Neuro HY Pearls:

1) Misc
a) Spinal Stenosis = Bilateral Low Back Pain That Radiates down to Both Legs, Pain Is Worse with Walking Up
Steps, Pain Is Relieved When Leaning/Sitting Forward. No Weakness, No Reflex and Sensory Deficits.
b) Elderly Patients with Falls and No Obvious Causes, 1st-Line Management = Review Medications.
c) Tx of Acute Neuritis 2/2 Zoster = NSAIDs, Tylenol, Opioids.
d) Post Herpetic Neuralgia, Defined As = Persistent Pain >4 Months after Rash Onset.
i) Tx of Post Herpetic Neuralgia = TCA, Pregabalin, Gabapentin.
(1) 2nd Line = Opioids/Topical Lidocaine Patch. *****Carbamazepine = Ineffective.
e) In Pts that meets Clinical Brain Death Criteria (More/Less Meets Basic Criteria for Death Pronouncement),
The Final test to Meet Brain Death = Apnea Testing.
f) Wernicke's Encephalopathy Clinical Triad = AMS, Ataxia, Opthalmoplegia + Nystagmus.
g) 1st line Tx of Bell's Palsy = Prednisone, +/- Valacyclovir.
h) Serotonin Syndrome S/S:
i) Hyperthermia, Tachycardia, Hypertension, Confusion, Diaphoresis, Muscle Rigidity, Clonic Movements, Dilated Pupils, Flushed
Skin.
ii) Normal Labs’ish
i) 1st-Line Tx of Serotonin Syndrome = Benzodiazepines. 2nd Line = Consider Cyproheptadine.
j) Management of Sports Related Concussion:
i) Once All Symptoms Have Resolved, Patient Is Back to Previous Cognitive State, Patient Can Participate in Graduated Return
to Play Protocol. Immediate Return to Play Is Not Recommended.
2) CVA
a) Antiplatelet-AntiThrombotic Therapy For Ischemic Stroke:
i) Presentation within 3.5-4 Hours Of Onset = Thrombolytic Therapy.
ii) CVA with No Prior Antiplatelet Therapy = Aspirin.
iii) CVA While on Aspirin Therapy = ASA + Dipyridamole, or, Plavix Alone.
iv)CVA On Aspirin Therapy with Intracranial Large Artery Atherosclerosis = ASA + Plavix.
b) Management of Carotid Stenosis:
i) Stenosis = 100%/Complete Occlusion: Management = Medical Therapy Only, Carotid Endarterectomy = No Benefit.
ii) Stenosis = <100%, Management = Carotid Endarterectomy.
c) Heparin DVT Prophylaxis Is Contraindicated for Hemorrhagic Stroke in the Acute Setting (First 24 hours, and can be started
after 24 hr + No evidence of further bleeding on repeat imaging). In This Setting, DVT Prophylaxis with Intermittent Pneumatic
Compression Device.
d) Blood Glucose Is the Only Test Necessary Prior to TPA Therapy. No Need for Coagulation Panel or CBC.
e) Spontaneous Intracranial Hemorrhage In the Lobes/Lobar Region In the Elderly = Cerebral Amyloid Angiopathy.
f) Spontaneous Intracranial Hemorrhage in the Basal Ganglia, Thalamus, Ponds, Cerebellum Region = Hypertensive
Hemorrhage.

g) Basal Ganglia Hemorrhage: Contralateral Hemiparesis and Hemisensory Loss. Gaze Palsy. Homonymous Hemianopsia.
h) Cerebellum Hemorrhage: Usually No Hemiparesis. Facial Weakness. Ataxia and Nystagmus. Neck Stiffness and Occipital
Headache.
i) Thalamic Hemorrhage: Contralateral Hemiparesis and Sensory Loss. Nonreactive Constricted Pupils. Upward Gaze Palsy. Eye
Deviates Towards Hemiparesis.
j) Pons Hemorrhage: Sudden Onset of Deep Coma and Total Paralysis. Reactive Pinpoint Pupils.
k) Damage to the Posterior Fossa Or Brainstem: Headache, Vertigo, Diplopia, Hiccups, N/V.
l) Lateral Medullary Syndrome = Medulla Oblongata Stroke, Presents As:
i) Numbness of the Ipsilateral Face.
ii) Numbness of the Contralateral Body.
iii) Horner's Syndrome.
iv)Abnormal Gag and Cough Reflex.
v) Nystagmus.
vi)Ipsilateral Ataxia.
vii) Negative tongue deviation (As Seen with Medial Medullary Syndrome).
m) Damage to the Cerebellar Hemisphere: Ipsilateral Ataxia, Ipsilateral Nystagmus, WITHOUT: Weakness and/or Numbness,
Headache, Vertigo, N/V.
