Tutorial for New-Extern

“Survival Neurology”
Surat Tanprawate, MD, MSc(London), FRCP(T)
Division of Neurology, Chiang Mai University
Neurology extern should know

Headache

Medical coma and confusional state

Acute stroke

Tonic-clonic seizure and status
epilepticus
I have headache !
?
?
?
?
Patient presents with
complaint of a headache
Critical first step:
Hx taking, physical
exam
Red flag signs or
alarming signs
Meets criteria for
primary headache
disorder?
Migraine
headache
Tension-type
headache
Cluster
headache
and other
TACs
Red flag signs
Investigation
Secondary
headache
disorder
Other (rare)
headache
disorder
(+) (-)
(+)
Headache: Key
1. Identify serious cause
Red flag sign?
2. Know common primary headache
— Feature of migraine, TTH,
trigeminal neuralgia
3. Consult specialist :
secondary headache
non responder
no idea
Normal neurological
examination
Abnormal neurological
examination
Focal neurologic s/s
other than typical
visual or sensory aura
Papilledema
Temporal
profile
Concurrent
event
Provoking
activity
Age
Age> 50
Sudden onset
-SAH, ICH, mass
lesion (posterior
fossa)
Worsening
headache
-Mass lesion, SDH,
MOH
Pregnancy, post
partum
-Cerebral vein
thrombosis, carotid
dissection, pituitary
apoplexy
Headache with
cancer, HIV,
systemic illness
(fever, arteritis,
collagen vascular
disease)
Neck stiffness
Triggered by
cough, exertion or
Valsava
-SAH, mass lesion
Worse in the
morning
-IICP
Worse on
awakening
-Low CSF
pressure
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Tension type
headache
Migraine
Cluster
headache
Unilateral
Throbbing
Nausea
Blur vision with zig zag line
Sensitive to light
Treatment

Life style modification

Acute treatment

Prophylactic treatment
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Pharmacotherapy of acute
migraine attack
Non-specific

Acetaminophen,

NSAIDs

caffeine

opioids

neuroleptic
Specific

Ergotamine(Cafergot)

Triptan
Ergotamine tartrate+ Caffeine
Ibuprofen (400)/
Naproxen (250),
Diclofenac(25)

1 tab prn headache
Cafergot

1 tab prn headache
(moderate to severe)
Recommended
medication for
migraine prevention
“EFNS guideline
2009”
Evers, S et al.
European Journal of Neurology 2009, 16: 968–981
Started when high
headache frequency,
high severity
Duration 3-6 months
TTH diagnostic criteria
“Featureless headache”

Headache with bilateral location,
pressing/tightening character, no
other associated symptoms

Common triggered by stress
Treatment of TTH

Life style modification: stress

Acute medication: simple analgesic,
NSAIDs, muscle relaxant

Prophylactic medication: TCAs,
Depakine

Non-pharmacologic intervention
COMA
and
ACUTE CONFUSIONAL
STATE
Alter mental status
Coma/alter level of
consciousness
Other: delirium,
aphasia, psychiatric
problem
Hx taking/physical
exam
clinical classification
1. coma with localizing sign
2. coma without localizing sign but with meningeal sign
3. coma without both localizing and meningeal sign
4. coma with seizure
2 component of consciousness: arousal and awareness
coma, vegetative state, minimally conscious state, and locked-in syndrome.
VARIOUS STATE OF CONSCIOUSNESS
Delirium
Acute confusional
state
Practical approach

History taking

as the patient can not talk, then ask their relative or witness

underlying disease is important (DM, atherosclerotic risk,
HIV)

symptoms before and during coma(neurological complain)

Physical exam

CPOMR (conscious level, pupil, ocular movement, motor
response, respiration)

