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Neurology and Rehab

Links

• local: Psychiatry
• Peripheral Neuropathy (AFP 2/98)

Bells (Bell’s) Palsy

• may be due to herpes, consider Lyme
• if quick onset and peaks in 3 weeks or less, most like Bell's palsy vs. sarcoidosis, MS, post-infectious demyelination syndromes or tumor.
• bilateral: Lyme or Sarcoidosis
• try Rx with valacyclovir (Famvir) and prednisone or Medrol dose pack

Concussion (sports)

Assessment and Management of Concussion in Sports - 9/1/1999 - American Academy of Family Physicians (not the best article! Doesn't define terms well enough.)

Symptoms

• early: headache, dizziness, confusion, tinnitus, N/V, vision changes
• late: fatigue, irritability, personality changes, poor concentration, memory problems, sleep disturbance

Management & Grading

This is pretty fuzzy, especially for 2nd/3rd concussions in the same season/athelete or if LOC occurs. These guidelines may be conservative. For all but the most mild first concussions patient must be able to exercise without headache or other symptoms for at least 1 week before returning to the game. (rev. 9/99)

Dementia

• theoretically there are reversible causes, but in practice it's rare to find a reversible cause. Most common reversible causes are alchoholism and subdural hematoma.
• depression often coexists with Alzheimers and may worsen dementia symptoms
• conditions may coexist, esp. vascular dementia with Alzheimer's Disease
• the division of the dementias into syndromes is as fuzzy as any classification of poorly understand conditions. Labels come and go, and syndromes split and merge. The key differentiator will the emergence of any effective treatments or preventions.
• see also Parkinson's Disease.

Headache

• see also Migraine and Headache Imaging

Intractable Headache (Unresponsive Migraine/Cluster)

• review potential migraine triggers
• repeat tests, especially consider LP (CSF pressure, inflammation, infection, neoplasm)
• consider urine toxicology screen, occult CO exposure, heavy metals, etc.
• consider "rebound headache" (whatever that really is), chronic paroxysmal hemicrania mimicking cluster headache (indomethacin), hypnic headache (lithium), hemicrania continua (indomethacin), sphenoid sinusitis, glaucoma, occult dental disorder, acoustic neuroma, menstrual headache, medication related, etc.
• most often: something we don't have a name for

Headache Imaging

• see Rosen 1998 headache imaging indications
• MRI best for vascular, lower regions
• threshold for imaging is lower in children than adults, esp h/a in under 3 yo child.
• image for obvious reasons (ICP, new seizure, neuro signs, EEG) plus:
  • Severe nocturnal h/a awaken from sleep (esp early AM) assoc w/ N/V (tumor)
  • severe occipital h/a increasing freq and duration (tumor)
  • significant changes in pain with cough, sneeze, head down (squishy?)
  • onset following head trauma (subdural, epidural, bleed)
  • rapid increase over days/weeks (vascular)
  • excruciating with max intensity in 2-3 min (aneurysmal rupture)
  • some would add: substantial change in pattern of chronic headache in older person
  • under 3 yo
  • h/a with short stature or growth deceleration
  • DI or neurofibromatosis
  • h/a in child with behavioral, personality or school performance changes

Migraine

See also Unresponsive Migraine.

Diet

avoid: caffeine, chocolate, alcohol, dairy products, nuts, yeasts, citrus fruits, MSG, nitrates (luncheon meats), missed meals

Acute Migraine

(dark room) Beware pregnancy, vascular disease!

Compazine/DHE HP Protocol

climaxed headache

• Compazine 5-10 mg IV
• DHE-45 .75 mg IV immediately p. compazine slow push over 3 minutes
• repeat DHE .5mg in 30 minutes if no relief

pre-climax

• Compazine 10 mg PO or suppository
• DHE-45 1.0 mg SQ or IM, may repeat after 30 minutes
• Migranal
• Imitrex injectable or nasal

Imitrex (Sumatriptan)

• self-dose syringe
• 6mg SQ, if symptoms clear then recurr may repeat at least 1 hour between doses
• max 2 doses daily, do not use with ergot or other vasoconstricting meds

Migranal

• Migranal (DHE/caffeine). 1 spray each nostril, repeat in 15 minutes. Max 2 Rx/week and 6 spray/day. Not in preg, breast, vascular, age>40

Misc and Alternative

Generally compazine or reglan first, then DHE in 3-30 minutes. Compazine is superior to reglan. 8% incidence dystonic reaction with IV!

