviral
paraneoplsticLambertEaton
antiganglionicAchreceptorsabs
Rehab
chronicresp.care
saliva
musclecramps
vertigo
Bldder
spasticity
Subtopic
Neuropathy
pearls
Presentations
Hypotension&fever
septicshock
DIC
autonomicneuropathy
progressiveweaknessetiologies
MG
Myopathies
ALS
symptoms
abnormalpupillaryexam
opticnerve
3thnerve
autonomicdisease
acutedescendingweakness
MG
MillerfisherGBS
Botulism
intermittentnumbnessorfootdrop CIDP
Dissectioncanpresentslikemigraine
fever,rigidity
Malignancyw/u
steroidtx
pretx
supportivetx
sparingtx
MTX
AZA
Cellcept
IVIG/plasmapherisis
thirdline
Cyclosporine
cyclophosphamide
others
NICU
Neuromuscular&respiratoryemergencies
Monitoring
signs
Increasedbreathingrate
decreasedO2
sweatning.weakcough
Respiratoryfailure
nosignsofdyspneainneuromuscularweakness
bedsidecountto30inonebreath
neckflexormusclespredicttherespiratorymuscles.
respiratoryfunctionexpiratorypeakflow
Vitalcapacity
ABG IncreaseCO2
ICUquadriplegiacriticalillnessneuropathy
criticalillnessmyopathy
EEGmonitoringind.
szpoststatus
encephalopathies/ietis
comaNMJblockage
severeNMJandGBS
vascularstroke
ISH
tech artifact succinylcholine
sz statusEpil.tx
versedloading
drip
Dilantin
Arivanloading
drip
propofulloading
drip
pentobarbitalloading
drip
Ketamineloading
maint.
others
VPA
Topamax
Keppra
theopental
paraldehyde
medical HTNpoststatus
stroke
surgery
CVS
tx
tPAHTN
post3hrs
interventional
IAtPA
deviceretreiver
stent/angioplasty
surgery
prevention surgical
Imaging
CTA
CTperfusion
MRI
rehab depression
ICH
prog
volume
IVH
deterioration
CVA
hydrocephalus
NCSE
medical
typecoagulopathy
Trauma
dx angio
IVH
noHTN
lobar
surgery
ICPmonitor
ventriculostomy
Parenchymalprobe
others centralveinoxymetry
evacuationcerebellar
CT
Clinical
IVH tx
medical
BPlowerBP
inc.BP
lowerICP
manitol
Hypertonicsaline
other
hyperventilation
barbiturate
hypothermia
Lasix
SZprophylaxis
NCSEclinical
tx
reversecoagulation
coumadin
FFP
VitK
fVII
PCC
heparin
Lovenox
argatroban
ITP
DVTprophylaxis
intubation
tech
weaning
trachestomy
weaning
dailylabs latelabs
Re-anticoagsdeepICH
LobarICH
FEN
NMJ MG labs AChr-
Muscles
Myotonicdystrophy
Statinsmyopathyclinical
tx
Muscledystrophies Baker's
LimbGirdlemuscledis.
Myositis
dx
tx
typespolymyositis
inclusionbodymyositis
Myalgia
txsupportive
cardiac
resp.
steroids
presentaion
cardiac
contracutres
bulpar
Dementia
types
Alzheimer
vasculardementia
LBDparkinsonism
dementia
fronto-temoral
txcognitive
behavioural
Movementsdis.
symptoms
dystonia
acute
tx
presentationoculogyriccrisis
dystoniastorm
ddx
chronic tx
Botox
medical
DBS
essentialtremor tx
chorealabs
tx
violentactivityBallismus
paroxysmaldyskinesia
diseases
Parkinson
tx
Sinemet
agonistnew
old
MAOb
COMT
anticolintergics
DBS
symptoms
fluctuation
offtime
dyskinesia
tx
etiologies
presentations
Pain
behavioral
psychosis
impulsecontrol
dementia
anxiety
dysautonomia
NMSofparkinson
exam
tests
Huntingtondis
tics tx
RLS
spine
rehab autonomicdysreflexia
symtoms
txacute
prophylaxis
spondolysis
tx
medical
epidurals
PT
surgery
symptoms
exam
etiologies muscoloskeltal facetjoint
transversemyelitis
symptoms
prognosis
testslabs
imaging
imaging MRI
noramlvariants
degenerativedis.
op&trauma
headache
migraine
prophylaxis
ACEi
bblockers
Cachannel
AED
TCA
NSAID
vitamins
PT
botux
sypmtoms
acute
migrainestatus
outptstriptans
fastmetl
Subq
N.spray
others
surgical
Chronicdaily tx
Trigeminalha
clustertx
prophylaxis
paroxysmalhemicrania
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loading0.2 mg/kg/
txRiserpine and Tetrabenzine are preferred over neuroleptics as they deplete dopamine and donot causetardive dyskenisia. however only Riserpine is available in US
CNSclosely related to parkinson and LBD.
