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Internuclear Ophthalmoplegia
Is a disorder of conjugate lateral gaze
in which the affected eye shows
impairment of adduction.
Caused by injury or dysfunction in the
medial longitudinal fasciculus (MLF), a
heavily-myelinated tract that allows
conjugate eye movement by
connecting the paramedian pontine
reticular formation (PPRF) -abducens
nucleus complex of contralateral side
to the oculomotor nucleus of the
ipsilateral side.
Internuclear Ophthalmoplegia
When an attempt is made to gaze
contralaterally (relative to the affected
eye), the affected eye adducts
minimally, if at all. The contralateral eye
abducts, however with nystagmus.
Additionally, the divergence of the eyes
leads to horizontal diplopia. That is, if
the right eye is affected the patient will
"see double" when looking to the left,
seeing two images side-by-side.
Convergence is generally preserved.
Internuclear Ophthalmoplegia
In older people, the disorder usually results from a
stroke, and only one eye is affected.
In younger people, it usually results from multiple
sclerosis, and both eyes are often affected.
Less common causes include Lyme disease,
tumors, and toxicity due to a drug (such as tricyclic
antidepressants).
Trigeminal Neuralgia
Usually occurs in middle-aged and older people, although it
can affect adults of all ages. It is more common among
women.
Symptoms: The pain can occur spontaneously but is often
triggered by touching a particular spot (called a trigger point)
on the face, lips, or tongue or by an action such as brushing
the teeth or chewing. Repeated short, lightning-like bursts of
excruciating stabbing pain
Usually, unilateral.
The pain usually lasts seconds but may last up to 2 minutes.
Recurring as often as 100 times a day, the pain can be
incapacitating.
Because the pain is intense, people tend to wince, and thus
the disorder is sometimes called a tic.
The disorder commonly resolves on its own, but bouts of the
disorder often recur after a long pain-free interval
Trigeminal Neuralgia
Etiology/ies:
In most cases, the cause is unknown.
A common known cause is an abnormally positioned artery that compresses the trigeminal
nerve near where it exits the brain.
Occasionally in younger people, trigeminal neuralgia results from nerve damage due to
multiple sclerosis.
Rarely, trigeminal neuralgia results from damage due to herpes zoster (a viral infection) or
compression by a tumor.
Bells Palsy
Symptoms: may feel pain behind the ear, then one side
of the face may become weak or completely paralyzed.
Wrinkling the forehead, blinking, and grimacing may be
difficult or impossible. For most people, the face feels
numb or heavy, even though sensation remains
normal.
The ear on the affected side may perceive sounds as
abnormally loud (hyperacusis) because the muscle that
stretches the eardrum is paralyzed.
Etiology/ies:
Bell's palsy may result from herpes simplex virus type
1, which causes herpes mouth infections.
But the cause is sometimes unknown.
Bells Palsy
Diagnosis:
no specific test, usually be diagnosed based on symptoms.
can be distinguished from a stroke because a stroke usually causes weakness only
in the lower part of the face rather than in the entire face.
EMG-NCV
x-rays, magnetic resonance imaging (MRI), or computed tomography (CT) tumors,
infection, skull fractures
A blood test may be done to check for Lyme disease, and a blood test and a chest xray may be done to check for sarcoidosis.
Treatment:
Corticosteroids may be used to reduce swelling of the nerve.
Artificial tears, eye patch, rehabilitation
With or without treatment, most people recover completely within several months.
Hemifacial Spasm
painless involuntary twitching of one side of the face
due to malfunction of the facial nerve.
affects men and women but is more common among
middle-aged and older women.
Symptoms: Muscles on one side of the face twitch
involuntarily, usually beginning with the eyelid, then
spreading to the cheek and mouth. Twitching may be
intermittent at first but may become almost continuous.
The disorder is essentially painless but can be
embarrassing.
Etiology/ies:
The spasms may be caused by an abnormally
positioned artery or loop of an artery that compresses
the 7th cranial nerve where it exits the brain stem.
Hemifacial Spasm
Diagnosis:
Magnetic resonance imaging (MRI) should be done to check for a tumor,
other structural abnormalities, and evidence of multiple sclerosis. Usually,
MRI can detect the abnormal loop of artery pressing against the nerve.
Treatment:
Botulinum toxin is the drug of choice. It is injected into the affected muscles.
The same drugs used to treat trigeminal neuralgiacarbamazepine,
phenytoin, gabapentin, baclofen, antidepressant may help
If drug treatment is unsuccessful, surgery may be done to separate the
abnormal artery from the nerve by placing a small sponge between them
(vascular decompression).
Glossopharyngeal Neuralgia
a rare disorder, usually begins after age 40 and occurs more often in men.
Symptoms: brief attacks of excruciating pain, affecting one side of the
tongue or throat and sometimes an ear.
