The “Little Red Book”

of
Neurology

A Residency Survival Guide

Revised May 2014

 The Little Red Book of Neurology
A Residency Survival Guide*

Neurology Residency Program

Barnes-Jewish Hospital
Washington University in St. Louis

Inpatient Neurology Logistics 2

Clinic Schedules and Logistics 6
Didactic Schedules 9
Neurological exam and Neuroanatomy 13
Diagnostic studies 23
Neurological Disorders 31
Stroke 31
Epilepsy 53
Sleep disorders 69
Headache 71
Neuromuscle disorders 75
Movement disorders _90
Multiple Sclerosis _97
Neuro-otology 104
Neuro-ID 109
Spine diseases 110
Functional symptoms 111
Coma prognosis 113

Notice: Medicine is an ever-changing field of science. This handbook has

been prepared to assist you during your neurology residency. However,
authors of this handbook cannot warrant that the information contained herein
is in every respect accurate or complete. Readers must always rely on their
own knowledge and judgment in evaluating and applying any information,
methods, and algorithm described herein and check the most current literature
and evidence-based practices. In addition, authors deny any financial conflict
of interest.

*Revised May 2014 by many current and former Neurology residents.

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 INPATIENT NEUROLOGY LOGISTICS
Neurology Floor. Two services: General and Stroke Neurology teams. Each
service consists of the attending, chief residents, 4 junior (PGY-2 & 3
residents), psychiatry and/or PM&R interns, NP, and medical students.
Schedule for junior residents: An 8-day cycle: call, post-call, short-call, off,
call, post-call, short-call, and continuity clinic.

Rounds: begin promptly at 7:30 am (8:15 on Weds/Thurs, after Morning

Report); arrive at hospital early enough to pre-round on your patients (on-call
person not before 6:30 am). Update census boards on 11-400, 11-500, and 10-
500 prior to 7:30 am daily. Put in orders (and if possible, discharge orders)
during rounds. Talk to the SW and case manager about discharges as soon as
you know a patient can go. It is helpful to provide a draft list each morning
BEFORE ROUNDS to the social worker and case manager with patients
expected to go home vs. inpatient rehab vs. SNF so that they can plan
accordingly while the team is rounding.

Calls: q4 for juniors and q2 for chiefs. . On-call junior arrives at 6:30 am and
leaves by 10:30 am on post-call day.
Sign-out: Each morning, get sign out from the post-call resident before pre-
rounding. All residents have to verbally sign-out to the on-call junior prior to
leaving the hospital. Additionally, each resident should update the “MD
Handoff” section of Compass with a current exam and plan for each problem
for their patients before leaving the hospital each day.

Pre-call days: Juniors have Continuity Clinic on pre-call Mon, Tues, or Wed
(peds residents only on Tue and Wed) and are off when pre-call falls on
Thurs, Fri, Sat or Sun.

Admissions: The on-call junior resident acts as the “team captain” for the day
and coordinates with the chief to distribute new admissions. New admissions
who are physically in the hospital by 3pm (either on floor or still in ED or
transferring out of NNICU) are typically admitted by the short-call resident,
psych intern, or PM&R intern. The on-call resident will start taking admits at
3pm. Patients admitted prior to 6:30 am should go to the on-call resident. For
patients that arrive after 6:30 am, the on-call resident must eyeball the patient
for stability and hand them out to the appropriate short call resident. All
patients should be at least “eyeballed” upon arrival to the floor. Admission
orders should be done within an hour of a patient’s arrival on the floor. There
are order sets in Compass for the following: Neurology Admission Orders,
Stroke Admission Orders, Post Alteplase Infusion Orders, 10500 SDU
Neurology Admission Orders, MS Exacerbation, IVIg, vEEG, Rituxan and
Cytoxan. Write a summary of the history/exam/plan in the “MD Handoff”
section of Compass as soon as possible. Dictate your H&P the day of
admission.
Procedures: LPs are generally done by the resident caring for the patient. For
other procedures (e.g.: central lines), you can call the medicine procedure
team on Monday through Friday, 8am to 5pm, at 294-4853. IV therapy places
PICC lines (order in Compass).

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Discharge and follow-up: Start discharge draft in Compass on the day of
admission, and update the Hospital Course section frequently as this
ultimately saves time and improves accuracy. Finish the discharge summary
the day before anticipated discharge. Follow PT/OT/ST recs everyday. All
patients must have a plan for follow-up appointment scheduled prior to
discharge. See below (under “Insurance and clinics for more details). If
patients don’t have insurance, complete the Medicaid application that will be
placed in the chart. Once Medicaid pending, they can go to TRISL and Barnes
Clinic. You may receive calls on patients discharged from hospital (before
their follow up). For residents who will follow up in the Resident COH clinic,
send a task in Touchworks to “BJ Neurology Secretary” to coordinate
appointments. For stroke patients who will follow up with one of the stroke
attendings, send a task to “Francesca Ryan” and include the name of the
attending or fellow who has agreed to see the patient.

NNICU: Read the NNICU handbook prior to beginning rotation. Calls are q3-
q5 shared by neurology PGY-2 & 3 and ED residents as well as NNICU NPs.
Signout starts at promptly at 0600 in the 10-400 workroom. The overnight
and day fellow will lead signout from 0600-0630, then from 0630-0700 you
should pre-round on patients to get additional details from the bedside nurse,
the plan from NSGY team, and examine the patient. From 0700-0800 the
team will do bedside walk rounds. BRIEFLY present any acute overnight
events and then the current exam in this format:
--mental status (e.g. opens eyes to voice, regards, follows commands, oriented
to place but not month/year)
--cranial nerves (pupils, corneals, VOR, eye movements, face, cough/gag),
--extremities (e.g. hemiparesis, drift, full strength, posturing, triple flexion)
Sit-down rounds are from 0800-1200. The bedside nurse will present most
of the information. You should be prepared to offer a plan for each organ
system for the day and then summarize the plan at the end.

Consults: Two teams: “AM Rounds” (takes new consults from 1200-1900
and rounds the following AM) and “PM Rounds” (takes new consults from
0700-1200 and rounds in PM). Each team consists of PGY-3 neurology
resident (runs the service), PGY-2 neurology resident (holds the tPA pager),
psychiatry and neurology interns, medicine residents, medical students, and an
attending. The PGY-2 will sometimes hold the tPA pager during rounds when
the counterpart team’s PGY2 has clinic. Holidays and weekends are staffed by
neurology PGY 2s and 3s only.

Night Float: From 1900 until 0700 the next morning, you are the only
neurologist to cover the entire hospital (with the exception of the neuro floor
and NNICU). You will be handed the consult and tPA pagers and consult
phone at 1900 in the 10-400 Resident Lounge (call 299-8635 if the consult
senior is not in the Lounge at 1900).

Consults: ER, inpatient floors, or ICUs will call consults. See in the order they
come, but triage based upon severity. A tPA page is an emergency and IS A
CODE. Respond immediately. Don’t refuse consults. When you get a

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consult in the ER, call back the ED communications center (758-6787).
Touch base with the ED resident or attending after you have seen the patient
to give prelim recs and call back after you have talked with your chief or
attending. The ER likes to keep things moving and we try to oblige. It is
important to make sure that all appropriate tests are completed in the ED to
ensure that the patient gets safe and appropriate disposition. All ER consult
notes are to be entered into HMED. Don’t hang out in ED after you are done
seeing your patient.

You may have to go to North Campus overnight to see urgent consults, but
realize that you may need to hustle back to the ED if the tPA pager goes off.

You may be called to do a lumbar puncture for patients who are on the OB-
GYN service. We have a relationship with them to do these when the need
arises. It’s often difficult to do these procedures when you’re carrying the tPA
pager, but you should work together with your floor resident and the OB-
GYN floor resident to help.

Who to call: All pts with a private service neurologist should be staffed with
that neurologist or whoever is covering for him/her. If in doubt, contact
Doctor’s Access Line. See below for instructions for Private Epilepsy
patients. Every patient being sent home must be staffed with the on-call
consult attending (usually by phone). All other patients will be staffed with
the on-call chief. If a patient is being admitted to neurology, staffing with the
chief is sufficient. Don’t give the neurology attending name to ED before
staffing with the chief. If a patient is being admitted to another service, he/she
will be staffed by the consult attending the next day (see below for algorithm).

Staffing night float consults:

Consults seen overnight who have not been staffed by phone and discharged
from the ED or admitted to General/Stroke/NNICU will be staffed the
following day as follows. Contact the AM Rounds consult attending and the
PM Rounds PGY3 each morning around 0530 or 0600 to let them know how
many patients need to be staffed (check at the beginning of each rotation to
determine the attending’s preference on time and mode of communication).
ED consults awaiting dispo decisions and urgent floor/ICU consults should be
staffed by the AM Rounds attending and PM Rounds PGY3 after hearing the
story from the NF resident in the lounge at 0700.

Private Epilepsy Patients:

1) Daytime (7am-5pm) ED consults on private epilepsy patients should be
discussed with the Epilepsy fellow. If the fellow says ok to d/c home, they
will not be discussed with anyone else. If fellow says admit to non-neuro
service, they will be staffed by consult attending. If fellow says admit to
neuro, they will go to the general service and be staffed with the general
attending.

2) After hours (5pm-7am) ED consults on private epilepsy patients will be

discussed with the on call epilepsy person. If on-call says d/c home, they will
not be discussed with anyone else. If on-call says admit to non-neuro service,

4  
 
they will be staffed by consult attending. If on-call says admit to neuro, they
will go to the general service and be staffed with the general attending.

3) Any consult on an inpatient who is a private epilepsy patient will be

handled by the consult service and discussed with the epilepsy fellow or on-
call epilepsy person only if needed.

Phone calls: You will also field phone calls from clinic patients. You do NOT
cover for attending neurologists, either private or faculty, or for
neuroradiology. For those calling with new symptoms or a seizure, have a low
threshold to have them come into the ED. Most calls are for medication
refills. Call in non-narcotic medications as a courtesy to the resident who is
the primary neurologist. Narcotic meds do not need to be filled during off-
hours. Document all calls in Allscripts as a “Call note,” and email or “task”
the resident a summary of what happened.

Electives: Check goals and objectives on the website prior to the rotation.

Code to Lounge/call rooms

10400 Lounge: 1, 2, 5, 4 (No housekeeping, clean up your own mess)
10400 NNICU call room: 1+2, 4, 5
11400 call room: 1,4,1,5, #
11400 conference room: 5,4,1,2,#
The key for the EEG suite is in the 11400 pyxis (ask any nurse to get it for
you) if you need to get in after hours. Keep the key in your pocket, as the door
will lock automatically

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 CLINIC SCHEDULE AND LOGISTICS
Clinic Schedules: dates and availability of selective and specialty clinics may
change; check a couple of weeks prior to your rotation/clinic.

Continuity Clinic (13:00-17:00 pm)

COH: Center for Outpatient Health

Day Mon Tue Wed Thu Fri

COH
Clinic COH & COH COH Shriner
Movement
Specialty Clinics (PGY-2)
AM Epilepsy MS-Parks Sleep NM Stroke
PM - Rehab Movement NM Dementia
Specialty Clinics (PGY-4)
AM Sleep MS-Parks Ophtho/Oto NM Stroke
PM - Rehab Movement NM Dementia
Selective Clinics (PGY-3 and 4)
MS MS MS MS Stroke
AM (Parks) (Wu/Cross) (Parks/WC) (Cross) Sleep
Sleep Sleep Otology NM ID
Sleep Sleep Oncology
MS MS MS NM ID
(Parks) (Cross) (Parks/WC) Otology Oncology
PM
Epilepsy TBI Movement Sleep Sleep
Sleep Epilepsy Sleep General
Sleep (Awadalla)

Neurology Outpatient Clinic Information

Insurance & Clinics:

Private or Medicare. Any subspecialty clinic (Epilepsy, Movement,
Neuromuscle, MS, Sleep, Stroke). Also can refer to private neurologists – see
list below1. Some insurance (e.g. Tricare – military) needs PCP to fill out
pre-certification.
Medicaid alone. Barnes COH or Connect Care
Illinois Public Aid (IPAC). COH as long as already established in some way
with WashU.
Patient Pay (no insurance). COH (but encourage them to sign up for ACA!)
1
Private Neurologists:
Call 1-866-TOPDOCS for other local referrals, or to be sure they accept their
insurance.

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- Dr. Stuart Weiss, CAM, x25954, fax x20338.
- Dr. Joseph Black, CAM 6th floor, same as Dr Weiss.
- Dr. Anna Conti, St John’s Mercy, 251-6075, fax 251-6634. Wants lots of
referrals, esp in Movement.
- Dr. Sylvia Awadalla, CAM 6th floor, x27241. Email/page her before referral
is made if appt is needed soon.
- Dr. David Carpenter, CAM 6th floor, x27498. Sees some general patients.
- Dr. Alison Leston, 3009 N. Ballas Rd., Suite 102B, Bldg B, 725-2010, fax
725-0709. Fax all notes before appt time.
- Dr. Barbara Green, Lee Tempel, William Logan and Phillip Lee, St John’s
Mercy, 621 S. New Ballas Road, Suite 5018-B, St. Louis, MO 63141, 227-
2020, fax 227-2023.
- Dr. Ksenija Kos, St John’s Mercy, 621 S. New Ballas Road, Suite 5003-B,
251-5910, fax 251-5911.
- Dr. John McGarry, St John’s Mercy, 621 S. New Ballas Rd, Suite 4019B,
251-5838, fax 251-6632.
- Dr. James Goldring, MoBAP, 567-3663, fax 567-3103. Fax all notes before
appt time.
- Dr. Ajitesh Rai, Alton Memorial Hospital, 618-465-8666.
- Dr. Justin Malone, Boone Hospital (Columbia, MO), 573-449-2141.
- Dr. Robert Gardner, Cape Girardeau, MO, 573-651-3188, fax 573-651-3048.
- Dr. Taylor Bear, St John’s in Joplin, MO, 417-659-6876, fax 417-659-6874.
2
Primary Care Clinics (No Insurance):
Grace Hill – Water Tower (4307 N Grand) -- 898-1717, pharmacy 814-8637
Grace Hill – Murphy O’Fallon (171 Biddle) – 814-8585, dental 814-8581
Grace Hill – South (3400 S. Jefferson) – 577-6232
Grace Hill – Soulard-Benton (2220 Lemp) – 814-8680, dental 814-8677
Grace Hill – St Patrick’s (800 N Tucker) – 802-0711
All Grace Hill Appointments – 421-4949
John C Murphy County Clinic – 522-6410
La Clinica Health Center (International clinic) – 664-5565
Peoples and Comprehensive Clinics are other options, but unknown pharmacy
plans.

Discount Prescription Info:

- WalMart supplies amitriptyline, carbamazepime, citalopram, fluoxetine,
nortriptyline, paroxetine, and trazadone for $4/month
http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf
- Target supplies baclofen, cyclobenzaprine, & naprosyn in addition to
Walmart list for 4/month.
http://sites.target.com/site/en/health/generic_drugs.jsp?sort=alpha
- Grace Hill supplies Keppra, Topamax, and Lamictal for $4/month
- John C Murphy supplies Topamax and Lamictal for $2/month

Ordering Outpatient Studies:

- VEEG, Ictal SPECT, MEG – Task “NLE:EMU Sec Team” on Touchworks,
or call x27174.
- Epilepsy Surgery Conference – Task Kathy Goggio on Touchworks to set a
date to present your case.

7  
 
- Sleep Studies – See instructions posted on the Neurology Resident Website
- All other studies just fill out specific forms at clinic

Guide for creating notes and ordering prescriptions in the attending

clinic

When seeing patients in the BJH Neurology Resident Clinic the resident is the
owner and BJ Neurology is the note type. However, when rotating through a
faculty specialty clinic the attending is the owner of the note. It is very
important to create your note correctly from the beginning so that your work
does not need to be repeated!
When residents create a note for the physician in the physician’s specialty
office, they need to select the encounter in the physician’s name from the
physician’s schedule. This note has an encounter created by the resident.
You can tell this is an encounter created by the user because the encounter
type is Office Visit instead of Appointment Encounter.
If a resident gets to this screen and the physician’s appointment encounter is
not listed at the top right of the note selector the resident needs to hit the
binocular icon and search for the physician’s appointment encounter.
The resident ALWAYS needs to search for the specialty name for which they
are working that day. All of Adult Neurology starts with NL-. The visit types
are tied to the specialty so the drop downs are defined by the specialty. This
is why it is very important to select the correct specialty when creating a note.
The owner should ALWAYS be the attending physician.

How to start a new structured note for a new patient visit:

Please choose the following: Specialty: NL–Stroke, NL–Multiple Sclerosis,
NL–Spinal Cord, etc. Visit type: Note – new patient, Note – established
patient, etc.
Owner: attending physician name.

How to copy forward a previous note: If you use “copy” to copy a note from
a previous visit: BE SURE THE DATE OF THE ENCOUNTER (VISIT) is
TODAYS DATE!!! When the note is complete, sign the note; which forces a
task to the attending physician. NEVER FINALIZE A NOTE. THE
RESIDENT SHOULD NEVER ADD THE TEACHING STATEMENT-
ONLY THE TEACHING PHYSICIAN CAN ADD THE TEACHING
STATEMENT AFTER THE RESIDENT HAS SIGNED THE NOTE AND
BEFORE FINALIZING THE NOTE.

