UMEM Educational Pearls - By WanTsu Wendy Chang

Category: Neurology

Title: Occipital Nerve Block for Migraine?

Keywords: occipital nerve block, migraine, headache (PubMed Search)

Posted: 2/14/2018 by WanTsu Wendy Chang, MD (Emailed: 2/15/2018) (Updated: 2/15/2018)
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  • Greater occipital nerve (GON) block with local anesthetics is an alternate treatment option for headaches.
  • Zhang et al. conducted a systematic review and meta-analysis of 7 randomized controlled trials assessing the efficacy of GON block for migraine.
  • Pooled outcome suggests that GON block: 
    • Reduces pain intensity (mean difference -1.24 [-1.98, -0.49], p=0.001)
    • Decreases analgesia medication consumption (mean difference -1.10 [-2.07, -0.14], p=0.02)
    • Has no significant impact on headache duration (mean difference -6.96 [-14.09, 0.18], p=0.06)

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Category: Neurology

Title: Reversible Cerebral Vasoconstriction Syndrome (RCVS)

Keywords: RCVS, thunderclap headache, migraine, SAH (PubMed Search)

Posted: 1/10/2018 by WanTsu Wendy Chang, MD
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  • Reversible cerebral vasoconstriction syndrome (RCVS) is the second most common cause of thunderclap headache after aneurysmal subarachnoid hemorrhage (SAH) and the most common cause of recurrent thunderclap headaches.
  • Up to 40% of patients with RCVS have a history of migraine.
  • It is associated with selective serotonin reuptake inhibitors (SSRIs), triptans, cocaine, marijuana, tacrolimus, oral contraceptives, as well as the peripartum period.
  • Symptoms are often triggered by emotional stress, sexual activity, showering, straining, and physical exertion.
  • Although the vasoconstriction is reversible, it can cause intracranial hemorrhage, seizures, stroke, and coma.
  • Diagnosis is by history, cerebral angiography and exclusion of aneurysmal SAH.

Bottom Line: Consider RCVS in the differential of thunderclap headache and in patients who present with worse than usual migraine headache.

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Category: Neurology

Title: A New DAWN for Stroke Intervention?

Keywords: DAWN, thrombectomy, mismatch, wake-up, stroke, penumbra (PubMed Search)

Posted: 12/13/2017 by WanTsu Wendy Chang, MD
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Takeaways

  • The DAWN trial was a multicenter, randomized, open-label study comparing endovascular thrombectomy plus standard medical care with standard medical care alone for patients with:
    • Acute stroke symptoms
    • Last known well 6 to 24 hours earlier
    • Evidence of intracranial ICA or proximal MCA occlusion
    • Mismatch between clinical deficit and infarct volume on CTA or MRA
  • The study found that patients receiving thrombectomy plus standard medical care had improved functional independence at 90 days as defined by modified Rankin Scale (mRS) of 0, 1, or 2 (49% vs 13%).
  • The trial was stopped early based on prespecified interim analysis intended with the adaptive trial design.
  • While the two treatment groups were similar, with median NIHSS score of 17, they had small infarct volumes and short time from symptom observation (4.8 vs 5.6 hours) compared to time of patient's last known well (12.2 vs 13.3 hours). 
  • 88% of the patients had unwitnessed stroke onset (including wake-up strokes), thus it is possible that these patients had actual ischemia times closer to 6 hours, thereby reproducing similar results as prior thrombectomy trials.

Bottom Line: The use of neuroimaging to identify an ischemic penumbra that may benefit from thrombectomy may be considered even for patients with time of last known well beyond 6 hours.

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Category: Neurology

Title: Isolated Aphasia - Is It a Stroke?

Keywords: aphasia, stroke, middle cerebral artery, MCA, mimic, NIHSS (PubMed Search)

Posted: 11/8/2017 by WanTsu Wendy Chang, MD
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Takeaways

  • A retrospective single center study reviewed 788 patients who presented to the ED with concern of stroke and found 21 (3%) patients had only aphasia symptoms by the NIHSS.
  • None of these patients had evidence of infarct on neuroimaging.
  • 3 of these patients were diagnosed with possible transient ischemic attack (TIA) though also had other possible diagnoses.
  • Toxic/metabolic disturbances (39%), followed by seizure (11%), syncope (11%), and chronic medical problems (11%) were the most commonly diagnosed stroke mimics.

Take Home PointThis small but interesting study looked at the incidence of isolated aphasia presenting for concern of stroke. They found that none of their patients had evidence of an infarct, suggesting that strokes affecting language without motor or sensory deficits are uncommon.

