Changes

=Brain=

=Brain=

==Stroke==

==Stroke==

! Artery !! Syndrome

! Artery !! Syndrome

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| Lacunar (thalamus) || Pure sensory

| '''Non-dominant parietal lobe''' || '''Clumsiness. Confusion. Construction apraxia (can't copy a drawing). Dressing apraxia (difficulty getting dressed).'''

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| Lacunar '''(internal capsule)''' || Pure motor

| Dominant parietal lobe || Math difficulties. Naming individual fingers. Impaired writing. Right/left confusion.

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| ACA || Contralateral leg weakness and sensory changes

| ACA || Contralateral leg weakness and sensory changes

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| '''PICA (medulla)''' || '''Wallenberg syndrome <u>(lateral medulla)</u>: nystagmus, vertigo, bulbar weakness (weak gag, dysphagia), Horner syndrome, loss of pain/temperature on ipsilateral face and contralateral body.'''

| '''PICA (medulla)''' || '''Wallenberg syndrome <u>(lateral medulla)</u>: nystagmus, vertigo, bulbar weakness (weak gag, dysphagia), Horner syndrome, loss of pain/temperature on ipsilateral face and contralateral body.'''

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*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.

*Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure. Stroke in a young IV drug user with a murmur, think '''mycotic aneurysm'''.

*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. Prevention includes aspirin, statin, clopidogrel, blood pressure control, rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).

*Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset if no contraindications. If large vessel occlusion, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, BP >180/105 mmHg, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed. Use caution in the 3-4.5 hr window in patients over 80, with DM, with a recent stroke, or on DOACs. '''Keep BP below 180/105 mmHg to avoid hemorrhagic transformation''' and avoid starting anticoagulation or anti platelet agents in the first 24 hrs after tPA. Prevention includes aspirin ('''even if patient has history of recurrent falls'''), statin, clopidogrel, blood pressure control ('''most important'''), rate/rhythm control or ablation/Watchman for Afib, weight loss, diabetes control, '''start ppx dose heparin between 24-48 hrs (if not already on thrombolytics, therapeutic anticoagulation, or DAPT)''', and smoking cessation. Treatment for hemorrhagic stroke includes blood pressure control, surgical decompression (ventricular shunt or craniotomy).

==Hematoma==

==Hematoma==

! Etiology !! Presentation !! Treatment

! Etiology !! Presentation !! Treatment

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| [[IIH]] || Can mimic migraine. Shows up in young, obese females, worse in the morning or with straining, can have papilledema on exam, elevated opening pressure on LP. || Acetazolamide (CA inhibitor '''decreases CSF production'''). Weight loss. Therapeutic LPs.

| [[IIH]] || Can mimic migraine. Shows up in young, obese females, worse in the morning or with straining, can have papilledema on exam, elevated opening pressure on LP ('''to avoid herniation, get an MRI first to rule out mass lesion if there is any suspicion at all'''). || Acetazolamide (CA inhibitor '''decreases CSF production'''). Weight loss. Therapeutic LPs.

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| Tumor || Progressively worsening headache, worse in the morning. Can have focal neural deficits based on location. || Treat the cancer

| Tumor || Progressively worsening headache, worse in the morning. Can have focal neural deficits based on location. || Treat the cancer

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| [[Giant Cell Arteritis]] || Jaw claudication, pain with hair combing, ipsilateral vision loss, associated with [[RA]], middle aged females. Temporal artery biopsy will show large vessel vasculitis with giant cells. || High dose steroids for 1-2 months. Don't wait for biopsy results.

| [[Giant Cell Arteritis]] || Jaw claudication, pain with hair combing, ipsilateral vision loss, associated with [[RA]], middle aged females. Temporal artery biopsy will show large vessel vasculitis with giant cells. || High dose steroids for 1-2 months. Don't wait for biopsy results.

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==Spinal Cord Compression==

==Spinal Cord Compression==

*H&P: Low back or neck pain associated with limb weakness, sensory changes

*H&P: Low back or neck pain associated with limb weakness, sensory changes

*Dx: Sensory level, pain, weakness, numbness, or hyperreflexia below the level of compression, bowel/bladder incontinence and saddle anesthesia with cauda equina. Stat MRI. Differential includes tumor, disc herniation, osteomyelitis, epidural abscess, aneurysm, epidural/subdural hematoma, fracture

*Dx: Sensory level, pain, weakness, numbness, or hyperreflexia below the level of compression, bowel/bladder incontinence and saddle anesthesia with cauda equina. '''Stat MRI'''. Differential includes tumor, disc herniation, osteomyelitis, epidural abscess, aneurysm, epidural/subdural hematoma, fracture

*Tx: Based on etiology. Don't give steroids for infection. May need neurosurgical decompression.