Attacks may be triggered by a particular action, such as chewing,
swallowing, talking, coughing, or sneezing.
The pain may last several seconds to a few minutes and usually affects
only one side of the throat and tongue.
Etiology/ies:
cause is usually unknown but sometimes is an abnormally positioned
artery that compresses the glossopharyngeal nerve.
Glossopharyngeal Neuralgia
Diagnosis:
Test done by touching the back of the throat with a cotton-tipped
applicator. If pain results, apply a local anesthetic to the back of the
throat. If the anesthetic eliminates the pain, the glossopharyngeal
neuralgia is diagnosed.
MRI is done to check for tumors.
Treatment:
The same drugs used to treat trigeminal neuralgiacarbamazepine,
phenytoin, gabapentin, baclofen, antidepressant may help
If drug treatment is unsuccessful, vascular decompression may de
done
PERIPHERAL NEUROPATHIES
Peripheral Neuropathy
Damage to nerves of the peripheral nervous system,
which may be caused either by diseases of or trauma to
the nerve or the side-effects of systemic illness.
The four cardinal patterns of peripheral neuropathy are
polyneuropathy, mononeuropathy, mononeuritis
multiplex and autonomic neuropathy.
The most common form is (symmetrical) peripheral
polyneuropathy, which mainly affects the feet and legs.
Mononeuropathy
Most common cause of is by physical compression of the
nerve, known as compression neuropathy (Carpal tunnel
syndrome, Meralgia Paresthetica).
The "pins-and-needles" sensation of one's "foot falling asleep"
(paresthesia) is caused by a compression mononeuropathy (a
temporary one which can be resolved merely by moving
around and adjusting to a more appropriate position).
Direct injury to a nerve, interruption of its blood supply
(ischemia), or inflammation can also cause mononeuropathy.
Mononeuritis Multiplex
Simultaneous or sequential involvement of individual noncontiguous nerve trunks,
either partially or completely, evolving over days to years and typically presents
with acute or subacute loss of sensory and motor function of individual nerves.
The pattern of involvement is asymmetric; however, as the disease progresses
deficit(s) becomes more confluent and symmetrical, making it difficult to
differentiate from polyneuropathy.
Therefore, attention to the pattern of early symptoms is important.
May also cause pain, which is characterized as deep, aching pain that is worse at
night, is frequently in the lower back, hip, or leg.
Mononeuritis Multiplex
It is caused by, or associated with, several medical conditions:
diabetes mellitus
vasculitides: polyarteritis nodosa, Wegener granulomatosis, and
Churg-Strauss syndrome
immune-mediated diseases like rheumatoid arthritis, lupus
erythematosus (SLE), and sarcoidosis
infections: leprosy, lyme disease, HIV
amyloidosis
cryoglobulinemia
chemical agents, including trichloroethylene and dapsone
rarely, the sting of certain jellyfish, such as the sea nettle
Polyneuropathy
Many nerve cells in different parts of the body are affected, without regard to
the nerve through which they pass. Not all nerve cells are affected in any
particular case.
In distal axonopathy, one common pattern, the cell bodies of neurons remain
intact, but the axons are affected in proportion to their length (Diabetic
neuropathy)
In demyelinating polyneuropathies, the myelin sheath around axons is
damaged, which affects the ability of the axons to conduct electrical impulses.
The third and least common pattern affects the cell bodies of neurones
directly, either the motor neurones (known as motor neurone disease) or the
sensory neurones (known as sensory neuronopathy or dorsal root
ganglionopathy).
Polyneuropathy
Effect of this is to cause symptoms in more than one part of the
body, often on left and right sides symmetrically.
The chief symptoms: weakness or clumsiness of movement
(motor); unusual or unpleasant sensations such as tingling or
burning; reduction in the ability to feel texture, temperature, and
impaired balance when standing or walking (sensory).
In many polyneuropathies, these symptoms occur first and most
severely in the feet.
Autonomic symptoms may also occur, such as dizziness on
standing up, erectile dysfunction and difficulty controlling urination.
Polyneuropathy
Usually caused by processes that affect the body as a whole.
Diabetes and impaired glucose tolerance are the most common
causes.
Other causes including inflammatory diseases such as lyme
disease, vitamin deficiencies, blood disorders, and toxins (including
alcohol and certain prescribed drugs).
Most types of polyneuropathy progress fairly slowly, over months or
years, but rapidly progressive polyneuropathy also occurs.
The treatment of polyneuropathies is aimed at eliminating or
controlling the cause, maintaining muscle strength and physical
function, controlling symptoms such as neuropathic pain.
Autonomic Neuropathy
Is a form of polyneuropathy which affects the non-voluntary,
non-sensory nervous system, affecting mostly the internal
organs such as the bladder muscles, the cardiovascular
system, the digestive tract, and the genital organs.
