1. Neurology Archer USMLE Step3 Reviews www.CcsWorkshop.com

2. Risk Factors - Stroke Age >50 Family history of CAD, CVD, or PVD before age 60 Clinical manifestations of CAD or PVD Hypertension Diabetes mellitus Elevated cholesterol Smoking Hyperhomocysteinemia Carotid bruit ( presene only if luminal stenosis >50%) History of TIA History of paroxysmal or persistent atrial fibrillation

3. Primary Prevention Of Stroke Control hypertension Use ACE inhibitor in high-risk patients if they are hypertensive or diabetic, or if they have already had a vascular ischemic event. Smoking cessation. Achieve glycemic control in diabeteics Start warfarin in most patients with nonvalvular atrial fibrillation in whom sinus rhythm cannot be restored, including (CHADS2) High-risk patients with previous embolization (TIA/CVA), age > 75, HTN, DM Type II and those with congestive heart failure or decreased left ventricular function Elderly patients to maintain an INR between 1.8 and 2.5

4. Primary Prevention Of Stroke Do not use warfarin in patients who cannot have adequate monitoring of INR, cannot receive medications in a predictable fashion, or have increased risk for bleeding (i.e., those with a high risk of traumatic fall (elderly), those with high-risk occupations, or those who have a bleeding disorder). Start antiplatelet therapy in Afib for prevention for storke- ASA 50 to 325 mg po qd, Clopidogrel, 75 mg po qd, or Aggrenox - in low-risk patients with nonvalvular atrial fibrillation (lone afib) - in higher-risk patients who decline anticoagulation, would not comply with INR monitoring, or are at very high risk for bleeding. Discontinue combination estrogen and progestin treatment in healthy postmenopausal women. Consider starting low-dose every-other-day aspirin in otherwise asymptomatic women over the age of 45.

5. Primary Prevention - Stroke Carotid endarterectomy should be considered in asymptomatic patients with >60% stenosis who have no other contraindications for surgery (especially severe cardiopulmonary disease), are under age 75, and are expected to live >5 years .

6. Stroke - Management Immediate Neurologic Assessment ( 75yrs. However, here consider it if pt is likely to live > 5yrs Symptomatic patient with carotid stenosis 60% Management Medical therapy: 5 year risk of CVA 12% Hypertension control Hyperlipidemia control with Statins Clopidogrel (Plavix) Surgical Procedures: 5 year risk of CVA 6% Carotid endarterectomy or Angioplasty & carotid stenting ( stenting can be considered in In symptomatic, highrisk candidates for carotid endarterectomy & In patients with surgically unapproachable stenosis)

16. Hemorrhagic Stroke Intracerebral hemorrhage Intracerebellar Hemorrhage Sub Arachnoid Hemorrhage

17. Intracerebral Hemorrhage (ICH) In any patient with stroke symptoms, obtain NON-CONTRAST CT head first to r/o hemorrhagic stroke Most common cause is HTN. Other causes are amyloid angiopathy, vascular malformations, coagulopathy and cocaine abuse Clues for Amyloid angiopathy primarily a lobar hemorrhage and seen mostly in elderly. Obtain cerebral angogram to rule out vascular malformations in : Patients with ICH who are age under 45 Patients who developed ICH after cocaine use Rx control BP to maintain SBP between 140 and 160 mm hg ( use IV labetalol or nitroprusside or nicardipine) Mannitol and Hyperventilation to reduce intra cranial pressure In intracerebellar hemorrhages, realize that its very close to brain stem so a mass effect can lead to Brain stem herniation. So, in intracerebellar hemorrhage, if extensive, will need URGENT SURGICAL DECOMPRESSION contact neurosurgeon STAT!

18. Subarachnoid Hemorrhage Common causes : Berry aneurysms, AV malformations, Neoplasms C/F: Severe headache, photophobia, loss of consciousness, papilledema Prevention : Obtain MRA to screen for Berry aneurysms in patients with ADPKD only if family member is diagnosed with an Intra Cranial Aneurysm or SAH, if the patient refers to symptoms related to an ICA or a patient has a high risk job In patients with incidental aneurysms, if size > 10 mm surgery. If size < 10mm, follow up MRI in 1 to 2yrs. Diagnosis : Non contrast CT first. If CT VE, LP if suspicion is high look for xanthochromia ( 10% SAH are missed by CT Scans) RX If there is a ruptured aneurysm, rx with surgical clipping in 48 hours Nimodipine to prevent post subarachnoid hemorrhage vasospasm and consequent, iscemic stroke ( Vasospasm after SAH is the most dreaded complication of SAH leads to stroke) Triple H therapy ( Induced Hypertension, hemodilution and hypervolemia) is also widely used in preventing and treating cerebral vasospasm after aneurysmal SAH.