• Compazine 10mg IV or 25mg PR BID or 10mg PO QID
• Reglan/DHE
  • 10 mg Reglan IV, wait 10-30 minutes, then DHE 0.5mg IV

NSAIDS

• Toradol 60 mg IM and Vistaril 30 mg IM
• Naprosyn 550 mg PR or PO BID-TID (max 3 days)
• Indocin 50mg PR or PO BID-TID

Midrin

• Often surprisingly effective, especially if pt. reports prior success. May help with some mixed headaches that are less clearly migrainous. 2 initially then 1 qH, max 5 in 12 hours

Status Migrainosus

Initial

• a) DHE as above q8h with Reglan 10mg IV beforehand
• b) Reglan/DHE

Subsequent

• vomiting: repeat in 1 hour with Reglan and .25 mg DHE, then every 30 minutes to maximum dose of 3 mg DHE per attack.
• no vomiting:repeat in 1 hour with Reglan and 1.0 mg DHE, then every 30 minutes to maximum dose of 3 mg DHE per attack.

Other Therapies

• Decadron/Compazine: compazine 5-10 mg IV and Decadron 8-10 mg IV
• Thorazine: sedate with IV overnight and hydrate

Migraine prophylactic therapy

(>3 h/a week)

• insomnia: Pamelor 10mg hs and up
• somnolence, depression: Prozac 5-10 mg qAM and up
• children: Periactin (will increase weight)

Menstrual Migraine

• begins 3 days before menses, ends before day 7
• NSAIDS day 19 through day 2 of next cycle (Naprosyn)
• DHE nasal spray for breakthrough
• Mg 500 mg qD and Ca 500 mg qD with NSAID (?data)

Mini Mental Status Exam (uncorrected)

Scores < 24 are associated with delirium, dementia or severe depression. In community dwelling persons > 65, 95% had a score of > 24.

1. What is the (year) (season) (date) (month)? (5 points).
2. Where are we (state) (county) (town) (hospital) (floor)? (5 points).
3. Name 3 objects: 1 second to say each. Then ask pt all 3 after being said. One point for each correct answr. (3 points).
4. Serial 7s. 1 point for each correct. Stop after five answers. OR, spell world backwards. (5 points.)
5. Ask for each of the 3 objects. One pt for each correct. (3 points)
6. Name a pencil and watch. (2 points)
7. Repeat: “No ifs, and, or buts.” (1 point)
8. Follow a 3-stage command: “Take the paper in your right hand, fold it in half, and put it on the floor.” ( 3 points)
9. Read and obey the following: “Close your eyes.” (1 point)
10. Write a sentence. (1 point)
11. Copy design. (1 point)
    

Nerve Testing and Innervation

Cranial Nerves

3rd (oculomotor)

• innervates levator palpebrae, medial, superior and inferior rectus (eg. not lateral -- that's 6th nerve) and inferior oblique and mediates pupillary constriction via parasympathetic fibers
• complete injury causes ptosis, abduction, no vertical gaze, pupillary dilation (variable) and lack of pupillary light reflex
• diabetic neuropathy is due to a microvascular injury, central fibers typically are perfused and survive. Central fibers are parasympathetic so pupil size/response is normal.

Peripheral Nerves

Dermatomes and Spinal Nerve Roots

Cervical nerve roots issue above disc (no C8 vertebrae), Lumbar below disc of same name. See also diagram of lower ext dermatomes.