strokecan predict the post tpa hemorrhage.
steroid taperno risk for MS
ventriculostomydrains IVH monitors hydrocephalus no need for daily csf cultures unless if there's fever. can be left for up to14 ds.
txstart with O2 100% @ 7-15 L/m Triptans and Ergots Lidocaine nasal drop 4-6% Prednisone 60 for daysthen taper off.
facet jointnot all agree on its existence steroid injection into facet joints might help mostly in neck possibleintervention is radio ablation of the innervating branch
NMJ blockageblockage with vecuronium can be reversed with neostigmine succinylcholine is not preferred b/ohyperkalemia. but it's very short acting, few min, compared to 20 min for non depolarizing agents.
acutefrom neuroleptics
acutelike any HTN managments with vasodilators Nitro sublingual or nitro paste 1/2 clonidine 0.1-.02hydralazine 10-20
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CSFCSF immune profile: usually normal MBP high unlike MS
psychosisdecrease the dopamine doses Seroquel UTI,or infection must be r/o early sign of behavioral problems ispaucity of speech and history. Psychosis usually underline a dementia remove anti cholinergics,Amantadine, D agonists,
lower BPMAP=130 ; SPB= 180 severe lowering casue ischemia. Nivadipine, Labetolol, esmolol. for renal pts: usedFenoldopam
HTNtreat if > 185/10 ; if no tPA treat only if > 220 Nitropaste labetolol 10mg q 5 min Nicardipine: 5 mg/hr dripcan be increased every 5-10 min
brainstemmimic: Bickerstaff encephalitis; or glioma
surgerycan not anticogaulate after the surgery mostly used in younger pt who b/o lack of atrophy tend to have worseICP
clinicalsystemic ds, arthritis, rash, dis of the heart, kidney, and liver, retinopathy peripheral nerve dis.
FFPFFP 15 mg/kg or 6 packs can cause volume overload; also pulmonary edema from allergic reactionnormalizes INR in 30 hrs
critical illness neuropathyh/o sepsis use differentiated from myopathy by abnormal phrenic nerve conduction axonal type ofneuropathy; differntiated from GBS by normal CSF
SinemetSinemet CR: does not improve the motor fluctuating and has unpredictable absorption and might increasenausea sudden withdraw can causes NMS like syn. however it can stopped in cases of severe dyskinesia
loading
-
0.1 mg/kg
Ballismuscan be b/l in HIV, non ketotic hyperglycemia,
noraml variantson para sagital : foramen look like upside down pear with the root occupying the third, conjoined nerves:tow nerve roots exiting from same foramen; it can be mistaken with disc fragment or tumor, nerve rootdiverticulum: expansion of the dura around the root make it look like nerve sheet tumor, Tarlov cyst: duraenoculated cysts in the sacrum Schmorl's Node: disk herniation into the vertebral body. can look like tumorinfiltration to the vertebra body, synovial cysts: from facets.
tmp controlnot shivering for cold not sweating for hot socks are not wet when removed excessive sweating
CVAischemia; hematoma expansion; edema
cognitiveACEi like Aricept. indicated for mild to moderate dementia Namenda for mod. to severe dementia. can beadded to Aricept.; it can worsen sz.
HTN post statususually does not need management as the AED meds and the positive pressure ventilation will lower it.
deep ICHanti-caogulation should be resumed in 1-2 weeks
late labsadrenal insufficiency after 1 week. cortisol < 5 once or < 15 twice. presents as low BP,
volumevolume: = largest diameters X number of slices X slices thickness / 2 Critical voulme= 30 ml
cardiacCardiac: Echo, EKG, Holter; tx with ACEi and B blockers can slow progress; later consider earlypacemaker
tx
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start prophylaxis tx on month before tapering off analgesics at the end of the taper to prevent reboundheadache can use: dexamethasone 4 mg bid for 3 days; or steroid Medrol pack or sumatripatans 100 mg tidfor 2 days (then prn) for milder pain: NSAID or hydroxyzine 50
oculogyric crisiscan mimics partial sz. with forced eyes deviation, hyperventilation can be from dpaminergic withdrawal orfrom neuroleptics. tx; anticholinergics (diphenhydramin 50 IV or bemztropin 1 mg)
etiologiesspecially if bulbar or mutlifocal. check: MG, Myopathies (LGMD, myositis..), ALS
medicalNSAID muscle relaxants: Flexeril steroids: Medrol pack 21 of 4 mg. start with 6 tabs and taper by one dailyfor total of 6 days. Neurontin TCA: for radicular pain patches: lidocaine, NSAID patches, opiates (Percocet,Oxycodone, Lortab=Vicodin, Tylenol with codein ) or Ultram
pre txDEXA bone scan for osteoporosis CXR for tuberculosis
manitolmannitol 20% ; 0.25 - 1.4 g/kg boluses over 20 min ; can repeat q 3 hrs. check osmolarity frequently, stop if> 320 stop if osmo gap > 15; osmo gap= measured osmolarity - (2Na+ bun/2.8 + gluc/18) risk of ARF,dehydration or rebound ICP
SjogrenSjogren antibodies anti SSA and SSB are only sensitive in 20% the dry mucosa can be part of the Sjogren orpart of the associated autonomic neuropathy.
