• The incidence of stroke (both ischemic and hemorrhagic) in pregnant and peripartum women is three times age-matched controls. This increased risk is mostly in the 3rd trimester and up to 16 weeks postpartum. 

• Consider other causes of stroke:  posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis and cardioembolic stroke from peripartum cardiomyopathy.

• CTs carry some risk due to the ionizing radiation, but with abdominal and pelvic shielding the exposure to the fetus is very low. MRIs do not carry that risk, but Gadolinium is absolutely contraindicated in pregnancy as it deposits in fetal tissue. 

• Pregnancy is a relative (not absolute) contraindication for tPA.

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The Beers' Criteria lists 34 classes of medications that may be potentially inappropriate for geriatric patients due to a high risk of complications including increased risk for falls. When prescribing medications from the emergency department in geriatric patients, try to avoid these categories if other options are available.

http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf

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Patients may present to the ED with new onset weakness due to myasthenia gravis (MG). A group that is frequently missed is late-onset MG, which occurs after the age of 50. It is frequently misdiagnosed as a stroke or transient ischemic attach (TIA).

Two cardinal features:

• fatiguability: must be distinguished from fatigue. 
• fluctuation

Bonus pearl: Ocular symptoms are present in up to 85% of patients with MG, with unilateral ptosis or asymmetric bilateral ptosis being the most common presentations.

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Magnetic resonance imaging (MRI) is the method of choice for imaging the spine for the suspicion of non-traumatic disorder, such as multiple sclerosis (MS), transverse myelitis, epidural abscess, spinal cord infarcts, and spondylotic myelopathy (changes in the spinal cord due to disk herniation or osteophytes in degenerative joint disease).

If the differential diagnosis includes infection, neoplasm, demyelination or inflammation, then IV contrast should be administered.

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You have a patient in whom you suspect meningitis, but he is on warfarin for a history of pulmonary embolism. You started empirical antibiotics. His INR is 2.6, and you want to do a lumbar puncture (LP) to confirm your diagnosis. Can you use Prothrombin Complex Concentrate to lower his INR and safely perform the LP?

Take Home Point:

Using PCC to lower INR to enable LP is relatively safe and effective in patients on vitamin K antagonists. The dose used was individually determined by the physician according to initial INR.

Limitation:

This is a retrospective study, with no control group. One patient (2.7%) had a myocardial infarction that was “possibly related” to the PCC administration. 

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Ataxia is an important clinical sign of cerebellar pathology, but how is it actually described?

Stance ataxia: inability to stand with feet together for more than 30 seconds

Gait ataxia

Sensory ataxia: the first 2 elements, in addition to a positive Romberg sign

Truncal ataxia: oscillation of body while sitting or standing

Limb ataxia: functional impairment in performing actions such as writing or buttoning and improves with slowing down the movement

Dysdiadokinesia: impairment of rapidly alternating movement

Intention tremor: tested by finger-to-nose and heel-to-shin.

Dysmetria: pastpointing or undershooting on finger-chasing or shin-tap.

Dysarthria: irregular and slow speech with unnecessary hesitation

Nystagmus and other ocular disturbances, such as ocular flutter and opsoclonus.

The first 3 are present in both cerebellar pathology and loss of proprioceptive input, the rest are usually due to cerebellar pathology or ataxic syndrome.

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Multiple sclerosis (MS) relapses are defined as new or worsening neurologic deficits lasting 24 hours or more in the absence of fever or infection. Symptoms may be visual, motor, sensory, balance or cognitive. It is a clinical diagnosis, but the presence of a new gadolinium-enhancing lesion on MRI can be used as a radiologic marker of an MS relapse. However, it is unclear whether asymptomatic lesions should be treated, making it prudent to rely on the clinical evaluation rather than the MRI for diagnosis.

Moderate to severe relapses should be treated within 1 week of onset. The mainstay of treatment for relapses is IV methylprednisolone, usually dosed at 500mg to 1g per day for 3-7 days.

Similar symptoms occurring in the presence of fever, heat exposure, stress or infection (such as urinary or upper respiratory tract infections) are "pseudoexacerbations", and should not be treated as an MS relapse.

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Short Answer: No

Classically, some therapies for headaches are thought to be effective in only certain classifications of headaches, such as triptans in migraines, or oxygen in cluster headaches. This is not necessarily true.

Triptans have been successfully used in cluster headaches, as found in the 2013 Cochrane review.¹

More recently, "high-flow" oxygen (referring to 12 L/min of oxygen, delivered through a facemask) has been studied in migraine headaches, with promising results. When compared with placebo (air), oxygen used for 15 minutes was more effective in pain relief and improving visual symptom, with no significant adverse events. ²

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A 25 year old patient presents to the emergency department (ED) with a first unprovoked seizure. His ED workup is normal and he is back to his baseline, and you plan to discharge the patient with outpatient follow up within 1 week. The patient is requesting to be discharged on an anti-epileptic drug (AED). What do you do?

Educate the patient about the risk of recurrence, and the possible side effects of AEDs!

The American Academy of Neurology (AAN) specifically addressed this in their 2015 guidelines. A few points to remember:

- The risk of recurrence is greatest within the first 2 years, and occurs in 21-45% of patients.

- The risk of recurrence increases with a remote brain lesion or injury, abnormal EEG, significant brain imaging abnormality or nocturnal seizures.