3) Brain Lesion/Cancer
a) Leptomeningeal Carinomatosis = Patients w/ Either Metastatic Breast Ca, Lung Ca, Metastatic Melanoma:
Presents As New Onset (Days-Weeks) Headache, Altered Mental Status, Seizures, Multifocal Neurological
Deficits.
i) 1st Line Imaging = MRI of Brain + Spinal Cord.
b) Glioblastoma = Rapid Neurologic Decline, Very Aggressive.
c) Meningiomas = Slow Progressive Clinical Deterioration, Slow-Growing.
d) Management of Solitary Metastatic Brain Tumor = Surgical Resection Followed by Radiation.
e) Seizures 2/2 Metastatic Brain Tumor In Patients Receiving Chemotherapy, Best AED = Valproic Acid, Lamotrigine, Keppra.
This Is Because These Do Not Induce Hepatic Enzymes And Have Limited Interaction with Chemotherapy Medication.
4) Seizures
a) Elderly Patients Presenting with New Mental Status Change and New Onset Seizures Should Be Treated Empirically For HSV
(IMMEDIATELY before further testing) with IV Acyclovir In Addition to Prophylactic Antibiotic for Meningitis.
b) 1st-Line AED for Seizures In Elderly Patients = Keppra, Lamotrigine and Gabapentin.
c) Tx of 1st Seizure In Patients with Abnormalities on Brain Imaging (Encephalomalacia) Or Other Risk Factors Such As
Head Trauma… = Start AED.
d) Seizures with Unilateral Convulsion, and, Aura Like Symptoms Are Features of Focal Epilepsy.
e) For Generalized Seizures, Treat with Broad-Spectrum Antiepileptics: Topamax, Keppra, Lamotrigine, Valproic Acid.
5) Other Dystonia Syndrome
a) Benztropine Is Used for Drug-Induced Dystonia (Painful Involuntary Contractions).
6) Parkinsons
a) Tx of Drug Induced Parkinson = Either Stop The Offending Medication, or, Switch to a Lower-Risk Antipsychotic Agent =
Clozapine, or, Quetiapine.
b) Parkinson-Plus Syndrome:
i) Rapid Onset of Parkinson-like Symptoms w/ Cognitive Decline, Symmetrical B/L Rigidity & Bradykinesia, Absent Tremors.
c) Patient Presenting with Inability to Smell, And REM Sleep Behavior Disorder (Dream-Enacting behaviors) = Early Parkinson's
Dz.
d) Patients Taking Carbidopa/Levodopa For Parkinson's Disease, are at Risk for Painful Involuntary Contractions When the
Dopamine Agonists Starts to Wear off. Management = Use Long-Acting Forms, Or, Change When the Patient Takes The
Medication.
7) MS
a) Fingolimod is used for MS, it is Teratogenic.
b) Management of Muscle Spasms and Cramps In Patients with MS = Baclofen.
8) Dementia
a) Elderly Patients With History of Silent Strokes Are at the Highest Risk for Dementia.
b) Diagnosis of Lewy Body Dementia Requires 2 Of the Following: Cognitive Decline/Dementia-Check MMSE, Visual
Hallucinations, Parkinsonism. Neural Imaging Is Not Necessary.
c) NPH Triad = Cognitive Impairment, Gait Instability, Urinary Incontinence.
d) Mild Cognitive Impairment: Impaired Short-Term Memory, However, Unlike Alzheimer's Dementia, Patients Will Have Intact
Executive Functions and Normal Ability to Complete Complex Tasks (Balance Checkbook), Patient Is Frustrated And
Aware.
9) Headaches
a) Tx of Migraine Not Responding NSAIDs/Oral Triptans = SQ Sumatriptan Injection Is 1st-Line.
b) Basiler Type Migraine Presentation = Focal Neurological Deficits + Visual Aura + Paresthesia + Aphasia + Migraine like
Headaches.
For Patients at Present Like This, Must Be Evaluated for Vascular Lesions with MRI And MRA Before Starting Symptomatic
Therapy.
10) Vertigo/Dizziness
a) Disequilibrium = Lightheaded and Dizzy without pre-syncope, syncope, ortho stasis, or vertigo. Management = Physical
therapy.
b) Vestibular Neuronitis = Acute, Severe, Persistent Non-Positional Peripheral Vertigo. Nausea and Vomiting Are Common.
Dick's Hall Pike Test Will Revoke Nystagmus after Brief Latency Period. Commonly Is Preceded by a Viral URI.
c) Labyrinthitis = Similar to Vestibular Neuronitis-Acute, Severe, Persistent Non-Positional Peripheral Vertigo. However, Unlike
Vestibular Neuronitis, Patient Will Have Hearing Loss.
d) Central Vertigo S/S = Dysarthria, Dysphasia, Diplopia, Weakness, Numbness, Ataxia + Vertigo. Must Check MRI To Assess
Brainstem Infarction.
11) Other Motor Weakness Syndrome
a) Guillain-Barré Syndrome-like Symptoms >8 Weeks = Chronic Inflammatory Demyelinating Polyreticuloneuropathy
(CIDP).
i) Guillain-Barré Syndrome = Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP).
b) Patients with Guillain-Barré Syndrome like Symptoms and (+) Bowel/Bladder Dysfunction = Transverse Myelitis.
i) GBS Will Not Have Bowel/Bladder Dysfunction.