parkinsonismmostly with no tremor wide fluctuation from day to day associated with REM behavior disorder.
Botoxboth type A and B are immunogenics
muscoloskeltalback pain in the absence of any neurological causes.
txtx; anticholinergics (diphenhydramin 50 IV )
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txIntra-ventricular tPA. drianage. incr. risk of bleeding along the drain.cc
depressionSSRI are best so it does not interfere with Warferin Lexapro 10 mg, celexa 20, zoloft 25
triptansTriptans ( or the combo ones with NSAIDS) for refractory cases use large doses: like sumatriptan 100 mgshould be given early in the attack
labsCSF: pleocytosis, IgG index , protein 14-3-3
AChr -if AChR was neg, always check MusK especialy in bulbar weakness and spared ocular. EMG, Endorphintest, thymus scan are likely normal. tx: is less effective
migrainemigraine with aura increase risk of CVD and CVA x 2
IA tPAfor distal clots beyond M2 up to 6 hrs
MRICT myelogram if MRI is not availbale MRI gradient for disks and MRI STIR for spine.
clinicalin encephalitis: fever lasts longer compared to ADEM where it lasts only 1 day.
txPropranolol, Mysolin and Klonopin Topamax works but needs dose >200 and cause side effects
Cyclosporinestart at 3-4 mg/kg/d and gradually inc. to 6 mg/kg/d goal is trough 50-200
EncephalomyeloradiculneuropathyEncephalitis with peripheral involvement. low reflexes. Enterovirus 71, Coxacie
symtoms
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sudden HTN and bradycardia with sweating.. triggered by bowel or urinary retention or ulcer
dystoniafor cervical dystonia: check the MRI cervical for cord compression
tumorlymphoma can respond to steroid then relapse with withdrawl
clinicalpain, weakness, ++ CK noticed by lying down aggravated with fasting can happen anytime after thetreatment. symptoms donot always resolves with stopping the meds. biopsy and EMG may be normal. insevere cases, changing the stating to another one will not work; try alternatively: niacin, bile resins.
hyperventilationgoal is Pco2 26-30 intermittent mandatory ventilation (IMV)at a rate of 16 to 20 per second,with tidalpressure of Cox 28 to 32 hg.Avoid severe hypocapnia of 60
txtx: decrease sinemet and add dopamine agonist (in particular Amantadine 100 bid) severe case needadmission for rhabomyolysis causing ARF or CHF or for respiratory dyskenisia
CTAsource images can estimate the infarcted core as accurate as CBV in Perfusion
loading1-4.5 mg/kg given with benzo
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labsanti-phospholipids abs, Lupus, Thyroid panel, ASLO, ESR, non ketotic hyperglycemia
MTXfaster than AZA start 7.5 mg/wk , inc. by 5 mg qwk until 20 mg/kw if no reponse, start IV MTX up to 60mg/qwk
fluctuationcan be non motor: like emotional, depression or activity level or even back pain.
angiorequired for: dural-arterial venous fistula vasculitis cortical vein thrombosis small AVM
techTV: 6 ml/kg ; pCO2=35- 40; O sat > 92 in MICU : slight hypercapnia is usually allowed to prevetmechanical lung injury; however this can increase ICP in NICU pats. high PEEP can increase ICP; this cancounterpart by elevating HOB
eyepupilomotor dysfunction; blurry vision
migraine statusdepaken 500 mg IV Ketorolac plus Prochlorperazine short run of IV steroid or Medrol pack
symptoms100% bladder dysfunction and parathesia. band like dysthesia in levels of lesions.