Most commonly autonomic neuropathy is seen in persons
with long-standing diabetes mellitus type 1 and 2.
In most but not all cases, autonomic neuropathy occurs
alongside other forms of neuropathy, such as sensory
neuropathy.
Autonomic Neuropathy
The signs and symptoms of autonomic neuropathy include the
following:
urinary bladder conditions: bladder incontinence or urine retention
gastrointestinal tract: dysphagia, abdominal pain, nausea, vomiting,
malabsorption, fecal incontinence, gastroparesis, diarrhea,
constipation
cardiovascular system: disturbances of heart rate (tachycardia,
bradycardia), orthostatic hypotension, inadequate increase of heart
rate on exertion
other: hypoglycemia unawareness, genital impotence, sweat
disturbances
Etiologies of PN
The causes are broadly grouped as follows:
Genetic diseases: Friedreich's ataxia, Charcot-Marie-Tooth syndrome, Hereditary neuropathy with
liability to pressure palsy
Metabolic/Endocrine: diabetes mellitus, chronic renal failure, porphyria, amyloidosis, liver failure,
hypothyroidism
Toxic causes: Drugs (vincristine, metronidazole, phenytoin, nitrofurantoin, isoniazid, ethyl alcohol),
organic metals, heavy metals, excess intake of vitamin B6 (pyridoxine)
Fluoroquinolone toxicity: Irreversible neuropathy is a serious adverse reaction of fluoroquinolone drugs
Inflammatory diseases: Guillain-Barr syndrome, systemic lupus erythematosis, leprosy, Sjgren's
syndrome, Lyme Disease, sarcoidosis
Vitamin deficiency states: Vitamin B12 (cyanocobalamin), vitamin A, vitamin E, vitamin B1 (thiamin)
Physical trauma: compression, pinching, cutting, projectile injuries (i.e. gunshot wound), strokes
including prolonged occlusion of blood flow, electric discharge, including lightning strikes
Others: shingles, malignant disease, HIV, radiation, chemotherapy
Treatment of PN
Pregabalin is an anticonvulsant drug used for neuropathic pain. It has also been found
effective for generalized anxiety disorder. It was designed as a more potent successor to
gabapentin but is significantly more expensive
Duloxetine, a serotonin-norepinephrine reuptake inhibitor, is also being used to reduce
neuropathic pain.
TENS (Transcutaneous Electrical Nerve Stimulation) therapy may be effective and safe in
the treatment of diabetic peripheral neuropathy.
A recent review of three trials involving 78 patients found some improvement in pain scores
after 4 and 6 but not 12 weeks of treatment, and an overall improvement in neuropathic
symptoms at 12 weeks.
(Jin DM et al, 2010)
A second review of four trials found significant improvement in pain and overall symptoms,
with 38% of patients in one trial becoming asymptomatic. The treatment remains effective
even after prolonged use, but symptoms return to baseline within a month of treatment
cessation.
(Pieber K et al, 2010)
Thank You!
CEREBROVASCULAR
DISEASE
What is a Stroke?
STROKE IS A BRAIN ATTACK!!!
Rapidly developing clinical symptoms and or signs of focal and at
times global loss of cerebral function with symptoms lasting more
than twenty four hours or leading to death with no apparent cause
other than that of vascular origin.
(Hatano 1976)
Acute loss of focal cerebral function with symptoms lasting for less
than twenty four hours, which after adequate investigation, is
presumed to be due to embolic or thrombotic vascular disease.
(Warlow and Morris 1982)
Classification
80%
rebrovascular Disease
Acute Stroke
15%
85%
Infarction
Hemorrhage
Intracerebral
Subarachnoid
15%
Cardiogenic embolism
Atrial fibrillation
Atherothrombotic Hemodynamic/
Ischemic heart disease
cclusive artery to artery emboli
Valvular heart disease
mall artery lipohyalinosis lacunes
Prosthetic cardiac valves
Other mechanisms
Infective endocarditis
Other, less common
5%
Other, unusual
Dissections
Hypercoagulable stat
Vasculitis
Systemic hypotension
Types of Stroke
Types of Stroke
Clinical Presentation
Clinically, symptoms depend on the area of cerebral
circulation affected and on the extent to which it is
affected.
1. Internal Carotid Artery (ICA) occlusion:
a. no characteristic clinical picture
b. may range from a TIA to infarction of a major portion
of the ipsilateral (on the same side) hemisphere
c. if adequate intracranial collateral circulation is
present, may see no signs or symptoms
Clinical Presentation
1. Internal Carotid Artery (ICA) occlusion:
d. Neurological symptoms:
1. monoparesis to hemiparesis with or without a defect
in vision
2. impairment of speech or language
3. transient monocular blindness
Clinical Presentation
2. Middle Cerebral Artery (MCA) occlusion:
a. opportunity for collateral circulation is restricted to
anastomotic blood flow from the anterior and
posterior cerebral arteries on the surface of the brain
Clinical Presentation
Middle Cerebral Artery (MCA) occlusion:
b. Neurological symptoms:
1. hemiplegia (paralysis of one side of the body)
2. hemisensory deficit
3. hemianopsia (blindness in 1/2 of the visual field)
4. aphasia (if infarct is in the dominant hemisphere)
.Since the MCA supplies the upper extremity motor
strip, weakness of the arm and face is usually worse
than that of the lower limb.