*Tx: Based on etiology. '''High-dose corticosteroids should be given stat for suspected epidural spinal cord compression.''' Don't give steroids for infection. '''If indicated by MRI results''', consult neurosurgery for decompression.

==Spinal Stenosis==

==Spinal Stenosis==

*H&P: Neurogenic claudication-low back pain that radiates to the buttock that is worse with spinal extension, walking downhill, and standing, better with walking downhill and leaning forward. Negative SLR.

*H&P: Neurogenic claudication-low back pain that radiates to the buttock that is worse with spinal extension, walking downhill, and standing, better with walking downhill and leaning forward. Negative SLR.

*Dx: Degenerative changes and neuroforaminal narrowing on xray or MRI.

*Dx: Degenerative changes and neuroforaminal narrowing on xray or '''MRI (preferred)'''.

*Tx: NSAIDs, PT; multimodal, MNB, MND, ESI, laminectomy

*Tx: NSAIDs, PT; multimodal, MNB, MND, ESI, laminectomy

! Syndrome !! Spinal Tracts Involved !! Presentation

! Syndrome !! Spinal Tracts Involved !! Presentation

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| Syrinx || Spinothalamic decussation at ventral commissure, then corticospinal tracts || Loss of pain and temperature bilaterally at the level of the lesion, followed by weakness

| Syrinx || Spinothalamic decussation at ventral commissure, then corticospinal tracts || Loss of pain and temperature bilaterally at the level of the lesion, followed by weakness.

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| Brown-Sequard || Hemi-cord dissection || Contralateral loss of pain and temperature, ipsilateral weakness and loss of light touch, vibration, and proprioception

| Brown-Sequard || Hemi-cord dissection || '''Contralateral loss of pain and temperature, ipsilateral weakness and loss of light touch, vibration, and proprioception'''. Shrapnel or knife wound to the back.

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| Anterior || Spinothalamic, Corticospinal || UMN syndrome at the level of the lesion, loss of pain and temperature below the lesion

| Anterior || '''Spinothalamic, Corticospinal''' || '''UMN paralysis and loss of pain and temperature below the lesion'''. Anterior spinal artery occlusion.

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| Posterior || Dorsal columns || Loss of light touch, vibration, and proprioception bilaterally below the level of the lesion

| Posterior || Dorsal columns || Loss of light touch, vibration, and proprioception (positive Romberg sign) bilaterally below the level of the lesion. Can be caused by Tabes Dorsalis.

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=Neuromuscular Junction=

=Neuromuscular Junction=

==Myasthenia Gravis==

==Myasthenia Gravis==

*H&P: Autoantibodies against AChR, presents with muscle weakness that worsens as the day progresses and with exercise and improves after sleep. Constantly used muscles (think postural muscles, diaphragm, and eyelids) are affected first. May have positive family history. May have thymoma.

*H&P: Autoantibodies against nAChR, presents with muscle weakness that worsens as the day progresses and with exercise and improves after sleep. Constantly used muscles (think postural muscles, diaphragm, and eyelids) are affected first. May have positive family history. May have thymoma.

*Dx: Look for ptosis that improves with ice pack test. Edrophonium test is positive. '''Single-fiber''' EMG shows unstable "jittery" baseline between APs. '''CT chest to look for thymoma.'''

*Dx: Look for ptosis that improves with ice pack test. Edrophonium test is positive. '''Single-fiber''' EMG shows unstable "jittery" baseline between APs. '''CT chest to look for thymoma.'''

*Tx: 1st line pyridostigmine. '''2nd line steroids or immunomodulating meds (e.g. cyclosporine, azathioprine). Plasmapheresis or IVIG for myasthenia crisis. Thymectomy may reduce symptoms and exacerbations.'''

*Tx: 1st line pyridostigmine. '''2nd line steroids or immunomodulating meds (e.g. cyclosporine, azathioprine). Plasmapheresis or IVIG for myasthenia crisis. Thymectomy may reduce symptoms and exacerbations.'''