Meningeal sign, seizure, other neurological symptoms?
clinical classification
1. coma with localizing sign
2. coma without localizing sign
but with meningeal sign
3. coma without both localizing
and meningeal sign
4. coma with seizure
COMA
Localizing sign-no
Meningeal sign-yes
Severe meningitis
or
Meningitis with complication;
hydrocephalus, vasculitis, infarct
Encephalitis
Subarachnoid
hemorrhage
- CT Brain
with contrast
- Lumbar
puncture
CT with CM in bacterial
meningitis
CT without CM in SAH
MRI Brain in viral encephalitis
Non-structural lesion caused
coma

Exogenous- drug, toxin (lead,
thallium, cyanide, methanol,
CO), addict substance (heroin,
amphetamine)

Endogenous- metabolic; Ca,
Na, glucose, hypoxemia,
hypercapnia, hypothyroid :::
internal toxin; uremia, hepatic
encephalopathy
Thesecausesarereversible;ifnolocalizingsign;labscreenfirst
Glucose,CBCwithPlt,BUN,Cr,Elyte,Ca,Mg,PO,Oxygensat
Keep in Extern’s Mind
Alter mental state
1. Ask history; if obvious history suggest cause, treat
immediately (hypoglycemia in DM patient, toxin
ingestion)

2. Restore vital signs (Oxygen, BP)...then taking lab
(glucose immediately, and other basic lab)

3. Physical exam: “CPOMR” + “Meningeal sign”
-) if coma with no both focal or meningeal sign: metabolic, toxic,
drug, diffuse intracranial lesion
-) if coma with meningeal sign; do CT brain emergency
-) if coma with focal sign; do CT brain emergency
-) if coma with sign suggesting to seizure: start AED
Delirium, Acute confusional state
- good wakefulness
- impair orientation
- fluctuation of consciousness
(usually occur at night)
- broader cause than coma
Etiologies -“ I WATCH DEATH “
! I = Infection

! W = Withdrawal
! A = Acute Metabolic
! T = Trauma
! C = CNS Pathology
! H = Hypoxia
! D = Deficiencies
(especially vitamin)
! E = Endocrinopathies
! A = Acute Vascular
! T = Toxins
! H = Heavy metals
Delirium management

Monitor VS and I/O

Ensure good oxygenation

D/C nonessential medications

Minimize opioids, Benzodiazepine, etc

Repeat PE, further lab, radiologic studies if cause not yet identified

! Antipsychotic Dosing in Elderly
!
Use clinical judgment depending on severity of symptoms for
starting dose:
!
Haloperidol
!
0.5mg mild
!
1mg moderate
!
2mg severe
Acute stroke
when we suspect stroke

when the patient has sudden neurological deficit;
symptoms depend on where is the brain is
involved

weak, numb

brain stem sign

cerebellar sign

cortical sign

alter mental state
Acute/sudden neurological deficit
Stroke?
Hx taking/physical
exam
With in 3.0-4.5 hrs
Call stroke fast track
> 3.0-4.5 hours
Brain imaging: CT
brain
Hemorrhage
Infarct
ABCD, Neuro sign
w/u stroke mimicker;
specially hypoglycemia in
DM, post-seizure
EKG
IV NSS, Lab (CBC plt,
PT, PTT, INR, BUN/Cr/
elyte
3.1%
3.6%
18.2%
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%
seizures
toxic/metabolic
PN palsy
tumour
SDH
confusional state
migraine
psychogenic
dementia
syncope/presyncope
MS
vertigo
TGA
SAH
miscellaneous
% of all stroke mimics (n=670)
Condition that mimic stroke
Stroke can be...
Ischemic 75%
Hemorrhagic
(25%);
subarachnoid,
intracerebral

Large-artery atherosclerosis(emboli/
thrombosis)

Cardioembolism(high-risk/medium-
risk)

Small-vessel occlusion(lacune)

