How do vascular neurologic problems present?
- Sudden onset
- w/o headache when they are occlusive
- w headache when they are hemorrhagic
How do brain tumors present?
- Constant, progressive and severe headache, sometimes worse in the morning
- Timetable of months
- As intracranial pressure increases, blurred vision and projectile vomiting occur
- Functional deficits are seen when tumor presses on an area assoc. w a particular function
How do infectious neurological problems present?
- timetable of days/weeks
- An identifiable source of infection is commonly found in the pt’s hx
- -Metabolic problems develop w/in hrs or days and affect the whole CNS
How long do degenerative diseases take before presenting sx?
-They have a timetable of years
What is an Transient Ischemic Attack (TIA)?
- Sudden, transitory losses of neurologic function, w or w/o headache, that resolve spontaneously leaving no sequela
- Specific sx depend on area affected, which is related to the vessels involved
What s the most common origin of a TIA?
->= 70% stenosis of internal carotid, or ulcerated plaque at carotid bifurcation
What is the significance of TIA’s?
-They predict strokes, which can be prevented with timely elective carotid endarterectomy
What is the work up of TIA’s?
- Duplex studies
- Surgery indicated if the lesions are found at the locations that explain the neurologic symptoms
What alternative tx can be used for TIA’s?
-Angioplasty and stent can be done if a filter is first deployed to prevent embolization of debris
How does an Ischemic stroke present?
-Sudden onset w/o headache but w neurologic sx present for >24 hrs, leaving permanent sequela. Not amenable to revascularization (except for very early strokes)
What is a hemorrhagic infarct?
-It can be a complication of an ischemic infarct when blood supply to that area of the brain is suddenly increased.
How are ischemic strokes managed?
- Vascular studies are done to identify lesions that might produce another stroke and prevent it.
- For existing infarcts, the only management available is assessment with CT and rehabilitation
How are early strokes treated?
- CT scan to r/o existing infarcts or presence of hemorrhage
- t-PA IV within 90 min and up to 3 hrs after onset of sx
In what patient is a hemorrhagic stroke commonly seen?
-Uncontrolled hypertensive with sudden onset of headache and goes son to develop neurologic sx
How is a hemorrhagic stroke managed?
- CT scan to evaluate location and extent
- Tx to control hnt and focused on rhabilitation
A patient c/o extremely severe headache of sudden onset like no other ever experienced before (Thunderclap: sudden, severe, singular) is suspicious for…?
- Subarachnoid bleeding from intracranial aneurysms
- In many cases the pt is not salvageable
- Patient may be sent home by mistake bc there is likely no neurologic findings (Blood in the subarachnoid space, so there’ snot hematoma pressing on the brain)
What are two red flag sx of subarachnoid aneurysm bleeding?
-Meningeal irritation and nuchal rigidity
What happens to patients who are not recognized to have a bleeding subarachnoid aneurysm?
-IF they survive, they may return in 10 days with a subsequent (and likely more severe) bleed.
What is the workup for subarachnoid aneurysm bleed?
- CT scan to look for bleeding
- Arteriogram to locate aneurysm
- Surgical clipping or endovascular coiling may be performed
- NOTE: Spinal tap looking for blood may be done, but should never be the first test. Always do CT first
What is the presenting history of Brain tumors?
- Progressively increasing headache for several months, worse in the mornings
- Eventually: accompanied by signs of increased intracranial pressure
What are sx of increased intracranial pressure?
- Blurred vision
- Papilledema
- Projectile vomiting
- Bradycardia (extreme d/t Cushing reflex)
- Hypertension (Extreme d/t Cushing reflex)
Which is the preferred study to visualize brain tumors?
-MRI bc it gives better details
How is increased intracranial pressure treated?
-High-dose steroids like dexamethasone (Decadron) while awaiting for surgical removal
What is a “silent area”?
An area of the brain where brain tumors can grow without providing any clue as to their location (no neurological sx)
