Neurological


Bell Palsy

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.
Video Credit: JJ MedEd


Encephalitis

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.
Video Credit: JJ Medicine


Ischemic Stroke

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)
Video Credit: Osmosis


Migraine

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

Video Credit: JJ Medicine


Transient Ischemic Attack

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. 
Video Credit: Lecturio

Brandon Simpson, PA-C
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  • Blog - 25 Feb 2021