2.
Clinical Presentation
3. Anterior Cerebral Artery (ACA) occlusion:
a. Neurological symptoms:
1. weakness of the opposite leg with or without
sensory involvement
2. apraxia (particularly of gait)
3. primarily affect frontal lobe function, producing
cognitive impairment (altered mental status,
impaired judgment)
Clinical Presentation
4. Posterior Cerebral Artery (PCA) occlusions:
a. Neurological symptoms:
1. Affect vision and thought, producing homonymous
hemianopsia, cortical blindness, visual agnosia,
altered mental status, and impaired memory.
Clinical Presentation
5. Vertebrobasilar Artery occlusions:
a. are notoriously difficult to detect because they
cause a wide variety of cranial nerve, cerebellar,
and brainstem deficits.
b. Neurological symptoms:
1. vertigo, nystagmus, diplopia, visual field deficits,
dysphagia, dysarthria, facial hypesthesia, syncope,
and ataxia
Clinical Presentation
5. Vertebrobasilar Artery occlusions:
b. Neurological symptoms:
2. Loss of pain and temperature sensation occurs on
the ipsilateral face and contralateral body (In
contrast, anterior strokes produce findings on one
side of the body only).
Clinical Presentation
Risk Factors
HYPERTENSION (2-4x)
DIABETES MELLITUS (1.5-3x)
ATRIAL FIBRILLATION (6x)
VALVULAR HEART DISEASE
CORONARY ARTERY DISEASE (3x) AND MYOCARDIAL INFARCTION (5x)
HYPERLIPIDEMIA
SYMPTOMATIC CAROTID STENOSIS
TIA (24-29% during the next 5 years (4-8% in 1 st mo. and 12-13% during the 1st year)
CIGARETTE SMOKING (1.5x)
ALCOHOL
PHYSICAL INACTIVITY
LIFESTYLE FACTOR: DIET
Diagnosis
Having a stroke is an emergency situation!
Diagnosis includes:
Good clinical history
A brief physical and neurological exams
Diagnostics (blood tests, imaging scans, and other
tests to quickly determine the cause, location, and
amount of damage).
Diagnostics
Imaging Studies
Cranial CT scan
Emergent noncontrast head CT scanning is mandatory for
rapidly distinguishing ischemic from hemorrhagic infarction
and for defining the anatomic distribution of stroke.
Dense Artery
sign
Insular Ribbon
sign (loss of insular
stripe)
Obscuration of lentiform
nuclei
Effacement of sulci
Large cortical infarcts tend to be wedgeshaped, while small subcortical infarcts are
usually round or ovoid
Encephalomalacia (gliosis is
isodense to CSF)
Volume loss leading to ex
vacuo dilatation of ventricles
CT FINDINGS: SAH
Imaging Studies
Magnetic Resonance Imaging (MRI)
MRI is useful for patients with acute ischemic stroke
involving cerebellar or lacunar pathology.
Disadvantages include its high cost, lack of ready
availability at most centers, and insensitivity for
detecting early hemorrhages.
DWI: acute
infarct
appears bright
T1
T2
medulla
T2
T1
Imaging Studies
Noninvasive arterial studies
Carotid duplex scanning
Transcranial Doppler (TCD) ultrasound
Echocardiography
Other tests
Angiography
PET scan
rinciples :
Stroke is a brain attack
needing emergency management, including specific treatments
and secondary and tertiary prevention.
Stroke is an emergency
where virtually no allowances for worsening are tolerated.
Stroke is treatable
optimally, through proven, affordable, culturally-acceptable and
ethical means.
Stroke is preventable
in implementable ways across all levels of society.
Thrombolysis (rTPA)
ELIGIBILITY CHECKLIST
INCLUSION:
Screening NIH
Onset < 3 hrs
CT no hemorrhage
EXCLUSION:
SBP > 185, DBP > 110
within 21 days
On anticoagulants / heparin within
48 hrs
Elevated PTT / PT > 1.5
Intravenous rTPA
Properly selected patients
within 3 hours
Dose : 0.9 mg / kg IV
10 % as bolus, 90% as drip for 1 hr
56 kg, female
Total dose = 50 mg
5 mg bolus (within 3 hrs of ictus)
NTI-PLATELETS
ASPIRIN
In 48 hours works!