CSFabnormal CSF immune profile
coumadinreverse with either: vit K + PCC vit K + FFP + f VII
clinicalworsening the consciousness level and spasticity
surgicalendarectomy for all stenosis over 70% for some of stenosis 50-69% Angioplasty and stenting only ifendarectomy is not possible for co moribidities
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loading12 mg/kg
Alzheimerinsight is usually saved until late.
rehabmaximum recovery is usually reached by the third month,
fatiguestimulants: Provigil, Ritalin, Concerta, Adderall XR, Straterra, or Amantadine Vyvanse: new agent. the best.Also acetyl-carnitine 1-3 gm bid Provigil can be used up to 600 mg/d. preferred to give holidays off themed. exercise: produce paradoxical effect need to pay attention to other factors: sleep disorder from musclejerks or from nocturia from neurogenic bladder.
chronic resp. careFVC q 3 ms vibrator assisted cough machine BiPaP Non invasive ventilator
Lambert EatonAutonomic neorapathy presents in 60%
fast metlprobably works same like regular tab Zomig ZMT, Maxalt MLT
prophylaxisconsider for 2 attacks /weeks. or for fewer if the attacks were disabling. birth control is required for most ofthose meds when other co morbid conditions co exist with migraine: use the best drugs for each and notnecessary the one drug for both placebo effect is 30s%. most drugs are 50s% consider underling depression
coagulopathyfluid-fluid level
cardiaccardiac involvement could be the only presentation can have either CHF or conduction block or arrythemia(Afib, V tach,...)
CT> 3 cm or ischemia of third of cerebellulm hemisphere. effacement of quadrigeminal cistern need daily CTto r/o acute hydrocephalus.
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clusterdifferentiate it from migraine: short escalating (10 min) and lasting ( 1.5 hrs) pt is agitated and restless,where in migraine he's calm unilateral with cranial autonomic dysfunction
ACEiACEi and ARI are prophylaxis effective and can be used to decrease CVD and CVA risks in pts with theaura migraine
exam
little sensory abnormality
dxanti Jo-1 see malignancy w/u
succinylcholinecan cause hyperkalemia should be avoided in NM disorders.
glucose intoleranceglucose intolerance can present just as combination of both pain and autonomic neuropathy
new
Requip and Mirapex
exam
remarkable sensory abnormality; specially vibration.
signsin respirtatory compromise from neuromuscular origin, the weakness can progress to failure with no signs ofrespiratory stress.
salivaanti cholinergics.; scopolamin patch for sever cases try botox
prophylaxisverapamil 160 tid ( twice the dose for migraine) lithium 150-300 tid Neurontin , Indomethacine, Ergotamin
resp.Resp: FVC lying and sitting, overnight pulse ox, Pulmonary function test
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post 3 hrsIV tPA can be given 3-5 hrs only if there is big mismatch on perfusion scan.
imagingalways consider brain MRI and evoked potentials.
IVHcritical volume is 20 ml
dystonia stormsevere generalized dystonia: need ICU admission and might need genearlized anathesia ( propofol) andmuscle blockers can be triggered from infection or drug chagne tx: try tthe combination of baclofen,depakote, pimozide. and Atrane but might need urgent DBS
behaviouralfor anxiety: Trazodone, Buspirone can help neurolyptics: likely to have no benefits can try : SSRI, AED, forAbulia: try sinemet, stimulants, SSRI
tximmunosuppresant might work better than AED for sz or behavioural.
tonic spasmsresembles tetanus or dystonis. responds to low carbamazepine, acetazolamide also clonazepam for pelvicspasms: Belladonna with opiods suppositories (B&O) intrarectally or vaginally.
Vital capacityICU criteria: bulbar dysfunction or automonic instability > 30% reduction in VC or sat
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impulse controlassociated with dopamine tx includes: gambling, shopping, OCD, hyperphagia, self feeling of clinicalworsening tx: decrease dopamine agonist, seroquel? anti depressents?
supportive txAlendronate 70 mg qweek vit D 800 qd Bactrim DS 3x per week Protonix or TUMS tid.
prognosis1/3 recover, 1/3 moderate and 1/3 severe disability
medicalhigh dose of anti-cholinergics Haldol
Topamaxthrough GT loading dose
Hypertonic salinecan be given as : bolus : HTS 23.4% ; 1 ml/kg ; then infusion 2-3 % at 0.1 - 1 ml/kg/hr or : 23.4% as 30-60cc iv bolus q 6 hrs. or 3% bolus 150 cc q 4-6 hrs or 3% infusion 0.5-1 cc/kg/hr side effects: CHF, bleeding
weaninggood strength: FVC > 15 ml/kg; NIF < -30
ICU quadriplegiaMRI cervical and brainstrem: r/o neck injury and brainstem stroke EMG: critical illness myopathy /neuropathy Spinal cord damage: ischemia or trauma
spinelesions extending longer; more in the thoracic . "transverse myelitis". lesions on axial view involves overhalf diameter of spine unlike MS mimic NMO; check NMO antibodies. NMO is relapsing remitting on MRIinfectious etiologies mimics ADEM: lylme, HTLV 1-2
vascular dementiausually presents shortly after CVA. urinary incontinence is early
chroniccan be tremor-like and repetitive or myoclonic pure neck tremor without associated hand tremor is likelydystonia, it's the most common presentation of Wilson dis. especially proximal tremor.
