
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.
Deep Dive

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.
Deep Dive

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)
Deep Dive

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

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.
Deep Dive