UMEM Educational Pearls - Neurology

Category: Neurology

Title: Ultrasound-Assisted Lumbar Punctures

Keywords: ultrasound, lumbar puncture, LP, landmark (PubMed Search)

Posted: 12/12/2018 by WanTsu Wendy Chang, MD (Updated: 8/17/2022)
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  • Lumbar punctures (LPs) are a common ED procedure with variable reported success rates.
  • A recent systematic review and meta-analysis looked at 12 studies comprising 957 adult and pediatric patients comparing pre-procedural ultrasound-assisted LPs with traditional landmark-based technique.
    • Some studies utilized ultrasound-assistance in all LPs, others selected patients who were anticipated to be difficult LPs.
    • No studies assessed dynamic ultrasound-guided LPs.
  • Overall, ultrasound-assisted LP was 90.0% successful compared with landmark-based LP that was 81.4% successful (OR 2.22, 95% CI = 1.03 - 4.77).
  • Ultrasound-assisted LP was also associated with reduced rate of traumatic LPs, shorter time to successful LP, and reduced patient pain scores.

Bottom Line: Consider using pre-procedural ultrasound-assistance for all lumbar punctures.

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Category: Neurology

Title: Seeing Double?

Keywords: diplopia, imaging, radiology, CT, ophthalmology (PubMed Search)

Posted: 11/28/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:

 

Clinical Situation

Suspected Diagnosis

Imaging Study

Diplopia + cerebellar signs and symptoms

Brainstem pathology

MRI brain

6th CN palsy + papilledema

Increased intracranial pressure (e.g. idiopathic intracranial hypertension or cerebral venous thrombosis)

CT/CTV brain

3rd CN palsy (especially involving the pupil)

Compressive lesion (aneurysm of posterior communicating or internal carotid artery)

CT/CTA brain

Diplopia + thyroid disease + decreased visual acuity

Optic nerve compression

CT orbits

Intranuclear ophthalmoplegia

Multiple sclerosis

MRI brain

Diplopia + facial or head trauma

Fracture causing CN disruption

CT head (dry)

Diplopia + multiple CN involvement (3,4,6) + numbness over V1 and V2 of trigeminal nerve (CN5) +/- proptosis

Unilateral, decreased visual acuity

Orbital apex pathology

CT orbits with contrast

Uni- or bi-lateral, normal visual acuity

Cavernous sinus thrombosis

CT/CTV brain

C.N.: cranial nerve

 

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Category: Neurology

Title: C-Spine Clearance by ED Triage Nurses?

Keywords: cervical, spine, clearance, triage, nurse, trauma (PubMed Search)

Posted: 11/14/2018 by WanTsu Wendy Chang, MD
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  • The Canadian C-Spine Rule (CCR) has been shown to decrease the use of cervical spine imaging in low-risk trauma patients.
  • While developed for use by physicians, CCR has also been validated in ED triage nurses with moderate interrater reliability (kappa 0.78) by Stiell et al. in 2010.
  • Stiell’s group has since implemented the use of CCR by ED triage nurses at 9 teaching hospitals in Ontario with a combined annual volume of approximately 670,000 ED visits.
  • 180 certified nurses evaluated 1408 patients.
    • 806 (57.2%) arrived with c-spine immobilization.
    • 602 (42.8%) had neck pain but no immobilization.
  • Overall, nurses removed immobilization in 331 (41.4%) patients and applied immobilization in 203 (14.4%) patients.
  • Diagnostic imaging was performed in 612 (43.4%) patients and found 16 (1.1%) clinically important and 3 (0.6%) clinically unimportant injuries.
  • There were no missed c-spine injuries to the knowledge of the authors as the study hospitals were closely connected with the regional spine centers.
  • Time from nursing assessment to discharge decreased by 26.0% (3.4h vs. 4.6h)

Bottom Line: ED triage nurses can safely use the Canadian C-Spine Rule.  This approach can improve patient care and decrease length of stay in the ED.

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Category: Neurology

Title: Neurosyphilis

Keywords: CSF, lumbar puncture, infectious diseases (PubMed Search)

Posted: 10/24/2018 by Danya Khoujah, MBBS
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Manifestations due to neurosyphilis present as one of 3 categories: stroke due to arteritis, masses in the brain (granulomata), and chronic meningitis.