Fewer recurrent strokes within 14 day
Fewer deaths / dependency at 6 months (IST and CAST
data, 1997)
Dose: 80 325 mg / day
Antiplatelet Trialist Collaboration:
145 trials with almost 100,000 patients showed
23% risk reduction for stroke, MI, and vascular death.
NTI-PLATELETS
Clopidogrel
Clopidogrel vs. Aspirin in Patients at Risk of
Ischemic Events (CAPRIE):
19,185 patients with prior stroke, MI, or PVD given
Clopidogrel 75mg/day vs. ASA 325 mg/day showed
8.7% RRR in stroke, MI, and vascular death over
ASA.
NTI-PLATELETS
Cilostazol
Cilostazol Stroke Prevention Study (CSPS):
1,095 patients with cerebral infarction at 1-6 months
were given Cilostazol 100 mg BID vs. Placebo,
showed RRR of 41.7%.
NTI-PLATELETS
Dipyridamole
European Stroke Prevention Study 2:
6,602 patients randomized to ASA 25 mg BID,
Dipyridamole 200 mg BID, ASA 25 mg BID +
Dypiridamole 200 mg, and placebo
Results: ASA better than placebo, Dipyridamole
better than placebo, combination of ASA and
Dipyridamole better than either one alone
NTI-PLATELETS
Ticlodipine
Canadian American Ticlodipine Study (CATS):
23% RR vs. placebo for stroke, MI, or vascular
death.
Ticlodipine Aspirin Stroke Study (TASS)
12% RR vs. ASA for stroke or death at 3 years.
NTI-COAGULANTS
Anecdotal evidence suggests that heparin may
benefit some patients with progressive stroke,
especially in the vertebrobasilar system, or strokes
involving only a small area of the brain that are
associated with an arterial or cardiac mechanism.
NTI-COAGULANTS
Anticoagulation is not without risk. Overall,
intracranial hemorrhage occurs in 1-4% of patients
who receive an anticoagulant for TIA or acute
stroke.
Accordingly, uncontrolled hypertension, intracranial
hemorrhage, and uncontrolled bleeding at another
site are contraindications to anticoagulation.
NTI-COAGULANTS
Patients with cardioembolic strokes also may be at
risk for hemorrhagic transformation.
Although some evidence indicates that early
heparinization is beneficial, some authors believe
that patients with cardioembolic stroke should not
be given anticoagulants until at least 48 hours after
symptom onset because of the risk of hemorrhagic
transformation (5-7 d for large cardioembolic
strokes).
NTI-COAGULANTS
Immobilized stroke patients who are not receiving
anticoagulants, such as IV heparin or an oral
anticoagulant, may benefit from low-dose
subcutaneous unfractionated or low-molecularweight heparin, which reduces the risk of deep vein
thrombosis.
The use of low-molecular-weight heparin as
treatment for acute ischemic stroke has not yet
been studied adequately.
EUROPROTECTANTS
Since the ischemic cascade is a dynamic process,
the efficacy of interventions to protect the ischemic
penumbra also may prove to be time dependent.
Citicoline (cytidine-5-diphosphate
choline) is an essential intermediate in the
biosynthetic pathway of structural
phospholipids which are important
constituents of all biological membranes,
including neuronal membranes
EUROPROTECTANTS
Data Pooling Analysis of Trials on Citicoline
Treatment of patients with moderate to
severe stroke with Citicoline within 24
hours resulted in 33% odds of complete
recovery at 3 months.
MAP = systolic + 2
(diastolic)
3
ACUTE STROKE
MANAGEMENT
Recognize stroke : History, PE and focused Neuro exam should be
done immediately
Prioritize diagnostic exams in the ER
ACUTE STROKE
MANAGEMENT
IV rTPA is strongly recommended in carefully selected patients with
acute ischemic stroke who can receive the medication within 3 hrs
ASA (80 325 mg) should be given to acute ischemic stroke
patients within 48 hrs of symptom onset
Do not forget NEUROPROTECTION: Avoid hypoxemia, hypohyperglycemia, hyperthermia, hypotension, hyponatremia
Rehabilitation
Physiotherapy
Optimize muscle function: e.g., mobility, balance,
coordination.
Help patients deal with disabilities: e.g., correct use
of a cane, walker, or brace.
Supplementary devices are indicated: e.g., for
feeding, dressing, and writing.
Rehabilitation
Speech therapy
Assists in improving verbal, written, or nonverbal communication skills:
e.g., for those with aphasia.
Diagnose and handle swallowing deficits to minimize complications.
