UMEM Educational Pearls - By Danya Khoujah

Category: Neurology

Title: Stroke and Pregnancy: What's Different?

Keywords: CT, MRI, tPA, peripartum, PRES (PubMed Search)

Posted: 3/22/2017 by Danya Khoujah, MBBS (Updated: 8/15/2022)
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  • The incidence of stroke (both ischemic and hemorrhagic) in pregnant and peripartum women is three times age-matched controls. This increased risk is mostly in the 3rd trimester and up to 16 weeks postpartum. 
  • Consider other causes of stroke:  posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis and cardioembolic stroke from peripartum cardiomyopathy.
  • CTs carry some risk due to the ionizing radiation, but with abdominal and pelvic shielding the exposure to the fetus is very low. MRIs do not carry that risk, but Gadolinium is absolutely contraindicated in pregnancy as it deposits in fetal tissue. 
  • Pregnancy is a relative (not absolute) contraindication for tPA.

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Category: Geriatrics

Title: Inappropriate Medications - Submitted by Jill Logan, PharmD, BCPS

Keywords: Beers list, iatrogenic, medications, pharmacology (PubMed Search)

Posted: 3/5/2017 by Danya Khoujah, MBBS
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The Beers' Criteria lists 34 classes of medications that may be potentially inappropriate for geriatric patients due to a high risk of complications including increased risk for falls. When prescribing medications from the emergency department in geriatric patients, try to avoid these categories if other options are available.

http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf

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Category: Neurology

Title: Strokes in Young Adults

Keywords: stroke, alcohol, substance abuse, mimics (PubMed Search)

Posted: 2/22/2017 by Danya Khoujah, MBBS (Updated: 8/15/2022)
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  • 15% of all cases of ischemic strokes occur in patients less than 45 years old.
  • To put things into perspective, incidence of stroke in this age group is twice that of multiple sclerosis.
  • Delayed diagnosis is due to several factors:
    • The relative rarity of the diagnosis in comparison to stroke mimics at this age, the 3 most common being: migraines, seizures, and Bell's palsy. 
    • Atypical presentations, such as acute vestibular syndrome. 
    • Although “typical" risk factors (such as smoking, diabetes and hypertension) are present in young patients with strokes, other factors to be considered are high-risk alcohol consumption, cocaine use (especially smoked), physical inactivity, sleep 6 hours or less a night, and known thrombophilia. 

 

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Category: Geriatrics

Title: Elder Abuse - How Much Are We Missing?

Keywords: physical abuse, neglect, identification (PubMed Search)

Posted: 2/5/2017 by Danya Khoujah, MBBS
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A recent study published in the Journal of American Geriatrics Society aimed to estimate the proportion of visits to US Emergency Departments (EDs) in which a diagnosis of elder abuse is reached.
Results: Elder abuse was diagnosed in 0.013% of the 6.7 million geriatric ED visits that were examined. This is well below the estimated prevalence in the population (which is anywhere from 5-10%).

What That Really Means: There’s a dire need of better identification of elder abuse in the ED, especially neglect, which is the most common and most difficult to identify.

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Patients may present to the ED with new onset weakness due to myasthenia gravis (MG). A group that is frequently missed is late-onset MG, which occurs after the age of 50. It is frequently misdiagnosed as a stroke or transient ischemic attach (TIA).

Two cardinal features:

  • fatiguability: must be distinguished from fatigue. 
  • fluctuation

Bonus pearl: Ocular symptoms are present in up to 85% of patients with MG, with unilateral ptosis or asymmetric bilateral ptosis being the most common presentations.

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Category: Neurology

Title: Spinal Cord Imaging 101

Keywords: contrast, epidural, multiple sclerosis (PubMed Search)

Posted: 10/26/2016 by Danya Khoujah, MBBS
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Magnetic resonance imaging (MRI) is the method of choice for imaging the spine for the suspicion of non-traumatic disorder, such as multiple sclerosis (MS), transverse myelitis, epidural abscess, spinal cord infarcts, and spondylotic myelopathy (changes in the spinal cord due to disk herniation or osteophytes in degenerative joint disease).

If the differential diagnosis includes infection, neoplasm, demyelination or inflammation, then IV contrast should be administered.

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Category: Neurology

Title: PCC before LP in Patients on Anticoagulants?

Keywords: lumbar puncture, meningitis, INR, warfarin, spinal, bleeding (PubMed Search)

Posted: 9/28/2016 by Danya Khoujah, MBBS
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Takeaways

You have a patient in whom you suspect meningitis, but he is on warfarin for a history of pulmonary embolism. You started empirical antibiotics. His INR is 2.6, and you want to do a lumbar puncture (LP) to confirm your diagnosis. Can you use Prothrombin Complex Concentrate to lower his INR and safely perform the LP?