How to write a prescription: When creating a prescription, the Attending’s

name should ALWAYS be listed as ORDERED BY: “Attending Name.”
Please make sure the Attending’s name is in the box as “ORDERED BY”
AND “MANAGED BY”. When printing a prescription in the Specialty
Clinics, make sure the Document type is Script-NL when you get the print
dialog box. Contact the attending physician you are working with if you have
questions. When printing a prescription in the BJH Neurology Resident
Clinic, the Document type should be Script-BJH NL.

8  
 
 DIDACTICS SCHEDULE
* Please note that dates, lectures, or speakers are subject to change.

Weekly Didactics:

Day Mon Tue Wed Thu Fri

Morning Morning Grand
AM Report Report rounds/
(bedside) (chief) CPC
Journal EEG/
Noon QI Stroke/ Club EMG/
CNS CNS L&L

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Clinical Neuroscience Lecture Series 2014-2015:
Location is West Pavilion Auditorium unless otherwise
indicated by text page on the day of conference

DATE TOPIC SPEAKER

WED 07/02/14 Billing and Compliance Julie
Lackey
WED 07/09/14 Neuroradiology: CT overview Shimony
WED 07/16/14 Ethics & New Innovations Evaluations Snider
WED 07/23/14 Neurological Examination Pestronk
TUE 07/29/14 Sleep & Fatigue deBruin
WED 07/30/14 Neuroimmunology 1 Cross
WED 08/06/14 Neuroimmunology 2 Wu
WED 08/13/14 Neuroimmunology 3 Parks
WED 08/20/14 EEG in Epilepsy Maccotta
WED 08/27/14 Intro to Epilepsy and Status Eisenman
Epilepticus/Non-epileptic events
WED 09/03/14 Neuroradiology:MRI overview Shimony
WED 09/10/14 Neuropharm: Antipsychotics (Out Of Eric Lenze
Town) - OPEN
WED 09/17/14 Neuropharm: Antidepressants Eric Lenze
WED 09/24/14 Cerebral Blood Flow & Metabolism Derdeyn
WED 10/01/14 Neuroradiology:Angiography D. Cross
WED 10/08/14 Neuro-oncology Campian
WED 10/15/14 Hold for Dr. Tran
WED 10/22/14 Hold for Dr. Tran
WED 10/29/14 Imaging and Treatment of Traumatic Brody
Brain Injuries
WED 11/05/14 Refractory Epilepsy/Epilepsy Surgery Hogan
WED 11/12/14 Neuro-toxicology Mullins
WED 11/19/14 Evoked Potentials Dan
Sweeney
WED 11/26/14 Cancelled due to holiday
WED 12/03/14 Resident Town Hall Chiefs/Dr.
Snider
WED 12/10/14 Neurogenetics Jeopardy Gurnett
WED 12/17/14 Neuropathology & Molecular Sonika
Diagnosis of Gliomas Dahiya
WED 12/24/14 Cancelled due to holiday
WED 12/31/14 Cancelled due to holiday
TUE 01/13/15 Neuromuscular: Antibody Testing Lopate
WED 01/14/15 Neuromuscular Diseases – Harms
Pathophysiology and Treatment
TUE 01/20/15 OPEN – Stroke Conference?? Check
with Francesca
WED 01/21/15 Neuromuscular: Muscle and Nerve Pestronk
Biopsy
TUE 01/27/15 The Cerebral Venous System: Goyal
Anatomy, Pathology, Evaluation and
Treatment
WED 01/28/15 Neuromuscular: Principles of Pestronk

10  
 
 Diagnosis in Neuromuscular Disease
WED 02/04/15 Movement Disorders 1; PD, ET; Criswell
clinical manifestations, pathology and
differential diagnosis
TUE 02/10/15 Movement Disorders 3: Botulinum Racette*
Treatment
WED 02/11/15 Movement Disorders 2: PD treatment   Ushe
WED 02/18/15 Movement Disorders 4: Neurologic Perlmutter
Voice Abnormalities  
TUE 02/24/15 Alzheimer’s Disease Morris
WED 02/25/15 RITE Review Snider
FRI 02/27/15 RITE EXAM IS TODAY
WED 03/04/15 Cognitive Deficits and Their Recovery Corbetta
(including aphasia, neglect) – Part 1
TUE 03/10/15 Cognitive Deficits and Their Recovery Corbetta
(including aphasia, neglect) – Part 2
WED 03/11/15 Sleep Disorders Overview Lucey
WED 03/18/15 Motor Recovery Carter
TUE 03/24/15 Complications of HIV Clifford
WED 03/25/15 Pharmacotherapy of Insomnia deBruin
TUE 03/31/15 Subarachnoid & Intracerebral Dhar
Hemorrhage
WED 04/01/15 Memory Systems of the Human Brain Petersen
WED 04/08/15 Dementia: Basic Science Holtzman
TUE 04/14/15 Neuro ID   Clifford
WED 04/15/15 Non AD Dementias Ghoshal
WED 04/22/15 Clinical Management of Brain Tumors Tran
(AAN – May cancel conference)
TUE 04/28/15 Overview of Neuro-ophthalmology G
VanStavern
WED 04/29/15 Neurofibromatosis Gutmann
WED 05/06/15 Molecular & Biochemical Basis of Lee
Ischemic Brain Damage
TUE 05/12/15 Neuro-ophthalmology – Visual Fields G
VanStavern
WED 05/13/15 Practical Anatomy and Physiology of Goebel
the Vestibular System
WED 05/20/15 Diagnosis and Treatment of the Goebel
Vestibular System
TUE 05/26/15 Nystagmus and other strange eye G
movements VanStavern
WED 05/27/15 Paraneoplastic syndromes Al-Lozi
WED 06/03/15 Peds: Clinical Aspects of Neurological Noetzel
Malformation
TUE 06/09/15 Peds: Newborn Neurology Smyser
WED 06/10/15 Peds: Language and Child Larsen
Development  
WED 06/17/15 Neuropharm: Anti-Epileptics Day
TUE 06/23/15 Peds: Neuromuscular Disorders 1 Connolly
WED 06/24/15 Neuroradiology:Neuroncology Vo
TUE 06/30/15 Peds: Pediatric Onset White Matter Soe Mar or
Diseases or Kristin
Peds: Pediatric Stroke Guilliams

11  
 
Useful Neurology websites:
American Academy of Neurology Practice Guidelines
http://www.aan.com/go/practice/guidelines
Becker Library (link to several textbooks and journals):
https://becker.wustl.edu/
Functional patients: www.neurosymptoms.org
Stroke center (neuroimaging collection is useful)
http://www.strokecenter.org/radiology/
WUSTL neurology website (Red Book, schedules, goals and objectives, etc)
www.neuro.wustl.edu
WUSTL neuromuscle (very useful for NM disease)
http://neuromuscular.wustl.edu/
You can find the updated schedule of all neuroscience lectures at:
http://neuroscienceresearch.wustl.edu/Event.aspx
Check MR compatibility of devices:
www.mrisafety.com
AND Dr. Virginia Simon highly recommended:
www.google.com

12  
 
 NEUROLOGICAL EXAM &
NEURROANATOMY

Cutaneous Fields of Peripheral Nerves & Dermatomes

Anterior View

13  
 
Cutaneous Fields of Peripheral Nerves & Dermatomes
Posterior View

14  
 
Brachial Plexus
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

15  
 
LumboSacral Plexus
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

16  
 
Top: Cavernous Sinus Anatomy; Bottom: Visual Field Defects
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

17  
 
Brain Stem Nuclei

18  
 
 19  
 
Mini Mental State Examination (MMSE)
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

20  
 
Montreal Cognitive Assessment

(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

21  
 
 22  
 
 DIAGNOSTIC STUDIES
Lumbar Punctures

Be sure to document a procedure note in Compass. All LPs during the day
should be staffed by an attending. If the LP was supervised, indicate that
accordingly and make that person a co-signer on the note.

Key Points for Performing a LP on Neurology

Always review patient data for contraindications:
- Ideally, platelets should be >50,000 and INR should be <1.5.
- Be sure to review the head CT prior to performing the LP for causes of
increased ICP.
- Dual antiplatelet therapy with aspirin and Plavix increases the risk of the
procedure.
- Always consent the patient.
- To order labels/print requisitions, type “CSF” in Compass and select the
studies you want. For cytology, select the “Cytology (Non-GYN)” order. A
requisition will print out on the printer. Flow cytometry can be ordered as a
miscellaneous lab. Print a “Save CSF” label and either collect a separate tube
or include the label with the tube that goes to microbiology.
Preparation: Prior to starting, gather what is not in the LP kits: sterile gloves,
extra lidocaine (only 2mL is in the kit; request additional lidocaine from the
patient’s nurse), Sprotte needle or other special spinal needles (for obese
patients, a 22 gauge 5 inch spinal needle is available in the 11400 supply
closet), betadine bottle (never use chlorhexidine as it is neurotoxic), extra
gauze (only 2 2x2 are in the kit), tape, extra containers for cytology and other
situations when extra spinal fluid is needed (there are four 10ML tubes in the
kit).
Sprotte needles are preferred on neurology because of lower risk of post-LP
headache. They are located in the nursing supervisor’s office on 11500. Ask
the charge nurse to let you into the office after hours.
Make sure to place the yellow sticker from the LP kit on the card on the
patient’s door.
Procedure: For a detailed LP procedure, refer to the website:
http://neuro.wustl.edu/files/1213/1489/8678/LumbarPunctureGuide.pdf
- If you are alone, open extra lidocaine prior to putting on sterile gloves, so
you can access it in sterile fashion.
- Cap and mask. Wash hands, glove, sterilize the field, and drape. Don’t forget
to perform a Time Out.
- After donning sterile gloves, arrange your tray. Open tubes and stand them
up for easy access.
- To measure opening pressure correctly, patients should be in lateral
decubitus. Hold the needle in place while they extend their legs. Have them
relax before reading the final measurement.
- In a morbidly obese patient or if an opening pressure is not needed, it is
helpful to perform the LP with the patient seated.
- Label all tubes. All labels must be initialed and dated/timed by you.
- Hand deliver all CSF to the specific lab (see chart below). Failure to hand
deliver CSF (i.e. nurse transport, tubing, lab transport, dropping labs off at

23  
 
 central distribution, etc) have all resulted in lost CSF in the past. It is difficult
to explain to a patient that you must place another needle into their back
because CSF was lost.
- If you are sending 14-3-3/tau for CJD, notify the lab by calling customer
service (2-1420) and also notify the technicians at the time of delivery. There
are orange stickers in the 11500 charge nurse office for the CSF tubes, and all
waste should be disposed of in special red biohazard bags marked “suspected
CJD” (charge nurse can help with this). Tests cannot be added on to CSF that
has been flagged as potential CJD. CSF that is being tested for CJD cannot be
sent for cytology due to risk of contamination.

Where to take the tubes: Refer to the table, to determine where each lab goes.
You will need to send separate tubes to each lab, but you can order multiple
labs on the same tube as long as all they are performed at the same place
(except separate cell counts). Deposit the extra lab labels in a bag with the
labeled tube. Call 2-1470 with specific questions:

Test Tube Location/Instructions

Cell Count/Diff 1&4 Hematology
Glucose/Protein 2 Chemistry
Gram stain and cultures 3 Microbiology
Trotter Studies/MS 2 Chemistry. Also order Trotter
Profile (CSF/Serum) studies from blood (red top tube) at
the same time as LP is performed.
Viral PCR studies 3 Microbiology
Arbovirus Panel 3 Microbiology
VDRL 1 or 4 Hematology
FTA-Ab 1 or 4 Hematology
ACE level 2 Chemistry
Cytology* Extra Surgical Pathology/3rd Floor
Flow cytometry* Extra Hematology
Chemistry (send-out) notify
14-3-3/tau 2 customer service prior to bringing
down the sample and notify the
technician upon delivery to the lab.
NMO Antibody 2 Chemistry (send-out)
Save CSF 3 (or extra) Microbiology

* Cytology/flow cytometry can only be done on weekdays before 3 pm.

Fluoro-Guided LP

Most of the time neuroradiology won’t do them unless: 1) Bedside LP has

been tried and failed, 2) the patient has an anatomic defect, like rods in their
back, 3) the private attending specifically asked for it, and/or 4) the patient
needs significant sedation.
- Neuro-radiology will almost never perform a lumbar puncture on a patient
on aspirin and Plavix.
- Order in COMPASS: “LP (Lumbar Puncture by Neuro Radiology)”

24  
 
- Neuro-radiology will collect a minimum amount of spinal fluid. If you
require more than 2-3 ml per tube, you should discuss it with neuroradiology
and indicate in the notes section of the requisition to indicate the number of
tubes that you need and the volume that you require.
- The CSF will be returned to the floor with the patient, taped to the front of
the chart. You are responsible for sending the CSF to the lab.

EEG

Place orders in Compass. Ambulatory EEGs are for outpatients; for inpatients,
specify “routine,” “stat,” or “continuous video EEG monitoring.”
EEGs should be reviewed by you personally for your education. The key for
the EEG suite is in the 11400 pyxis (ask any nurse to get it for you) if you
need to get in during off hours. Keep the key in your pocket, as the door will
lock automatically.
Routine EEG: if ordered before ~ 3:30 PM, it should be done the same day.
Call the EMU (7-0788) to verify it’ll be done if the order goes in late and it is
important. Readings generally come up in ClinDesk after 5PM; go check in
the EMU suite if you don’t see it there by the next day.
Day Time Stat EEG: Put the order in Compass (sometimes the ED will order
in HMED but sometimes you have to put the order in Compass), and call the
monitoring room and tell them what you want. In case you can’t get in touch
with anyone fast you can page the on-call EEG Tech’s pager (call the
operator). All stat EEGs need to be read by a neurologist at the time of the
test; generally speaking, if you order it, you read it. The tech will page you
once the EEG is running.
Weekend and Night Stat EEG: Stat EEGs should be ordered only if it will
urgently change management. You should always discuss with your chief
before ordering a stat EEG. If someone is obviously seizing, don’t wait for the
EEG, just treat the seizure! Only done for cases when we suspect status
epilepticus. Call the operator to page the EEG tech on call. Let them know the
patient’s information and that you will be reading the EEG. They will call you
once the EEG is hooked up; you must go and read the EEG promptly. If you
have questions about the EEG, call your chief or the epilepsy fellow on call.
Continuous EEG monitoring: Unless it is a scheduled admission in the EMU,
you should not order a continuous EEG without discussion with the chief.
You or the chief will need to discuss with the EEG fellow/attending whether
equipment is available, before you can order it.
Routine EEGs on weekends: Routine studies on inpatients on the General
Neurology and Stroke services can be ordered between 0800-1200 on
Saturday and Sunday and will be completed between 0800-1630. Reads
should be available the next day. Stat EEGs should not be ordered on the
weekends purely to facilitate disposition.

EMG/NCS

Use the order set in COMPASS. Always check the box indicating that
“relevant studies to be determined by physician in charge”. Make sure to
indicate your specific question on the order form. Patients who are
coagulopathic may not get their study until their INR is <1.4. Make sure the

25  
 
patient is stable enough to go to the CAM (mobile studies are only done for
ICU patients). If you write for one over the weekend or late at night, call the
following weekday morning to see that the order went through. Handwritten
results will be in the chart with the patient, and official results need to be
requested from EMG or can be referenced in Allscripts after several weeks.

CT

Place the order in Compass (nearly always without contrast). For STAT head
CT call CT reservation desk first (otherwise, it will not be done). For most
stat CTs, you should personally accompany the patient to the scanner with a
nurse. For CT reading, call the neuroradiology reading room (2-2562) during
business hours (8-5) and ER reading room (8-6895) during non-business
hours.
Read all your own CTs, especially during off hours when the ED radiology
resident is reading the scans. In addition to looking for hyperdensities
concerning for bleeding, look for early signs of ischemia including sulcal
effacement, loss of the gray-white differentiation, insular ribbon, obscuration
of the lentiform nucleus, or a hyperdense vessel sign. Other things to look for
include hydrocephalus and subdural hematoma.

MRI

Common MRI sequences:

• T1: like anatomy; i.e. gray is gray, white is white, & CSF is dark.
• T1 with contrast: compare with T1 without contrast. Bright areas represent
areas of disruption of BBB (tumor, hematoma), look specifically for (lepto-
or pachy-) meningeal enhancement.
• T2: H2O is bright (CSF is white, fat is black), good to see vessels which
should be black unless thrombosed.
• FLAIR: Like T2, except CSF made dark. Best for seeing pathology. Very
nice resolution
• STIR: Like T2, CSF and fat are dark. Mainly used in the spine imaging.
• T2*, GRE (gradient echo): All blood, including acute and chronic, are
black. Blooming artifact.
• SWI: similar to T2*, except may be better at showing acute blood.
• DWI (Diffusion weighted imaging): CSF is dark, low resolution; Cytotoxic
edema (i.e. stroke) is bright; Things that are bright on T2/Flair will “shine
through.”
• ADC: CSF is bright, low resolution; Cytotoxic edema (i.e. stroke) is dark.
Use ONLY to confirm that DWI-bright area is truly due to diffusion
restriction.
• PWI (perfusion weighted imaging): Usually used for evaluation of tumor
recurrence vs. radiation necrosis. Can be used to determine penumbra
(Pefusion-Diffusion Mismatch).
• MRA (MR angio): several different types, some requiring contrast and
some not (such as time of flight; TOF). Always look at source images.
• MRV (MR venogram): good ones generally require contrast. Use to look
for venous thrombus.

26  
 
• Diffusion Tensor Imaging (DTI) and tractography: Not routinely reported,
used for pre-surgical planning.
• MR spectroscopy (MRS): Not a routine sequence; added value in
differentiation of recurrence of tumor vs. radiation necrosis, and metabolic
workup in pediatrics.