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b blockersPropranolol 40-400 mg, Metoprolol,100 -200 Atenolo 50-200
inclusion body myositisasymmetric, and more in flexors muscles. muscle biopsy is neg in 1/3 usually refractory to tx.
drip1 mg/kg/hr
Huntington disacanthocytosis can mimic HD on MRI and chorea findings. there is associated neuropathy and high CK alsoHD like disease , in blacks, is identical to HD but neg genetic test ,
Dilantinactually may not work at all. so if benzo failed go to propofol
heparin1 mg protamine reverse 100 u heparin in the last 4 hrs. 1000 units/hr heparin is reversed by 25 mg protamine
paroxysmal dyskinesiacongenital. responds to klonopin, carbamazepine,
Sub qbest for pts with nausea Imitrex
Malignancy w/uCT chest/pelvic, Mamogram, colono-scope.
labCSF: elevated WBC and immune profile neg viral c/s in 70%
interventionalbetter only for: large vessels occlusion in ICA, MCA no response to Iv tPA beyond 3 hrs
Clinicaldepressed consciousness brainstem compression signs; ispsilateral babenski
tx
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same like neuropathy: Neurontin, PT, NSAID. short course of steroids
inc. BPto avoid ischemia start with norepinephrine or phenylephrin; aslo vasopressin dopamine is poor in NICU
device retreiverfor MCA/ICA +/- IA tPA up to 8 hrs
CVSRt stroke: bradycardia Lt stroke: tachycarida
contracutreslimited ROM: joints contractures, spine rigidity and limited ROM are remarkable in Emery -Dreifuss AD. inthe X linked form, contractures precede weakness. Myotonic dystrophy can have limited ROM.
etiologieslikely to result from pt self medicating dysregulation, also might be from infections
ISHpredicting vasospams before they are detected on Doppler by decrease in the A rythem variability.
drip9 mg/hr
sypmtomsthe aura can be dysartheria but not weakness. symptoms should be at least 5 min headache should followwithin 60 min Triggers include: chocolate, ETOH, cheese, sweetners
oldAmantadin or Bromocriptine
prophylaxisclonidine 0.2 bid prazosin 0.5-1 qd
non taperrisk for MS 25% prepubertal; 85% post puberty
post viral+/- AIDP
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symptomsexcessive saliva, inability to whistle. SOB
Traumabrain contusion mostly frontals
maint.0.5-2.5 mg/kg
critical illness myopathyh/o steroid ; muscle blockage use elevated CK normal phrneic nerve study; abnormal diaphragm EMGprognosis is worse
txversed drip
drip0.25-0.4 mg/kg/hr as per EEG
PNSoften combined with pain's small fibers involvement as well.
symptomspain can improve by worsening of the diesease unlike neurological symtoms which usually worsen.
cyclophosphamidePO 1 mg/kg/d or IV 1 gm/m2/ q month
AZAslow, takes 6 ms. start 50 mg qd; inc to 2-3 mg/kg within 2 ms can cause sever flu-like symptoms
txsee steroid tx start prednisone ( 1 mg/kg) or 100 qd for 1-2 w then qod if no response by 4-6 ms then stopwhen response plateau then taper off by 5 mg q 2 weeks Cellcept 1 gm bid can be started along steroids or ifthere is relapses
Chronic dailysame is analgesics over use 15 days per month; 8 of them are migraines it's uncertain if NSAID causes thatas NSAID can be given daily to prevent migraine
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degenerative dis.once myelomalacia develops " increased spine signal on T2" it's unlikely for symptoms to resolve withsurgery. the endplates changes from degenerative dis. can mimic tumor infiltration; however the hallmark isthe location along the endplates edges only. Signal on T1 or T2 can be anything' facet joint dis. : causesmuscle skeletal pain on its own, or contribute to spinal stenosis. Also it can be associated with synovial cystwhich causes bones erosions. Para articular defect: shortening of the pedicles causing congenitalspodolithisis.
Vit Kvit K IV 10 mg X 3d
othersErgots. (cafergot, ?excedrin migrain? Combos (Fiorinal, Fioricet, Esgic,) all are caffein + ASA + Butalbitalfor sedation. Midrin has vasocnstrictor.. All are less effective to migraine than triptans.