Take Home Point:

Using PCC to lower INR to enable LP is relatively safe and effective in patients on vitamin K antagonists. The dose used was individually determined by the physician according to initial INR.

Limitation:

This is a retrospective study, with no control group. One patient (2.7%) had a myocardial infarction that was “possibly related” to the PCC administration. 

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Category: Neurology

Title: What is Ataxia?

Keywords: cerebellar disease, tremor, nystagmus (PubMed Search)

Posted: 8/24/2016 by Danya Khoujah, MBBS
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Ataxia is an important clinical sign of cerebellar pathology, but how is it actually described?

Stance ataxia: inability to stand with feet together for more than 30 seconds

Gait ataxia

Sensory ataxia: the first 2 elements, in addition to a positive Romberg sign

Truncal ataxia: oscillation of body while sitting or standing

Limb ataxia: functional impairment in performing actions such as writing or buttoning and improves with slowing down the movement

Dysdiadokinesia: impairment of rapidly alternating movement

Intention tremor: tested by finger-to-nose and heel-to-shin.

Dysmetria: pastpointing or undershooting on finger-chasing or shin-tap.

Dysarthria: irregular and slow speech with unnecessary hesitation

Nystagmus and other ocular disturbances, such as ocular flutter and opsoclonus.

The first 3 are present in both cerebellar pathology and loss of proprioceptive input, the rest are usually due to cerebellar pathology or ataxic syndrome.

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Over the past few years, there have been numerous studies discussing the "best" way to diagnose subarachnoid hemorrhage (SAH). These 2016 guidelines review the current evidence.
Classic approach: dry CT, and if negative perform the lumbar puncture (LP)
It is the most common approach, with the most robust evidence. Still considered "standard of care"
Dry CT alone: Sensitivity of a dry CT alone for SAH has increased with improved technology, and the sensitivity is highest when done within the first 6 hours of headache onset. Despite studies quoting a sensitivity of 100% within 6 hours, this evidence is still insufficient due to concerns for selection bias in the study, and the fact that the CTs in the study were read by neuroradiologists.

CT/CTA: CTA is very sensitive for aneurysmal SAH (98% for aneurysms >3mm). CTA would miss non-aneurysmal SAH, but would detect aneurysms that may or may not need to be treated before rupture. It is a reasonable strategy to exclude aneurysmal SAH in select patients, and in patients who refuse LPs or in whom the LP results are equivocal.
Bottom Line: CT/LP is still standard of care, with CT/CTA being an acceptable alternative if LP is equivocal or refused by the patient. CT alone is NOT enough to exclude SAH.

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Multiple sclerosis (MS) relapses are defined as new or worsening neurologic deficits lasting 24 hours or more in the absence of fever or infection. Symptoms may be visual, motor, sensory, balance or cognitive. It is a clinical diagnosis, but the presence of a new gadolinium-enhancing lesion on MRI can be used as a radiologic marker of an MS relapse. However, it is unclear whether asymptomatic lesions should be treated, making it prudent to rely on the clinical evaluation rather than the MRI for diagnosis.

Moderate to severe relapses should be treated within 1 week of onset. The mainstay of treatment for relapses is IV methylprednisolone, usually dosed at 500mg to 1g per day for 3-7 days.

Similar symptoms occurring in the presence of fever, heat exposure, stress or infection (such as urinary or upper respiratory tract infections) are "pseudoexacerbations", and should not be treated as an MS relapse.

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Category: Neurology

Title: Does the Headache Classification Matter in the ED?

Keywords: headache, analgesia, cluster, migraine, oxygen (PubMed Search)

Posted: 5/25/2016 by Danya Khoujah, MBBS
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Short Answer: No

Classically, some therapies for headaches are thought to be effective in only certain classifications of headaches, such as triptans in migraines, or oxygen in cluster headaches. This is not necessarily true.

Triptans have been successfully used in cluster headaches, as found in the 2013 Cochrane review.1

More recently, "high-flow" oxygen (referring to 12 L/min of oxygen, delivered through a facemask) has been studied in migraine headaches, with promising results. When compared with placebo (air), oxygen used for 15 minutes was more effective in pain relief and improving visual symptom, with no significant adverse events. 2

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A 25 year old patient presents to the emergency department (ED) with a first unprovoked seizure. His ED workup is normal and he is back to his baseline, and you plan to discharge the patient with outpatient follow up within 1 week. The patient is requesting to be discharged on an anti-epileptic drug (AED). What do you do?

Educate the patient about the risk of recurrence, and the possible side effects of AEDs!

The American Academy of Neurology (AAN) specifically addressed this in their 2015 guidelines. A few points to remember:

- The risk of recurrence is greatest within the first 2 years, and occurs in 21-45% of patients.

- The risk of recurrence increases with a remote brain lesion or injury, abnormal EEG, significant brain imaging abnormality or nocturnal seizures.