Although serum VDRL/TPPA tests will be positive in almost all patients, it’s important to remember that the diagnosis requires the presence of ALL of the following criteria:

1. positive treponemal (e.g. FTA-ABS, TP-PA) AND nontreponemal (e.g. VDRL, RPR) serum test results

2. positive CSF VDRL OR positive CSF FTA-ABS test result 

3. one CSF laboratory test abnormality, such as pleocytosis (cell count >20/μL) or high protein level (>0.5 g/L)

4. clinical symptoms

This is important because the treatment of neurosyphilis is distinctly different from other forms, as it requires admission for IV antibiotics for at least 10 days.  

Bonus Pearl: CSF RPR is unreliable as it is more likely to be falsely positive than other specific CSF testing.

 

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Category: Neurology

Title: Early Dual Antiplatelet Therapy for Stroke Prevention?

Keywords: stroke, TIA, antiplatelet, aspirin, clopidogrel, POINT, CHANCE (PubMed Search)

Posted: 10/10/2018 by WanTsu Wendy Chang, MD
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Takeaways

Does using a combination of aspirin and clopidogrel decrease your patient’s risk of recurrent stroke after a minor ischemic stroke or high risk TIA event?

  • The recent international Platelet-Oriented Inhibition in New TIA and Minor Stroke (POINT) trial compared 4881 patients receiving aspirin/clopidogrel vs. aspirin/placebo within 12 hours of symptom onset.
    • Patients who received DAPT had a lower rate of major ischemic events at 90 days compared to aspirin/placebo (5.0% vs. 6.5%, p=0.02).
    • However, patients who received DAPT had a higher rate of major hemorrhage compared to aspirin/placebo (0.9% vs. 0.4%, p=0.02).
  • A similar Chinese study, the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial, compared 5170 patients receiving DAPT vs. aspirin/placebo within 24 hours also found lower rate of stroke (8.2% vs. 11.7%, p<0.001) but similar rates of moderate/severe hemorrhage (0.3% vs. 0.3%, p=0.73).
  • Major differences between these two trials are the population studied and the duration of DAPT, as POINT utilized DAPT for 90 days while CHANCE utilized DAPT for 21 days.

Bottom Line: The use of DAPT in minor ischemic stroke and high risk TIA reduces the risk of recurrent stroke.  However, the duration of DAPT may affect the risk of major hemorrhage.

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Category: Neurology

Title: Must transverse myelitis be symmetrical?

Keywords: weakness, sensory symptoms, MRI, LP (PubMed Search)

Posted: 9/26/2018 by Danya Khoujah, MBBS
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Although transverse myelitis classically presents with bilateral and symmetric symptoms, it may be “partial” - symptoms would be asymmetric, or specific only to particular anatomic tracts.
In patients with risk factors (e.g. recent infection, history of autoimmune disease or cancer) and subacute ascending weakness/sensory symptoms, perform a thorough neurological exam, and obtain a gadolinium-enhanced MRI of the entire spine and/or lumbar puncture if you suspect transverse myelitis. 

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Category: Neurology

Title: Weakness.. and a rash?

Keywords: shingles, weakness, infection (PubMed Search)

Posted: 8/22/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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In patients presenting with acute weakness of the limb or trunk, be sure to ask about history of shingles or rash. They may have segmental zoster paresis.

Patients may develop weakness in a myotomal distribution similar to the dermatomal sensory symptoms and rash. However, weakness may develop up to 4 weeks after the rash, making the connection between the two presentations less apparent. 

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Category: Neurology

Title: Anticoagulation in Cerebral Venous Thrombosis

Keywords: cerebral venous thrombosis, CVT, anticoagulation, low molecular weight heparin, LMWH, UFH (PubMed Search)

Posted: 8/8/2018 by WanTsu Wendy Chang, MD
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  • Anticoagulation is the mainstay for treatment of acute cerebral venous thrombosis (CVT) to prevent clot propagation, recanalize occluded veins and sinuses, and prevent new venous thrombosis.
  • A recent meta-analysis of 4 RCTs compared the efficacy and safety of low molecular weight heparin (LMWH) vs. unfractionated heparin (UFH) for the treatment of CVT.
  • All studies were small, with 20 to 66 patients each.
  • Treatment with LMWH compared with UFH had similar mortality (OR 0.21; 95% CI 0.02-2.44; p=0.21) and disability (OR 0.5; 95% CI 0.11-2.23; p=0.36). 