Occupational therapy
Optimize functional capacities: e.g., writing and other functions to assist
in daily living (ADL)
Complications
Problems due to loss of mobility (joint Reduced ability to
contractures, pressure sores)
function or care for
self
Permanent loss of movement or
Decreased life span
sensation of a part of the body
Side effects of
Bone fractures
medications
Muscle spasticity
Aspiration
Permanent loss of brain functions
Malnutrition
Reduced communication or social
interaction
Prognosis
The long-term outcome from a stroke depends on the extent of
damage to the brain, the presence of any associated medical
problems, and the likelihood of recurring strokes.
22% of men and 25% of women who have an initial stroke die
within a year.
51% of men and 53% of women under age 65 who have a
stroke die within 8 years.
Prognosis
Some survivors experience depression following a stroke;
early treatment for depression can positively impact
rehabilitation.
Between 50 and 70% of stroke survivors regain functional
independence; the sooner rehabilitation begins, the greater
the chance of leading a productive life.
Between 15 and 30 percent of stroke survivors experience
permanent disability.
20% require institutional care at three months after onset.
Thank You!
Treatment and
Prevention
of Stroke
Infarct
Thrombotic
Embolic
Hemorrhage
ICH
SAH
Temporal Profile
Risk Factors
HPN
DM
Smoking
Hyperlipidemia
Age
Heart Disease
1. MEDICAL SUPPORT
2. THROMBOLYSIS
3. ANTI-COAGULATION
4. ANTI- PLATELET AGENTS
5. NEUROPROTECTION
I. MEDICAL SUPPORT
*BP control
MAP = S + 2D / 3
not > 20 % of MAP
Exceptions:
LVF
AMI
Aortic Dissection
*Drugs
Nicardipine
Nitroprusside
Esmolol / Labetolol
Hydralazine (?)
*Fever
Increase brain damage
Treat the source
Paracetamol
Blood Sugar
Treat Hyperglycemia > 180
Thrombolytic Therapy
rTPA
Streptokinase
Golden period 3 hours
Guidelines:
BP < 180 / 220
CT no bleed
mild and severe are not treated
III.ANTI-COAGULATION
ANTI- COUAGULATION
Heparin
- carotid a occlusion
- basilar a thrombosis
- fluctuating exam
LMWH
ASA
ANTI-PLATELET AGENTS
ASA 80 325 mg
Dypiridamole
ESPS 2 results
ASA > placebo
Dypiridamole > placebo
ASA + Dypiridamole > than each alone
Clopidogrel
Caprie
Claire
Cilostazol
Triflusal
TACIP
Embolic
Coumadin
INR 2 to 3
metal values 3 to 4.5
V. NEUROPROTECTION
Neuroprotectors
Dexa NO
Mg SO4
Hypothermia
Barbiturate Coma
Citicoline
Piracetam
Surgical Management
Carotid NASCET
Craniotomy
Ventriculostomy
ACE inhibitors
ARBI
ICH
- HPN
- Location
- Size
a x b x c / 3 (mm)
Golf ball = 30 to 40 cc
Increase ICP
Mannitol
Hyperventilation
Raise Head
RICH trial
Poor outcome
Age
Deep hemorrhage
Ventricular extension
Large volume
Coexisting disease
SAH
Headache
Nape pain
Prognosis: vasospasm
re-rupture
MEDICAL MANAGEMENT:
MANNITOL
DEXAMETHASONE
TRIPLE H hypertension, hemodilution, hypo-volemic
therapy
NIMODIPINE
SAH
SURGICAL MANAGEMENT:
CLIPPING
COILING
Prognostication
Prognosis by Neuro Exam
a. Day of Presentation: corneal, pupillary, and
occulocephalic responses
1) Absence of 1 of the 3: 95% vegetative / severely
disabled
2) Absence of 2 of the 3: 99% vegetative / severely
disabled
Prognostication
b. Day 1:
1) Spontaneous Eye Movements: 99% w/o will be vegetative
/ severely disabled
2) Motor Withdrawal to pain: 90% w/o will be vegetative /
severely disabled
c. Day 3:
1) Motor Withdrawal: 100% w/o will be vegetative /
severely disabled
2) Spontaneous Eye Opening: (+) withdrawal but eyes
closed 80% will be vegetative / severely disabled
Prognostication
Day 7:
1) Spontaneous Eye Opening: (+) withdrawal
but eyes closed 100% will be vegetative /
severely disabled
2) Obeying Commands: (+) eye opening, dont
follow commands 80% will be vegetative /
severely disabled
Thank you!
HEADACHES
Pain-Sensitive Structures
of the Head
Venous sinuses
Dural arteries
Proximal 50% of the larger
arteries of the circle of Willis
Dura at the base of the
brain
All extracranial structures
Pain-Insensitive
Structures
of the Head
Brain parenchyma
Ependyma
Choroid
Pia
Arachnoid
Dura over convexity
Skull
General Mechanisms of
Headache
Epidemiology
Classification of
Headaches
Primary headache
disorders
Secondary headache
disorders
Epidemiology
Primary Headache
h
h
h
Lifetime Prevalence
Tension
Migraine
Cluster
69%
15%
0.1%
Secondary Headache
h
h
h
h
h
h
h
Hangover
Fever
Metabolic disorder
Disorders of nose/sinuses
Head trauma
Disorders of eyes
Vascular disorders
72%
63%
22%
15%
4%
3%
1%
Approach to a
Patient with
HEADACHE
Questions to Ask in
Obtaining a Headache
History
Do you have other medical
problems? If so, what?