- AED therapy is likely to reduce the risk of a 2nd unprovoked seizure by about 35% over the next 2 years, but the delay in initiating therapy does not increase the long-term remission risk.

Is it different if the patient had multiple seizures within 24 hours?

Patients presenting with multiple seizures in a 24-hour period were as likely to have seizure recurrence as those presenting with a single seizure, irrespective of etiology or treatment.

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Category: Neurology

Title: Epilepsy in the Elderly: Is it Different?

Keywords: geriatrics, seizures, mimics, TIA, syncope (PubMed Search)

Posted: 3/23/2016 by Danya Khoujah, MBBS
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Epilepsy in older adults is common, with an incidence equal to (if not higher) than infants.
The most common type is focal seizures, with strokes and neurodegenerative diseases being the most common underlying causes.
Management of epilepsy in the elderly is challenging because of many reasons:
- A large number of disorders may mimic seizures, and 25-50% of patients with presumed epilepsy end up diagnosed with non-epileptic events, such as tremor, non-epileptic myoclonus, syncope, confusion, agitation, cataplexy and limb-shaking TIAs.
- Status epileptics in the elderly has double the incidence of the general population and a significantly higher mortality rate.
- The role of newer anti-epileptics (drugs other than benzodiazepines, phenytoin and phenobarbital) is unclear due to lack of adequate studies in this age group.
- Antiepileptic drug clearance (both renal and hepatic) is affected by normal physiological changes in this age group, increasing the side effects and decreasing tolerance, even to doses lower than usual.

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Category: Neurology

Title: Psychogenic Non-Epileptic Seizures (PNES)

Keywords: pseudoseizures, EEG, somatoform, psychiatric (PubMed Search)

Posted: 2/24/2016 by Danya Khoujah, MBBS
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Nonepileptic seizures are episodes of altered movement or sensation, with no associated ictal abnormal electrical brain discharges. 88% of non-epileptic siezures are psychogenic in nature (PNES), and can be difficult to diagnose, especially in the absence of video-EEG. The average delay in diagnosis is 1-7 years, mostly due to the fact that no single clinical data point is definitely diagnostic. This leads to a larger consumption of healthcare resources and iatrogenic symptoms from AEDs.
Some features that point towards the diagnosis of PNES:
- Seizures related to a specific stimulus, such as sounds, food or body movement. An emotional stressor being a precipitant is not pathognomonic for PNES.
- The character of the convulsive movements is different in PNES. The convulsive activity tends to have the same frequency throughout the seizure, with a varied amplitude, as opposed to a true seizure, where the frequency decreases throughout the seizure with an increase in amplitude.
- Resisting eyelid opening
- Guarding of hand dropping on face
- Visual fixation on a mirror or when moving the head from side to side
Keep in mind that PNES and epilepsy can co-exist in up to 30% of patients.
Bottom Line: If you have a clinical concern about PNES, refer the patient for an outpatient video-EEG/neurology followup.

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Category: Neurology

Title: Intubating the Neurologically Injured Patient

Keywords: airway, intubation, intracranial hemorrhage, ketamine, opiates, RSI (PubMed Search)

Posted: 1/27/2016 by Danya Khoujah, MBBS
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Airway management is an integral part of caring of critically ill patients, but is there anything that should be done differently in the neurologically injured patient?

  • Injured brains are particularly sensitive to hypoxia. Avoid it by appropriate positioning and preoxygenation.
  • Consider fentanyl and/or ketamine for sedation for RSI, as fentanyl can blunt the hemodynamic response to intubation, while ketamine is hemodynamically neutral and safe.
  • Consider Esmolol (1.5mg/kg) prior to intubation to prevent sympathomimetic surge during intubation in the absence of multiple injuries.
  • There is no role for the use of a defasciculating dose of neuromuscuclar blockade during RSI

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Category: Neurology

Title: Herpes Encephalitis

Keywords: CSF, LP, HSV, infection (PubMed Search)

Posted: 12/22/2015 by Danya Khoujah, MBBS (Emailed: 12/23/2015) (Updated: 1/16/2016)
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HSV infection of the CNS is one of few treatable viral diseases. HSV encephalitis of older children and adults is almost always caused by herpes simplex virus type 1 (HSV-1), and in individuals older than 20, is due to HSV reactivation.

Temporal lobe localization is characteristic for HSV encephalitis in individuals older than 3 months, and is responsible for its characteristic presentation, namely bizarre behavior and expressive aphasia.

CSF analysis will usually reveal an elevated protein level, and a lymphocytic cellular predominance.

CSF protein concentration is a function of disease duration, and will continue to rise even with administration of treatment (acyclovir) and may remain elevated after the completion of therapy.

5% of CSF samples will be totally normal, and the diagnosis will only be revealed with positive PCR detection of viral DNA in the CSF, which is the gold standard for diagnosis.

