Neurological

Rapid Review

• Background
  • Sudden unilateral peripheral facial nerve palsy due to inflammation at the geniculate ganglion.
  • Most commonly caused by herpes simplex virus (HSV)
• Signs/Symptoms
  • Unilateral facial nerve paralysis that involves the forehead (unlike stroke which spares forehead)
  • Other symptoms include hyperacusis, inability to produce tears, taste alterations
• Diagnosis
  • Clinical diagnosis
• Treatment
  • Prednisone (initiate within 72 hours of onset). Consider acyclovir for severe presentations
  • Protect the cornea (artificial tears, taping eye shut, protective glasses)
• Disposition
  • Most cases can be discharged with PCP/opthamology follow up within 1 week
  • Admit if there is any concern for possible stroke.

Pearls

• If tone is still present in the patient’s forehead, do NOT diagnose them with Bell palsy.
• Most patients will recover in a few weeks, but it may take up to 5 months for full resolution.

Deep Dive

• Bell’s Palsy (Merck Manual)

Rapid Review

• Background
  • Inflammation of the brain parenchyma, typically due to hematogenous viral infection. HSV is the most common cause.
  • Caries a 10% mortality
• Signs/Symptoms
  • New psychiatric symptoms, cognitive deficits, seizure, fever, headache
  • Presents similarly to meningitis, but usually (-) Kernig’s and (-) Brudzinski’s
• Diagnosis
  • CT/MRI and lumbar puncture 
  • Viral PCR to identify specific etiology (west nile, HSV, varicella, etc.)
• Treatment
  • Acyclovir (until specific etiology identified)
  • Empiric antibiotics appropriate until meningitis ruled out
• Disposition
  • Admission is required for all patients with known or suspected encephalitis

Pearls

• Although encephalitis and meningitis can present similarly, encephalitis has a greater tendency to cause AMS, seizures, and neurological deficitis.
• Encphalitis can be caused by several different viral etiologies, but treatment with acyclovir should be administered empirically for HSV infection until proven otherwise.

Deep Dive

• Encephalitis (Life in the Fast Lane)

Rapid Review

• Background
  • Sudden loss of circulation to an area of the brain, causing ischemia and tissue death. 
  • May be caused by a thrombotic occlusion (80%) or an embolism from another area of the body.
• Signs/Symptoms
  • Varies based on site of occlusion
  • Common s/s include hemiparesis, motor deficits, sensory loss, “locked-in” syndrome, tonic gaze towards lesion
• Diagnosis
  • Non-contrast CT
• Treatment
  • tPA within 4.5 hours of onset (if no contraindications)
  • Keep BP < 185/110 if using thrombolytics (use labetalol, nitroglycerin, nicardipine, etc.)
• Disposition
  • Admission for all patients with acute CVA.  Consult neurology/neurosurgery
  • ICU indicated if hemodynamically unstable, recent administration of thrombolytics, or severely decreased LOC.

Pearls

• CVAs are time-sensitive events. Establishing the last known well time is paramount for making therapeutic and disposition decisions.  
• If the patient is not receiving thrombolytics, they should be given aspirin 324 mg (unless contraindicated)

Deep Dive

• Ischemic Stroke (SAEM)

Rapid Review

• Background
  • Migraine is an episodic primary headache disorder
• Signs/Symptoms
  • “POUND” (pulsatile quality, onset/duration of 4-72 hours, unilateral, nausea/vomiting, disabling in quality)
  • (+/-) aura, photophobia, abnormal movements, speech problems. 
• Diagnosis
  • Clinical diagnosis
• Treatment
  • Triptans (Sumatriptan), dihydroergotamine, NSAIDs (Ibuprofen, Ketorolac), and antiemetics (prochlorperazine, metoclopramide)
• Disposition
  • Most patients can be discharged as long as symptoms are controlled and they are not experiencing and focal neurological deficits.
  • Patients with frequent migraines should follow up with primary care/neurology.

Pearls

• Steroids such as dexamethasone have not been shown to be helpful for acute pain relief, but may reduce rates of migraine recurrence within 72 hours.
• Opiates should very rarely be used for the management of migraines.

Deep Dive

• Migraine (EMRA)

Rapid Review

• Background
  • Transient episode of focal brain, retinal, or spinal cord ischemia that causes sudden neurologic deficits, without any acute infarction
  • Lasts approximately 15-30 minutes on average. 10% of patients will have a stroke within 90 days.
• Signs/Symptoms
  • Vision changes, dysarthria, focal weakness, abnormal gait
• Diagnosis
  • Clinical diagnosis
  • Non-contrast CT to rule out hemorrhage or mass
• Treatment
  • Antiplatelet therapy (Aspirin + dipyridamole or clopidogrel monotherapy).
  • Should follow up with neurology within 24-48 hours.
• Disposition
  • Some patients may be discharged if certain criteria are met (completely resolved symptoms, reassuring neuroimaging, access to close neurology/PCP follow-up, etc.) However, strokes can be preceded by TIAs, often within 48 hours.

Pearls

• Hypoglycemia is a common stroke/TIA mimic. Be sure to do a rapid blood gluose test early. 
• Patients with atrial fibrillation have an exceptionally high-risk of TIA/CVA recurrence. 

Deep Dive

• Updates on TIA (emDOCs)