Do you take any medicines?
If so, what?
Do any of your family
members have headaches?
Performing the
physical exam
The primary purpose of the
physical examination is to
identify causes of secondary
headaches
Only a minority of
headaches are secondary,
but this category contains
the most life -threatening
conditions
Performing the
neurological exam
mental status
level of
consciousness
cranial nerve
testing
pupillary
responses
funduscopic exam
motor strength
testing
sensation
pathologic reflexes
(e.g. Babinski's
sign)
cerebellar function
and gait testing
signs of meningeal
irritation (Kernig's
and Brudzinski's
signs)
Funduscopic exam
Papilledema
Diagnostic Alarms
Sudden onset
Increased frequency
and severity
Associated with
systemic illness
(fever, meningismus,
rash)
Altered
consciousness or
focal neurologic
deficits
Papilledema
Significant trauma
Warning Signs
Suspected recent
subarachnoid hemorrhage or
meningitis
Other abnormal neurological
signs
hemiparesis
diplopia
ataxia
Warning Signs
Persistent or increasing
vomiting
Seizures
Endocrine disturbances (e.g.
acromegaly, diabetes
insidipus, amenorrhea,
galactorrhea, impaired male
sexual function or beard
growth and poor growth in
Overall Approach
Chief Complaint: HEADCHE
Headache Alarms
Evidence of serious headache disorder
by history or physical exam
NO
Diagnosis of
Primary Headache Disorder
YES
Treat Primary
Headache
YES
Work-up to identify/exclude
Secondary Headache etiology
NO
Consider work-up for
secondary headache
Primary headache is
the illness itself
Primary headaches
The Primary
Headache Disorders
I.
II.
Migraine
Tension-type
headache
III. Cluster headache
Primary headaches
Differentiated by
Duration
Frequency
Location
Severity
Quality of pain
MIGRAINE
HEADACHE
Migraine headaches
Unilateral
Throbbing pain
Moderate to severe
Aggravated by
movement
4-72 hours
Nausea +/vomiting
Photophobia
Types of Migraine
Migraine without aura
(common migraine)
Migraine with aura
(classical migraine)
Migraine Variants
Ophthalmoplegia
Hemiplegia
Complicated
Phases of Migraine
Premonitory phase
Aura phase
Headache phase
Resolution phase
Migraine
Premonitory
Occurs in more than 50% of cases
Phase
Migraine
Premonitory
Psychological Neurological
Phase
Depression
Sluggishness
Euphoria
Hyperactivity
Hypertalkativ
e-ness
Drowsiness
Stiff neck
Autonomic
Anorexia
Photophobia
Food craving
Phonophobia
Thirst
Osmophobia
Constipation
Concentration
difficulty
Urination
Cold feeling
Yawning
Migraine
Aura Phase
Present in classical migraine
Develops in > 4 minutes, lasts
less than one hour
Characterized by visual,
sensory, motor, language and
brainstem dysfunctions
Develops headache within one
hour after end of aura
Migraine
Headache Phase
Hemicranial
Gradual onset
Throbbing
Moderate-severe
Duration of 4 72 hours
Aggravated by physical activity
Associated features
Related to trigeminovascular events
Migraine
Resolution Phase
The patient feels bad or
good after disappearance
of the headache
The Modified
Diagnostic
Criteria of
Migraine
of the
International
Unilateral location
Pulsating quality
Moderate to severe intensity
Worsened by physical activity
Trigger Factors of
Migraine
Psychological
Physical
Stress
Hormonal Changes
Tension
Sexual activity
Anxiety
Letdown
Changes in sleep
Fatigue
Trigger Factors of
Migraine
Dietary
Environmental
Temperature/
weather changes
Bright light
Odors
High altitude
Alcohol
Certain foods
Missed or
delayed meals
Management of
Migraine
Behavioral modifications
Headache treatment
A. Abortive
B. Preventive
Migraine management
Behavioral Modifications
Regularization of meals, sleep,
exercise
Avoidance of migraine triggers
Avoidance of overuse of analgesics
Stress management
Migraine management
Abortive Pharmacotherapy
Starting doses
Maximum
doses
6 mg
Ergotamine
1-2 mg PO
Sumatriptan
25-100 mg PO
300 mg
Zolmitriptan
6 mg SC
12 mg
Chlorpromazin
e
25-50 mg
IV/IM
400 mg
Prochloperazi
ne
5-10 mg IV/IM
Dexamethaso
ne
40-100 mg PO
120 mg
30-60 mg IM
1500 mg
Prednisone
Ketorolac
Naproxen