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Category: Neurology

Title: Traumatic Brain Injury in Older Adults - The Silver Tsunami?

Keywords: traumatic brain injury, TBI, fall, subdural hematoma, SDH, elderly (PubMed Search)

Posted: 10/11/2017 by WanTsu Wendy Chang, MD
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Traumatic brain injury (TBI) is associated with close to half of major trauma admissions in adults over age 65 in the U.K.

Falls accounted for 85% of all TBIs, while 45% of patients had subdural hematomas (SDH).

More than 3/4 of patients were treated conservatively, though outcomes were not significantly better than those who underwent neurosurgical intervention.

Higher age is associated with higher mortality and greater disability.

Bottom Line: Trauma in older adults is increasing and fall prevention is important in reducing significant injuries.

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Category: Neurology

Title: IV vs. Non-IV Benzodiazepines for Cessation of Seizures

Keywords: seizure, status epilepticus, benzodiazepine, RAMPART, pediatric (PubMed Search)

Posted: 9/13/2017 by WanTsu Wendy Chang, MD (Updated: 9/14/2017)
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Takeaways

IV vs. Non-IV Benzodiazepines for Cessation of Seizures

  • A meta-analysis by Alshehri et al. included 11 studies with a total of 1633 patients, comparing IV vs. non-IV benzodiazepines from any route (buccal, intranasal, intramuscular) for seizure cessation in status epilepticus.
  • They found that non-IV benzodiazepine is more effective than IV benzodiazepine in patients presenting without IV access.
  • The largest and highest quality study included in the meta-analysis was the RAMPART study, which was also the only study to include adults.
  • When considering pediatric studies only, there is no difference between IV vs. non-IV benzodiazepine in seizure cessation for status epilepticus.

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Rapid detection of bacterial meningitis using point-of-care glucometer

  • CSF:blood glucose ratio is a useful characteristic in differentiating bacterial meningitis from viral meningitis. 
  • Normal CSF glucose is at least 2/3 of serum glucose level.
  • In bacterial meningitis, CSF:blood glucose ratio is usually <0.4
  • Rousseau et al. conducted a study comparing CSF:blood glucose ratio obtained using a bedside glucometer with the laboratory.
  • They found the optimal cutoff of CSF:blood glucose ratio using a bedside glucometer is 0.46 compared to 0.44 using the laboratory.
  • This proof-of-concept study suggests that a point-of-care glucometer can be used for rapid diagnosis of abnormal CSF:blood glucose ratio in the evaluation of meningitis.

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Category: Neurology

Title: What is the cause of this patient's decreased vision?

Keywords: Terson syndrome, vitreous hemorrhage, intraocular hemorrhage, subarachnoid hemorrhage (PubMed Search)

Posted: 7/12/2017 by WanTsu Wendy Chang, MD
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Question

50 YOF with acute onset of worst headache of life associated with nausea and vomiting.  Patient is somnolent, will rouse to noxious stimuli and complains of a headache as well as decreased vision.

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Category: Neurology

Title: What is the role of EEG for first-time seizures in the ED?

Keywords: seizure, electroencephalogram, EEG, epilepsy, antiepileptic (PubMed Search)

Posted: 6/14/2017 by WanTsu Wendy Chang, MD
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Takeaways

 

What is the role of EEG for first-time seizures in the ED?

  • Wyman and colleagues performed a prospective trial on the use of 30-minute routine electroencephalogram (EEG) in the ED after a first-time seizure or recurrent seizure without performance of a previous EEG to guide decision making in the initiation of antiepileptic medication.
  • A diagnosis of epilepsy based on EEG findings was made for 21% of patients (n=15/71).
  • Antiepileptic medication was initiated in 24% of patients (n=17/71), including 2 patients with abnormal but not epileptic EEG findings.

Take Home Point:  A 30-minute routine EEG in the ED in adults with an uncomplicated first-time seizure revealed a substantial number of epilepsy diagnosis and can change ED management with immediate initiation of antiepileptic medication.

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Category: Neurology

Title: Vasogenic Cerebral Edema

Keywords: vasogenic cerebral edema, white matter, blood-brain-barrier, steroids (PubMed Search)

Posted: 4/26/2017 by WanTsu Wendy Chang, MD
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Vasogenic Cerebral Edema
  • Vasogenic cerebral edema is most commonly seen with brain tumors and cerebral abscesses.
  • It mainly involves the white matter.
  • Gray-white differentiation is maintained, so the edema has a finger-like pattern on CT (see Figure).
  • It is caused by disruption of the blood-brain-barrier, thus responds to treatment with steroids.