- AED therapy is likely to reduce the risk of a 2nd unprovoked seizure by about 35% over the next 2 years, but the delay in initiating therapy does not increase the long-term remission risk.

Is it different if the patient had multiple seizures within 24 hours?

Patients presenting with multiple seizures in a 24-hour period were as likely to have seizure recurrence as those presenting with a single seizure, irrespective of etiology or treatment.

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Airway management is an integral part of caring of critically ill patients, but is there anything that should be done differently in the neurologically injured patient?

• Injured brains are particularly sensitive to hypoxia. Avoid it by appropriate positioning and preoxygenation.
• Consider fentanyl and/or ketamine for sedation for RSI, as fentanyl can blunt the hemodynamic response to intubation, while ketamine is hemodynamically neutral and safe.
• Consider Esmolol (1.5mg/kg) prior to intubation to prevent sympathomimetic surge during intubation in the absence of multiple injuries.
• There is no role for the use of a defasciculating dose of neuromuscuclar blockade during RSI

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HSV infection of the CNS is one of few treatable viral diseases. HSV encephalitis of older children and adults is almost always caused by herpes simplex virus type 1 (HSV-1), and in individuals older than 20, is due to HSV reactivation.

Temporal lobe localization is characteristic for HSV encephalitis in individuals older than 3 months, and is responsible for its characteristic presentation, namely bizarre behavior and expressive aphasia.

CSF analysis will usually reveal an elevated protein level, and a lymphocytic cellular predominance.

CSF protein concentration is a function of disease duration, and will continue to rise even with administration of treatment (acyclovir) and may remain elevated after the completion of therapy.

5% of CSF samples will be totally normal, and the diagnosis will only be revealed with positive PCR detection of viral DNA in the CSF, which is the gold standard for diagnosis.

The sensitivity of MRI is similar to CSF analysis, with 5% of patients with HSV encephalitis having a normal MRI on presentation, and subsequently developing abnormalities.

Of note, HSV-2 tends to cause aseptic meningitis rather than encephalitis in adults, and has a benign course.

Bottom Line? Keep a high index of suspicion for HSV encephalitis, and treat the patient empirically despite a normal CSF/MRI pending PCR results.

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Ketamine has been the drug du jour for everything from agitation to pain, but status epilepticus?

Looking at the pathophysiology of seizures, they occur due to an imbalance between excitatory mechanisms (through glutamate at the NMDA receptors) and inibitory mechanisms (at GABA receptors). The mainstay for seizure treatment has been mostly potentiation of the inhibitory mechanisms, but why not inhibit the excitatory mechanisms at the NMDA receptors?

Ketamine is the only NMDA antagonist that has been investigated for refractory status epilepticus, mostly in retrospective small series, with only 3 prospective cohort studies, totaling to 162 patients (110 adults and 52 pediatrics). Variable results were recorded, from studies with complete response in all patients to complete treatment failure, with a total of 56.5% of the adult patients having electrographic response. The optimal bolus dose appears to be 1.5-4.5 mg/kg, with an infusion of up to 10 mg/kg/hour.

Bottom Line? Consider using ketamine in patients who are in refractory status - after benzodiazepines, a 2nd line agent (such as fosphenytoin, valproic acid or levetiracetam) and IV anesthetics have failed.

(NMDA: N-methyl-D-aspartate, GABA: -aminobutyric acid)

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A thunderclap headache is defined as a very severe headache that reaches its maximum intensity within 1 minute.

One of the most common causes (and the one associated with this buzzword on board questions!) is subarachnoid hemorrhage, but what else can cause a it?

- Reversible cerebral vasoconstriction syndrome (RCVS): suggested by recurrent thunderclap headaches (2-10) over 1 to 2 weeks. Normal CT and LP, with vasoconstriction on angiography. Can lead to SAH, ICH or ischemic stroke.

- Cervical artery dissection

- Cerebral venous sinus thrombosis

- Spontaneous intracranial hypotension: characterized by orthostatic HAs and auditory muffling.

- Intracerebral hemorrhage

- “Primary”: a diagnosis of exclusion

Bottom line? All patients with thunderclap HA should have a stat head CT with no contrast, then have SAH excluded with an LP, CTA or MRI/MRA. Just because you excluded SAH in a patient with thunderclap headache does not mean you’re done with the emergency workup. 

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Status migrainosus is a migraine that lasts more than 72 hours, and can be rather challenging to control. A few tips to tackle this are:

1. Adequately hydrate all patients (IV fluids are usually required, especially with severe nausea/vomiting)

2. Establish realistic expectations for the patient. A patient with chronic daily headaches will not be pain-free in the ED.

3. Use IV nonopioid medications for pain control

1^st Line:

- Dopamine Antagonists: in increasing efficacy

- Metoclopramide

- Phenothiazines: prochlorperazine, promethazine and chlorpromazine

- Butyrophenones: droperidol and haloperidol

- NSAIDs: such as Ketorolac IV or IM

2^nd Line:

- Corticosteroids: Do not treat the migraine in the ED, but prevent headache recurrence within 72 hours.

- Magnesium Sulfate: Has shown mixed efficacy. More likely to have a sustained benefit in patient with serum magnesium level of 1.3mg/dL or less.

- Valrpoic Acid: Be careful of combining it with Topiramate.

- Vasoconstrictors: Triptans, ergotamine, dihydroergotamine. Effective, but use is limited by contraindications.

- Opioids: Last resort