Order the MRI in Compass with the body part to be imaged (usually brain
and/or some combination of cervical, thoracic and lumbar spine). Include the
reason for the study because different suspected etiologies require special
protocols (see below). Decide whether contrast should be used; It most often
is unless the patient cannot tolerate it due to allergy or poor renal function.
Order angiography (MRA) or venography (MRV) when indicated. An MRI
screening form must be completed and faxed immediately to Radiology to
exclude MRI-incompatible implants. The MRI will not be completed until this
form is sent, and often you will not know until you inquire!
MRI scheduling is difficult to predict. If you need a stat MRI for stroke, order
the MRI under a hyperacute stroke protocol and call the Neuroradiology
reading room, or if after hours, the fellow (see separate guide for stroke
protocols for the current contact numbers). Again, Make sure to ask RN to
complete the screening form ASAP and fax to Radiology to avoid delays. You
can find out about your patient’s MRI time at x21672 . To find out when a
patient will go to MRI, call 2-1636 and select option 2 for the secretary.
Because ER cases take priority, do not count on a specific time. In all cases,
offer to wheel down the patient.
Protocols: If you want a certain sequence, make sure you specify it. This is
especially important for ED consults and spine cases (if contrast is needed
which often is the case). Please remember that good communication with
Neuroradiology and the MRI technician as well as relevant history and
clinical suspicion can avoid a multitude of problems. Commonly used
protocols and their special features are the following:
• Stroke: DWI & ADC, as well as T1, T2, FLAIR, and SWI. Contrast
assists in assessment of stroke age.
• Hyperacute stroke: DWI & ADC, FLAIR, and SWI. Without contrast.
• Epilepsy: Fine coronal temporal lobe FLAIR sections. With Contrast.
• MS: Sagittal FLAIR. With contrast.
• Carotid Dissection: Neck MRA + (T1 fat saturated). Acute intramural
hematoma is best seen in non-contrast T1.
• Central Venous Thrombosis: MRV
• Tumor: pre and post contrast T1.
• Orbit: Cranial nerves 1-3. With contrast.
• Internal auditory canal: Cranial nerves 4-12. With contrast.
• CSF flow: assess CSF flow through aqueduct and/or foramen magnum.
• Brachial plexus. With contrast.

When in doubt, write out all the sequences you want and/or discuss with the
neuroradiologist and technician. You can also call neuroradiology to get a list
of current protocols and to find out which would be most appropriate for your
patient in unusual cases.
Read all your MRIs yourself. If you need an overnight read from neurorads
call their on-call fellow at 508-3767. You can review outside films or difficult

27  
 
imaging with neuroradiology on the 3rd floor of Mallinkrodt. They also always
appreciate it if you can bring in prior imaging from outside hospitals.

Contra-indications and complications:

- Pacemakers, defibrillators, eye or cochlear implants, orthopedic hardware,
metal of any type may prohibit MRI. If a patient does have any metal or
implant, discuss directly with the radiology fellow or attending before the
patient goes down for the scan and then discuss with the MRI technician to
prevent the patient from being sent back without a scan. Patients and their
families can be helpful in tracking down the brand/model of a device. You can
find detailed MR compatibility of instruments on the website: mrisafety.com
- Make sure you ask the patient whether he/she is claustrophobic. A small
dose of PRN Lorazepam can be ordered “on call to MRI.” Consider PO
because IV medication of any type requires the conscious sedation sheet to be
filled out, and continuous monitoring during the scan. Any IV medication
requires the nurse to travel with the patient. Remember, being courteous and
prompt in this respect will make things easier (consider PO/SL medication if
appropriate). If a patient is elderly, has COPD or has any other risk of
hypoventilation or hypotension, be cautious. With very agitated or
claustrophobic patients, you will need to call anesthesia to arrange for
sedation; this may take several days until their schedules permit.
- A complication from gadolinium contrast (nephrogenic systemic fibrosis ;
NSF) has been identified in people with renal insufficiency. Contrast will not
be given to people with creatinine clearance less than 30 (but half dose
contrast is an option with Cr Cl 30-60; discuss with neuroradiology).

Stages of Blood T1 T2 Mnemonic

< 24 h Iso Bright I Bleed
1-3 days Iso Dark I Die
3-7 days Bright Dark Bleed Die
7-14 days Bright Bright Bleed Bleed
> 14 days Dark Dark Die Die

Outside Imaging Studies

Upload all relevant outside imaging from the CD to lila.carenet.org as soon as

possible (i.e. as soon as you get the disc) as it can take some time for images
to be pushed to ClinDesk. Most scans can be uploaded for “reference” only
and do not require a “consult.”

Carotid Duplex Scan/Doppler Ultrasound

Order carotid duplex scans in Compass. This test is done in the Vascular lab.
The preliminary results are hand-written in the chart in the Notes section.
When a patient needs carotid dopplers over the weekend, page the Vascular
fellow. Reserve weekend scans for a patient who would be a candidate for
urgent endarterectomy or other significant plan change based on the results.

28  
 
 Cerebral Angiogram

Place order for “cerebral angiogram” in COMPASS, clearly stating the reason
for the study, then call interventional neuroradiology at x22584 with the
patient information. Studies are occasionally done same-day, but typically
should be ordered the day before. For stat, weekend, or night orders, call the
Neurointerventional Fellow at 314.766.4482. This is rarely done. Preliminary
results are hand-written in the chart and the dictated report is up in Clindesk
within a day
Preparation:
- NPO after midnight
- IV fluids (hydrate well, particularly in elderly and those with renal failure)
- Premedicate with Benadryl/Prednisone if IV dye allergy (follow order set in
Compass).
- AM labs: PT, PTT, CBC, BMP
- If renal insufficiency: consider Muscomyst 600mg PO bid x2days starting
1day before the procedure, or 3 amps (150 mEq) sodium bicarbonate into 1L
D5W, given at 3mL/kg x1hour prior to the procedure, then 1ml/kg/hour
x6hours afterwards.

CT Myelogram/Ventriculograms

These are quite uncommon but neurosurgery sometimes asks for them.
Remember you can get CSF from this study and can ask radiology to get some
fluid for you while they are at it. You order this in COMPASS. Similar to
fluoro-guided LPs, you will need CBC and coag values. Contrast allergies and
renal protection should be addressed the same as for angios.
Patients need to be NPO past midnight. Most important: there is a long list of
meds that can theoretically lower seizure threshold and the patients must be
off of them for at least 48 hours or they won’t do the study. This includes
SSRIs, TCAs, and a number of others. If you’re not sure, ask, because finding
out after they reject the patient and make you wait an additional 48 hours is a
big pain.

Cisternograms

Sometimes this study is used to look for evidence of NPH. You can get CSF
for studies with these, too. The problem with this test is that two different
divisions are involved in arranging it (neuroradiology and nuclear medicine).
Also, they need to have the tagged radionucleotide molecules available, which
sometimes requires 2-3 days to arrange.

Transthoracic Echocardiogram

These are done Monday to Saturday. Results are posted in Clindesk at the end
of the day usually. You can call the reading room if it is not.

29  
 
 Transesophageal Echocardiogram

Patients need to be NPO overnight or at least 6 hours, and cannot be

coagulopathic. Call the TEE fellow (424-9930) if there are specific concerns.
Most of the time they want a TTE before the TEE, unless the patient has a
mechanical valve or known history of endocarditis. Discuss the procedure
beforehand with the patient so they will understand they will need to be
sedated and have the TEE probe advanced down the esophagus.

Lower Extremity Venous Dopplers

These are done on the vascular lab on the 5th floor of Queeny tower on
Monday through Friday. Results are hand-written into the chart, and show up
in Clindesk a week or so later. We typically order these on immobile patients
hospitalized for 7-14 days.

30  
 
 STROKE
Cerebral Vasculature  

31  
 
  

32  
 
  

33  
 
 Stroke syndromes  
S troke  S yndrome Vessel S igns
 
AC A C ontralateral   h emiparesis  a nd  s ensory  loss  (leg>arm);  
abulia;  a kinetic   m utism;  p aratonia;  a praxia;  u rinary  
  incontinence;  transcortical  m otor  a phasia

MC A C ontralateral   h emiparesis  a nd  s ensory  loss  (face,  

arm>leg);  c ontralateral   h emianopia;  a phasia;    a praxia;  
  extinction;  n eglect
PC A C ontralateral   h emianopia  with  m acular  s paring;  
contralateral  s ensory  loss  (thalamic);  a lexia  without  
  agraphia  (dom   h emisphere);  isolated  a chromotopsia

Anterior  C horoidal   Anterior  C horoidal  o ff  IC A C ontralateral   h emiparesis;  c ontralateral  s ensory  loss;  
(posterior  limb  o f  IC ,   homonymous  h emianopia  s paring  h orizontal  m eridian
thalamus,  L GN)
 
Dejerine-­‐R ussy Thalamo-­‐g eniculate   a rtery  off  P C A C ontralateral   s ensory   loss   (acute);  s evere  d ysesthesia  
(Thalamic  p ain  s yndrome) (later);   transient  c ontralateral   h emiparesis;  
  choreoathetoid,   b allistic  m ovements

Anterior  T halamic Polar  a rtery  o ff  P C omm Abulia;  a pathy;  d isorientation;   c ontralateral  e motional  
facial  p aralysis;  rare  h emiparesis

Paramedian  T halamic  
Perforating  a rteries  o ff  P C A   S omnolence;  transient  L OC ;  m ood  d isturbance;  v ertical  
(also  A rtery  o f  P ercheron  infarct   gaze   a bnormalities;   a bnormal  s leep;  thermodysregulation
for  b ilateral  p aramedian  
thalami)
 
L acunar   L ocation Ass ociated  S igns
S yndrome
 P ure  s ens ory   T halamic  VP L ;  IC ;  c orona   Without  weaknes s
los s radiata;  s ubthalamus ;  
midbrain,   p arietal  c ortex

 Phemipares
ure  
is
IC ;   c orona  radiata;   b as is  
pontis ;   m otor  c ortex
Without  s ens ory  los s

C lums y  hand-­‐ G enu   o f   IC ;   b as is   p ontis ;  IC ;   S upranuc lear  fac ial  

dys arthria c erebral   p edunc le;  putamen pals y;  tong ue  deviation;  
dys arthria;   d ys phag ia;  
los s   o f   fine   h and  motor  
s kills
A taxic   P os terior  limb   o f   IC ;   b as is   C ontralateral  
hemipares is pontis ;   r ed   n uc leus ;   hemipares is ;  ips ilateral  
lentiform     n uc leus ;   ataxia
s uperfic ial  A C A
Unilateral   S ubthalamic   n uc leus C ontralateral  
hemiballis mus hemiballis mus

34  
 
 Brainstem syndromes  
Brainstem   Vessels Location Findings
S yndrome
Parinaud Basilar Dorsal   m idbrain Vertical   g aze   palsy;  c onvergence   retraction  

Weber
 
Ventral   m idbrain,   C NIII,  
nystagmus;   e yelid   retraction
Ipsilateral   III   palsy;   c ontralateral  hemiparesis
CST

Benedikt Ventral   m idbrain,    C NIII,   Ipsilateral   III   palsy;   c ontralateral  hemiparesis;  

C S T,   red   nucleus contralateral   a taxia

Top   of  the  basilar Occipital   lobes,   m  edial   Visual   a nd   oculomotor   a bnormalities;   hallucinations;  
temp   lobes,   midbrain,   behavioral   a bnormalities;  s omnolence;   motor  deficit  
cerebral  peduncles;   usually   s pared
  thalamus
One-­‐a nd-­‐a -­‐half Paramedian   p ons Ipsilateral   C N  V I   palsy;   c ontralateral   INO
 
Millard-­‐G ubler Ventral   p ons ,   C NVI,  V II,   C ontralateral   hemiplegia   s paring   face;   ipsilateral  
CST C NVI  palsy;   ipsilateral  C NVII   palsy   (peripheral)
 
Foville   Ventral   p ons ,   C NVII,   C ontralateral   hemiplegia   s paring   face;   Ipsilateral  
PPR F C NVII   palsy   (peripheral);   inability   to  look   towards  
  side   of   lesion
Marie-­‐F oix Lateral   p ons ,   middle   Ipsilateral   a taxia;   c ontralateral   hemiparesis;   v ariable  
  cerebellar  peduncle contralateral   pain/temp   loss

Medial   medullary Vertebral/Anterior   C S T,   medial   leminiscus,   Ipsilateral   C NXII   palsy;   c ontralateral   hemiparesis;  
spinal/Basilar C N   X II contralateral   s ensory   loss
 
Lateral   medullary Vertebral/PIC A S TT,   trigeminal   nucleus,   Ipsilateral   H orner’s;   ipsilateral  limb   a taxia;   ipsilateral  
inf   c erebellar   peduncles,   pain/temp  loss  in   face;   c ontralateral  pain/temp   loss   in  
  vestibular   nuclei,   nucleus   body;   nystagmus;  dysarthria;   dysphagia;   hemiparesis  
ambiguus usually   s pared

**Acute Stroke Protocols: Please see

separate Stroke Cards**  
 

35  
 
 Inpatient Stroke Management
Generally, post-tPA patients, drips and ships from OSH, non-ICU patients
with hemodynamic or cardiac rhythm instability or intense respiratory care,
those needing close monitoring q2h neuro checks, and patients recently
moved out of the ICU get admitted to Step Down Unit on 10500. All other
non-ICU patients go to the floor. For every SDU patient, ask yourself every
day if he/she still has Step Down needs; if not, place transfer to floor order
early after discussing with Stroke Chief.

With every stroke admit, ask yourself: does this patient have a stroke or TIA?
If so, where is the stroke? Why did he/she have a stroke? How can I prevent
complications from the stroke? And how can I prevent a future stroke? Tailor
your tests and care accordingly and use evidence where possible.

Admission Orders
- Use the Compass stroke order set.
- Vitals: q4h for the first 24h, more frequent if large or posterior circulation
stroke. Permissive hypertension is OK after stroke; treat for MAP >130 for
ischemic stroke or MAP >110 for hemorrhagic stroke. PRN antihypertensive
orders can be found on the post-tPA order set (hydralazine if relatively
bradycardic, otherwise labetalol).
- Activity: Everyone needs an activity order so therapy can work with them.
Make sure to order fall precautions in patients with altered LOC or gait
difficulty. Ad lib – only patients with extremely minor deficits. Up with
assistance – almost everyone. Bedrest – 12h post-tPA (after that can be up
with assist for therapy eval), post procedures. Call PT/OT/ST at the beginning
of the day to prioritize patients pending discharge.
- DVT prophylaxis: Most stroke patients get Lovenox 40mg s.c. daily. Use
heparin for patients with renal failure or hemorrhage. Start DVT prophylaxis
24 hours after tPA. Make sure to adjust doses for obese patients. Order SCDs
and TED hose for everyone unless they have a known DVT.
- Nursing: Discontinue Foleys wherever you find them.
- Diet: The nurses automatically will do a bedside dysphagia screen. If
patients fail, speech therapy must evaluate them prior to allowing them to
have a diet.
− IVF: For most patients, maintenance IV fluids will be normal saline at about
1 – 1.5 ml/kg/hr. Patients who are NPO need D5 added to their fluids. Do
not use hypotonic fluids unless specifically instructed to do so by a senior or
attending.
− SMART consult: Everyone who has TIA, ischemic stroke, hemorrhagic
stroke, SAH, and CVT needs this order.  
 
Labs
- BMP, HFP, CBC, PT, PTT, troponin x 2 and, UA/micro/Cx, urine drug
screen, HIV and RPR (attending dependent), Hb A1c, fasting lipid panel
− If CT suggests embolic stroke, send blood cultures and consider empiric
antibiotics (discuss with the chief).
− In young patients, consider hypercoagulable workup (see below)

36  
 
Blood Pressure Management
- Management of home blood pressure medications is attending dependent. In
general hold home anti-hypertensives or give half the home dose. Do not
abruptly discontinue beta blockers, and be cognizant of diagnoses like CHF
that necessitate continuing ACEs. Nitrates probably should be continued. In
people with troponin elevations or EKG changes, discuss explicit MAP goals
with the chief.
- In the ICU, we follow MAPs; MAP’s of 120-130 are acceptable in ischemic
stroke. Alternatively, the most recent American Stroke Association guidelines
recommend treating SBP≥220 mm Hg or DBP≥120 mm Hg.
- Most patients should be restarted on some anti-hypertensive prior to
discharge. This will likely need to be titrated further by their PMD as an
outpatient.

Diabetes diagnosis and management  

- Order Accuchecks q4 hours (if NPO) or QID with meals, sliding scale
insulin for all diabetic patients.
- If patients are on home insulin, generally use half the home dose at least
initially. Patients’ diabetes is usually more controlled in the hospital due to
better diet control. Hold all oral diabetes medicines on admission and resume
oral diabetes medication at discharge
- Use caution in diabetic NPO patients – generally, they should have D5 in
their IV fluid
- For new diagnoses, consult the diabetes educator

Antiplatelets

1. Generally patients who are admitted with ischemic stroke or TIA will be
placed on ASA 325mg unless they are already on another antiplatelet. Hold
antiplatelets for 24 hours post tPA. For NPO patients, remember ASA
300mg can be given PR. Secondary prevention starts inpatient (see
Secondary Prevention table below for more info). If patients are on Aspirin
81mg at home, generally we place them on 325mg while in hospital and
lower the dose as an outpatient.
2. For those with recurrent strokes and already on one antiplatelet, consider
discussing switching antiplatelet with your team. Aggrenox has been shown
to have minor benefit over aspirin; Plavix has minor benefit over aspirin in
patients with peripheral vascular disease. Remember there is no evidence
for dual antiplatelet therapy being better than one alone for preventing
future stroke. Choice of antiplatelet will be attending dependent.
3. If patient is on an anticoagulant there is no need for antiplatelet unless it's
used for another reason (i.e. cardiac protection). Check with the prescriber
of either medication before stopping it. For secondary prevention
guidelines, see table below.