Stroke of other determine etiology

Stroke of undetermined etiology
TOAST, Trial of Org 10172 in Acute Stroke Treatment.
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
TOAST classification
Anterior vs Posterior
circulation
“Acute brain attack”
ABCD, Neuro sign
w/u stroke mimicker; specially
hypoglycemia in DM, post-
seizure
EKG
IV NSS, Lab (CBC plt, PT,
PTT, INR, BUN/Cr/elyte
CT Brain non-contrast
emergency
clinical stroke
within 2-4.5 hours
Activate Fast tract for
rt-PA
CT Brain normal or evidence of acute ischemic stroke
IV rtPA if indicated
CT brain,
non-contrast
Ischemic stroke
Hemorrhagic stroke
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Minor or subtle signs : loss of
lentiform nucleus, loss of insular
ribbon, loss of gray-white
differentiation and sulcal
effacement
Standard treatment in acute
ischemic stroke

IV rtPA within 3 hrs : NNT=10 (now 3-4.5
hrs)

Stroke unit : NNT = 30-40

ASA within 48 hrs : NNT 140

Early decompressive surgery for malignant
MCA infarction : NNT =2 for death prevent
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Brain herniation

Subfalcine (A)

Uncal (B)

Central (C)

Extradural (D)

Tonsillar (E)
Herniation syndrome
Treatment IICP

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g5"$h"-G osmotherapy:

Mannitol* 0.25-0.5 g/kg M"<K/1*+91*e-; 20 ;"i
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Km1 10% Glycerol 250 ml M"<K/1*+91*e-; 30-60
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Km1 50% Glycerol 50 ml M"<N":l;/8 4 Jj<

Z/8/Km1 Furosemide 1 mg/Kg M"<K/1*+91*e
Treatment IICP

Kc:+d2<:"$-G hypotonic solution

Kc:+d2<7")8L"*11:n+5; g5"$h"-[`1
Q)2K"2-5-;:$ofB:"$K"2-5p*N:q

Hyperventilation +r1-G Pco2 30-35 mmHg
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Keep in Extern’s mind
Stroke
1. when the sudden neurological deficit occur;
suspect stroke...every case

2. check time and onset (eligible for rt-PA??) and
exclude mimicker cause (hypoglycemia, seizure)

3. if within 4.5 hours; call resident/neurologist
“activate FAST TRACT” can request CT brain
emergency

4. check v/s, assess severity, check and follow up
neurological signs
Seizure and status
epilepticus
Patient come with clinically
suspected seizure
Known case
epilepsy with
recurrent seizure
First diagnosed
seizure
Status
epilepticus
Seizure
mimicker
Cause?
Treatment options
Treatment cause
AED?
Seizure or Not seizure

Seizure mimicker

pseudo-seizure

convulsive syncope

movement disorder: myoclonus,
chorea, paroxysmal dyskinesia

hypnic jerk
Seizure vs Syncope
Bhidayasiri R. et al. Neurological differential diagnosis 2005
Identify cause of seizure
(symptomatic seizure)
Acute symptomatic
seizure

Stroke

Metabolic
disturbances

CNS infection

Trauma

Drug Toxicity

Hypoxia
Remote symptomatic
seizure

Pre-existing epilepsy

Ethanol abuse

Old CVA

Relatively long-
standing tumors
What should we do?

Evaluate ABCD, and check basic lab,
intubation or oxygen therapy if indicate

If seizure is not stop; start AEDs

Complete general, and neuro-exam

Brain imaging if indicate
New proposed
definition of SE

Status Epilepticus Cooperative Study
group (1998)

SE > 10 minutes

Lowenstein DH (1999)

SE > 5 minutes
Complication of SE

Acidosis

Cerebral edema

Hypoglycemia

Other: arrhythmia, hyperthermia,
hyperkalemia, DIC, rhabdomyolysis,
myoglobinuria, renal failure
Management of SE
Key

treat early as possible

step up AED is depended on stage of
SE

add on therapy is needed

monitor EEG regularly, even if no
obvious seizure
Define stage of the
status epilepticus

Pre-monitory status(0-5 min)

Early status(5-30 min)

Established status(30-60 min)

Refractory status(>60 min)
Drug used

diazepam, phenytoin(Dilantin), valproic
acid(Depakine), levetirazetam(Keppra)