Bottom Line: LMWH appear to be similar in efficacy and safety compared with UFH for the management of CVT.

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Category: Neurology

Title: An ischemic stroke.. of the spinal cord?

Keywords: infarct, paralysis, numbness (PubMed Search)

Posted: 7/25/2018 by Danya Khoujah, MBBS
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An infarct of the spinal cord is technically considered a stroke

The most common risk factor is a recent aortic surgery. Can also occur with straining and lifting (rare)

Patients will present with symptoms of spinal cord involvement with a hyperacute onset (less than 4 hours)

Although the “classic” presentation is anterior cord syndrome (flaccid paralysis, dissociated sensory loss (pinprick and temperature), preserved dorsal column function), patients may present with loss of all functions below the level of infarct due to spinal shock, confusing the clinical picture.

The most common level is T10

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Category: Neurology

Title: Can my patient with dementia refuse treatment?

Keywords: capacity, dementia, altered mental status, medicolegal, ethics (PubMed Search)

Posted: 6/27/2018 by Danya Khoujah, MBBS
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Medical decision-making capacity refers to the patient’s ability to make informed decisions regarding their care, and emergency physicians are frequently required to assess whether a patient possess this capacity. Patients with acute or chronic neurological diseases (such as dementia) may lack this capacity, and this should be identified, especially in life-threatening situations. The patient must have the ability to:

  • communicate a consistent choice

  • understand (and express) the risks, benefits, alternatives and consequences

  • appreciate how the information applies to the particular situation

  • reason through the choices to make a decision

There are numerous tools that may help with this assessment, but none has been validated in the ED. Be careful of determining that the patient lacks capacity just because of the diagnosis they carry. 

 

BONUS PEARLS:

 

 

  • Capacity is a fluid concept; a patient may have the capacity to make simple decisions but not more complex ones. Capacity may also change over time

  •  

  •  

  • Psychiatry consultation to determine capacity is not obligatory but may be utilized for a second opinion.  

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Category: Neurology

Title: Neuroimaging in Syncope - Is It Necessary?

Keywords: Syncope, neurological, neuroimaging, CT, MRI (PubMed Search)

Posted: 6/13/2018 by WanTsu Wendy Chang, MD (Updated: 8/17/2022)
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  • The use of neuroimaging in syncope-related ED visits increased from 21% in 2001 to 45% in 2010.
  • A recent single-center retrospective study of 1114 patients who presented to the ED with syncope found that 62.3% patients underwent CT, while 10.2% underwent MRI.
  • A subset of patients (10.4%) sustained mild head trauma (GCS 14-15) due to syncope and all received neuroimaging.
  • Neuroimaging studies were not found to be beneficial in patients without features of:
    • Confusion
    • Amnesia
    • Focal neurological deficit
    • Dizziness
    • Severe headache
    • Nausea and vomiting
    • Signs of serious head injury
    • Intracranial malignancies
    • Use of anticoagulant drugs

Bottom Line: Consider obtaining neuroimaging in patients presenting with syncope only if clinical features suggest probable neurological syncope.

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Category: Neurology

Title: Lhermitte's Sign

Keywords: myelopathy, myelitis, physical exam (PubMed Search)

Posted: 5/23/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Lhermitte’s phenomenon is as a sign of cervical spinal cord demyelination. It is considered positive if flexion of the neck causes a tingling sensation moving down the limbs or trunk, and may be reported as a symptom or elicited as a sign. This is due to stretching of the dorsal column sensory fibers, the commonest cause of which is multiple sclerosis. Other causes include other myelopathies, such as B12 deficiency, radiation and toxic (due to chemotherapy) or idiopathic myelitis. Its sensitivity is low at 16%, but its specificity for myelopathy is high at 97%.

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Category: Neurology

Title: Predicting ICH Expansion

Keywords: Intracerebral hemorrhage, ICH, hematoma expansion, prediction score, BAT score (PubMed Search)

Posted: 5/9/2018 by WanTsu Wendy Chang, MD (Updated: 8/17/2022)
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Takeaways

  • CT angiography (CTA) spot sign is a strong predictor of intracerebral hemorrhage (ICH) expansion.
  • However, since CTA is not part of the routine diagnostic workup of acute ICH, other predictors using noncontrast head CT have been reported in the past.
  • A 5-point BAT score can be used to identify patients at high risk of hematoma expansion:

  •  
  • Patients with a score ≥ 3 have a higher risk of hematoma expansion

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Category: Neurology

Title: Atypical Stroke Symptoms

Keywords: stroke, altered mental status, gender, sex, confusion (PubMed Search)

Posted: 3/28/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Patients may present atypically with ischemic strokes, reporting symptoms such as face or hemibody pain, lightheadedness, mental status change, headache and non-neurological symptoms.