Statins: New ATP4 guidelines say that for all patients with a history of
cardiovascular disease or stroke, atorvastatin 40-80mg or rosuvastatin 20-
40mg should be given regardless of LDL level. Generally anyone admitted

37  
 
with stroke will be placed on high dose statin, but consider h/o side effects.
For outpatient primary prevention of diabetic patients aged 40-75 with LDL
70-189, without cardiovascular or stroke history, you can use lower doses of
statins or less intense statins.

Other studies

- Noncontrast head CT should be done in the ED. Look at this yourself. If a

patient is transferred from an outside hospital, look at their films and load onto
LILA when possible.
- MRI/MRA/MRV: Generally, the ward patients don’t get an MRI unless
there is something atypical about the presentation. Multiple vascular
territories, inability to localize the lesion, funny CT findings, questionable
seizure, prior deficit interfering with evaluation are all reasons to get an MRI.
MRA should be discussed on a case by case basis. When venous thrombosis is
suspected, MRV is done, usually on an urgent basis.
- Cerebral angiogram: This might be ordered to prepare surgeons for CEA
after suggestive carotid doppler results. It might be ordered for patients being
worked up for vasculitis, RCVS, or other vasculopathies. Consult with team
before ordering. NPO before midnight.
- CXR should be done in the ED as screen for infection, pulmonary edema,
and cardiomegaly.
- Telemetry on all stroke patients. Don’t forget to look at it every morning.
- TTE only for stroke patients who have an abnormal cardiac exam, telemetry
changes, EKG changes, CXR findings, positive troponin, or history of cardiac
disease, and have not had one in the past year. TEE to elucidate TTE findings
discussed with team first.
− Lower extremity dopplers: Besides clinical suspicion for DVT or
unexplained white count in an immobile patient, consider ordering it for
DVT as a cause for cryptogenic stroke in a patient found to have a PFO.
Carotid dopplers are for patients with anterior circulation strokes only, who
are possible candidates for endarterectomy (e.g. life expectancy >5 years).
See table for guidance below.

38  
 
TIA prognosis

The ABCD2 score is a risk assessment tool designed to improve the prediction
of short-term stroke risk after a transient ischemic attack. The score is
optimized to predict the risk of stroke within 2 days after a TIA, but also
predicts stroke risk within 90 days. The ABCD2 score is calculated by
summing up points for five independent factors. Scores ≥ 4 may benefit from
admission and expedited w/u.

Percentage risk of stroke by ABCD score.  

Reference: Johnston SC, Rothwell PM, Huynh-Huynh MN, Giles MF,

Elkins JS, Sidney S, "Validation and refinement of scores to predict very early stroke risk after transient
ischemic attack," Lancet, 369:283-292, 2007  
 

39  
 
Medical complications

- Edema: High risk patients are those with large strokes, posterior fossa
strokes, and young patients. Edema from stroke peaks at about 72hours, but
can be as early as a few hours and as long as 7 days. All stroke patients should
be on Q4hour neuro checks initially (consider q2 and transfer to stepdown or
ICU for large strokes and posterior fossa strokes). Patients with malignant
edema and clinical change may receive osmotic or surgical management. On
the floor, you can give mannitol as long as you have a plan to transfer to
higher level of care; discuss with chief before doing so. Do not give hypotonic
fluids to stroke patients without prior discussion with the team!

- Hemorrhage: Patients with intracranial hemorrhage go to the ICU or

stepdown unit for initial observation. Large and embolic strokes are more
likely to have hemorrhagic transformation. Patients who receive tPA are at
risk for hemorrhage, consider rescanning before starting any anticoagulation.
In any stroke patient, changes in the exam warrant a STAT noncontrast head
CT to exclude hemorrhage.

- Falls

- DVT/PE

− Atrial fibrillation: It's not uncommon to diagnose new Afib in stroke

patients or for them to go into RVR. Always confirm tele events with EKG.
Remember rate control agents: metoprolol, diltiazem, digoxin; consider
transfer to SDU/ICU if hemodynamically unstable. Involve Cardiology for
difficult to control Afib. For anticoagulation for secondary prevention,
consider warfarin vs. newer agents with reduced risk of bleeding
(dabigatran, rivaroxaban, apixaban). This will depend on the team, patient,
and insurance coverage. Wafarin for new Afib can be started without
heparin bridge.  
 
− MI: A higher than expected proportion of stroke patients have MIs. A
patient having an acute MI will need slightly more aggressive blood
pressure (and heart rate) control than the usual stroke patient. Some may
also need a heparin gtt. Involve Cardiology.

- UTI: Remove foleys as soon as you can to prevent UTI. Avoid quinolones
for treatment of UTI if at all possible due to risk of lowering seizure threshold.

- Pneumonia: Use appropriate aspiration precautions.

- Aspiration: Be aware of patient’s swallowing status. Keep at risk patients

NPO until formal speech evaluation. Make sure NG tubes are placed
promptly. In patients who will likely need G-tube, make sure to discuss with
family early and hold Plavix for 5 days prior to surgery. Both VIR and GI can
place G-tubes – VIR will do it faster.

40  
 
- Social: Keep the family closely informed of progress. Always address code
status with the patient (if able) and their families. Designate one family
member as the point person, and make a point to update them daily.
Placement at rehab/SNF, G tube, complications, etc are all difficult for
families to process, but much easier for them (and you) if they have been
informed all long.  

Disposition

Disposition depends on therapy recommendations. Check Compass for

therapy recommendations and discuss with Social Work as soon as you know
a patient will need to be placed in a SNF or rehab. Every stroke patient should
have follow-up scheduled. Those with private insurance can be seen in the
Stroke Clinic (x27382). Medicaid patients can follow up in Residents' clinic
(x29100 or x72110). Gateway or uninsured patients need a referral from their
PCP to Residents' clinic. For neurologists elsewhere in MO, refer to “Local
Neurologists” on our website:

http://neuro.wustl.edu/employee-info/neurologyresidents/usefulinformationandtools/

Below is a guideline for physician discharge summary of stroke patients:  

 
- Discharge Diagnosis / Stroke Details (Ischemic or ICH, Location: clinical
localization, CT or MRI, occluded vessel if imaging available)
- Stroke Etiology if readily identified (common or uncommon etiologies such
as hypotension, iatrogenic, dissection, genetic diseases, venous infarcts,
inflammatory conditions, Moyamoya, SCD, etc.); name occluded vessel(s) if
imaging obtained).
- Acute Stroke Treatment if applicable and available to you
- IV tPA: Time from Sx onset to treatment, Initial NIHSS, D/C NIHSS if
available or exam progression, complications. Don't forget the Stroke
Thrombolytic document in Compass for every stroke admit.
- Endovascular Rx: Type of Rx Time from Sx onset to treatment, Initial
NIHSS, D/C NIHSS if available or exam progression, Complications
- Heparin Drip: Reason for Rx and length, Plan for continued anticoagulation
(if any)
- Acute Stroke related medical complications and management, by system;
ICU details if applicable
- RISK FACTORS: Lipid Profile and Hgb A1c, Extracranial Atherosclerotic
Disease (modality and results), Intracranial Atherosclerotic Disease (modality
and results), Aortic/Cardiac Embolism sources (EKG, Tele, TTE, TEE),
Hypercoagulable states (list pertinent positive and negative labs)
- Secondary stroke prevention: Surgical (done or to be considered after
recovery), Antiplatelet agent or Oral Anticoagulation (reason for not
prescribing if indicated), Statin, DM education/consult if requested, HTN
regimen
- Non-Stroke Discharge Diagnoses (list by system, with management or F/U
details if consults were requested)
- Other relevant Brief Hospital Course

41  
 
- Discharge Exam or NIHSS if available
- Discharge Medications (indicated if new medication or existing/?dose
changed)
- Swallowing and Feeding status
- PT/OT/ST recommendations
- Recommended disposition / barriers / placement
- Stroke F/U plan
- PCP F/U plan: Often Case Managers can help set this follow up.

Remember, it's important to document why usually important and indicated

treatments are NOT given, especially antiplatelets, statins, and
anticoagulation.

Management of Carotid Disease

Symptomatic - Avg/low surgical risk 70-99% CEA within 2
- best if life expectancy >5 stenosis weeks
year of event
- Nondisabling stroke or when possible
TIA in last 6 months
- Perioperative risk of
stroke/death <6%
- Surgically accessible
lesion
- Avg/low surgical risk 50-69% CEA within 2
- best if life expectancy > 5 stenosis weeks
year of event
- Nondisabling stroke or when possible
- TIA in last 6 months
- Perioperative risk of
stroke/death <6%
- Male
Female 50-69% Medical
stenosis management
All patients <50% Medical
stenosis management
- Avg/low surgical risk 70-99% Consider carotid
- Surgically inaccessible stenosis artery stenting
lesion
- Radiation induced
stenosis
- Restenosis after CEA
- Patient <70 years old
- Periprocedral morbidity
and mortality < 4 and 6%
respectively
Asymptomatic - Avg/low surgical risk 60-99% Consider CEA
- life expectancy > 5 year stenosis
- Male
- Perioperative risk of
stroke/death <3%

42  
 
Etiology of stroke/Special considerations

Carotid disease
Remember that percentage of blockage is based on NASCET criteria from
angiography data. Carotid dopplers are the best screening tool for carotid
disease and are most sensitive in <50% ICA stenosis and 100% stenosis.
Carotid revascularization w/in 2 weeks of stroke or TIA is preferred over
delaying for 6 weeks or more. CEA preferred, more safe than carotid artery
stenting, but consider stenting when patient has high surgical risk, has
contralateral carotid occlusion, or has recurrent stenosis after CEA.

Cerebral dissection

Also rare and outcomes vary. Trauma is the most common cause. CTA may
be better than MRA for detecting intimal flaps, pseudoaneurysms, and high
grade stenosis. TPA has been shown in meta-analyses to be generally safe to
use in ischemic strokes caused by dissection. RCTs are lacking, and
management is attending dependent. Common practice is to initiate
anticoagulation in the acute setting, repeat angiography as an outpatient; if
dissection resolves, transition to antiplatelet.

Patent Foramen Ovale

CLOSURE 1 showed that PFO closure followed by ASA + Plavix for 6 mos
then ASA alone did not add benefit over medical therapy alone in preventing
stroke or TIA (NEJM 2012); RESPECT showed no benefit of PFO closure for
adults with cryptogenic ischemic stroke in intention-to-treat analysis but better
than medical therapy alone in as-treated analysis (NEJM 2013); PC trial
showed percutaneous PFO closure did not significantly reduce risk for
embolic recurrent events or death compared with medical therapy (NEJM
2013). When PFO present, perform LE Dopplers.

43  
 
Cerebral venous thrombosis

CVT is rare, but a higher clinical suspicion should be expected for strokes in
age <50 and women. Headache is the most common presentation, followed by
seizures, focal deficits, and encephalopathy. Anticoagulation is the main
treatment, and may be used even in the setting of mild ICH or hemorrhagic
transformation; tailor to individual patient and discuss with team. Recurrence
is low, but much higher in the setting of thrombophilias and systemic venous
thromboemboli.

AHA guideline on CVT. Stroke, 2011.

44  
 
Hypercoagulable work up

Thrombus location Hypercoaguable states

Inherited thrombophilias: Factor V Leiden,

protein C deficiency, protein S deficiency,
Venous prothrombin gene mutation,
antithrombin III deficiency,
high concentration Factor VIII, ENT infections

Antiphospholipid antibodies (cardiolipin,

lupus anticoagulant), homocysteinemia,
Arterial and/or dysfibrinogenemia, antithrombin III
Venous deficiency (homozygous), prothrombin
gene mutation, sickle cell disease, pregnancy,
malignancy

Consider hypercoagulable work up if patient has one or more of the following:

1. Repeated thrombotic events
2. Family hx
3. First event < 45
4. Unusual site (e.g. cortical vein thrombosis)

Suggested approach to hypercoagulable workup:

Tier 1
1. CBC/diff, PLT, coags, transaminases
2. Fibrinogen
3. SPEP
Tier 2
4. Protein C/S activities
5. Antithrombin III activity
6. Activated protein C resistance
7. Anti-phospholipid antibodies, including ß2-glycoprotein if high
suspicion
8. Lupus anticoagulant
9. ANA, RF
10. Homocysteine
11. Sickle prep / Hb electrophoresis
Tier 3 / Should refer for genetic counseling
12. Prothrombin G20210A mutation
13. Factor V Leiden mutation
14. MTHFR mutation (C677T)
Tier 4 / Should refer to Hematology
15. Chronic compensated DIC
16. Dysfibrinogenemia (thrombin time, reptilase time, fibrinogen
functional and antigen assays)
17. Plasminogen antigen and activity
18. Sepsis / cancer

45  
 
Confirmatory panel (after 12 weeks): will need to be repeated to confirm
persistent abnormality, if they were abnormal initially.
- Lupus anticoagulant
- APLAs
- Immunological assay of protein C/S, antithrombin (as appropriate)

Interactions/Caveats:
1. Heparin: Decreases antithrombin; interferes with some lupus anticoagulant
tests
2. Warfarin: Decreases protein C/S; can sometimes increase antithrombin (in
patients with deficiency)
3. Recent thrombosis (< 10 days): Consumes antithrombin and protein C/S;
increases factor VIII (acute phase reactant)

Outpatient issues/Secondary Stroke Prevention

Stroke rehabilitation
Most recovery of deficits occur by 3-6 months after stroke. Rehab is targeted
at adapting to disability.
1. Depression – FLAME trial showed fluoxetine 20mg daily started w/in 5-
10d of stroke regardless of diagnosis of depression improves motor
outcomes at 3 mos (Lancet 2011); depression is common and
antidepressants should be considered when indicated.
2. Therapy – Medicaid patients can get outpatient PT/OT/ST. You can also
refer patients to Muscles in Motion, a stroke exercise program. It is not free
but sometimes there are discounts. Look for brochures in the COH work
room. Consider AFO devices for foot drop, referral to medical supply store
for canes and walkers. Patients with worse than 20/200 vision from cortical
blindness or otherwise can be referred to low vision services for devices
and adaptive techniques. Refer to website for area sites:
http://www.enhancedvision.com/low-vision-resources/missouri-low-vision-
resources.html
3. Spasticity – Treat with frequent stretching, splints, consider
baclofen/tizanidine/benzos but use with caution. Consider botox for focal
spasticity.

Most of outpatient stroke management is focused on secondary stroke

prevention. Refer to AHA website for specific guidelines:

http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsQ
-Z/Stroke-Statements-Guidelines_UCM_320600_Article.jsp

46  
 
 47  
 
From Continuum, Cerebrovascular Disorders, April 2014:

Intracranial hemorrhage
(For more details see Stroke Cards and the ICU handbook)

I. Inpatient medical management

A. General monitoring
1. Patients will have standard cardiovascular monitoring with
frequent assessment of vital signs and continuous telemetry as well
as monitoring for change in neurologic status
2. Intracranial pressure monitoring may be considered for patients
with a GCS score of <8, those with clinical evidence of
transtentorial herniation, or those with significant IVH or
hydrocephalus

48  
 
 a. Cerebral perfusion pressure of 50 to 70 mm Hg will be
targeted
B. Management of blood pressure
a. See ED section. INTERACT trial suggested aggressive
SBP lowering to <=140 reduce hematoma growth, but no
change in outcomes. Discuss with team before aggressive BP
lowering.
C. Management of glucose
Glucose will be monitored (every 2 hours if >250 mg/dL; every 4
hours if <250 mg/dL) and normoglycemia (100-180 mg/dL) targeted
with an insulin sliding scale
D. Management of seizures
1. Clinical or electrographic seizures will be treated with
antiepileptic drugs
2. Consider EEG monitoring for patients with depressed mental
status out of proportion to degree of brain injury
E. Venous thromboembolism prophylaxis
1. Intermittent pneumatic compression will be used
2. Low-dose subcutaneous low molecular weight heparin or
unfractionated heparin will be administered after 48 hours
unless medically contraindicated
F. Nutrition
1. Patients will not be fed orally until swallowing is evaluated
a. If aspiration is detected or the patient is not alert
enough to eat safely, nasogastric tube feeding will be begun
II. Inpatient surgical management
A. Clot removal
1. Surgical clot removal will be considered for patients with
cerebellar hemorrhage who are deteriorating neurologically or who
have brainstem compression and/or hydrocephalus from
ventricular obstruction
2. Surgical clot removal will be considered for patients presenting
with lobar clots >30 mL and within 1 cm of the surface
B. External ventricular drainage
1. Ventricular drainage will be considered in patients with
hydrocephalus and decreased level of consciousness
III. Discharge instructions
A. Blood pressure control
After the acute ICH period, a normal BP of <140/90 mm Hg
(<130/80 if diabetes or chronic kidney disease) will be targeted
B. Avoidance of antithrombotic therapy
Determination will be made taking into account vascular risk
factors, age, ICH location, and suspected ICH etiology
C. Multidisciplinary rehabilitation will be recommended as needed
in the inpatient, outpatient, or home setting
ICH score
Used to predict 30 day mortality. In the original study, no patient had a score
of 6, but this score is associated with mortality as 100% of those with score 5
had died. ICH volume is calculated by ABC/2 score.