CT perfusionbest triage for new CVA along with CTA CBF and MTT showes penumbra but CBV showes the ischemiccores CBV can be visualized from the source imaging of CTA as oligoemic area
drip0.1-2 mg/kg/hr
CVSorthostatic hypotesnion: can presents as fatigue after prolonged standing or bathing.. resting tachycardia,sinus pauses; abnormal RR variation- fixed HR- , QT prolongation, slow recovery after exercise. sustainedhypertension; paroxysmal hypo- hypertension.
dementiavisual hallucination and good insight that's not real
Lobar ICHanti coagulation risk is high.
txTetrabenzine, Reserpine, Neuroleptics, Klonopine, valproic acids
diseasesconsider other eitologies: Para neuplastic syn. infections: HIV, virals,... heavy metal poisonings
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essential tremorin severe cases there is rest tremor and must be recognized from parkinson's tremor a cluse is response toETOH; (myoclonic dystonia also responds to ETOH)
epiduralshelp only the pain for few weeks. effect resolved by 3 ms does not improve outcomes or activities orneurological symptoms.
Viral c/snasal and rectal viral culture. CSF culture is usually neg.
choreadifficulty maintain protruded tongue is pts with Huntington dis.
steroid dependentboys, sz, ON, plaques responds to immunosupprsent
deteriorationdec. glasco scale or incr. NIHS by 2
abscesscan be ring enhancing: mimic abscess or cystecircusis, l
MRIsmall multipile lesions on spine, involving less than cross diameter of spine on axial and less longitudeextension on sagital.
MAO bRasagiline is MAOi b that can be used with SSRI. it's also available as patch
stent / angioplastyfor athersclersis. is inferior to endarectomy except for high risk pts
PTChiropracter: good only for back pain with no radiculopathy, mostly for cervical pain.
INF reactionNaprelan: extended release naproxen, prednisone 10 mg at the day of injection, pentoxifulline, Treximet forha. for site reaction. EMLA-lidocaine topical- ; ethyl chloride cold spray.
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autoimmuneany of those illustrated sub types can have the Ach receptors antibodies of the ganglio neuronic cells.
GIBloating, fullness, Nausea severe constipation, less common diarrhea post prandial sym: fatigue, lightheadedness, sleepiness ; hypotension. acalculeus cholecystitis.
Ca channelverapamil (80 tid), nifedipine, dilitazem all results are ambiguous. they work best for hemiplegic migraineor migraine with prolonged aura. Nifidepine is vasodilator and occasionally can worsen
bulparcan be only nasal speech
N. sprayworks faster than tab. Imitrex, Zomig
Lovenoxonly partially neutralized with protamine; use max dose of 50 mg protamine.
DBSin the Globus Palidus. best for generalized dystonia with mutation DYT1
respiratory functionvital capacity: done with max exhalation. normal 40-70 ml/kg Maximal inspiratory pressure: done with maxsuctioning in, Normal > 100, F > 70 Maximal expiratory pressure: done with max blowing out normal > 200, F> 140
MRIcontrast is contradicated in severe renal failure or HD. it can cause Nephrogenic systemic fibrosis. Microbleeds on GRE scan are not contradiction for giving tPA
dementiaAricept and rivastigmine. however they might increase tremor. cognitive test best by mocatest.org
muscle crampsquinine is the best, baclofen, Neurontin, Magnisum
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Keppra1-3 gm
Arivanshould not exceed the max amount b/o metabolic acidosis induced by the solvent, propyl glucocol.
Muscle dystrophiesDuchene's or Baker's are tested by DNA mutation for the dystrophin.
surgeryindication for symptomatics 70-99% and may be indicated for symptomatics 50-69%. may be not indicatedfor women. For asymptomatics 60-99% had to be decided on individual bases ASA is recommended perioperative and to 3 ms after surgery is best done within 2 weeks of CVA
hemicrania continuacontinues headache resemble chronic daily ha but unilateral.
trachestomyafter 7 ds. however can wait for 2-3 weeks to see if pt is improving neurologically
f VIInormalized INR in 8 hrs but INR should not be used for monitoring half life is 2.5 hrs; thus it should be usedin conjuction with FFP dose : 1.2 - 4.8 mg
ALSthe pathognomic finding sometimes is hyper reflexia including jaw jerk
hypothermia34 c. side effects: rebound hyperthermia causes mortal ICP pneumonia bradycarida thrombocytopenia
ddxcan mimics focal sz pharyngeal and vocal cords dystonia must be recognized from titanus, cervical dystoniamust have MRI cervical to r/o fxs or arthritis neck rigidity from menengial irritation can mimic dytonia tooalso neck and pharyngeal infections or cellulitis hypocalcemia can presents with titanus like or paroxysmaldystonia MS can have acute tonic spsams: tonic spasms
SZ prophylaxisfor 1 week Dilantin, Keppra
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post encephalitis.pt can present first with viral (HSV) encephalitis, recover then relapse when ADEM occur. this must bedistinguished from recurrence of the infection. in encephalitis: fever lasts longer; in ADEM it's only for 1 d.
