Dawson's fingers - periventricular plaques visualized on T2 MRI, diagnostic of the autoimmune central nervous system demyelinating disorder known as multiple sclerosis.
Uhthoff's phenomenon - characteristic heat intolerance described by MS patients who report exacerbations of symptoms when core body temperatures increases. Thought to be a result of decreased nerve conduction in the setting of heat stress and pre-existing plaques already impeding nerve conduction. Although first observed in 1890 by German neuro-0phthalmolagist Wilhem Uhthoff, it wasn't supported by electrophysiological data until 2004. MS patients with spinal cord lesions/brainstems tend to have poorer prognoses. Treatment with interferons (beta) decrease relapse by 1/3. Tysabri decreased by 2/3 but associated w/PML after ~18 doses, CD4 count less than 500
treatment of MS in pregnancy overview: 0-3 months do nothing, 3+months consider steroids, try to ride it out w/o treatment if possible. pregnancy can have protective effects by virtue of mom's hormone profile (^^progesterone/estrogens), postpartum can create lots of exacerbations when hormone profile decreases. Marijuana (synthetic controlled doses) has been found to be successful in decreasing MS associated muscle spasm and dolor in controlled trials. Smoking marijuana has a vast case report history of treating pain associated w/MS.
Don't forget to ask about handedness.
Aphasia is a disturbance in language that does not result from impaired motor function (thats dysarthria). There are six dimensions:
1. Spontaneous speech
2. Comprehension
3. Naming
4. Repetition
5. Reading
6. Writing
Although upper motor neurons are classically associated w/hyperreflexia and increased tone, an acute stroke with have a period of flaccid paralysis and and tone will begin to increase.
Admission note includes:
CC
HPI
PMH
Past Surg/Med
Allerg
Social History
Fam History
ROS
Exam
Labs
Imaging
Impression w/differential
Plan (either system or problem based)
Frontal lobe lesion clue: cant saccade contralaterally, ipsilateral gaze deviation
Posterior lesion clue: gaze deviates contralaterally
Medical stroke work up:
MRI/MRA
ASA 325mg
Stating 80mg (no matter the lipid profile they do better with them)
TTE/TEE
Acute steroid side effects to watch out for:
Gastritis (give Nexium)
Hyperglycemia (insulin sliding scale)
Hip osteonecrosis
Catacracts/glaucoma
Immunosuppression
stroke 3rd leading cause of death in US, 780K a year, 150K die a year. $60 billion annual cost.
Hemorrhagic strokes #1 cause HTN - normally rupture in deep structures and subcortical branches-
50% of the time: Putamen (pure motor stroke)
50% of the time: either caudate, thalamus, pons, cerebellum
>65 years old -amyloid angiopathy commonly lobar strokes
dosen't fit above? think tumor/abscess/vascular malform
Ischemic strokes - 80% of strokes
can be caused by htn - think deep structures
atherosclerotic strokes
large vessel can have embolus
artery to artery
cardioembolic
dissection
artery to artery embolus
progressive occlusion
full thickness rupture b/c intracranial vessels have thinner media and do not have external elastic lamina.
can be sudden/spontaneous
sudden neck trauma
fibromuscular dysplasia
substance abuse
hypercoaguable states
cancer
heme cancer
genetic (antiphospholipid, factor V etc..., homocysteine, vasculitides)
vasculitides
infxn, autoimmune, endovascular lymphoma
#1 CNS vascular pathology - granulomatous angiitis
"depression can influence recovery"
ACEi/ARBs not as good in African American populations for controlling BP, better to use diuretics or Ca++ channel blocker
advice from site director during clinic, "learn at least one personal thing about each patient and you will be ahead of the game"
"surgery is an option of last resort"
Epilepsy driving laws - need to be 1 year seizure free, doctor does not have duty to report to DMV,
infections also cause cardioembolic stroke - bacterial endocarditis
"DVT prophylaxis starts w/fondaparinux then start heparin in a few days"
Key to neurology - where's the lesion? should be able to get the answer if you take a careful history.
Person having ischemic stroke, allow them to autohypertense - don't treat BP until > 220/110 only need one pressure to exceed. If you are planning to give tPA, the cutoff is reduced to 185/110.
Post stroke HTN normally decreases in 48 hours by self, 4-5 days patient returns to pre-ischemic pressures. Restart antihypertensives ~72 hours after.
Types of neglect:
spatial neglect - looks only to one side, doesn't even know other side of visual field exist have them draw the face of clock
auditory neglect- wont hear you if your voice coming from neglected side (very strange phenomenon)
tactile neglect
visual neglect
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