=Autoimmune Disorders=

=Autoimmune Disorders=

==Guillain-Barré syndrome==

==Guillain-Barré syndrome==

*H&P: Ascending paralysis typically following a respiratory or GI (e.g. campylobacter) infection. Also known as Acute Inflammatory Demyelinating Polyneuropathy (AIDP). Lasts 2-4 weeks. If it lasts > 8 weeks, think CIDP, C for Chronic. '''Hyporeflexia and parasthesias'''.

*H&P: Ascending paralysis that has an onset of '''days''', typically following a respiratory or GI (e.g. campylobacter) infection. Also known as Acute Inflammatory Demyelinating Polyneuropathy (AIDP). Lasts 2-4 weeks. If it lasts > 8 weeks, think CIDP, C for Chronic. '''Hyporeflexia and parasthesias'''.

*Dx: Clinical. Can get EMG which shows slow conduction (due to demyelination). LP will show albuminocytologic dissociation (elevated protein, normal WBCs).

*Dx: Clinical. Can get EMG which shows slow conduction (due to demyelination). LP will show albuminocytologic dissociation (elevated protein, normal WBCs). '''Differential includes transverse myelitis, which is more likely to have a sensory level and bowel/bladder involvement, and tic paralysis which progresses over hours'''. Get an MRI to rule it out if diagnosis is unclear'''

*Tx: Usually self resolves. Plasmapheresis or IVIG.

*Tx: Usually self resolves. '''Frequently monitor vital capacity at bedside.''' '''Plasmapheresis or IVIG''' speed up resolution of symptoms '''and are indicated in patients who are nonambulatory and had symptom onset within last 4 weeks'''.

==Multiple Sclerosis==

==Multiple Sclerosis==

*H&P: Demyelinating autoimmune disease that can be relapsing remitting, primary or secondary progressive, or progressive/relapsing.

*H&P: Demyelinating autoimmune disease that can be relapsing remitting, primary or secondary progressive, or progressive/relapsing.

*Dx: MRI shows periventricular fingerlike white matter lesions, LP shows oligoclonal bands, '''VEPs show delayed conduction'''

*Dx: MRI shows periventricular fingerlike white matter lesions, LP shows oligoclonal bands, '''VEPs show delayed conduction'''

*Tx: '''1st Copaxone or interferon'''. '''2nd Dimethyl fumarate, natalizumab, teriflunomide'''. Acute exacerbations use high-dose steroids.

*Tx: '''1st Copaxone (i.e. Glatiramer acetate), or interferon'''. '''2nd Dimethyl fumarate, natalizumab, teriflunomide'''. Acute exacerbations use high-dose steroids (IV or PO are equally effective, but PO is preferred in patients with '''optic neuritis'''). Symptom targeted treatment: SSRIs for depression; PT, stretching, massage, '''baclofen''' for spasticity; amantadine for fatigue; Gabapentin for neuropathic pain; timed voiding, fluid restriction, or oxybutynin for urinary incontinence

=Neuropsychiatric Disorders=

=Neuropsychiatric Disorders=

==Dementia==

==Dementia==

*H&P:  

*H&P:  

*Dx: Differentiate from MCI (which has less severe symptoms that do not interfere with ADLs). Differential includes [[Alzheimer disease]] (most common), Parkinson disease, Lewy body dementia, '''frontotemporal dementia (Pick disease)''', vascular dementia, and [[Creutzfeld Jacob disease]] (prions). Check for '''reversible causes''' (TSH, B12, B6, urine tox screen, EtOH levels, infectious workups, depression screen).

*Dx: Differentiate from MCI (which has less severe symptoms that do not interfere with ADLs). Differential includes [[Alzheimer disease]] (most common), Parkinson disease, Lewy body dementia, '''frontotemporal dementia (Pick disease, 20% of patients can have UMN/LMN disease)''', vascular dementia, and [[Creutzfeld Jacob disease]] (prions, myoclonus, rapidly progressive, mutism). Check for '''reversible causes''' (TSH, B12, B6, urine tox screen, EtOH levels, infectious workups, depression screen).

*Tx: Based on etiology. '''AChE inhibitors: donepezil, <u>rivastigmine</u>, galantamine.''' Memantine ('''NMDA antagonist'''). Assisted living and social support.

*Tx: Based on etiology. '''AChE inhibitors: donepezil, <u>rivastigmine</u>, galantamine.''' Memantine ('''NMDA antagonist'''). Assisted living and social support.