Neurological

  • Bell’s Palsy
  • Encephalitis
  • Ischemic Stroke
  • Migraine
  • Transient Ischemic Attack

Bell’s Palsy

  • 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)
Video Credit: JJ MedEd

*Deep Dive: Bell’s Palsy (Merck Manual)



Encephalitis

  • 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
Video Credit: JJ Medicine

*Deep Dive: Encephalitis (Life in the Fast Lane)



Ischemic Stroke

  • 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.)
Video Credit: Osmosis

*Deep Dive: Ischemic Stroke (SAEM)



Migraine

  • 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)
Video Credit: JJ Medicine

*Deep Dive: Migraine (EMRA)



Transient Ischemic Attack

  • 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.
Video Credit: Lecturio

*Deep Dive: Updates on TIA (emDOCs)


Brandon Simpson, PA-C
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