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81-100 of 382 results with category "Neurology"
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What is the role of EEG for first-time seizures in the ED?
- Wyman and colleagues performed a prospective trial on the use of 30-minute routine electroencephalogram (EEG) in the ED after a first-time seizure or recurrent seizure without performance of a previous EEG to guide decision making in the initiation of antiepileptic medication.
- A diagnosis of epilepsy based on EEG findings was made for 21% of patients (n=15/71).
- Antiepileptic medication was initiated in 24% of patients (n=17/71), including 2 patients with abnormal but not epileptic EEG findings.
Take Home Point: A 30-minute routine EEG in the ED in adults with an uncomplicated first-time seizure revealed a substantial number of epilepsy diagnosis and can change ED management with immediate initiation of antiepileptic medication.
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Vasovagal syncope is a subtype of neurally mediated syncope, and it is distinctly different from orthostatic hypotension.
Patients with orthostatic syncope have severe orthostatic hypotension that results in transient loss of consciousness immediately or within moments of standing up. This is different from neurally mediated syncope, which develops gradually under conditions of prolonged orthostatic stress such as standing for several minutes. Tilt table testing is useful for true orthostatic syncope, but not for neurally mediated syncope. In addition, checking for “orthostatic hypotension” may not capture patient with orthostatic syncope, because the hypotension occurs so quickly after standing up. Of note, patients may still have orthostatic tachycardia or intolerance with neurally mediated syncope.
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- Vasogenic cerebral edema is most commonly seen with brain tumors and cerebral abscesses.
- It mainly involves the white matter.
- Gray-white differentiation is maintained, so the edema has a finger-like pattern on CT (see Figure).
- It is caused by disruption of the blood-brain-barrier, thus responds to treatment with steroids.
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- The Glasgow Coma Scale (GCS) is an instrument widely used to assess level of consciousness by EMS.
- The motor GCS (mGCS) and Simplified Motor Scale (SMS) have been proposed to simplify EMS triage.
- A number of retrospective studies have compared these scales.
- Chou et al. performed a systematic review and meta-analysis of 18 studies with a total number of 1.7 million patients to compare the predictive utility of these scales for identification of patients with severe traumatic injury.
- The total GCS was slightly better than the mGCS or SMS on predicting mortality, neurosurgical intervention, severe traumatic brain injury, and emergent intubation.
Bottom Line: The motor GCS and Simplified Motor Scale (SMS) have similar discrimination when compared with the total GCS, and may be easier to use.
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- The incidence of stroke (both ischemic and hemorrhagic) in pregnant and peripartum women is three times age-matched controls. This increased risk is mostly in the 3rd trimester and up to 16 weeks postpartum.
- Consider other causes of stroke: posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis and cardioembolic stroke from peripartum cardiomyopathy.
- CTs carry some risk due to the ionizing radiation, but with abdominal and pelvic shielding the exposure to the fetus is very low. MRIs do not carry that risk, but Gadolinium is absolutely contraindicated in pregnancy as it deposits in fetal tissue.
- Pregnancy is a relative (not absolute) contraindication for tPA.
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- Headache is the 4th most common ED visit in the US.
- Clinical experience suggests that IV fluids (IVF) are commonly used as adjunctive treatment for headaches, however, the efficacy is unknown.
- A retrospective study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) found that ED length of stay was significantly greater in patients who received IVF than in those who did not (202 min vs. 131 min, p<0.001) even after adjusting for initial pain score, sex, age, and mode of arrival.
- A post-hoc analysis of data collected from 4 ED-based migraine trials found that IVF was not associated with improvement of pain score or sustained headache freedom.
- There is no current evidence to suggest a direct analgesic effect of IVF in the treatment of headaches.
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- 15% of all cases of ischemic strokes occur in patients less than 45 years old.
- To put things into perspective, incidence of stroke in this age group is twice that of multiple sclerosis.
- Delayed diagnosis is due to several factors:
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- The relative rarity of the diagnosis in comparison to stroke mimics at this age, the 3 most common being: migraines, seizures, and Bell's palsy.
- Atypical presentations, such as acute vestibular syndrome.
- Although “typical" risk factors (such as smoking, diabetes and hypertension) are present in young patients with strokes, other factors to be considered are high-risk alcohol consumption, cocaine use (especially smoked), physical inactivity, sleep 6 hours or less a night, and known thrombophilia.
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- Aphasia is an impairment of language
- 3 important assessments in an aphasic patient are fluency, comprehension, and repetition (see attached figure)
- Patients with fluent speech are able to generate speech spontaneously, though the content of their speech may have errors
- Patients with non-fluent speech have difficulty initiating speech
- Patients who have fluent speech but are unable to repeat have a problem with comprehension or a disconnect between the sensory and motor components of language
- In Wernicke’s aphasia, patients cannot comprehend what they read and hear
- In conduction aphasia, patients can comprehend what they read and hear
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Patients may present to the ED with new onset weakness due to myasthenia gravis (MG). A group that is frequently missed is late-onset MG, which occurs after the age of 50. It is frequently misdiagnosed as a stroke or transient ischemic attach (TIA).
