28 1 / 2012

  • Triad of bleeding, visual changes, neuro symptoms
  • Get CBCdiff, coags, BMP, peripheral smear for roulette formations, serum and urine electrophoresis
  • Careful hydration and diuresis
  • If extreme WBC, needs leukophoresis
  • If extreme proteinemia, needs plasmapheresis
  • If not immediately available, do 100-200cc phlebotomy

27 1 / 2012

  • Pure Motor
  • Pure Sensory
  • Sensory-Motor
  • Clumsy Hand/Dysarthria

26 1 / 2012

  • Conversion Disorder
  • Delerium
  • Todd’s Paralysis/Postictal
  • Hyperglycemia
  • Hypoglycemia
  • Intracranial Mass
  • Metabolic/Toxic Encephalopathy
  • Complex Migraine

01 1 / 2012

Cerebral Venous Sinus Thrombosis:

  • Stroke from thrombosis of the dural sinuses
  • Headache, abnormal vision, stroke signs
  • Can have seizures
  • Can have cranial nerve findings
  • CT Venography best test with MRI
  • Treatment is heparin/coumadin/anticoagulation

Cavernous Sinus Thrombosis:

  • Blood clot in the cavernous sinus
  • Usually from infection from the midface spreading backwards
  • Change in vision, exophthalmos, headache, cranial nerve palsies
  • MR venogram best test
  • Broad spectrum antibiotics, consult neurosurgery to evaluate for drainage

17 12 / 2011

  • High Protein: Guillan-Barre
  • Oligoclonal Bands: MS

12 12 / 2011

Oculomotor palsies often have pupillary involvement because the parasympathetic nerves innervating the iris travel with the third nerve.

Pupillary involvement is a crucial diagnostic sign — compressive lesions (mass) tend to involve the pupil, while vascular lesions actually spare it.

The parasympathetic fibers run on the outside of the nerve, while the motor fibers run on the inside. If they have a diabetic neuropathy or vasculopathy, the parasympathetic fibers will be spared (they’re closer to the blood supply) while the motor fibers will be ischemic: a down and out eye with an intact pupil reflex.

(But regardless: ophtho needs to see them!)

From Ophthobook.com

06 12 / 2011

(Otherwise it’s complex febrile seizure):

  • Patient age between 6 months and 5 years
  • Generalized tonic–clonic convulsion
  • Spontaneous cessation of convulsion within 15 minutes
  • Return to alert mental status after convulsion
  • Documentation of fever (>38.0°C)
  • One convulsion within a 24-hour period
  • Absence of preexisting neurologic abnormality

01 12 / 2011

Detect subtle weakness with:

  • Heel Rise Test: Stand on one foot and rise heel
  • Squat Test: Have them squat and then try to stand

Botulism (Descending)

  • Presynaptic ACh toxin-mediated inhibition
  • Irreversible until new NM junctions are made
  • Wound botulism from IVDU
  • Descending paralysis/CN palsies
    • Proptosis, diplopia, facial weakness, speech changes, ptosis, double vision
  • In infants, weak suck and cry, floppy baby
  • Admit to ICU for observation
  • Give antitoxin
    • Test for hypersensitivity first before given (made from horse serum)
    • Do not give to infants
    • Can instead get HBIG (human botulism immunoglobulin), call 510.231.7600.

Guillan-Barre (Ascending)

  • Assoc with campylobacteria diarrhea
  • Weakened reflexes
  • Peripheral polyneuropathy
  • 1–4 week prodrome
  • Can be confused with Transverse Myelitis or Epidural Abscess/Compression
    • Usually GBS has less sensory deficits than the others
    • No clonus in GBS, Babinski negative in GBS
  • Having pain with sensory deficits does NOT rule out GBS
  • Miller-Fisher Variant: Ophthalmoplegia, areflexia, ataxia
  • Descending paralysis instead of ascending
  • Pure Sensory GBS: Ascending sensory loss with absent reflexes
  • Autonomic-Only GBS
  • LP can diagnose: high protein, few WBCs (albumincytologic dissociation).
    • Can be normal in first week
  • To assess disposition, check FVC.
    • FVC normal = 65ml/kg
    • If less than 1/2 predicted, admit to ICU
  • High Risk GBS for Respiratory Compromise:
    • Onset to admission < 7 days
    • Inability to lift elbows/head above bed
    • Inability to stand
    • Ineffective cough
    • Elevated LFTs
  • Treatment is either IVIG or Plamapheresis
  • No benefit to steroids

28 11 / 2011

Ask About:

  • Alcohol
  • Diabetes
  • HIV
  • Heavy Metals
  • Syphillis

Carpal Tunnel

  • Association with pregnancy, hypothyroid, DM, renal failure, acromegaly, steroid use
  • Weakness of thumb adduction, thenar atrophy
  • Median nerve distribution pain
  • Place in splint with NSAIDs

From Critical Decisions June 2010