4-8 mg PO
250-750 PO
40 mg
32 mg
200 mg
Migraine management
Preventive Pharmacotherapy
Starting doses
Maximum doses
Propranolol
40 mg PO
320 mg
Metoprolol
50 mg PO
450 mg
Flunarizine
5 mg PO
10 mg
Divalproex
250 mg PO
3,000 mg
Methysergide
2mg PO
40 mg
Tolfenamic
acid
100 mg PO
600 mg
25 mg PO
200 mg
Topiramate
Migraine
management
Indications of Preventive
therapy
Diagnosis of migraine
Acute therapy is needed more
than 2x per week
Acute therapy is ineffective,
intolerable, contraindicated
2 or more attacks/month that
produce disability for > 3 days
Headache is associated with
neurologic deficit
TENSION-TYPE
HEADACHES
Tension-Type
Headaches
Band-like, bilateral
Tightness/pressure/ dull ache
Radiates to neck and shoulders
Mild to moderate
Not aggravated by movement
30 min to several days
Tension-Type Headache
(TTH)
Previous Labels
Tension headache
Psychogenic headache
Muscle contraction headache
Tension-type headache
Types
Episodic tension-type headache
Chronic tension-type headache
TTH associated with disorder of
pericranial muscles
TTH unassociated with disorder of
pericranial muscles
Tension-type headache
1. Pressing, tightening
2. Mild to moderate severity
3. Bilateral location
4. No aggravation by routine physical
activity
B. Both of the following:
1. No nausea or vomiting
2. No photo/phonophobia, or one of them is
present
C. At least one of the following:
1. No cause for secondary headache
2. If one is present, the onset of the TTH is
not in close
temporal relation to it
Tension-type headache
Management
A. Pharmacological therapy
1. Abortive
2. Preventive
B. Non-pharmacologic therapy
1. Psychophysiologic
2. Physical
Management of TTH
Abortive Pharmacotherapy
Analgesics: paracetamol
NSAIDs : aspirin, indomethacin,
naproxen, ketorolac
Combination: analgesic + caffeine +/butalbital
Muscle relaxants : no proven value
Management of
TTH
Management of
TTH
Preventive Pharmacotherapy
Tricyclic antidepressants
Selective serotonin re-uptake
inhibitors
Migraine preventive drugs
CLUSTER
HEADACHES
Cluster headaches
Unilateral
Hot poker/
stabbing pain
Excruciating
Autonomic
dysfunction
Restless
15 min to 3 hours
Clinical Features of
Cluster Headache
Striking periodicity: cluster starts in
the same season; headache starts at
the same time
Stereotypical features: same side,
same location
Pain : excruciating, deep, boring
Associated features: autonomic
Headache frequency: usually 1-2/day
Headache duration: 30-180 minutes
Cluster periods: 1-2/year
Cluster duration: 1 week 1 year
Management of
Cluster Headache
Abortive treatment
Preventive treatment
Avoidance of triggers
Surgery of the trigeminal
ganglion
Cluster Headache
Abortive treatment
100% O2 at 7-10 L/min. for 15
mins
Sumatriptan 6 mg SC
Dihydroergotamine 1mg IV/IM
4-6 % Lidocaine, nasally
Cluster Headache
Preventive treatment
Verapamil 120-480 mg
Ergotamine 3-4 mg/day
Lithium carbonate 300 mg BID
Methysergide
Valproate
Corticosteroids
Secondary headache
is the symptom
Secondary Headaches
Certain features of the history
will make you suspect
secondary headache
Physical exam will be abnormal
Focal neurologic findings
Signs of infection
Evidence of head trauma
Secondary Headaches
Findings on history
First or worst HA ever
Sudden-onset headache
Increase frequency & severity of
usual HA
Age > 40 years old
Increase in pain with coughing,
sneezing, straining
Wakes patient from sleep or
disturbs sleep
Secondary Headaches
Findings on history
HIV +
History of cancer
History of head trauma
Symptoms of infection
Fever, nausea, and vomiting
Photophobia
Stiff neck
Secondary Headaches
Findings on PE
unilateral loss of sensation
unilateral weakness
unilateral hyperreflexia
signs of infection
Secondary Headaches
Findings on PE
Head trauma
Papilledema
Changes in mental status
Ataxia
Red Flags on PE
Papilledema
Meningitis
Mass lesion
Pseudotumor cerebri
Diagnostic Studies
Computerized tomography
Hemorrhage, tumor, abscess, AVM
Lumbar puncture
Hemorrhage, infection, increased CSF pressure
HEADACHES
Thank You!