Two cardinal features:
- fatiguability: must be distinguished from fatigue.
- fluctuation
Bonus pearl: Ocular symptoms are present in up to 85% of patients with MG, with unilateral ptosis or asymmetric bilateral ptosis being the most common presentations.
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- Limited data is available to guide when individuals should return to driving after a concussion.
- Cognitive impairments in reaction time, executive function, and attention can persist even after symptoms of a concussion resolve.
- Schmidt et al. compared driving performance between individuals within 48 hours following symptom resolution after a concussion with matched controls using simulated driving.
- They found that concussed individuals had poorer driving performance despite being asymptomatic.
- This study is limited by a small sample size (n=28), however, it raises interesting questions regarding whether driving should be restricted following concussions and how should readiness to return to driving be determined.
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Impact of an ED pharmacist on time to thrombolysis in acute ischemic stroke
- Prior studies showed that incorporation of ED pharmacists within ED clinical teams lead to more rapid treatment of trauma, stroke, and STEMI.
- A recent retrospective study conducted by Montgomery et al. showed that having an ED pharmacist on the stroke alert team increased the number of patients meeting goal door-to-needle time of 60 minutes.
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Patient found pulseless after submersion in water for 20 minutes. After ROSC, patient’s GCS was 3 and pupils are dilated and nonreactive.
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Magnetic resonance imaging (MRI) is the method of choice for imaging the spine for the suspicion of non-traumatic disorder, such as multiple sclerosis (MS), transverse myelitis, epidural abscess, spinal cord infarcts, and spondylotic myelopathy (changes in the spinal cord due to disk herniation or osteophytes in degenerative joint disease).
If the differential diagnosis includes infection, neoplasm, demyelination or inflammation, then IV contrast should be administered.
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Updated Guidelines for Traumatic Brain Injury
The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brian Injury (TBI) was recently updated and published in September 2016.
Updated recommendations include:
- Prophylactic hypothermia is not recommended (Level IIB).
- Phenytoin is recommended for seizure prophylaxis (Level IIA).
- There is insufficient evidence to recommend levetiracetam over phenytoin.
- Maintain SBP 100 mmHg for patients 50-69 years old or 110 mmHg for patients 15-49 or >70 years old (Level III).
- Treat intracranial pressure (ICP) > 22 mmHg (Level III)
- Target cerebral perfusion pressure (CPP) between 60-70 mmHg (Level IIB).
For the executive summary and complete guidelines, go to https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/
You have a patient in whom you suspect meningitis, but he is on warfarin for a history of pulmonary embolism. You started empirical antibiotics. His INR is 2.6, and you want to do a lumbar puncture (LP) to confirm your diagnosis. Can you use Prothrombin Complex Concentrate to lower his INR and safely perform the LP?
Take Home Point:
Using PCC to lower INR to enable LP is relatively safe and effective in patients on vitamin K antagonists. The dose used was individually determined by the physician according to initial INR.
Limitation:
This is a retrospective study, with no control group. One patient (2.7%) had a myocardial infarction that was “possibly related” to the PCC administration.
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- Beware of the patient who can't open his/her eyes but is otherwise awake!
- This coma mimic is the result of eyelid apraxia, which is the inability to voluntarily open eyes despite intact frontalis muscle contraction and absent oculomotor dysfunction.
- This can be seen in injuries of the nondominant hemisphere (e.g. R MCA stroke), medial frontal lobe, bilateral thalami (e.g. bilateral thalami stroke), and brainstem (e.g. progressive supranuclear palsy).
- When asking these patients to open their eyes, they may use their forehead muscles to try and raise their eyelids.
Ataxia is an important clinical sign of cerebellar pathology, but how is it actually described?
Stance ataxia: inability to stand with feet together for more than 30 seconds
Gait ataxia
Sensory ataxia: the first 2 elements, in addition to a positive Romberg sign
Truncal ataxia: oscillation of body while sitting or standing
Limb ataxia: functional impairment in performing actions such as writing or buttoning and improves with slowing down the movement
Dysdiadokinesia: impairment of rapidly alternating movement
Intention tremor: tested by finger-to-nose and heel-to-shin.
Dysmetria: pastpointing or undershooting on finger-chasing or shin-tap.
Dysarthria: irregular and slow speech with unnecessary hesitation
Nystagmus and other ocular disturbances, such as ocular flutter and opsoclonus.
The first 3 are present in both cerebellar pathology and loss of proprioceptive input, the rest are usually due to cerebellar pathology or ataxic syndrome.
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