1/23/2017 NO DISCLOSURES NEURO ANATOMY OBJECTIVES TYPES OF ISCHEMIC STROKE CORTEX

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1 NO DISCLOSURES WALKS LIKE A DUCK QUACKS LIKE A DUCK MIGHT NOT BE A DUCK STROKE MIMICS Ann Lage, APN, ACNS-BC Carle Foundation Hospital Carle Neuroscience Institute OBJECTIVES NEURO ANATOMY Overview of neuroanatomy as it relates to ischemic stroke pathology Review of neurologic exam Identify diagnoses that mimic ischemic stroke Learn more about stroke mimics and how to identify them Learn about subsequent care/treatment TYPES OF ISCHEMIC STROKE CORTEX Atherosclerotic/Thrombotic Plaque formation ICAD/ECAD Thickening of vessels stenosis Thrombotic Dissection Embolic Ulcerated or unstable plaque Cardioembolic Atrial fibrillation PFO Thrombus within the heart Low EF Coagulopathy Vegetation on valve Lacunar End destination arteries Affecting smaller area Small and round Frontal lobe Motor control of voluntary muscles Personality Concentration Organization Problem solving Ability to express thoughts (Broca s area) Temporal lobe Hearing Memory of hearing and vision Parietal lobe Sensory areas of touch, pain, temperature Understanding speech, language (Wernicke s area) Occipital lobe Visual recognition 1

2 DIFFERENCE IN HEMISPHERES SUBCORTEX Right Movement/feeling to the left side of the body Spatial orientation Creativity Insight Left Movement/feeling to the right side of the body Language Number skills Reasoning Scientific functions Internal capsule thick band of white matter lateral to the thalamus Basal ganglia helps modulate movement Thalamus relay station of the brain Hypothalamus links nervous system to endocrine system; regulates body temp, fluid/electrolyte balance, blood pressure, body weight Amygdala emotions, emotional behavior, motivation Hippocampus new memories; learning BRAINSTEM CEREBELLUM Midbrain Relays motor impulses cerebral cortex to pons Relays sensory impulses spinal cord to thalamus CN III & IV Pons Apneustic and pneumotaxic center CN V, VI, VII, VIII Medulla CN IX, X, XI, XII Vital centers: Respiration, heart rate Decussation of pyramids 2 nd largest part of the brain One tenth of the brain but contains nearly half the neurons in the brain Coordinates intended movements initiated by the motor cortex Regulates balance and posture Results in skilled movements like dancing, speaking, catching a ball NEURO EXAM CRANIAL NERVES Neuro exam seems messy, tricky even Clinical exam History and the patient s story Orientation CN II XII Motor coordination, strength, drift? Sensory positive vs negative phenomenon Reflexes Speech FAST (Sanders, 2017) 2

3 Facial weakness due to injury of CN VII outside of the central nervous system Unclear etiology, thought to be due to reactivation of HSV1 or varicella-zoster What s in the story Noticed facial droop Abrupt onset to progression over several hours Neuro deficits get attention.neurology consult Exam Facial droop (Complete vs incomplete) Grade I - IV Unable to close the eye on the affected side Not blinking with same frequency as other eye May have Jaw pain/ear pain Impaired taste Lacrimation Hyperacusis Facial twitch No abnormalities beyond territory of facial nerve Look for forehead wrinkling (preserved in stroke) Treatment with antiviral & steroids the sooner the better Protect the eye (patch, eye gtts/ointment) The more the severe the more protracted recovery, several days to several months Migraine with aura producing neurologic deficit Visual disturbance Hemiparesis Hemisensory paresthesia Dysarthria Aphasia Neuro deficits get attention...neurology consult Appropriately concerned patient What s in the story Symptom onset usually gradual Migrainous March Migraine history? Positive or negative phenomenon and when? Exam Headache vs acephalgic Neuro deficit Often paresthesia, most often tingling but can be numbness Weakness hemiplegic migraine Lacking something else, lack of corresponding deficit that localizes to same area of the brain Deficits usually last 15 to 60 minutes or longer Tricky incidence between PFO and migraine Imaging unless you re sure 3

4 Inappropriate electrical activity Originates from the cortex Todd s paralysis Brief period of temporary paralysis (partial or complete) following a seizure Neuro deficits get attention...neurology consult What s in the story Seizure history? What did the family witness? Nocturnal incontinence or buccal trauma Several TIAs of same presentation Exam Weakness to one side Confused/blunted Paresthesia? Positive vs negative Jacksonian March Rapid improvement of deficit Seizure workup/management Do we know why there was seizure activity? Yes Manage meds/lifestyle No Dig deeper into patient s history EEG Imaging What does it look like? Confusion/Difficulty with speech Family: something is really wrong Inappropriate words, gibberish On exam fluctuating symptoms Confusion Perseveration (not making sense, flight of ideas) Weakness (general) Asterixis Infection Metabolic disturbance Polypharmacy Some meds can cause deleterious neurologic symptoms Delirium Diminished cognitive reserve Treat underlying cause Maintain safe environment Provide routine (day/night) Diminish sequelae of hospitalization Recovery varies and can be protracted 4

5 Benign Paroxysmal Positional Vertigo Peripheral vestibular disorder Occurs in middle-aged to elderly 50% over age 60 Half will have one occurrence (VonBrevern et al, 2006) What s is the story Quite distressed Activity at onset Getting in or out of bed Looking up Bending over Lying down/rolling over in bed Exam Nystagmus that fatigues Reproduction of symptoms with position change Palliation of symptoms after position change maintained BE FAST (Intermountain Healthcare, Utah) Balance Eyes (vision) No cerebellar symptoms at rest or in absence of symptoms Meclizine prn Physical Therapy Epley maneuver STRANGER THINGS HAVE HAPPENED Electrolyte imbalance (potassium & magnesium) Weakness Undiagnosed dementia/cognitive decline Speech issues Functional cases Stuttering speech Weakness REFERENCES WHAT S THE WORST THING??? Keep possibility of a stroke diagnosis in the forefront of your thinking as you work through these patients Questions?? AANN (2010). AANN Core Curriculum for Neuroscience Nursing (5 th ed). Glenview, IL: American Association of Neuroscience Nurses. Azarbal, B., Tobis, J., Suh, W., Chan, V., Dao, C., & Gaster, R. (2005). Association of Interatrial Shunts and Migraine Headaches: Impact of Transcatheter Closure. Journal of American College of Cardiology, (45)4, Gates, P. (2010). Clinical Neurology: A primer. Chatswood, NSW: Elsevier Australia. Greenburg, D.A., Aminoff, M.J., & Simon, R.P. (2012). Clinical Neurology (8 th ed). Novato, CA, SanFrancisco, CA, Atlanta, GA: The McGraw-Hill Companies, Inc. Morgan, B. (2011). Neurologic Assessment Tips. Sanders, K. (2017). Teach me Anatomy: Summary of the Cranial Nerves. UpToDate (2016). Bell s Palsy: Treatment and Prognosis in Adults Evaluation of the Adult with Acute Weakness in the Emergency Department Hemiplegic Migraine VonBrevern, M., Radtke, A., Lezius, F., Ziese, T., & Neuhauser, H. (2007). Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry, 78(7),