 

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Category: Neurology

Title: Simplified GCS vs. Full GCS? Which One To Use?

Keywords: Glasgow Coma Scale, GCS, motor GCS, mGCS, Simplified Motor Scale, SMS (PubMed Search)

Posted: 4/12/2017 by WanTsu Wendy Chang, MD
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Simplified GCS vs. Full GCS?  Which One To Use?

  • The Glasgow Coma Scale (GCS) is an instrument widely used to assess level of consciousness by EMS.
  • The motor GCS (mGCS) and Simplified Motor Scale (SMS) have been proposed to simplify EMS triage.
  • A number of retrospective studies have compared these scales.
  • Chou et al. performed a systematic review and meta-analysis of 18 studies with a total number of 1.7 million patients to compare the predictive utility of these scales for identification of patients with severe traumatic injury.
  • The total GCS was slightly better than the mGCS or SMS on predicting mortality, neurosurgical intervention, severe traumatic brain injury, and emergent intubation.

Bottom Line:  The motor GCS and Simplified Motor Scale (SMS) have similar discrimination when compared with the total GCS, and may be easier to use.

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Category: Neurology

Title: IV Fluids for Headache?

Keywords: headache, migraine, intravenous fluids, IVF (PubMed Search)

Posted: 3/8/2017 by WanTsu Wendy Chang, MD
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IV Fluids for Headache?
  • Headache is the 4th most common ED visit in the US.
  • Clinical experience suggests that IV fluids (IVF) are commonly used as adjunctive treatment for headaches, however, the efficacy is unknown.
  • A retrospective study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) found that ED length of stay was significantly greater in patients who received IVF than in those who did not (202 min vs. 131 min, p<0.001) even after adjusting for initial pain score, sex, age, and mode of arrival. 
  • A post-hoc analysis of data collected from 4 ED-based migraine trials found that IVF was not associated with improvement of pain score or sustained headache freedom.
  • There is no current evidence to suggest a direct analgesic effect of IVF in the treatment of headaches.

 

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Category: Neurology

Title: Back to the Basics: Aphasia

Keywords: aphasia, fluency, comprehension, repetition, Broca's aphasia, Wernicke's aphasia, conduction aphasia (PubMed Search)

Posted: 2/8/2017 by WanTsu Wendy Chang, MD
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Back to the Basics: Aphasia
  • Aphasia is an impairment of language
  • 3 important assessments in an aphasic patient are fluencycomprehension, and repetition (see attached figure)
  • Patients with fluent speech are able to generate speech spontaneously, though the content of their speech may have errors
  • Patients with non-fluent speech have difficulty initiating speech
  • Patients who have fluent speech but are unable to repeat have a problem with comprehension or a disconnect between the sensory and motor components of language
    • In Wernicke’s aphasia, patients cannot comprehend what they read and hear 
    • In conduction aphasia, patients can comprehend what they read and hear

 

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Attachments

20170208_Figure.jpg (84 Kb)


Category: Neurology

Title: Driving after concussion: Is it safe to drive after symptoms resolve?

Keywords: concussion, driving performance, cognitive impairment (PubMed Search)

Posted: 1/11/2017 by WanTsu Wendy Chang, MD
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Driving after concussion: Is it safe to drive after symptoms resolve?
  • Limited data is available to guide when individuals should return to driving after a concussion.
  • Cognitive impairments in reaction time, executive function, and attention can persist even after symptoms of a concussion resolve.
  • Schmidt et al. compared driving performance between individuals within 48 hours following symptom resolution after a concussion with matched controls using simulated driving.
  • They found that concussed individuals had poorer driving performance despite being asymptomatic.
  • This study is limited by a small sample size (n=28), however, it raises interesting questions regarding whether driving should be restricted following concussions and how should readiness to return to driving be determined.

 

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Category: Neurology

Title: ED Pharmacist on Time to Thrombolysis

Keywords: pharmacist, thrombolysis, door-to-needle time, acute ischemic stroke (PubMed Search)

Posted: 12/14/2016 by WanTsu Wendy Chang, MD
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Takeaways

Impact of an ED pharmacist on time to thrombolysis in acute ischemic stroke

  • Prior studies showed that incorporation of ED pharmacists within ED clinical teams lead to more rapid treatment of trauma, stroke, and STEMI.
  • A recent retrospective study conducted by Montgomery et al. showed that having an ED pharmacist on the stroke alert team increased the number of patients meeting goal door-to-needle time of 60 minutes.