The sensitivity of MRI is similar to CSF analysis, with 5% of patients with HSV encephalitis having a normal MRI on presentation, and subsequently developing abnormalities.

Of note, HSV-2 tends to cause aseptic meningitis rather than encephalitis in adults, and has a benign course.

Bottom Line? Keep a high index of suspicion for HSV encephalitis, and treat the patient empirically despite a normal CSF/MRI pending PCR results.

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Category: Neurology

Title: Ketamine.. for Status Epilepticus?

Keywords: Seizure, Status Epilepticus, Dissociative Agents (PubMed Search)

Posted: 11/26/2015 by Danya Khoujah, MBBS
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Ketamine has been the drug du jour for everything from agitation to pain, but status epilepticus?

Looking at the pathophysiology of seizures, they occur due to an imbalance between excitatory mechanisms (through glutamate at the NMDA receptors) and inibitory mechanisms (at GABA receptors). The mainstay for seizure treatment has been mostly potentiation of the inhibitory mechanisms, but why not inhibit the excitatory mechanisms at the NMDA receptors?

Ketamine is the only NMDA antagonist that has been investigated for refractory status epilepticus, mostly in retrospective small series, with only 3 prospective cohort studies, totaling to 162 patients (110 adults and 52 pediatrics). Variable results were recorded, from studies with complete response in all patients to complete treatment failure, with a total of 56.5% of the adult patients having electrographic response. The optimal bolus dose appears to be 1.5-4.5 mg/kg, with an infusion of up to 10 mg/kg/hour.

Bottom Line? Consider using ketamine in patients who are in refractory status - after benzodiazepines, a 2nd line agent (such as fosphenytoin, valproic acid or levetiracetam) and IV anesthetics have failed.

(NMDA: N-methyl-D-aspartate, GABA: -aminobutyric acid)

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A recent study compared IV metoclopramide to IV acetaminophen for pain relief in primary headaches in the ED. 100 patients were randomized to either receiving 10 mg of IV metoclopramide, or 1 g of IV acetaminophen.
The results? Patients had better faster pain relief with acetaminophen IV (at 15 minutes, vs 30 minutes for Metoclopramide), and both drugs had the same therapeutic effect at 2 hours.
Bottom Line? Don't discount the benefit of acetaminophen in managing headaches in the ED.

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Category: Neurology

Title: Thunderclap Headache

Keywords: SAH, cerebral venous thrombosis, head CT (PubMed Search)

Posted: 9/23/2015 by Danya Khoujah, MBBS
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A thunderclap headache is defined as a very severe headache that reaches its maximum intensity within 1 minute.

One of the most common causes (and the one associated with this buzzword on board questions!) is subarachnoid hemorrhage, but what else can cause a it?

Reversible cerebral vasoconstriction syndrome (RCVS): suggested by recurrent thunderclap headaches (2-10) over 1 to 2 weeks. Normal CT and LP, with vasoconstriction on angiography. Can lead to SAH, ICH or ischemic stroke.

- Cervical artery dissection

- Cerebral venous sinus thrombosis

- Spontaneous intracranial hypotension: characterized by orthostatic HAs and auditory muffling.

- Intracerebral hemorrhage

Primary”: a diagnosis of exclusion

Bottom line? All patients with thunderclap HA should have a stat head CT with no contrast, then have SAH excluded with an LP, CTA or MRI/MRA. Just because you excluded SAH in a patient with thunderclap headache does not mean you’re done with the emergency workup. 

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Category: Neurology

Title: Status what?! - Conquering Migraines

Keywords: migraine, headache, opioids, dopamine antagonist (PubMed Search)

Posted: 8/26/2015 by Danya Khoujah, MBBS
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Status migrainosus is a migraine that lasts more than 72 hours, and can be rather challenging to control. A few tips to tackle this are:

1. Adequately hydrate all patients (IV fluids are usually required, especially with severe nausea/vomiting)

2. Establish realistic expectations for the patient. A patient with chronic daily headaches will not be pain-free in the ED.

3. Use IV nonopioid medications for pain control

1st Line:

- Dopamine Antagonists: in increasing efficacy

- Metoclopramide

- Phenothiazines: prochlorperazine, promethazine and chlorpromazine

- Butyrophenones: droperidol and haloperidol

- NSAIDs: such as Ketorolac IV or IM

2nd Line:

- Corticosteroids: Do not treat the migraine in the ED, but prevent headache recurrence within 72 hours.

- Magnesium Sulfate: Has shown mixed efficacy. More likely to have a sustained benefit in patient with serum magnesium level of 1.3mg/dL or less.

- Valrpoic Acid: Be careful of combining it with Topiramate.

- Vasoconstrictors: Triptans, ergotamine, dihydroergotamine. Effective, but use is limited by contraindications.

- Opioids: Last resort