Changes

=Brain=

=Brain=

==Stroke==

==Stroke==

*H&P: Ischemic stroke risk factors parallel ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent focal neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer. Different brain areas cause different stroke syndromes, such as thalamic strokes (pure sensory), insular strokes (pure motor), left MCA (dysphasia), right MCA (left arm and face), cerebellar (ataxia, poor coordination), posterior cerebral artery (homonymous hemianopsia), ACA (personality changes, leg weakness)

*H&P: Ischemic stroke risk factors parallel ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent focal neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer. Different brain areas cause different stroke syndromes, see table below:

*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.

 

*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).

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

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

| Left MCA || Motor and sensory deficits in right arm, right face; aphasia

| Right MCA || Motor and sensory deficits in left arm, left face; neglect

| '''PCA (cerebellum, midbrain)''' || '''Homonymous hemianopsia; ataxia, poor coordination; Weber syndrome: ipsilateral CN III palsy and contralateral arm/leg weakness.'''

| '''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.'''

| Lacunar (thalamus) || Pure sensory

 

*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 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==

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| '''Tension''' || dull/tight/pressure, bilateral, band-like, can extend into the neck and shoulders, triggered by stress, lasts up to 7 days || NSAIDs/APAP, massage, heat, relaxation || Avoid triggers

| '''Tension''' || dull/tight/pressure, bilateral, band-like, can extend into the neck and shoulders, triggered by stress, lasts up to 7 days || NSAIDs/APAP, massage, heat, relaxation || Avoid triggers

|}

|}

==Seizure==

==Seizure==

*H&P: Aura, can have a guttural cry at onset, symmetrical rhythmic convulsions, eyes remain open and deviate towards contralateral side during focal phase, lateral tongue lacerations, bowel/bladder incontinence, post-ictal state, post-seizure myalgias, can have transient weakness that mimics stroke (Todd paralysis)

*H&P: Aura, can have a guttural cry at onset, symmetrical rhythmic convulsions, eyes remain open and deviate towards contralateral side during focal phase, lateral tongue lacerations, bowel/bladder incontinence, post-ictal state, post-seizure myalgias, can have transient weakness that mimics stroke (Todd paralysis)

*Dx: EEG. Differentiate between focal (simple and complex) and generalized (grand mal, petit mal, myoclonic, atonic). Differential includes metabolic (hepatic encephalopathy, hyponatremia, hypomagnesemia, hypercalcemia, hypoglycemia), infectious (meningitis), intoxication (e.g. INH, Bupropion), EtOH withdrawal, neoplastic (brain tumor), vascular (aneurysm, stroke, hemorrhage, dissection). To evaluate for secondary causes, get CBC, BMP, LFTs, EtOH level, urine tox screen, AED levels, consider MRI in an adult with first-time seizure.

*Dx: EEG. Categorize as focal (simple and complex) versus generalized (grand mal, petit mal, myoclonic, atonic). '''Juvenile myoclonic epilepsy (JME) has bilateral polyspike and slow wave EEG pattern in interictal period, myoclonus within 1 hr of waking, eventual progression to generalized tonic-clonic'''. Differential includes metabolic (hepatic encephalopathy, hyponatremia, hypomagnesemia, hypercalcemia, hypoglycemia), infectious (meningitis), intoxication (e.g. INH, Bupropion), EtOH withdrawal, neoplastic (brain tumor), vascular (aneurysm, stroke, hemorrhage, dissection). To evaluate for secondary causes, get CBC, BMP, LFTs, EtOH level, urine tox screen, AED levels, consider MRI in an adult with first-time seizure.

*Tx: [[AEDs]] (no first line agent, decide on a case-by-case basis). For [[status epilepticus]], ABCs, give IV lorazepam, fosphenytoin if seizure persists, consider induced coma if all else fails.