othersTacrolimus: similar to Cyclosporine Chlorambucil: similar to cyclophosphamide. Remicade: TNF blocker;also Rituximab
op & traumasyringes tetheres cord arachnoiditis
acutetypical acute tx is: vit B2 / Magnesium 400 mg (or feverfew) Inderal LA 60 qam ( or tompamax) ZomigZMT prn (or Maxalt). for vomiting: nasal spray or injections)
presentationsRespiratory dyskenisia can presents as SOB and dyspnea. it can alternate very rapidly with off times. (likeevery 15 min) painful dystonia can present during off times
imaginglesions are one age. Later scans can show new small lesions but actually they were old but not visible then.no black holes. involvement of deep gray matter nucleus. less likely to involve the corpus collusum
Cellceptno hepatic or renal toxicity 1 gm bid
para neoplsticautonomic panel includes : anti P/Q type Ca; Ach receptors; Neuronal nicotine receptors abs; anti CV 2; antipurkinje cellPCA2; Anti Hu positive
Trigeminal hain a subtype of cluster headache, symptoms can e very short, lasting only seconds, and can be triggered withcertain head movements.
exam
postural instability test : evaluates risk for fall. need to pull the pt one step backward. also: feet should be innormal position unlike Romberg where feet should be closed together needs to document the time of lastdose
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exam
Spine ROM, palpating the spine, straight leg and head compression
sparing txMethotrexate, Cellcept. Azathioprine, IVIG
fronto-temoralunlike Alzheimer, starts with personality problems; insight is impaired early , speech problem is early memory loss is late, had two types: frontal dominant, with personality changes ; and temporal dominant withprogressive aphasia that's either fluent or non fluent. the fluent subtype has semantic dementia or visualagnosia with loss of words meanings. Primary progressive aphasia is a type of the temporal dominant,
LeukoodystrophyLarge WM lesions mimic leukodystrophies.
hypnic haha in elderly resembles cluster for being nocturnal but no autonomic features.
weaningcan wean regardless of the neurological status if was not neurologically deterioration and if able to coughand suction less than 1 q 2 hrs. can breath and FiO2< 50%.
RLScan be in arms or trunks only 5% have iron deficiency, can be associated with neuropathy or radiculopathy.the best tx then is Neurontin
surgicalclosure of PFO occipital nerve block
theopentalis long acting and fat soluble form of pentobarb
Tigeminal neuralgiathe ha is electrical shocks
Neuropathysymptomatic in only 10% likely to present along retinopathy and nephropathy UE involvement is likely dueto CTS and mono neuritis
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preventionASA: decrease risk by 14% with no dose difference. entero coated ASA is less efficient than regular ASA.Ticlopidine; is an old analogue to ASA with same stroke prevention but more side effects (neutropenia)Plavix is slightly better than ASA Aggrenox: the best prevention. can cause headache, so it can be started qdfor few days with ASA then bid. it lacks the cardiac prevention profile unlike ASA or plavix in Afib if pt isunable to take warferin, ASA is given instead at 325 mg all pt should be placed on statins regardless of LDLlevels; however the high doses of statins (lipitor 80) can increase risk of hemorrhage. statins should not bestopped suddenly. ACEi are not unique among HTN meds for stroke prevention anti coagulation in thefollowing cases: Afib, Mitral stenosis, severe CHF
testsfloudri dopa PET scan showes decreased asymmetric uptake. help to recognize psychogenic cases
GUBladder: frequency, urgency, incontinence. impotence
surgeryto preserve the neuro function but likely would not restore it. two parts: decompression and stabilization
propofulcauses hypotension less mortality than barbiturate so if benzo failed, propofol should be tried next
Lasixgiven in combination with the other agents.
AEDonly toapamax (25-100) , valproate ; possibly neurontin
Painfrom axial rigidity. involves back, shoulder, neck.. can fluctuate with on- off motor response. Also can befrom Dystonia can be discomfort from sensory symptoms or RLS usually correlates with off time tryapomorphine. but also dyskinesia.
anxietyfor insomnia: trazodone, Remeron also seroquel, for panic attacks: if routine tx failed, try ampomorphine orextra LD to abort.
argatrobancan not be reversed.
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vertigoScopolamine patch Benzos less response is with Meclizine other etiologies are: labrynth fistula, vestibularMigraine. consider ENG
EEGSZ or slowing. lesions of the gray matter.
