Author: Don Stader, MD
- Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients < 30
- VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation.
- VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner’s Syndrome, Wallenberg Syndrome)
- Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits.
Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238.
Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54.
Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724.
Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
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Author: Peter Bakes, MD
- Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are “dizzy.”
- Differentiate central vs. peripheral vertigo
- Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia).
- Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms.
- Episodic? BPPV or Meniere’s Disease. BPPV has not auditory symptoms and is associated with head position; Meniere’s has hearing loss, tinnitus, and ear fullness.
- Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM).
Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.
Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.
Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.
Author: Dylan Luyten, MD.
- Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
- Young person with back pain needs to be evaluated for injection drug use (major risk factor).
- Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
- Treatment is IV antibiotics and surgical debridement.
Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.
Author: Sue Chilton, MD
- IV drug use and spinal procedures are major risk factors.
- Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
- MRSA is most common organism, but GNR and MSSA are also possible.
Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.
Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.
Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.
Author: Peter Bakes, M.D.
- Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance.
- Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration.
Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery, 58(SUPPL. 3). DOI: 10.1227/01.NEU.0000210364.29290.C9.
Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care. 2016. 24(2):294-307. doi: 10.1007/s12028-015-0194-x.
Author: Michael Hunt, MD
- Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3.
- Alternative scoring system is the GCS-P score which is GCS score – number of non-reactive pupils.
- GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months.
- GCS-P score is a better prognostic indicator than GCS score.
Han J, et al (2014). External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. Journal of Neurotrauma. 31(13):1146-52.
Maas AI, et al. (2007). Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. Journal of Neurotrauma. 24(2):232-8.
The CRASH trial management group, & the CRASH trial collaborators. (2001). The CRASH trial protocol (Corticosteroid randomisation after significant head injury) [ISRCTN74459797]. BMC Emergency Medicine, 1, 1. http://doi.org/10.1186/1471-227X-1-1.
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Author: Dylan Luyten , MD
- Rare autosomal dominant condition that is often misdiagnosed as a psychiatric illness.
- Presents as profound muscle weakness with frank paralysis that is often precipitated by vigorous exercise, high carb diet, high sodium load, or by high temperatures.
- Supplemental potassium can rapidly reverse symptoms.
- Important to rule out thyrotoxicosis (get a TSH!).
- Prevention is key: adhering to a low carb and low sodium diet with supplemental potassium can help prevent episodes.
Vicart S, Sternberg D, Arzel-Hézode M, et al. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2014 Jul 31]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/?report=classic
Statland JM, Fontaine B, Hanna MG, et al. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle & Nerve. 2018;57(4):522-530. doi:10.1002/mus.26009.
Author: Jared Scott, M.D.
- Recent study compared Compazine with Benadryl vs. Dilaudid for acute migraine management in the ED.
- Compazine + Benadryl demonstrated migraine relief in 60% of patients compared to the 31% of patients who were relieved with Dilaudid.
- Compazine + Benadryl is a superior migraine treatment than Dilaudid.
Friedman BW, et. al. (2017). Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine. Neurology. 89(20):2075-2082
Author: Sam Killian, M.D.
- Spinal cord injury without radiographic abnormality (SCIWORA) is a diagnosis defined as traumatic injury to spine with clinical sx of traumatic myelopathy (paraplegia, paresthesias, FND) without radiographic abnormalities.
- Term was established in 1970’s before MRI and accounted for about 15% of injuries at the time (mainly children). Today SCIWORA accounts for about 10% of spinal injuries.
- Belief is that injury causes subtle movement of the spinal cord from its natural position with resultant contusion or ischemia with subsequent deficits.
- Treatment involves prolonged immobilization (up to 12 weeks).
Walecki, J. (2014). Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) ? Clinical and Radiological Aspects. Polish Journal of Radiology,79, 461-464. doi:10.12659/pjr.890944