19. Meningitis

20. Meningitis Symptoms : Fever, Photophobia, Headache, Neck stiffness, vomiting, seizures Use physical exam findings to confirm a diagnosis of meningitis. Look for: Fever Nuchal rigidity Brudzinski's sign Kernig's sign Signs of encephalitis, such as weakness and change in mental status

21. Meningitis Do lumbar puncture to obtain CSF for: Protein, glucose, and cell count determinations Gram stain and bacterial culture PCR testing for enterovirus and HSV if bacterial Gram stain and culture results are negative and cell counts suggest viral meningitis Obtain CT scan before lumbar puncture in patients with: ( HIPFAN) Immunucompromised state (I) History of CNS disease (H) New onset seizures (N) Papilledema (P) Altered level of consciousness ( suggests encephalitis)(A) Focal neurologic signs (F) Be aware that delay in initiating appropriate antibiotics while awaiting results of CT scan in patients with bacterial meningitis may result in an adverse clinical outcome.

22. Meningitis

23. Meningitis Empiric Rx Base empiric antibiotic therapy on: Patient's age CSF gram-stain result Potential bacterial pathogens Knowledge of local resistance patterns for those pathogens Thereafter, base targeted antibiotic therapy on culture results and susceptibility data. Administer dexamethasone 15 to 20 minutes before the first antimicrobial dose in adult patients with suspected meningitis.

24. Meningitis Emperical therapy Predisposing Factor AGE 50 years Common Bacterial Pathogens Antimicrobial Rx Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species Streptococcus pneumoniae , Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli N . meningitidis, S. pneumoniae Ampicillin plus cefotaxime or ampicillin plus an aminoglycoside S. pneumoniae, N. meningitidis, L. monocytogenes , aerobic gram-negative bacilli Vancomycin plus a third-generation cephalosporin Vancomycin plus a third-generation cephalosporin Vancomycin plus ampicillin plus a thirdgeneration cephalosporin

25. Meningitis Emperical therapy Predisposing Factor Common Bacterial Pathogens Antimicrobial Rx Basilar skull fracture S. pneumoniae, H. influenzae, group A -hemolytic streptococci Vancomycin plus a thirdgeneration cephalosporin Penetrating trauma Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic gramnegative bacilli (including Pseudomonas aeruginosa ) Aerobic gram-negative bacilli (including P. aeruginosa ), S . aureus , coagulase-negative staphylococci (especially S. epidermidis) Coagulase-negative staphylococci (especially S. epidermidis), S. aureus, aerobic gram-negative bacilli (including P. aeruginosa ), Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem YOU ARE Adding an antipseudomonal antibiotic. HEAD TRAUMA Postneurosurgery CSF shunt Vancomycin plus cefepime, vancomycin plus ceftazidime, or vancomycin plus meropenem Vancomycin plus cefepime,c vancomycin plus ceftazidime,c or vancomycin plus meropenem

26. Fall Prevention - Elderly

27. FALLS IN ELDERLY Epidemiology Falls occur in >30% of age over 65 years in community Serious injury occurs in >20% of falls in older adults Most falls occur in and around the patient's home Risk Factors for falls Environmental hazards (most common) Altered gait or balance Lower extremity Muscle Weakness Dizziness or Vertigo Syncope Postural Hypotension Decreased visual acquity Arthritis Dementia or Altered Level of Consciousness Major Depression Medication use (especially more than 4 medications) Class IA Antiarrhythmics, Digoxin, Diuretics , Anticonvulsants , Psychotropic medications like Benzodiazepines & Antipsychotics

28. Screening and Evaluation for fall risk Get Up and Go Test Cardiovascular exam Postural Hypotension , Arrhythmias , Carotid Bruits Neurologic Exam Assess coordination and balance , Lower extremity muscle strength & Proprioception and vibration sense Miscellaneous exam Visual Acuity , Joint exam Diagnostics in cases of fall history Complete Blood Count Thyroid Function TeSts Chemistry panel including Renal Function tests Serum Vitamin B12 Electrocardiogram Echocardiogram Brain Imaging

29. Get up and Go Test Technique: Direct patient to do the following Rise from sitting position Walk 10 feet Turn around Return to chair and sit down Interpretation Patient takes 30 seconds to complete test Suggests higher dependence and risk of of falls

30. Fall Risk - Prevention Use Assistive Devices Wear flat, rubber soled shoes Use ambulatory aid as needed (cane or walker) Consider Hip protection device Two convex shields worn inside underwear pocket Greatly reduces Hip Fracture Incidences Wearing pads: 0.39 Hip Fractures per 100 falls Not wearing pads: 2.43 Hip Fractures per 100 falls May reduce Incidence of pelvic fracture

31. Fall Risk Prevention Education Proper lifting technique No stooping; bend knees and keep back straight Optimize Comorbid Conditions Assess number/type of medications Check Visual Acuity Vision