49  
 
 50  
 
(A*B*C)/2 score
A = the largest cross-sectional diameter (to nearest 0.5cm)
B = the largest diameter to A on the same slice
C = the approximate number of 1cm slices on which the ICH is seen
/2 = added to approximate the volume of an ellipsoid

Resources/References
Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr,
Greenberg SM, Huang JN, MacDonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ.
(2010). Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for
healthcare professionals from the American Heart Association/American Stroke Association. Stroke.
2010 Sep;41(9):2108-29.

Causes of ICH

Cause Common Location Comments

Head trauma Frontal lobes, anterior Coup and contracoup injury

temporal, SAH

Hypertensive Putamen, globus pallidus, Small vessel injury

hemorrhage thalamus, cerebellum, pons

Hemorrhagic BG, subcortical, lobar Up to 6% of ischemic

transformation strokes, especially large
strokes

Metastatic brain Lobar Lung, melanoma, RCC,

tumor choriocarcinoma, thyroid
tumors are common
bleeders

Coagulopathy Any Uncommon; reverse when

able

Drug related Lobar, SAH Cocaine, amphetamines

AVMs Lobar, IVH, SAH Risk 2-4% per year for

bleeding

51  
 
 Aneurysm SAH, parenchymal Consider mycotic aneurysm
in infected patients

Amyloid Lobar Degenerative disease of

angiopathy vessels, linked to AD and
patients over 60

Cavernous angioma Parenchymal Popcorn appearance on

MRI; multiple cavernomas
associated with gene
mutations; occult on 4v
angiogram

Dural aVF Lobar, SAH Bleeding caused by venous

hypertension

Capillary Commonly brainstem Rare; usually occult on 4v

telangiectasias angiogram

Subarachnoid hemorrhage: A brief word

Generally, SAH patients go to Neurosurgery. Rarely, you will get a NSG

transfer for non-intervenable minor SAH or convexity SAH. For acute
management, see ICU handbook. On the floor, remember at least q4hr neuro
checks and the complications of SAH: delayed cerebral ischemia (vasospasm
peaks 4-8 days after date of bleed), rebleeding, hydrocephalus, cardiac
complications, fluid/electrolyte balance, seizures, and edema.

52  
 
 EPILEPSY

53  
 
 54  
 
Epilepsy Management - General Flowchart

Getting the right history: Each seizure has a [beginning, middle, end] = [aura,
ictus, postictal period]
- Start by asking about the semiology
- eyes open/closed
- head center/left/right
- shaking of L or R arms or legs
- any spread or progression of shaking, or whether it all started
simultaneously
- any bowel/bladder incontinence
- any tongue biting (front or side)
- any injury in the course of the seizure
- length of time the shaking was going on

- Then ask if the patient ‘knew it was coming’ or had an ‘aura’

- sometimes focal jerking, focal tingling, auditory, olfactory,
gustatory, or with visual changes

- Then ask if they were confused, tired, fatigued, or had a headache afterwards
- confusion from seizures is more severe and more prolonged than
in syncope (10-15mins)

Elements Suggesting Seizure

- Tongue biting, head turning, incontinence, full-body rigidity, prolonged
confusion/somnolence

Elements Suggesting Pseudoseizure

- Induced with suggestion/flashing lights, avoidance behavior, eye closure,
asynchronous movements

Level 1 Diagnostics
- all patients with spells deserve a workup including detailed neuro exam,
brain MRI, and EEG
- routine brain MRI is sufficient or a first time seizure or spell
- epilepsy protocol MRI is needed for recurrent seizures or spells (fine cuts
thru cortex/temporal lobes)
- standard 20-minute EEG is typical, but may be repeated or extended (up to 1
hour) for increased sensitivity

Level 2 Diagnostics
- Video EEG with hyperventilation, strobe lights, exercise, sleep deprivation
is the gold standard test for evaluating spells
- Even if the events are not captured, the interictal Video EEG may be
characterized as normal or abnormal

Treatment Decisions:
- It is not always clear exactly who needs to be on an AED, especially on
inpatients.

55  
 
- Patients with an epileptiform EEG or an abnormal brain MRI almost always
require AED treatment
- The following are some guidelines in cases where the EEG and bMRI are
negative

- Patients with more than 1 unprovoked seizure separated by days (definitely)

- Patients with more than 1 unprovoked seizure during the same day (maybe)
- Patients who had a prolonged seizure which spontaneously resolved (maybe)

- Patients with an electrolyte or metabolic abnormality which cannot be

quickly reversed (probably)

- Patients with only very unconvincing history or witness report of spells (no)
- Patients with indeterminate events not yet on medications (probably not)
- Patients with indeterminate events already on medications (consider increase
if previously responded)

Choosing an AED:
Always based on comorbidities and psychosocial factors. Consider each
below category:

Confirmed or Suspected Generalized Epilepsy: Keppra, Zonegran, Depakote,

Topamax, Lamictal, Benzos
Partial Epilepsy: All of the above + All other known antiepileptics

IV Formulations Available: Phenytoin, Depakote, Keppra, Vimpat, Benzos

Slowest Titrations: Lamictal (Months) > Topamax (Weeks) >
Carbamazepine/Oxcarbazepine (Few Weeks)

Migraine Relief: Topamax, Zonegran, Depakote, possibly Keppra

Makes Headaches Worse: Lamictal

Cheap like 5/mo (if uninsured): Carbamazepine, Topamax, Zonegran (thru

BJC)
More like $25/mo (if uninsured): Keppra, Phenytoin, Depakote, Lamictal
Possibly even more (if uninsured): Oxcarbazepine, Vimpat

Better studied in pregnancy: Lamictal, Keppra, Carbamazepine

Better avoided in pregnancy: Phenytoin, Depakote, Topamax

Possible to take once daily: Phenytoin, Zonegran, Lamictal, Depakote ER

(maybe)
Better to take twice daily: All of the above + All other known antiepileptics
(most people forget some of the time)

Side Effects to Discuss with Patients

Keppra – Agitation/Irritability (‘it makes you more of who you are’)
Depakote – Weight Gain, Hair Loss, Possible hepatotoxicity or
hyperammonemia syndrome

56  
 
Topamax – Weight loss (usually desirable), migraine relief, Word finding
difficulties, renal stones
Zonegran – Weight loss (usually desirable), renal stones, decreased sweating
Phenytoin – Gingival Hypertrophy
Carbamazepine – Hyponatremia, Agranulocytosis
Lamictal – higher than usual risk of severe rash (10%)

Management During Pregnancy

Maintain ideal seizure control for about 6 months prior to pregnancy
Start Folate 1-4mg/day in anticipation of pregnancy
Check Baseline then monthly levels of AEDs once pregnant
Adjust dosage of AEDs based on baseline level of drug
In-office visit once per trimester
Maintain full dose AED for 1 month after delivery
Taper dosage slowly over the next month to baseline dosage

Interview Routine for each New/Return patient:

1) Document Seizure semiology, Seizure etiology, Current medication
regimen, and Current seizure frequency
2) Review results of prior EEG and Brain MRI testing
3) Review side effects and determine if troublesome
4) Increase or additional AEDs if not controlled, decrease/crosstaper if side
effects
5) If atypical features or not controlled on 2 agents, consider Video EEG.
Consider surgery if focal onset.
6) Remind patient of driving restrictions, remind women of need for folic acid
if childbearing age

AED Selection
* Adopted from L&L presentation by Dr. Day

PGE - Broad Spectrum Agents: VPA #1 (SANAD Rec #1), LAM

(pregnancy), LEV, TPM (SANAD Rec #2), ZON, ?ONFI/BZD, PB, FLB,
Banzel, Mysoline

CPS – Broad + Narrow: CBZ #1 (SANAD Rec #1), LAM (SANAD Rec #2),
LEV, TOP, ZON, LAC, VPA, PHT, BZD, Diamox, OXC, GBT, Lyrica,
VGB, TGB, Potiga, Perampanel

57  
 
Loading Doses/Initial Doses for Commonly Used Anticonvulsants

Medication Dose Notes

Fosphenytoin 15-20 mg PE/kg IV Check level 1 hour
Infuse at max rate of 150 after infusion (Goal
mg PE/min 20). Watch for
hypotension.
Phenytoin 15-20 mg/kg PO in 3 Use Dilantin
divided does q 3 hours Infatabs for oral
loading. Initial
maintenance dose
300 mg QHS
Depakote 15-18 mg/kg IV or PO, Divided BID
(divalproate) load 20 mg/kg IV for
status epilepticus
Phenobarbital 20 mg/kg IV (max Intubate first when
infusion 75mg/min) giving IV.

4-8 mg/kg PO loading

dose then 2-4 mg/kg QHS
Carbamazepine Start 200 mg PO BID Increase by 100mg
QOD to target
(600-1600 mg/day)
Keppra Start 500 mg BID, Adjust dose for
(levetiracetam) maintenance up to 2000 renal failure.
mg BID
Topamax Start 25 mg QD, Can increase by 25
(topiramate) maintenance 150-200 BID mg each week
Lamictal Depends on concurrent Can start patient on
(lamotrigine) AEDs, maintenance prepackaged dose
between 100-400 mg BID titration packs.
Vimpat Start 50 mg QD, Available IV, may
(lacosamide) maintenance up to 200 mg load with 200 mg
BID IV x1 followed by
PO maintenance
dose the next day.

58  
 
 59  
 
 60  
 
 61  
 
 62  
 
Epilepsy Admission: typically are 1) video EEG monitoring patients, 2) new
onset seizure patients and 3) epileptic patients with prolonged post-ictal
periods or increased seizure frequency who need observation.

Epilepsy Monitoring Unit (EMU) Patients: The nurse practitioner, when

available, will care for the private patients. You will cover the ward service
patients and, sometimes when the NP is absent, the private patients. Keep
regular contact, at least daily, with the epilepsy fellow and/or attending.
Usually, patients are monitored for 1) characterization (Epileptic,
psychogenic, or other? Focal or generalized?) or 2) evaluation for surgery.
Some patients will be transferred from the ICU after placement of grids and
strips for invasive monitoring.

Admitting EMU patients

• Take the latest note for the Resident Bin in the EMU.
• If presenting to the Epilepsy attending, note
o Referring physician (Outside versus Epilepsy attending)
o Reason for admission (characterization, pre-surgical, ictal SPECT,
invasive monitoring, etc.)
o Number and types of spells
o Medicines, especially AEDs, and whether VNS
o History and physical with attention to
o New spell types
o Medication changes (prescribed or not)
o Triggers such as flashing lights or sleep deprivation
o Timing of last medication doses
• Admission orders in COMPASS
o Continue home medications except for deferral of AED decisions
to attending/chief
o EMU (EEG Continuous with Video Recording)
o Peripheral IV (necessary for possible status epilepticus)
o Activity: Up with assistance, Out of bed TID,
o Seizure precautions, CCTV
o Exercise bicycle TID as desired
o NO heparin/enoxaparin, SCD/TEDs or other prophylaxis unless
otherwise indicated
o NO labs for private patients, few for ward ones
o Vitals Q8 or less
o Diet: Same as home.
o Studies: Order any special PET or MRI if necessary. If admitted
for ictal SPECT, order it daily the night prior and you should
call to confirm the order was received. Continue until the patient
seizes.

Daily care of EMU patients

• See private patients early and leave the note in the chart.
• Change AED doses per the plan for tapering.
• Discuss briefly with the fellow/attending/chief.
• Resist the urge to overtreat. Choose medicines they probably would take
at home for the same problems.

63  
 
Discharge of EMU patients
• Anticipate discharges and have orders on hold whenever possible.
• For epileptics, restart AEDs with first doses before discharge, possibly
with adjustments. Prescribe Lorazepam 1 mg PO BID x 3 days when
appropriate.
• For non-epileptics, restart AEDS only if there is a non-seizure reason
the drug is being prescribed (e.g. gabapentin for pain)
• Arrange follow up as appropriate, sometimes with PMD for psychologist
referral for non-epileptic patients. Jerry Breakstone is a social worker
with an interest in treating non-epileptic patients (phone # 314-398-
0453).
• Dictate a Discharge Summary with a referral to the Video EEG report
for details.

Tips for EMU patients

• Grids: Never, ever give a patient with intracranial grids an AED without
discussing with the attending/fellow! Notify the epilepsy
attending/fellow immediately if a grids patient seizes. NSGY is the
primary admitting service, so you don't have to put in any orders and
keep your interactions and notes brief and to the point. Cross cover
questions not related to seizures should go to NSGY.
• You may occasionally admit a patient who came in for Wada testing
after angiography when the PACU is full for observation, often only
until he/she is off bedrest (2-6 hours usually, depending on closure
device). Keep orders simple.
• Not all seizures require contacting the Epilepsy fellow or attending.
1. A single non-GTC seizure from which the patient recovers does
not require a call.
2. If a patient has a prolonged event or more than one event, review
the EEG yourself. If you are sure it is a pseudoseizure, you do not
need to call. Do not tell the patient/family that it is a
pseudoseizure, as this decreases the chance of capturing further
events. Tell them that the patient is stable, but that the final report
won’t be back until the attending looks at the EEG in the morning.
3. If a patient has more than one GTC in a 24 hour period, or multiple
seizures between which they do not return to baseline, call the
fellow or attending. The Epilepsy service will also communicate
with you other reasons to call for these patients.
• The vast majority of seizures in EMU patients do not require treatment.
Do not treat with anticonvulsants (including benzodiazepines!) unless
the patient has had a seizure for greater than 5 minutes or multiple
seizures without returning to baseline. Always try to contact the
Epilepsy fellow or attending before treating. Remember, the reason
these patients are in the hospital is to have their AEDs weaned to capture
seizures for characterization. Treating with an anticonvulsant has a high
chance of preventing the team from capturing seizures for the rest of the
admission.

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Ictal SPECT: A fraction of patients admitted to the seizure monitoring unit
are admitted for "ictal SPECT". The goal of an ictal SPECT admission is to
capture the seizure onset zone by injecting a radioactive tracer (Technetium)
at the time of seizure onset in the hope that the tracer is taken up by areas of
increased metabolism, including the ictal onset zone. The sooner you inject,
the faster the tracer is taken up by the seizing brain, and the smaller the area
involved is, helping better localize the ictal onset zone. That is why there is a
nurse that sits by the patient for the entire duration of the contrast agent ready
to inject at the first sign of a seizure. The agent’s radioactivity decays until it
is no longer effective, usually in 6-7 hours.
For a typical ictal SPECT admission, make sure that the SPECT contrast is
ordered to be at the bedside the night before EACH DAY of admission. You
order "Neuralyte" to the bedside to be available at 7 AM each day. On the first
day of admission (typically a Monday) call Nuclear Pharmacy at 22799 to
notify them that you will need contrast starting the next day (Tuesday).
Continue ordering it until the patient has a seizure and it is determined that a
repeat ictal scan will not be needed.
Because SPECT scans are not done on weekends, the window of opportunity
lasts from approximately 7 AM to 3 PM Tuesday to Friday. AEDs are often
weaned more aggressively than for patients admitted for standard video-EEG
monitoring due to these time constraints.
When the SPECT nurse sees a seizure and injects the patient, the seizure is
reviewed by the epilepsy fellow/attending. If the seizure is typical and the
injection was sufficiently close to the onset, the fellow/attending will decide
whether to restart the patient's AEDs. Often Lorazepam also is given for a few
days. It is done to prevent seizures during the SPECT scan. An interictal
(baseline) SPECT scan usually is obtained the next day.

New Seizures: Patients with new onset seizures typically require admission.
Every patient who seizes should have finger stick BG, basic labs (BMP, Mg,
Phos, UA, UDS, EtOH level, CBC, coags), a head CT, CXR (to exclude
infection), and an EKG (sometimes what looks like a seizure may, in fact, be
arrhythmia-related syncope). The threshold for LP should be low when the
suspicion for infection is high and no other source is evident.
For a simple single seizure from which the patient fully recovers, orders in
addition to routine ones include the following:
• Seizure precautions
• CCTV (often)
• Up with assistance
• MRI epilepsy protocol +/- contrast
• Routine EEG
• Peripheral IV
Review seizure precautions with the patient personally. They include no
driving, no operating heavy equipment, no submersible amounts of water e.g.
baths or swimming, no holding babies while standing, and avoidance of
heights and open fires. The patient must be seizure-free for 6 months before
driving privileges can be restored in MO. In IL, the laws are more lenient and
patients only need a note from their doctor. Remind the patient that a seizure
can happen any time and that there could be fatal consequences for the patient
and others. Also educate the patient and family on what should be done if the

65  
 
patient were to have another seizure and when they should call 911 (seizing
more than 5 minutes, not returning to baseline, injury or dyspnea).
Beware of non-convulsive status epilepticus in anyone who is not returning to
baseline mental status or is persistently encephalopathic. Order a stat EEG,
even in the middle of the night, after discussing with the chief or attending. If
you decide on stat EEG after hours, place the order and have the on call EEG
technician paged by calling the operator.
If there is any hint of an infection—headache, white count, fever, less-than-
supple neck, persistent post-ictal confusion—the patient must have an LP.
Start patients on antibiotics as well as acyclovir to cover for HSV until the
CSF results are back. For elderly or otherwise immunologically compromised
patients, be aggressive on starting antibacterial coverage as they may not have
the classic fever/stiff neck/elevated white count. Draw blood cultures prior to
giving antibiotics.
A single seizure, if there is no focal finding on MRI or EEG, does not require
starting AEDs. Initial therapy depends a great deal on the seizure type, cause,
patient age, comorbidities, etc. and is beyond the scope of this handbook.
Evaluation typically is complete within 1-2 days. Upon discharge from the
floor, patients need repeated education on seizure precautions. Remind them
that the driving restriction is regulated by the state!