*Tx: [[AEDs]] (no first line agent, decide on a case-by-case basis). For [[status epilepticus]], ABCs, give IV lorazepam, fosphenytoin if seizure persists, consider induced coma if all else fails.

| Lamotrigine || Broad (also mood stabilizer) || SJS

| Lamotrigine || Broad (also mood stabilizer) || SJS

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|-

| Valproate || Broad || Teratogenic, weight gain, hair loss, tremor, liver failure

| Valproate || Broad (also JME) || Teratogenic, weight gain, hair loss, tremor, '''thrombocytopenia''', '''pancreatitis''', liver failure

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|-

| Topiramate || Broad (also migraine ppx) || Cognitive impairment, weight loss, kidney stones

| Topiramate || Broad (also migraine ppx) || Cognitive impairment, weight loss, kidney stones

==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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|}

*H&P: Unilateral, idiopathic facial weakness that self resolves.

*H&P: Unilateral, idiopathic facial weakness that self resolves.

*Dx: Clinical based on symptoms. Differentiate from stroke by looking for forehead and eyelid muscle involvement (spared in stroke).

*Dx: Clinical based on symptoms. Differentiate from stroke by looking for forehead and eyelid muscle involvement (spared in stroke).

*Tx: Steroids or just wait. Some people give acyclovir because of presumed association with VZV. Ophthalmic ointments or tape on eye to prevent corneal drying at night.

*Tx: 1st line is '''steroids''' or waiting. Some people give acyclovir because of presumed association with VZV, but the '''evidence is lacking, and this remains controversial'''. Ophthalmic ointments or tape on eye to prevent corneal drying at night.

==Carpal Tunnel Syndrome==

==Carpal Tunnel Syndrome==

=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.'''

=Movement Disorders=

=Movement Disorders=

==Parkinson Disease==

==Parkinson Disease==

*H&P:

*H&P: Neurodegenerative progressive disease with motor symptoms (pill-rolling tremor, cogwheel rigidity, masked facies, stooped posture, shuffling gait, trouble initiating movements, soft speech) preceding neuropsychiatric symptoms (dementia, depression, psychosis). Caused by destruction of dopaminergic neurons in the substantia nigra.

*Dx:

*Dx: 2/4 TRAP symptoms (Tremor, Rigidity, Akinesia/Bradykinesia, Postural instability) one of which must be bradykinesia. Rule out other causes of Parkinsonism with MRI (e.g. drugs, vascular dementia, Lewy body dementia, multi system atrophy). Responds to carbidopa-levodopa.

*Tx:

*Tx: 1st line Carbidopa-Levodopa. '''DA agonists''' ('''Pramipexole''', '''Bromocriptine''', Ropinarole). '''Anti MAO (selegiline), anti COMT (etacapone), and anticholinergics (benztropine)'''. Deep brain stimulator or pallidectomy.

==Huntington Disease==

==Huntington Disease==

*H&P:

*H&P: Choreiform movements, Parkinsonism, depression, psychosis. Shows up in mid-adulthood, fatal by mid 50s usually. Autosomal dominant.

*Dx:

*Dx: Family history + symptoms. Or genetic testing. '''MRI can show caudate atrophy.'''

*Tx:

*Tx: Supportive. '''Chorea: Benzodiazepines, valproate; Parkinsonism: Carbidopa-Levodopa; Depression: SSRIs; Psychosis: atypical antipsychotics'''

=Autoimmune Disorders=

=Autoimmune Disorders=

==Guillain-Barré syndrome==

==Guillain-Barré syndrome==

*H&P:

*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:

*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:

*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:

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

*Dx:

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

*Tx:

*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:

*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:

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

==Wernicke-Korsakoff Syndrome==

==Wernicke-Korsakoff Syndrome==

*H&P:

*H&P: History of heavy EtOH use. Vitamin B1 (thiamine) deficiency.

*Dx:

*Dx: MRI shows atrophy of mammary bodies. EtOH level. Presents with ataxia, '''ophthalmoplegia''', confusion, confabulation, retrograde amnesia. Differential includes NPH.

*Tx:

*Tx: High dose thiamine. Electrolyte repletion. Multivitamin. CIWA protocol for EtOH withdrawal.