Phenobarbital, propofol, midazolam,
thiopental

Topiramate(feed)
drug use depend on stage of status
stage of status AED treatment
Premonitory (0-5 min) Diazepam (i.v. bolus)
Early (5-30 min)
Diazepam (i.v. bolus) followed by
phenytoin (iv load) or sodium valproate
(i.v. loading) or levetiracetam (i.v.)
Established (30-60 min)
half dose i.v. load of previous drug, if
seizure don’t stop, load another drug
Refractory ( > 60 min)
Propofol (i.v.), or midazolam (i.v.), or
thiopental (i.v.) or phenobarbital (i.v.) or
topiramate (feed)
Diazepam

diazepam 10 mg (2-5mg/min)

max 10 mg per dose

can be repeated 2 doses
Phenytoin

Vial: 250 mg/5 ml/vial

0.9% NaCl (don’t use infusion pump)

starting dose: 20 mg/kg (rate < 1 mg/kg/min)

maintenance: 5-8 mg/kg/day

e.g. weight 50 kg

Dilantin 1000 mg+0.9%NSS 100 cc iv drip in 20
min. then Dilantin 100 mg+0.9%NSS 100 cc iv
drip in 15 min
Valproic acid

Vial: 400 mg/4 ml/vial

0.9% NaCl or 5% Dextrose

starting dose: 20-30 mg/kg (rate < 50 mg/min)

maintenance: 1-2 mg/kg/hr (max 60 mg/kg/day)

e.g. weight 50 kg

Depakine 1000 mg+0.9%NSS 100 cc iv drip in 30
min. then Depakine 100 mg/hr (10 cc/hr)
warning: hepatotoxicity
Midazolam

Vial: 1 mg/ml/vial, 5 mg/ml/vial, 15mg/ 3ml

0.9% NaCl or 5% Dextrose/w

starting dose: 0.1-0.3 mg/kg bolus (rate < 4 mg/min)

maintenance: 0.05-0.4 mg/kg/hr

e.g. weight 50 kg

Midazolam 5 mg iv bolus then + Midazolam (1:1)iv
drip 5 cc/hr (0.1 mg/kg/hr)
Levetiracetam
(Keppra)

Vial: 500 mg/5 ml

0.9% NaCl or 5% Dextrose/w 100 ml

starting dose: 2,000-4,000 mg/kg in 15 min

maintenance: 10-30 mg/12 hr

e.g. weight 50 kg

Keppra 2000 mg iv in 15 min then 1000 mg iv q 12
hour
Propofol

Vial: 10 mg/ml

5% Dextrose/w

starting dose: 2 mg/kg bolus

maintenance: 5-10 mg/kg/hr

e.g. weight 50 kg

Propofol (2:1) iv 100 mg then 250 mg/hr
Consult *#2" is required
Thiopentone

Vial: 1 g/vial

starting dose: 100-250 mg in 20 min then 50 mg q
2-3 min until seizure stop

maintenance: 3-5 mg/kg/hr
Consult *#2" is required
Phenobarbital

Vial: 200 mg/4 ml in sterile water 10 ml

5% Dextose

starting dose: 20 mg/kg (rate < 100 mg/min)

maintenance: 1-4 mg/kg/day
Topiramate
for SE

Clinical trial: 500 mg every 12 hours
noso/orogastric feed for 2 days then
150 mg-750 mg every 12 hours

Effective dose: 300-1600 mg/day
Monitoring

Tapering off AED

seizure stop > 24 hours

Burst suppression on EEG > 24
hours

Slow tapering off AED

if seizure recur, increase AED dose
enough to control seizure
Keep in Extern’s Mind
Seizure
1. Seizure or not seizure: history, neuro exam

2. Identify cause, ABCD management

3.Start AEDs if seizure tend to be recurrent

4. if seizure is going to be status; need to be
quick, and follow up the status epilepticus
guideline therapy
openneurons
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