Known Seizure Disorder: The ED handles many patients with known

epilepsy without calling Neurology; they will check basic labs and send the
patient home if everything is normal and the patient wakes up. You may be
called for curbside consultation AEDs. If drug levels are low because of
noncompliance, the patient may need a loading dose but there is no reason to
change the maintenance dose. Find out the outpatient neurologist, recommend
follow-up in the near future, and let the person who manages them long-term
decide. (You can even call the clinic physician in the morning and ask what to
do and call in a script if anything needs to be changed.) If the patient seized
because of alcohol withdrawal, it usually is not helpful to change AEDs.
You will get called about how to “load” patients who are subtherapeutic. If
the patient has missed one or two doses, and the levels are slightly low, have
the ED give the missed dose and resume their normal schedule. If levels are
unmeasurable, restart the previous dosing and consider giving Lorazepam
1mg BID for three days for coverage until drug levels become therapeutic.
Some patients with known seizure disorders will lead to Neurology consults
due to prolonged confusion, often from a combination of post-ictal confusion
and benzodiazepine. Consider having the ED transfer the patient to OBS for
observation if there is no additional evaluation needed. The ED might be
resistant. Consider giving a definite cutoff time for return to baseline and then
admission. You must always sign out these patients to the next Neurology
resident covering the ED. Quite often the patient will wake up and then can be
discharged from the ED. Other patients do require admission due to prolonged
post-ictal confusion, overmedication or, rarely, because the pattern or type of
seizure has changed.
Always establish the baseline seizure frequency in these patients (with family
if necessary). Find out who manages the AEDs and ask about any changes in
medications (including AEDs as well as antibiotics, antidepressants, OTC
medications, etc.) or missed doses. Check drug levels. Thoroughly investigate

66  
 
for infection. UTI is frequent. Check blood cultures, CXR, LP; even dental
abscess or skin abscess may be the culprit. The most common cause of
lowered seizure threshold will be alcohol withdrawal—usually these people
have been seen in the ER and admitted multiple times, but not always.
Monitor closely for autonomic instability in these patients. They may need
some standing benzodiazepines for alcohol withdrawal. If a patient is having a
new type of event or a flurry of spells for no identifiable reason, continuous
EEG might be indicated.
In addition to other orders, make sure the ones below are ordered. Peripheral
IV is necessary due to risk of status epilepticus. Consider EEG and brain
imaging depending on the presentation. Make sure they all have working IV
access. Review seizure precautions upon discharge.
• Seizure precautions
• CCTV (often)
• Up with assistance
• Peripheral IV

Ongoing Seizure and Status Epilepticus: A seizing patient on the floor

should be seen immediately. Whenever possible, witness the seizure activity
yourself, because 1) many abnormal movements called seizures by others are
not, and 2) the patient’s appearance during a seizure has clinical value.
Examine the patient carefully for eye or head deviation and subtle rhythmic
movements of the hands or oral muscles. The direction of gaze deviation at
the beginning of a seizure is particularly important.
If a patient is seizing for more than 5 minutes, or seizes more than once
without regaining consciousness, they are considered to be in status
epilepticus. Be wary of patients who aren’t waking up after a seizure—they
may be in nonconvulsive status epilepticus. Discuss with the chief at this point
whether a stat EEG is necessary and whether to start treating. Revisit the
question of stat EEG if the seizures do not clearly stop within the first few
rounds of treatment. Status epilepticus is treated as follows (and is outlined in
the BJH Tool Book):

Status EpilepticusManagement
1. One Seizure – less than 5 minutes
a) Already on AEDs: observe, no acute interventions
b) Not on AEDs: consider starting on AED based on clinical
information and workup
2. One seizure lasting more than 5 minutes or recurrent seizures without a
return to baseline in between
a) Benzodiazepines (Lorazepam, Diazepam, Midazolam)
b) Lorazepam (Ativan) 0.1 mg/kg (up to 10mg total of a 100kg or
larger patient)
i. Strategy #1 – Give ½ total dose and observe for 5
minutes, give the other ½ total
dose if not improving.
ii. Strategy #2 – Give 2mg increments every 2-5 minutes
until there is a clinical/EEG improvement
3. Seizures continue despite Ativan
a) IV AEDs:

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 i. Widely accepted first line agents for status epilepticus
1. (Fos)Phenytoin (Most commonly used, may not help and
could worsen PGE)
2. Valproic acid (use instead of PHT if you suspect PGE,
avoid in mitochondrial disease)
3. Phenobarbital
ii. Other medications often used
1. Levetiracetam
2. Lacosamide
b) Fosphenytoin 20mg PE/kg (IV max flow rate 150mg PE/min) OR
phenytoin 20mg/kg (IV max flow rate 50mg/min) (Refer to IV
therapy guidelines as well)
c) If patient still having seizures 20 minutes after loading, an
additional (fos)phenytoin 10mg (PE)/kg can be given. If not
already done by this point, call for a STAT EEG which can be
extended and/or changed to Video/EEG monitoring as needed.
d) Obtain 1 hr postload level (Goal Total PHT level 15-25, Free PHT
1.5-2.5)
4. Seizures continue (Super refractory seizures)
a. Intubate
b. Options
1. Midazolam 0.2mg/kg x1, then 0.1-2.0 mg/kg/hr
2. Phenobarbital 10mg/kg q10 minutes PRN, up to 3 doses
3. Propofol
4. Pentobarbital\
5. Cooling to 32 degrees C (ALWAYS also must use
paralytics (shivering) and sedatives)
c. If seizures remain uncontrolled
1. Ketamine
2. Magnesium

Formulas for managing phenytoin:

For low albumin (technically less than 4.5 which will make the denominator
1, but practically speaking less than 3.5), use the Sheiner-Tozer equation to
correct (or adjust) measured total Dilantin concentrations (assumes no
clinically significant renal failure or protein binding medications):
Corrected total Dilantin level = Measured total Dilantin level /(0.2(serum
alb) + 0.1)
Let’s say the measured total Dilantin level was 3.1 and the albumin was 2.5:
Corrected total Dilantin level = 3.1/(0.2(2.5) + 0.1) = 3.1/(0.6) = ~5.2

Then to calculate for reloading the patient, use this equation:

IV load = (Goal total Dilantin level – Corrected total Dilantin level) x Vd;
Where Vd = wt(kg) x 0.7

If the patient weighs 68kg and we want to get level up to 20, then: IV load =
(20 – 5.2)(68)(0.7) = 704mg or ~ 700mg

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 SLEEP DISORDERS
In general, we do not treat primary sleep-related conditions in the resident
clinic.
- However, a large proportion of our patients with uncontrolled headache,
seizures, and pain have poor sleep
- Screen these patients for OSA, and if they sufficient risk factors, refer them
for polysomnogram

Sleep Study Admits:

You may admit a patient who comes into the hospital for a scheduled inpatient
sleep study. These patients are admitted as a 23-hour admission usually
because they are too obese or otherwise too sick to be studied as an outpatient
at the sleep lab.
• Do not order labs, telemetry, or overnight neuro/vitals checks on these
patients.
• Patients typically take their PM meds before coming, but may need their
AM dose of meds before leaving
• Have their paperwork ready for discharge. The sleep attending will see
the patient in the morning and discharge them.
• The on-call sleep fellow is available for any questions. If you don’t
know who that is, you can ask the sleep tech.
• Pay attention to their medical comorbidities…they may unexpectedly
become very sick!

Obstructive Sleep Apnea:

• Common symptoms of OSA include loud snoring, witnessed apneas,
awakenings with gasping, morning headaches, and daytime sleepiness.
• Risk factors include obesity, a large neck, and a narrow airway.
• Diagnosis and treatment starts with a polysomnogram with CPAP
titration.
• Patients always say they have trouble tolerating the mask at first, but it
takes 4-8 weeks to fully adjust. Try Ambien x 1 week if needed.
• Inpatients with recurrent respiratory failure from obesity or underlying
pulmonary issues may benefit from an emergent sleep study

Tips for good sleep hygiene (counseling patients):

• Avoid napping during the daytime, keep a regular schedule of getting up
at same time everyday including weekends.
• Avoid caffeine, alcohol, large meal/fluid intake before bedtime.
Exercise regularly.
• Establish a “worry period” and write down “things to do” for the next
day well before bedtime.
• Try to go to bed only when you are drowsy. Avoid reading, watching
TV in bed.

Restless Leg Syndrome

• Common symptoms include an uncomfortable (antsy or creeping)
sensation with an urge to move the legs. The sensation is relieved

69  
 
 temporarily with activity but then comes back again with inactivity and
symptoms are worse in the evening.
• Try to decrease anti-dopaminergic or anti-depressant medications;
Compazine, TCAs and SSRIs can make RLS worse.
• Check ferritin (goal >50 ng/ml) as treating iron deficiency can help.
• First line treatment is pramipexole 0.125mg or ropinirole 0.25 mg (1-2
hours before bedtime). Side effects include nausea, sedation and rarely it
causes gambling or compulsive behavior.
• Ideally these patients should have a sleep study first since their RLS may
be due to underlying OSA

Narcolepsy with or without cataplexy

• Patients will have daytime sleepiness with early REM onset during their
naps.
• Cataplexy is characterized by sudden transient loss of muscle tone
brought on by strong emotions (most reliably laughing or joking).
Weakness is typically bilateral and can be partial (for example just the
face or neck) or generalized resulting in collapse. Consciousness is
preserved.
• They can also complain of sleep paralysis or hypnagogic/hypnopompic
hallucinations.
• For diagnosis, patients will need a Multiple Sleep Latency Test after a
documented restful night of sleep. A mean latency period of less than 8
minutes with 2 sleep onset REM episodes during 4 or 5 daytime naps is
diagnostic of narcolepsy.
• Treatment is typically with stimulants or sodium oxybate.
• As for cataplexy, abruptly stopping a patient’s TCA or SSRI can put
them into status catapleticus severe, nearly continuous rebound
cataplexy that can last up to several hours). Treatment is resuming their
antidepressant.
• These patients are typically cared for in the sleep clinic.

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 HEADACHE
Goals
1. Assessment and workup for secondary headaches,
2. Identification and avoidance of unnecessary workup for primary
headaches
3. Symptomatic management of both.
Red flags – seriously consider secondary headache causes”
• Host: Age>50, immunocompromised, or coagulopathic.
• Time-course: New, sudden (eg thunderclap), or progressive (severity or
frequency);
• Features: Signs of high (worse supine/in AM, with
cough/sneeze/Valsalva/bending over) or low (orthostatic) ICP; any focal
deficits, fever, meningeal signs, weight loss, jaw claudication,
intractable vomiting.
Thunderclap causes: SAH*/sentinel bleed/aneurysm, stroke,
meningitis/encephalitis, sinus thrombosis, dissection, HTN/PRES, RCVS,
spontaneous CSF leak, pituitary apoplexy, 3rd vent colloid cyst/aqueductal
stenosis
* HCT is >99% sensitive for SAH if obtained within 6h of HA onset.
Other commonly encountered secondary headaches: post-LP (fluids,
caffeine, blood patch), pseudotumor (ophtho eval, LP), OSA (morning
headaches), post-TBI
Headache management:
ED abortive trials:
• 1-2 rounds (commonly ketorolac/anti-emetics/droperidol) + hydration is
reasonable, discuss with ED team.
• Pre-admit labs: Urine hCG, CBC, BMP, UDS, UA/Cx, EKG
On floor:
• Aggressive hydration and nausea tx (all inpts should be on IVF and at
least prn if not scheduled anti-emetics).
• DO NOT WAKE IF SLEEPING. No vitals at night.
• Smokers: nicotine patch, strongly counsel re: cessation
• Consider abortive or prophylactic regimens on discharge.
o At home:Treat headaches with abortives at ONSET.
• Headache “hygiene”:
o Avoid caffeine, nitrates (lunch meats, hot dogs, etc), MSG,
alcohol, nicotine.
o Stay well-rested, hydrated and physically active.
• Medication overuse headaches: At risk if using analgesics >15d/mo
o Stop the analgesics, may need to monitor for withdrawal
o Consider bridge therapy/prophylactic.
• Non-pharmacologic options: biofeedback, CBT.
• Pregnancy: Avoid triptans/ASA/NSAIDS (but not absolute if
refractory)
Resources: http://www.ihs-classification.org/en/

71
 

 
Outpatient status migrainosus options (when 1st line abortives have
failed)
Steroid taper
Rapid Onset Triptan/Ergot
Indomethacin
Occipital nerve block (more
useful in cervicogenic
HAs/occipital migraines)
Prednisone 60 mg/day, decrease by 10
mg/day until off
Medrol dose pack—follow insert
intructions (6 day methylprednisolone
taper)
Sumatriptan SQ, Rizatriptan ODT,
Zolmitriptan ODT, DHE IN
50 mg BID x 1 wk (has suppository
formulation if nausea)
2-4 cc bupivacaine + 40 mg
dexamethasone

Inpatient status migrainosus options

DHE (contraindicated if CAD) Get baseline ECG. Pretreat w/ anti-
emetics.
MD gives 0.5 mg test dose, IVP over 3-5
min. Repeat ECG. If OK, give additional
0.5 mg IV, then 1 mg q8hr. Consider
reduced dose for severe nausea.
NSAIDs Ketorolac 15-30 mg IVq6-8hr. Max 3
days
Anti-emetics Prochlorperazine/metaclopramide 5-10
mg/day
Tx dystonia/akathisia w/
diphenhydramine
Droperidol Currently not available at BJH
Get baseline ECG, then daily for QTc
0.625-2.5 mg IV q6hr. Max 2-3 doses
Methylprednisolone 250 mg BID + PPI, sleep aid, SSI
VPA Check/monitor CMP
Load 15 mg/kg (max 1 g) then 5 mg/kg
q8hr
Magnesium 1-2 g IV q12hr. Monitor for diarrhea.
Haldol (Headache. 2006 5 mg; relatively new since droperidol was
May;46(5):781-7) d/c’d. Probably would not give >1-2
doses
One potential algorithm: 1) 2-3 doses Ketorolac+Prochlorperazine+IVF;
2) DHE 2-3 doses; 3) VPA 2-3 doses, 4) Magnesium 1-2 doses, 5) Haldol x
1-2 doses, 6) IV methylprednisolone x 2-3 doses; 7) repeat from
beginning.

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Episodic Migraine abortive
Triptans Most common: sumatriptan 25-100 mg at HA
onset (equivocal if needed at aura onset);
repeat in 2 hr if needed
Contraindications: basilar/hemiplegic
migraine, CAD, stroke, uncontrolled HTN,
pregnancy
DHE 1 spray (0.5 mg) in each nostril, repeat PRN
15 min. Max 4 sprays/HA, 6/24hr, 8/wk.
Avoid concurrent use w/ Triptans.
NSAIDs Ibuprofen/Naproxen
Anti-emetics Prochlorperazine/metaclopramide
Other Tylenol, Midrin, Fioricet, opiates
- Consider combination therapy (e.g.
Triptan+NSAID+Compazine) at start of HA if incomplete
relief to individual drugs
- Risk of medication overuse HAs with the following: 1)
butalbital > 5days/mo; 2) DHE/Triptains/opiates >10 days/mo;
3) simple analgesics >15 days/mo

Migraine prophylaxis – strong/moderate evidence for efficacy (2012 AAN

guidelines)
Amitriptyline Start 10-25 mg qHS; titrate up
weekly. Typical dose 50-150 mg
qHS
Venlafaxine Start 37.5 mg; titrate up monthly.
Typical dose 75-150 mg qday
Valproic acid Start 250 BID; titrate up weekly.
Typical dose 500-1000/day
Topiramate Start 25 mg qHS; titrate up every
2-4 wks. Typical dose 50-200
mg/day
Propranolol Start propranolol 20 mg BID;
Metoprolol/timolol also effective titrate up every 2-4 wks. Typical
dose 80-180 mg/day
- Can also consider Botox. Only FDA approved treatment for
chronic migraine. Not listed in AAN migraine guidelines.
- Remember SLEEP/HYDRATION/CAFFEINE can play a huge
roll in chronic HAs.