PCCProthrombin complex concentrate concentrate of 2, 7, 9 and 10 normalize INR in 1- 2 hrs. dose: 15 u/kg forINR < 5 ; or 30 u/kg for INR > 5
Limb Girdle muscle dis.presents as proximal weakness. type I is dominant, type II is recessive. Lamin deficiency can only beconfirmed with DNA testing. Muscle biopsy is neg.
COMTEntacapone and Tolcapone
Fulminateage < 2 yrs. not immunized. edema, bleeding, residual deficits and recurrence
ITPsymptomatic hematoma (not in the brain ) can be reversed : 2 FFP + 20 cryprecipitate + 6 Platelets
pentobarbitalcaused hypotension and decrease cardiac mortality
intractable haconsider MRI with MRV/MRA LP with pressure reading ESR for giant cell arteriits Indomethasine. tx
reverse coagulationhematoma can expand for 7 ds. normal INR does not necessary remove risk of bleeding b/o factor 9 is notmeasured. you need to correct the factors to 30-50% of their normal values
TCAanitryptalin, nortryptalin 10-50 mg; but not SSRI
behavioralfor fatigue see: fatigue in MS
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DDXB12 deficiency: mimics MS or ADEM on MRI Sarcoidosis:causes basilar menegitic enhancement, WMlesions and vasculitis. also orbital pseudotumor
Bldderfor nocuria only: can try DDAVP 0.1 - 0.4 mg/d Uninhibited neurogenic bladder : (anticholinergics)Propantheline 15 mg q.i.d.and titrate Oxybutynin (Ditruban) 5mg b.i.d.and titrate CatheterizationNeurogenic bladder (cholinergics) Bethanechol Baclofen Catheterization
DBSperformed in the sub-thalamic neuclus. specially for dyskinesia and prolonged off time must be young andcognitively intact
DVT prophylaxisstrokes induce low grade of DIC; slightly high FDP start with pneumatic compression from day 2: can useheparin 5000 sq TID or lovenox 40 subq if DVT developed: need IVC filer.
NSAIDcan be used, less likely to develop rebound ha. naproxen, Indomethasine,
dysautonomiaincludes: orthostatic hypotension, dysphagia, urinary retention
Myalgiabiopsy only required if there's weakness, elev CK, exercise confined, isolated maylgia could have abnormalbiopsy but it's not specific or diagnostic the finding of non tender points in pt with myalgia supports dx ofFibromyalgia.
Ketaminecan be used for conscious sedation with versed for minor surgery in older kids can cause agitation cause nochange in BP or increase.
Dissection can presents like migrainewith unilateral headache, intermittent numbness or weakness
spasticityBaclofen start at 10 mg qhs and titrate Dantrolene start at 25 mg qd Tizanidine (Zanaflex)Benzodiazepines Botox IM for focal spasticity Baclofen pump for refractory
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intubationfor change in mental status. like for GCS < 8 in stroke: it's usually required after few days, during the edemaphase.
SubtopicLocally: lidoderm, capsaicin cr, compound creams: 12% neurontin + 5% lidocaine
vitaminsriboflavin B2, 400 mg Mg 400 mg co enzyme Q 150 - 300 mg, Feverfew petasites hybridus 150mg qdmelatonin 3 mg qhs
NMS of parkinsonhyperpyrexia syn of PD. presents like NMS: fever, rigidity, rhabdomyolysis, DVT/PE results from abruptwithdraw of sinemet. tx with sinemet; also can giveh bromocriptine or Dantroline 10 mg/kg IV ; same likeNMS
fever, rigidityNMS, Serotonin syn, PD like NMS Tetanus also think of Anticholinergics or toxins for fever witout rigidity
PTconsider chirpopractic or acupunctures.
daily labsAnemia: keep Hg > 7 Na: avoid hypo; but hyper is ok if euvolumic. Glucose control ABG: avoid hypoxemia
Re-anticoagsshould be held for 1-2 weeks
botuxif the previous tx failed.
FENNPO for several days including NG. maint. IV are NS with 20 kcl 50-100 cc/hr
Musclesconsider genetic tests in many muscles dis. could avoid doing biopsy. such as : duchene's and Baker's MD95%; Myotonic dystrophies 100%, FSH 98%; Limb- Girdle dis. I is dominant, II is recessive. both only50% go to genetests.org
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Movements dis.general w/u for unclear movements dis: Imaging: PET, PET with fludro dopa labs: heavy metals, para-neuplstic panel, rheumatology panel, thyroid, HD genetic, blood smear, wilson panel, HIV para neuoplasticw/u and body scans. blind tx: reserpine, Klonopin +/- anticholinergics. also consider clozapine, or verapamilafter all think of psychogenic