Parkinson's Disease

• ref: AFP 2006
• Unified Parkinson Disease Rating Scale

Differential diagnosis

• drug induced: may persist after discontinuation, may suggest a pre-parkinsonian state
• vascular: risk factors and stepwise progression, MRI shows lesions
• essential tremor: action based, may have mild rigidity, no levodopa response (therapeutic challenge?), better with alcohol, bilateral
• NPH: urninary incontinence, MRI
• Demential with Lewy bodies: more common than once thought. Delirium, hallucination, dementia faster than expected. PET scan. Overlaps with Parkinson's and Alzheimer's -- may appear to be mixture of the two. Unclear if this is truly a different disease from Parkinson's or if they are both variations of an underlying disorder.
• progessive supranuclear palsy: rare. eye motion limitation
• Shy-Drager syndrome/multiple system atrophy with autonomic failure: rare. Unstable BP a clue.
• Corticobasal degeneration: asymmetric parkinson without problems stopping gait

Therapy changes (2008)

• L-Dopa variants remain a mainstay of therapy
• Dopamine agonists parlodel adn pergolide are still around
• entacapone extends the efficacy of L-Dopa and seems safe (COMT inhibitor)
• apomorphine (Apokyn) via infusion pump
• nerve cell implants were tried and have been largely discarded
• deep brain stimulation implants cntinue to be in favor, with a recent shift to the subthalamic nucleus

Stroke Rehab Orders (ref. # 921)

1. diet and nutrition
   • beware dysphagia
   • hydration
   • high fiber diet
   • multivitamin
2. frequent repositioning
   • right and left 30 degree oblique positions
   • pillow under heels prn
3. environmental cues (time and place, pictures)
4. daily skin inspection
5. pressure-relieving mattress surface
   • 2 inch eggcrae foarm padds
   • Geo-matt foam padds
   • Clinitron
6. bowel and bladder management
   • toilet 30 minutes after breakfast
   • timed voiding q2-4h, manual bladder pressure prn (Crede)
   • clean-out if necessary
   • stool softeners
   • prompted voiding
   • intermittent catheterization as necessary
7. early mobilization
   • daily leg dangling
   • slow elevation from supine to sit to standing
8. elastic stockings
9. range of motion joint exercises
10. subcutaneous heparin
11. incentive spirometry and respiratory care

Swallowing Assessment post CVA

If abnormal do barium study.

Time to swallow

• tsp water
• sip water
• tsp applesauce

Time from initiation to completion of palpated swallow

• normal: < 1.7 sec
• > 10 sec is significantly abnormal

Response to test fluid

• Drink 3 oz water non-stop
• Positive responses within 1 minute
  • cough
  • “wet” or hoarse sounding speech

Seizure and Epilepsy

Meds

• many new meds, frequently more effective than prior
• vagal nerve implant also an adjunct
• temporal lobe epilepsy may be well controlled by surgery
• AFP review - use in elderly

Status Epilepticus

• Versed (midazolam) 0.15 to 0.3 mg/kg IM, usually effective within 10 minutes.
• Diastat rectal diazepam (may not be available), or rectal parenteral diazepam (dose unclear)

Epilepsy Therapy (discontinuation criteria)

scoring

• sum > 495: remission likely, d/c meds
• 2 years without seizures: d/c meds

Vertigo

Types

• vestibular neuritis: benign, starts over a few hours, peak first day, improves within days, mostly better after a week. Fast phase of nystagmus is away from the involved ear.
• inferior cerebellar infarct: vertigo, nystagmus, postural instability - this is the tricky one! Needs MRI, admission
• vertebrobasilar ischemia: abrupt onset, pts have risk factors for stroke.
• brainstem stroke: diploplia, reduced vision, etc.
• Meniere's: tinnitus, reduced hearing.

Warning signs

• diploplia
• weakness
• speech difficulties
• unable to walk

When to suspect inferior cerebellar infarct

• age > 50 + risk factor for stroke
• unable to walk (peripheral lesions may have trouble walking, but can almost always walk)
• central nystagmus
  • vertical, rotatory, changes direction with change in direction of gaze.
  • not suppressed by visual fixation, change direction at endpoint of gaze
• Romberg
  • peripheral lesion: pts lean or fall in one direction (opposite direction of fast phase of nystagmus)