Migraine prophylaxis – weak/insufficient evidence for efficacy (2012 AAN

guidelines)
Carbamazepine, Gabapentin, Nicardipine, Nifedipine, Verapamil,
Nimodipine, acetazolamide, Candasartan, Lisinopril, Clonidine
Some of these may be efficacious in other HAs, i.e. verapamil in cluster
HA

Alternative Headache management

Cognitive behavioral Possible benefit, essentially no risk

73  
 
therapy/Acceptance Commitment (Continuum 2012;18(4):796–806)
Therapy
Aerobic exercise (40 minutes 3 As efficacious as Topamax in one
times a week) study, though absolute changes very
small (Cephalalgia
2011;31(14):1428Y1438)
Magnesium Start 400 mg qday. Titrate every 4-6
weeks. Typical dose 400-1200/day in
divided doses.
Coenzyme Q10 300 mg qday; may have insomnia,
high cost
Riboflavin 400 mg qday; may take up to 3 months
to work
Butterbur 150 mg qday; may have teratogenic,
carcinogenic, and hepatotoxic
properties
Feverfew Not available as prescription in US.
OTC feverfew has highly variable
levels of active ingredient
Acupuncture Studies suggest high efficacy, but
powerful placebo effect difficult to
control for. (Cephalalgia
2008;28(9):969Y979)

Headache in pregnancy
- Strongly consider imaging given hypercoagulability in
pregnancy, especially in new HAs
- Most migraines improve in pregnancy
- PPx: in general it is recommended that pharmacologic ppx
stop during pregnancy
- Mg and B2 safest ppx
- Nonpharmacologic therapies are recommended: relaxation,
massage, exercise, avoidance of triggers
- Consider IVF, Zofran, Tylenol, IV Mg, or opiates for abortive

Additional reading:
Evidence-based guideline update: Pharmacologic treatment for episodic
migraine prevention in adults. Neurology April 24, 2012 vol. 78 no. 17 1337-
1345
Headaches. Continuum Neurol 2012;18(4).
International Headache Society Classifications. http://ihs-classification.org/en/

74  
 
 NEUROMUSCLE DISORDERS

75  
 
 Radiculopathies
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

76  
 
 Entrapment Neuropathies
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

77  
 
 78  
 
 Treatment of Neuropathic Pain

79  
 
 Paraneoplastic Syndromes
80  
 
 Paraneoplastic Neuromuscle Disease

81  
 
 Paraneoplastic Antibodies

82  
 
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

Medications adversely affecting NM transmission

83  
 
 Summary of EMG findings

84  
 
 85  
 
Typical Entrapment and Length-dependent neuropathies

Carpal Tunnel Syndrome

- pt c/o pain/paresthesias radiating from the wrist to the first 3 fingers along
with “dropping things”
- tapping &flexing the wrist reproduces the pain
- exam: possible loss of sensation along the first 3.5 digits & thenar atrophy,
possible weakness of APB/Opponens
- patients with weakness proceed to EMG/NCS and see a surgeon
(neuro/plastics/ortho)
- treatment is with neutral position wrist splints at night +/- scheduled aleve x
2-4 wks +/- neuropathic pain meds

Dorsal Radial Neuropathy

- pt c/o pain/paresthesias overlying the dorsal surface of the hand along the
first 3 fingers after being handcuffed
- tapping along the radial side of the wrist may reproduce the tingling
- exam: possible decreased sensation along the affected area
- treatment is with avoidance of trauma to the medial wrist (no wrist brace!)
+/- neuropathic pain meds

Ulnar Neuropathy at the Elbow

- pt c/o pain/paresthesias along the small 2 fingers and ‘dropping things’
- tapping along the medial elbow may cause tingling in the affected area
- exam: possible loss of sensation along the smallest 2 digits, possible
hypothenar atrophy, possible thumb adduction, FDI/ADM weakness
- patients with weakness proceed to EMG/NCS and see a surgeon
(neuro/plastics/ortho)
- treatment is avoidance of trauma to the elbow, elbow pads at dialysis/while
driving, neuropathic pain meds

Distal Symmetric Polyneuropathy

- many different causes, most of which are either not-reversible or idiopathic;
ask about a family hx!
- starts in the feet, ascending to the knees, then affecting the hands and elbows
- detailed exam reveals length-dependent sensation to cold/pinprick/cotton and
diminished reflexes at the ankles/knees
- 1st tier labs: CBC, CMP, TSH, free T4, B12, RPR, HIV, Hepatitis Panel, S-
Ifix, U-Ifix
- 2nd tier labs: ESR, CRP, ANA, ANCA, ENA, Paraneoplastic Panel
- treatment is with neuropathic pain medications

Gabapentin: Start 300 TID x 2 weeks, 600 TID x 4 weeks, then 900 TID
afterwards if needed
Amitriptyline/Nortriptyline: Start 25mg/n x 2 wks, 50mg/n x 2 wks, then
75mg/n, max 100mg/night

86  
 
Cymbalta: Start 60mg/n x 1 month, then 30/60 x 1 month, max 60 bid
Effexor: Start 37.5mg bid x 2 weeks, 75mg bid, max 112.5-187.5 bid
Lyrica: Start 75 bid x 1 month, max 150 bid

Evaluation of LBP
- a very frequent consult from PCPs, probably as often as getting consulted for
headache or seizures
- the question at hand is “does the patient have a myelopathy” and “does
the patient need surgery”
- try to figure out which nerve root is most likely involved
- test strength in the postulated nerve root, and if normal, the patient does not
need surgery for motor weakness
- test tone and reflexes, and if normal, the patient does not need surgery for
myelopathy
- treat the pain with aleve or other neuropathic pain meds
- EMG/MRI reserved for refractory pain or cases when there is motor
involvement or cancer history

Inpatient Neuromuscle
There are two main types of private neuromuscle patients: 1) chronic patients
getting admitted for IVIg, steroids, or 2) acute attacks of new or chronic
conditions (i.e. GBS, myasthenia gravis, mononeuritis multiplex, acute CIDP).
For all these patients, the neuromuscle fellow will be your contact person. A
schedule for the neuromuscle fellow on call is available on the neurology
website under the fellows section in the employee info section. Dr. Pestronk
prefers that the neuromuscle service be consulted for any patient on the
ward service with a neuromuscular condition.

Chronic conditions (stiff person syndrome, multifocal motor neuropathy,

other immune-mediated neuropathies, chronic immune/inflammatory
demyelinating polyneuropathy (CIDP), ALS):
• Clinic notes can be accessed through Allscripts.
• For IVIG and Rituximab, pretreat with 650mg of Tylenol and 25mg of
p.o. Benadryl. Patients need to have a UA, CXR, CBC, CMP,
Immunofixation, all immunoglobulin titers (IgG, IgA, IgM), sometimes
Pestronk labs, and sometimes immune competence panels drawn before
they receive IVIG or Rituximab. The standard dose for IVIG is 1g/kg
body weight/day x 2doses. The 2 doses can be run within a few hours of
each other unless the patients are old (> 65 yo) or with comorbidities
that increase their risk of developing thrombosis or renal failure.
Coronary artery disease and CHF are also relative contraindications to
quick “back to back” infusions. The standard dose of Rituximab is
375mg/M^2 and the infusion rate is started at 25mg/hr which may be
doubled up to 100mg/hr if BP tolerates.
• Rituximab and cyclophosphamide infusions need attending signatures,
assign these orders to the respective attending.
• Cyclophosphamide is used to treat CNS vasculitis, inflammatory motor
neuropathies, particularly anti-MAG and M-protein related neuropathies.
Patients should be well-hydrated before during and after infusion with 3-
4L IV D51/2NS at 150mL/hr (if tolerated) to prevent cystitis. Pretreat

87  
 
 with zofran 30min prior to infusion. Keep strict I’s and O’s. Obtain all
the above labs prior to treatment. Cyclophosphamide is dosed 1gm/M2
given over 3 hours.
• G-tubes are placed by VIR or GI. Both require patients to be NPO after
midnight. Tube feeds start the next morning, and patients are discharged
on postop day 2 once TFs are at goal. Consult nutrition services for TF
recs.
• If the attendings come by to measure quantitative strength, please dictate
these numbers into your admission notes

Acute conditions
These are typically GBS, MG, or acute CIDP patients
• The neuromuscle “panel” for patients with neuropathy/ plexopathy, etc.
of unknown etiology may include any or all of the following: HgbA1C,
B12 (plus minus B12 deficiency panel), TSH, ANA, ENA, ANCA,
rheumatoid factor, ESR, CRP, cryoglobulins (specify “send at 37
degrees”), hepatitis panel, HIV, quantitative IgG/IgM/IgA, serum
immunofixation, urine immunofixation, serum free light chain ratio, 24
hour urine heavy metals, copper level. Often you will also send 2 red
top tubes to Dr. Pestronk’s lab for miscellaneous antibody studies. You
may also be asked to send specific Pestronk antibody panels depending
on the patient’s presentation (i.e acute neuropathy, motor neuropathy,
demyelinating panel, motor neuropathy, myopathy, sensory neuropathy,
sensory neuronopathy). The specific antibodies tested can be found on
the WashU Neuromuscle website.
• Patients with suspected GBS should have a lumbar puncture done ASAP
to look for cytoalbuminologic dissociation in the CSF and to rule out
mimics of GBS such as lymphoma or other infectious/inflammatory
polyradiculopathies. As with any lumbar puncture always SAVE AS
MUCH CSF AS POSSIBLE so that additional studies can be added later
if indicated.
• GBS/CIDP patients will need an EMG/NCS which can be ordered
bedside if they are too unstable.
• Nerve and muscle ultrasound should always be considered as a way to
complement EMG-NCS and can sometimes be coordinated with the
EMG-NCS. The order is available on the EMG-NCS order form in
COMPASS. In some cases it can also help with selecting a biopsy site.
• Plasmapheresis patients will need VIR to place a catheter. If the catheter
needs to be kept in for more than 14 days then the catheter needs to be
tunneled. Patients need to be NPO for 6 hours prior to catheter
placement. Lab medicine runs the pheresis machine. Call them ASAP.
• If a patient needs urgent plasmapheresis, call the VIR fellow stat at 554-
8026 for a line placement, as well as lab medicine stat at 424-1154.
[confirm numbers]
• For muscle or nerve biopsy, document explicitly (ex: left gastrocnemius
and left sural nerve). Usually the side OPPOSITE from the EMG/NCS
will be biopsied, to avoid nonspecific inflammation. In patients with
severe neuropathies, the gastrocnemius can often be “end stage” and of
low diagnostic utility and a proximal muscle (i.e. quadriceps) may have

88  
 
 a better diagnostic yield. Always ask the neuromuscle staff where to
biopsy.
• Remember to order q4-q8 hour NIF/FVC: Consider ICU transfer if NIF
is less negative than -20, or FVC < 1.0 liter, or either value is heading in
the wrong direction. A useful bedside test is to see how many numbers
they can count on a single breath. One number equals about 100 ml of
FVC. There are no substitutes for clinical judgment. Even if a patient
has good numbers, if they are breathing too hard on your assessment,
realize that he or she will tire out and suddenly decompensate. The
neuromuscle fellow on call is available 24 hours per day and serves as
your “chief” if you ever have any questions regarding ill patients on the
neuromuscle service.
• Watch out for autonomic instability. Only treat high blood pressures if
there is evidence of end organ damage or concurrent active coronary
artery disease etc. that makes treatment imperative. Low blood pressures
can be treated with volume resuscitation. Always keep track of your
patient’s bowel movements and urine output as constipation and
retention are not uncommon and both can lead to devastating outcomes
if they go unrecognized.

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 MOVEMENT DISORDERS
(Daroff and Bradley, Bradley’s Neurology in Clinical Practice, Elsevier, 2012)

90  
 
 Causes of Ataxia

91  
 
 Diagnostic  Approach  to  Adult-­‐Onset  Ataxia    
(Klockgether,  Lancet  Neurology,  2010)  

Treatment of hyperkinetic movement disorders

(Jankovik, Lancet Neurology, 2009)

Dystonia: Anticholinergic drugs, baclofen, botulinum toxin, globus

pallidus internus DBS, repetitive transcranial magnetic stimulation

Hemifacial spasm: Botulinum toxin

Tremors (essential tremor): Propranolol, primidone, topiramate, botulinum

toxin, ventral intermediate nucleus DBS

Tics (Tourette’s syndrome): Fluphenazine, risperidone, botulinum toxin

Chorea (Huntington’s disease): Tetrabenazine

Tardive dyskinesia: Withdrawal of the causative treatment, tetrabenazine

(for tardive stereotypy, tardive chorea, tardive tremor), botulinum toxin (for
tardive dystonia)

Restless legs syndrome: Dopamine agonists (cabergoline, pramipexole,

ropinirole, rotigotine), gabapentin, iron, levodopa, methadone, oxycodone

Myoclonus: Clonazepam, levetiracetam, piracetam, sodium valproate

92  
 
 Clinical Diagnosis and Evaluation of Tremor
(Smaga, AFP, 2003)
 
 

 
 

 
 

93  
 
  

94  
 
 Management of Drug-Related Issues in PD

Movement disorder patients are rarely admitted, and the ones who are come in
a few flavors: 1) pre-surgical ON/OFF motor evaluation for deep brain
stimulators 2) PD patients who become psychotic or orthostatic on their meds
or need placement, 4) large volume LP for NPH.

For all movement disorders patients:

• Call Theresa at 747-0722 or Amy 747-2453 to obtain the last few notes
for the patient.
• In addition, speak with the attending about the patient, and discuss in
detail the plan. The movement disorder attendings are extremely
particular. Do not change medications without explicitly going over the
doses.
• No antipsychotics except for Seroquel or Clozapine. Never EVER give
Haldol.
• Similarly, no antiemetics except ondansetron
• Specify exactly the medication time of intake tablet strength and number
of tablet per dose (ex: Sinemet 25/100 give 1.5 tabs at 6AM, 1 tab at
12PM, 1.25 tabs at 6PM). Note that Sinemet comes in regular (10/100
dark blue pill, 25/100 yellow pill, 25/250 light blue pill) and Controlled-
Release (50/200 orange pill or 25/100 light brick pill).

For the pre-surgical ON/OFF evaluation patients,

• “23-hour observation” status, not admission.
• Diet: For the pre-surgical ON/OFF evaluation patients, patients may eat
until midnight, and thereafter have full liquid breakfast (to maximize
absorption of levodopa) and regular lunch (to prevent patient
irritability).
• For the pre-surgical ON/OFF evaluation, hold all PD meds after
midnight; the patients are evaluated and videotaped in the OFF state the
next morning around 9 am by the DBS nurse. The attending or his nurse
will specify how much Sinemet should be given in the morning
(following a protocol); this is crushed and dissolved in orange juice for
faster absorption. Then the patient is videotaped in the ON state (on
meds) and discharged AFTER Movement sees the patient in the early
afternoon, typically before 3 pm
• Labs: None for pre-surgical ON/OFF evaluation.

For the psychotic patients,

• Start thiamine supplementation (IM), check basic labs, UA/micro, and if
the attending wants, chest X-ray, CT of head, TSH, B12, RPR to look
for treatable causes of dementia/encephalopathy.
• Sinemet, agonists, and amantadine can all cause hallucinations but don’t
stop anything until talking to an attending
• And remember PD patients are very much at risk for delirium in the
hospital

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For patients with orthostasis
• Start with non-pharmacological approaches first. Avoid lying down for
long periods, consider an abdominal binder or compression stockings
(but these can be too hard for a PD patient to put on), increase salt
intake.
• Typically the first line medications are midodrine or fludrocortisone first
(let the attending decide). If midodrine is started then remember to tell
patients to sit upright and don’t give it less than 4 hours before bedtime.

For patients admitted to rule out NPH,

• This is a tough admission! Typically you will need to do 1-3 large
volume taps (30-60cc, one LP per day) with PT to see them
immediately before then 30minutes afterward.

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 MULTIPLE SCLEROSIS
Outpatient MS Diagnosis and Management
Patients with suspected multiple sclerosis are often admitted for an expedited
work up and consideration for steroid treatment.

Diagnostic work up
• An initial Brain MRI is always indicated. If it is ordered with an
"MS Protocol" it will include a sagittal FLAIR. If you are
concerned for current exacerbation order the MR with contrast.
• Lumbar puncture are commonly performed for MS - order MS
Profile labs (Trotter studies). These require nursing to send down
two red-top tubes with blood.
• Oligoclonal bands are reasonably sensitive (>90%) but poorly
specific for MS
• OCTs may be considered in cases where objective evidence of
optic neuritis or prior optic neuritis may be beneficial
• VEPs, SSEPs, BEPs are done infrequently but can be considered if
imaging cannot be obtained or in other very particular
circumstances.

Treatment
• If the patient is determined to be in an exacerbation steroid
treatment may help speed recovery - see below in the MS
Exacerbation section for particulars
• If the patient is thought to have MS they may be started on a
DMARD. This is often deferred to the outpatient setting, but
should be addressed as promptly as possible. If you will be
following a patient in the clinic, obtain the paperwork for the
DMARD of your choice and send it off prior to discharge. If they
are to be followed by the MS division they may benefit from being
seen by the neuroimmunology fellow (discuss this with your team
before calling the consult).
• If the patient has a clinically isolated syndrome many practitioners
would advocate starting DMARD therapy. Discuss this with your
team.

Multiple Sclerosis Exacerbation:

Patients with MS exacerbations or suspected exacerbations may be given a

course of steroids to hasten improvement. Note that this has been shown to
hasten recovery but the evidence does not show a change in long term
outcome.
If the patient has a minor deficit, an outpatient course of PO steroids may be
considered.
In cases where MS exacerbations are severe or debilitating, patients may be
admitted for a course of IV methylprednisolone.
• Methylprednisolone is dosed at a total of 1gm QDay. Typically
this is initiated at 250 mg Q6 hours. If the patient demonstrates

97  
 
 that they are able to tolerate the medication well, doses may be
stacked for convenience (500 Q12 or 1gm QDay)
• Prescribe calcium carbonate, vitamin D, Nexium 40 BID for all
patients on IVMP
• Some routinely prescribe ambien PRN as steroids commonly
disturb sleep.
• Sliding scale insulin should be prescribe for all patients on IVMP
• IVMP is typically followed with an oral steroid taper. The dosing
and duration of this taper is highly variable and clinician
dependent.
• Some common PO steroid regimens
o Oral dexamethasone 4mg tablets (4 tablets QDay x 4
days, 3 3 days, 2 x 2 days, 1 x 1 day then off)
o Oral prednisone 10 mg tablets (6 tablets QDay x 5 days,
5 x 5 days, 4 x 5 days, 3 x 5 days, 2 x 5 days, 1 x 1 days
then off)
o Trotter taper:
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
80 mg 80 mg 80 mg 80 mg 60 mg 60 mg 60 mg
Day 8 Day 9 Day Day Day Day Day 14
60 mg 40 mg 10 11 12 13 NO
40 mg 40 mg NO 40 mg
Day Day Day Day Day Day Day 21
15 16 17 18 19 20 10 mg
20 mg NO 20 mg NO 10 mg NO
Day Day Day Day
22 23 24 25
NO 5 mg NO 5 mg

Outpatient Multiple Sclerosis Management:

DMARD management, and symptomatic therapy encompass the bulk of

outpatient MS management. Most patients with relapsing remitting MS
should be started on DMARD medications early but decisions on the sorts of
patients that would benefit from DMARD therapy and choice of particular
DMARD can become quite complicated and as such are best performed in
consultation with an MS attending - if one is not available immediately in
clinic typically they are happy to assist you by email. Typically patients are
started on injectable medications initially owing to their lower expense, better
side effect profile, and need for less frequent and less intensive monitoring.
All DMARDs may be available to your patients however through assistance
programs. Refer to tables on the following pages for details regarding
DMARD use, adverse effects, monitoring etc.