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Category: Neurology

Title: Subarachnoid Hemorrhage -- Or Is It?

Keywords: subarachnoid hemorrhage, mimic, pseudosubarachnoid hemorrhage, cerebral edema (PubMed Search)

Posted: 11/9/2016 by WanTsu Wendy Chang, MD
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Question

Patient found pulseless after submersion in water for 20 minutes.  After ROSC, patient’s GCS was 3 and pupils are dilated and nonreactive.

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Category: Neurology

Title: Updated Guidelines for Traumatic Brain Injury

Keywords: Brain Trauma Foundation, BTF, guideline, traumatic brain injury, TBI (PubMed Search)

Posted: 10/12/2016 by WanTsu Wendy Chang, MD
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Updated Guidelines for Traumatic Brain Injury

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brian Injury (TBI) was recently updated and published in September 2016.

Updated recommendations include:

  • Prophylactic hypothermia is not recommended (Level IIB).
  • Phenytoin is recommended for seizure prophylaxis (Level IIA).
    • There is insufficient evidence to recommend levetiracetam over phenytoin.
  • Maintain SBP 100 mmHg for patients 50-69 years old or 110 mmHg for patients 15-49 or >70 years old (Level III).
  • Treat intracranial pressure (ICP) > 22 mmHg (Level III)
  • Target cerebral perfusion pressure (CPP) between 60-70 mmHg (Level IIB).

For the executive summary and complete guidelines, go to https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/


Category: Neurology

Title: My Patient Won't Open His/Her Eyes!

Keywords: eyelid apraxia, eye opening apraxia (PubMed Search)

Posted: 9/14/2016 by WanTsu Wendy Chang, MD
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My patient won't open his/her eyes!
 
  • Beware of the patient who can't open his/her eyes but is otherwise awake!
  • This coma mimic is the result of eyelid apraxia, which is the inability to voluntarily open eyes despite intact frontalis muscle contraction and absent oculomotor dysfunction.
  • This can be seen in injuries of the nondominant hemisphere (e.g. R MCA stroke), medial frontal lobe, bilateral thalami (e.g. bilateral thalami stroke), and brainstem (e.g. progressive supranuclear palsy).
  • When asking these patients to open their eyes, they may use their forehead muscles to try and raise their eyelids.

Category: Neurology

Title: What's the cause of this patient's hemiplegia?

Keywords: Uncal herniation, ipsilateral hemiplegia, Kernohan's notch, Kernohan's sign (PubMed Search)

Posted: 8/10/2016 by WanTsu Wendy Chang, MD
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Question

Patient presents after a fall confused, not moving his right side, but moving his left side spontaneously.  What's the diagnosis?
 

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20160810_Figure_2.jpg (38 Kb)


Category: Neurology

Title: Screening Tool for Large Vessel Occlusion Strokes?

Keywords: Large vessel occlusion stroke, endovascular intervention, Field Assessment Stroke Triage for Emergency Destination, FAST-ED, NIHSS, Rapid Arterial Occlusion Evaluation, RACE, Cincinnati Prehospital Stroke Severity scale, CPSS (PubMed Search)

Posted: 7/13/2016 by WanTsu Wendy Chang, MD
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Screening Tool for Large Vessel Occlusion Strokes (LVOS)?
 
  • Endovascular intervention for acute ischemic stroke from ICA or proximal MCA occlusion is a Level IA recommendation1.
  • Identification of patients who may benefit from endovascular intervention begins in the prehospital setting.
  • Several prehospital stroke scales exist, but have not been validated using arterial imaging to determine the presence of LVOS.
  • The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale (see Table 1) was designed based on items of the NIH Stroke Scale (NIHSS) with higher predictive value for LVOS.

  • The FAST-ED scale has comparable accuracy to predict LVOS to the NIHSS, and higher accuracy compared to the Rapid Arterial Occlusion Evaluation (RACE) and the Cincinnati Prehospital Stroke Severity (CPSS) scale
  • The FAST-ED scale also provides 3 distinct groups for the likelihood of LVOS:
    • Score 0 or 1: <15%
    • Score 2 or 3: 30%
    • Score >= 4: >60%

Bottom Line: Additional assessment of gaze deviation, aphasia and neglect, as included in the FAST-ED scale, increases the accuracy of predicting LVOS.  

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