Up to 25% of patients will have these symptoms.

Women are more likely than men to present with these atypical (or “nontraditional”) symptoms, especially altered mental status.

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Category: Neurology

Title: Prehospital Stroke Scales for Large Vessel Occlusion

Keywords: stroke, prehospital, large vessel occlusion, NIHSS, RACE, LAMS, VAN (PubMed Search)

Posted: 3/14/2018 by WanTsu Wendy Chang, MD (Updated: 8/17/2022)
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Takeaways

  • A recent systematic review evaluated the diagnostic accuracy of 19 prehospital stroke scales.
  • Arm motor strength is the most frequently evaluated item by the scales (15/19), followed by gaze (13/19) and language (13/19).
  • Only 4 scales (RACE, LAMS, VAN, sNIHSS-EMS) were performed by paramedics in their original studies.
  • The NIHSS, LAMS, and VAN appear to have better results in predicting large vessel occlusion.
  • The presence of hemineglect, a sign of cortical involvement, improved the accuracy of the scale.

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Category: Neurology

Title: Headache in the Bodybuilder

Keywords: headache, steroids, bleed (PubMed Search)

Posted: 2/28/2018 by Danya Khoujah, MBBS
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Benign headaches are common in bodybuilders. However, several less benign headaches are worth noting:

  • Low cerebrospinal fluid (CSF) pressure headache: caused by a small dural tear mostly at the thoracic level. Similar to postdural headache. Treated by recumbency, and blood patches if recalcitrant.
  • Subarachnoid hemorrhage (SAH)
  • Spontaneous intracranial hemorrhage
  • Ischemic stroke
  • Dural sinus thrombosis

All except the first two are exclusively reported in patients on anabolic steroids, growth hormone, and/or “energy” supplements. Make sure to ask your patient about these risk factors.

 

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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)
Click here to contact WanTsu Wendy Chang, MD

  • 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: Brain Tumor Imaging 101

Keywords: edema, hemorrhage, tumor, CT, MRI, contrast (PubMed Search)

Posted: 1/24/2018 by Danya Khoujah, MBBS (Updated: 8/17/2022)
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Although MRI is more sensitive for identifying tumors of the CNS, CT is usually the first line imaging modality in the ED. Some pearls:

  • Hyperattenuation = bright = dense (blood)
  • Hypoattenuation = dark = radiolucent (fluid, air, lipid, scar)
  • Masses that are darker + increased volume or mass effect = edema (image 1)
  • Masses that are darker + decreased volume = scar tissue or atrophy (image 2)
  • Masses that are bright + edema = hemorrhage (image 3)
  • Adding IV contrast improves detection of tumors: abnormal enhancement from disruption of blood brain barrier, necrosis or increased vascularity. (Image 4)

Image 1 Courtesy of Radiopedia.orgImage 2: courtesy of Dr Chris O'Donnell, Radiopaedia.orgImage 3: courtesy of Dr David Cuete, Radiopaedia.orgImage 4: Courtesy of David Kernick, and Stuart Williams Br J Gen Pract2011;61:409-411

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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: Cerebral Venous Thrombosis (CVT)

Keywords: headache, seizure, stroke, neurological deficit, thrombogenic (PubMed Search)

Posted: 12/27/2017 by Danya Khoujah, MBBS (Updated: 8/17/2022)
Click here to contact Danya Khoujah, MBBS

Cerebral venous thrombosis is a rare (but dangerous) cause of headaches and strokes in patients below the age of 50. It includes thrombosis of the cerebral veins and major dural sinuses. 
A d-dimer can NOT be used to rule it out, as it would be falsely negative in up to 40% of patients. A dry head CT is completely normal in 30% of patients, with nonspecific changes present in another 30%.

Take home: If you are considering the diagnosis, obtain a CT venography (95% sensitive) and don’t rely on a negative dimer or dry head CT.

 

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