MS patients suffer from a variety of symptomatic complaints which may be

amenable to medical therapy. Complaints such as oscilopsia, Lhermitte's
phenomenon, depression, urinary difficulties, spasticity, erectile dysfunction,
pain syndromes, fatigue and gait disturbance may be amenable to treatment.

98  
 
For further details refer to the article on symptomatic management in the
suggested reading.

Inpatient MS Management
There are two types of MS inpatients: newly diagnosed and return visitors
with an exacerbation. There is an “MS Exacerbation Order Set” in COMPASS
to help you.

Nursing
• Accuchecks and sliding scale insulin: for diabetics and anyone on
steroids. Start with q4 hours, change to QID if several normal sugars.
• Post void residuals: Check by bladder scan at least once, and if it is
>100, straight cath, and continue to check q6h. No Foleys.
Medications
• Solumedrol: Standard dosing is 250mg IV Q6h, but can be stacked 1gm
q24h or 500mg q12h for convenience and disposition. Discuss with the
attending. Often you will start with the Q6h dosing to make sure the
patient can tolerate. If giving a large dose, it’s best to give it over 30
minutes
• Interferons, Copaxone: continue home dose, if any, and discuss with
attending for newly diagnosed MS.
• Ambien PRN QHS, as solumedrol can cause jitteriness and insomnia
• Calcium carbonate + Vitamin D (1.25g/200 unit) BID.
• GI prophylaxis, Nexium 40 mg BID for anyone on steroids
• Other home medicines such as bladder/bowel agents or anti-spasticity
drugs. Severe MS patients are basically spinal cord injury patients and
are dependent on many medications.
Labs
• BMP, CBC, LFTs (if on interferons), UA/micro/cx. If on interferons,
you may be asked to check neutralizing antibodies.
• For new diagnosis:
o ANA, ESR, ENA, HIV, B12, 2 red top tubes for Trotters
(Immunology Profile CSF/Serum), and vitamin D levels.
o CSF for routine studies, cultures, and Trotters
o Consider NMO antibody in patients with long spinal lesions,
optic neuritis; best characterized in serum but can be sent from
CSF also. Consider Lyme and HTLV based on presentation.
Studies
• EKG (before solumedrol)
• CXR if any suspicion for pneumonia
• MRI (+/- gadolinium) if the attending requests
• Bone density scan if the attending requests
• For new diagnosis:
o Brain MRI (as above)
o Lumbar puncture (as above)
o Consider visual evoked potentials (VEP), somatosensory evoked
potentials (SSEP), brainstem auditory evoked potentials (BAEP)

99  
 
Discharge
• Some patients will require a steroid taper, a practice that varies with
attending. A suggested taper is: Dexamethasone 4 mg tab 4 PO x 4 days,
3 PO x 3 days, 2 PO x 2 days, 1 PO x 1 day, stop. # 30, no refill
• “Trotter Taper” may sometimes be requested
•
Other
• PICC placement if patient has poor venous access. Solumedrol can be
given in a peripheral IV until the IV therapy team is available.
• PT/OT/ST evaluations
• Social work if patient may need acute rehab
• Case coordination if patient needs home health services renewed.
• Wound care consult if decub ulcers
Complications
• Hyperglycemia: Follow FSBG on all patients getting steroids. Non-
diabetic patients with high blood sugars on steroids may warrant
diabetes consultation (they may need insulin at home while on steroids).
• Urinary Tract Infections: Untreated UTIs can cause MS pseudo-
exacerbations. Make sure to check UA/culture before admitting a patient
from the ED for steroids. On the floor, avoid Foleys, check post-void
residuals.
• Pneumonia: Should be ruled out if considering steroids. If you have any
suspicion, get a CXR. Consider speech evaluation to assess swallowing
(PNA is often due to aspiration in MS patients).
• Mood disorder: Depression is common in MS patients; be sure to screen
for it. Also, steroids can cause mania and psychosis.
• Osteoporosis: Everyone on steroids should be on supplemental calcium.
Patients with chronic disease are prone to osteoporosis and may need a
DEXA (typically done as outpatient). If necessary to do while inpatient,
expect that you will need to call the department and explain why. NO
calcium-containing products/meds 24 hours prior to DEXA.
• Falls: Fall precautions +/- CCTV.
• Peptic ulcers: Prophylaxis with PPI (especially while on steroids).
• Decubitus ulcers: Usually seen in chronic MS patients. Order a wound
care consult in Compass.

Suggested Reading:
Polman CH, Reingold SC, Banwell B, Clanet M, Cohen JA, Filippi M, Fujihara K, Havrdova E,
Hutchinson M, Kappos L, Lublin FD, Montalban X, O'Connor P, Sandberg-Wollheim M, Thompson
AJ, Waubant E, Weinshenker B, Wolinsky JS. Diagnostic criteria for multiple sclerosis: 2010 revisions
to the McDonald criteria. Ann Neurol. 2011 Feb;69(2):292-302.
Klawiter EC. Current and new directions in MRI in multiple sclerosis. Continuum Lifelong Learning
Neurol). 2013 Aug;19(4):1058-73.
Markowitz C. Symptomatic Therapy of Multiple Sclerosis. Continuum Lifelong Learning Neurol
2010;16(5):90–104.
Wingerchuk DM1, Lennon VA, Lucchinetti CF, Pittock SJ, Weinshenker BG. The spectrum of
neuromyelitis optica. Lancet Neurol. 2007 Sep;6(9):805-15.

100  
 
 101  
 
 102  
 
 103  
 
 NEURO-OTOLOGY
Vertigo

104  
 
 105  
 
Vertigo is a frequent reason for consults. Distinguishing central and peripheral
etiologies is key. Take a good history, ask about tinnitus, do the Dix-Hallpike
maneuver for at least a minute in each position (have an emesis bucket
handy!), look in their ears, and test hearing. No test perfectly distinguishes
central and peripheral vertigo, but searching for neighborhood signs that
localize the lesion to the brainstem is paramount.
Use the algorithm HINTS (Head Impulse, Nystagmus Testing, Test of Skew).
Any one of the following is concerning for a central lesion: negative head
impulse, nystagmus that is vertical or variable in its direction and skew
(vertical misalignment) on cross cover fixation testing. Patients with
peripheral vertigo may complain of “double vision” from nystagmus, but they
should not have true diplopia or disconjugate eye movements on formal
testing. Any patient in whom you cannot confidently exclude a peripheral
lesion needs an MRI.
For BPPV, it’s usually best to give the patient a script for Antivert and the
ENT clinic phone number to schedule for the Epley maneuver as an
outpatient. You can try the Epley maneuver in the ED using the diagram
below. Also give the patient information, such as from UpToDate, on
performing the Epley at home.
See Next page for Dix-Halpike and Epley maneuvers.

Bell’s Palsy

This is another frequent night float call. Most of the time the ED physicians
take care of this without calling you; if they are consulting you, it’s usually
because there is something atypical about the presentation.
• Make sure to ask about associated symptoms (hyperacusis, altered taste,
altered lacrimation).
• Realize that patients may complain of numbness - it’s generally because
their immobilized face feels weird), but they should not have actual
decreased sensation to pin/temperature on formal testing.
• Ramsay Hunt syndrome (VZV reactivation) is a rare cause and will
present with deafness, vertigo, auricle pain and vesicles in the auditory
canal and can be further treated with acyclovir.
• Recurrent Bell’s palsy is rare, and should trigger further evaluation
(including lumbar puncture, MRI, HIV, Lyme, etc).
• Treatment for patients presenting early (usually <72 hours) after onset of
symptoms is prednisolone 60 mg x5 days then taper by 10 mg per day.
In most recent RCT, antiviral therapy was not shown to be helpful. Eye
protection (lacrilube, patch), is essential.
• It is unclear if facial exercises improve outcome.
• Reassure the patient that 90% recover in 2 months.
• The patient should follow-up in clinic to monitor for resolution.

Suggested Reading:
HINTS to Diagnose Stroke in the Acute Vestibular Syndrome. Stroke. 2009
Nov;40(11):3504-10.
BPPV. N Engl J Med 2014; 370:1138-1147

106  
 
 107  
 
From Neurology Continuum (Oct 2012)

108  
 
 NEURO-ID

• Bacterial meningitis and HSV meningoencephalitis are conditions with a

high morbidity and mortality when not immediately treated. If there is a
suggestion of meningitis, a LP needs to be performed.
• If a patient is acutely and/or critically ill and the history and physical is
suggestive of meningitis, antibiotics should be initiated before the LP,
should the procedure be delayed.
• Generally, if the LP cannot be performed prior to the initiation of
antibiotics, it should be performed shortly after, given that antibiotics
can sterilize the CSF in some cases in less than an hour, making the CSF
culture unreliable.
• Dexamethasone has been shown to improve outcome when given before
or concurrently with antibiotics. We usually give dexamethasone 10 mg
q6 hrs, administered 20 minute prior to antibiotics.
• For community acquired bacterial meningitis, ceftriaxone is considered
first line treatment. If you are concerned about nosocomial meningitis,
you may want to choose cefepime to cover the SPACE organisms
(Serratia; Pseudomonas; Acinetobacter; Citrobacter, Enterobacter).
• Acyclovir can cause renal failure, so ensure hydration while patients are
on this medication. Adjusting for renal dysfunction is important.

Common Empiric Antibiotic Dosing for Meningitis in Adults

Drug Dose Notes

Vancomycin 15 mg/kg Modify dosage based on renal
(actual dysfunction and age (see
weight) q12 Toolbook). Check trough prior
hr; dose to to 4th dose. Goal should be 15-
the nearest 20 mcg/ml.
250 mg.
Max daily
dose 4.5 g.
Ceftriaxone 2 g q12 hrs No dosage modification
required for renal failure.
Cefepime 2 g q8 hrs Modify dosage in patients with
renal dysfunction
Ampicillin 2 g q4 hrs Modify dosage in patients with
renal dysfunction. Use if
concern for Listeriosis
(neonates, age over 50,
pregnant, alcoholic,
immunosuppressed)
Acyclovir 10 mg/kg q8 IMPORTANT: Modify
hrs dosage in patients with renal
dysfunction. Dose by actual
body weight unless obese than
ideal body weight should be
used. Ensure hydration.

109  
 
 SPINE DISEASES

110  
 
 FUNCTIONAL PATIENTS
- In general, always give the patient the benefit of the doubt, since many will
embellish their true findings.
- Avoid calling a patient functional until they have been formally staffed in
person by an attending.
- Diseases like multiple sclerosis and stroke often have symptoms of various
localizations and ages, making cases challenging.

Functional Weakness
- A normal Brain or Spine MRI can be very reassuring that there is no acute
central lesion
- Absent reflexes in the setting of acute weakness can be very localizing or
suggestive of underlying illness
- Push patients to give their “full effort”, especially when walking, they will
suddenly improve when walking faster
- Referring a patient to clinic to document stability of findings can be an
option to the ‘Million-Dollar Workup”.
- Hoover sign can be supportive of functional overlay, but does not rule out
neurological disease
- Always check rectal tone & postvoid bladder scan to evaluate for
myelopathy

Functional Numbness/Tingling
- A normal Brain or Spine MRI can be very reassuring that there is no acute
central lesion
- Consider using a cotton swab to evaluate for “numbness”. If sensation is
intact to cotton wisp, it is probably not “numb”
- Most patients with mild isolated facial paresthesias have no acute brainstem
pathology if no neighborhood findings are present
- Most patients with mild isolated limb paresthesias have an entrapment or
radicular lesion if no weakness is present
- Bilateral arm paresthesias may signify central cord syndrome, always image
the C-spine
- Hugging sensations may signify a transverse myelitis
- Splitting the midline with vibration can be supportive of functional overlay,
but does not rule out neurological disease

Pseudoseizures
- Always respond to the patients with concern, but do not give Ativan if it’s
not a seizure
- A reasonable number of true epileptics also have pseudoseizures. Treating
the underlying seizures reduces the pseudoseizures
- It is not infrequent that patients will cry ‘wolf’ for all pseudoseizures, then
be completely unaware of true underlying seizures
- Always perform a prolonged video EEG before deciding that patients have
pseudoseizures
- Look for sz w/suggestion, presence of family, avoidance behavior, eye
closure, motor pauses, out-of-phase body movements, pelvic thrusting

111  
 
- These pts respond to activation techniques such as flashing lights /
hyperventilation
-­‐  If  EEG  is  connected  during  a  pseudoseizure,  close  their  eyes  to  help  bring  
back  the  normal  posterior  dominant  rhythm

112  
 
 COMA PROGNOSIS
You will frequently be called by the ICUs for patients who have suffered a
devastating hypoxic ischemic injury. The consultation is usually for
assistance with determining neurologic prognosis, or to rule out seizure. It is
helpful to clarify with the primary team exactly what their question is at the
time the consult is called, and if neurology remains on board for any length of
time, continue to have discussions with the primary team about the role of the
consulting neurology team. These consults can become difficult and, at times,
ethically challenging. Clear communication is of paramount importance.

Myoclonus and other “jerks” in Hypoxic Ischemic Injury

These patients frequently develop myoclonic jerking post-arrest and non-
neurologists often interpret it as seizure. Post-arrest myoclonus is generally
considered a poor prognostic sign. We do not treat it unless it is interfering
with the patient’s care or is disturbing to the patient’s family. You can use
benzodiazepines for treatment; alternatively, Keppra and valproic acid have
some utility for myoclonic jerking. In rare cases, sedating with propofol has
been done. Be cautious, as post-arrest patients can also develop non-
myoclonic seizures. If there is any doubt, it is always a good idea to obtain an
EEG. Post-arrest patients can also develop Lance—Adams syndrome, which
causes myoclonic jerks but has a much better prognosis.

Significance of physical findings in coma following cardiac arrest

Patients with less chance of regaining independence

Initial exam No pupillary light reflex
One day Motor response no better than flexor and spontaneous eye
movements neither orienting nor roving conjugate
Motor response no better than flexor, no spontaneous eye
Three days
opening
Motor response not obeying commands and spontaneous eye
One week
movements neither orienting nor roving conjugate.
Oculocephalic response not normal, not obeying commands,
Two weeks no spontaneous eye opening, eye opening not improved at
least 2 grades from initial examination
Patients with best chance of regaining independence
Pupillary light reflexes present and motor response flexor or
Initial exam extensor. Spontaneous eye movements roving conjugate or
orienting
Motor response withdrawal or better and eye opening
One day
improved at least 2 grades
Motor response withdrawal or better and spontaneous eye
Three day
movements normal
One week Motor response obeying commands
Two weeks Normal oculocephalic response

113  
 
 Clinical parameters May predict poor prognosis
Duration of anoxia >8-10 minutes
Duration of CPR >30 minutes
Pupillary light reaction Absent on day 3
Motor response to pain Absent on day 3
Brainstem reflexes Absent
Blood glucose on admission >300 mg/dL
Glascow coma score on day 3 <5
GPCS on day 3 <22

Always wait at least 72 hours post-event before leaving prognosis statements

on a consult. Remember that the guidelines for prognosis derived from the
Levy criteria do not always apply to patients who are were treated with
therapeutic hypothermia or patients with major metabolic or infectious
aberrations. If major derangements exist, these must be corrected before any
statements about prognosis can be made. The following table from Wijdicks,
et al. 2006 applies only to patients who were NOT treated with therapeutic
hypothermia.

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Patients who have undergone therapeutic hypothermia must be evaluated
differently. The largest study was by Fugate et al, 2010 in 192 patients.
Unlike normothermic patients, loss of motor responses better than extension at
day 3, and high NSE levels were found to be unreliable. This has been
confirmed by other studies. See table below.

Blondin et al, 2011’s review on prognosis after hypothermia suggests that loss
of pupils or corneals at 72 hours is still the best predictor of poor prognosis.
Again, loss of motor responses was less strong of a predictor and myoclonus
during hypothermia as not a strong predictor. They also recommend that
SSEPs and NSE levels should be checked 48 hours after rewarming. See table
below.

The metabolism and pharmacokinetic properties of certain sedating

medications, including morphine, fentanyl, and propofol, are altered during
therapeutic hypothermia and special care should be taken when making
recommendations regarding neurologic prognosis in patients who have
received sedating medications in conjunction with therapeutic hypothermia.

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 BRAIN DEATH EVALUATION
If you are called to see a patient and you are concerned the patient may be
brain dead, perform and document a neurologic exam as you would for a
comatose patient (including the date/time of exam, any relevant sedating
medications, metabolic abnormalities, temperature, etc) and then contact the
fellow in the NNICU to arrange a time to staff with a NNICU fellow or
attending. These consults are not staffed as typical consults with the consult
attending. DO NOT WRITE THE WORDS “BRAIN DEATH” IN THE
CHART WITHOUT FIRST STAFFING WITH A NNICU ATTENDING.

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