CertMedEd – Neurology Clinical Pearls

CertMedEd – Neurology Clinical Pearls

Frequently asked Neurology questions at our CertMedEd 3-day CME & 100% Guaranteed PANCE/PANRE Board Review courses answered by Michael Leddy, MMS, PA-C:

Q: 1.  What is treatment for migraine either in ED or inpatient setting?

A:  The migraine treatment cocktail that I order the is most effective is as follows in this order:

Depacon 1000 mg IV infuse over ten minutes.  The rate is important and the pharmacy will give you a hard time regarding this.
Decadron 10 mg IV x 1
Thorazine 25 mg IV Q 4 hrs or Compazine 10 IV Q 6
DHE 1mg IV

Avoid all narcotics.

Q: 2 .  What is the difference in the work up for TIA vs. CVA?

A:  First, a Transient Ischemic Attack is due to a temporary loss of blood flow to any part of the central nervous system or eyes, with complete resolution of symptoms and a nonfocal exam within 24 hours.  There is a debate currently over changing this to two hours.  MRI inaging after the event will not show any evidence that it occured.  Cerebrovascular accident can be hemorrhagic or ischemic (thrombotic or embolic), has symptoms and exam findings of a longer duration and also will have positive findings on MRI imaging (with diffusion images).  CT of the brain will most likely be negative in the first 24 hours and therefore is only useful in the setting of suspected hemorrhage.  A patient often leaves the ED after a negative CT being told that he/she had a “mini stroke” only to have MRI evidence of a much larger insult when seen in follow up.  All TIAs should be considered serious as 22-25% pt will have a CVA within first 90 days.  Workup for both is the same:  MR Brain, carotid ultrasound, echocardiogram (preferably transesophageal), lipid panel. Additional studies such as MRA, hypercoaguable work up can be done pending the results of the initial studies. Treatment is antiplatelet agents and risk factor modification.  If Afib is present then full anticoagulation.  Heparin is no longer typically used because of increased risk of intracranial bleed.

Q3:  What is an effective treatment for Trigeminal Neuralgia?

A:  The “gold standard” is Carbamazepine.  However it needs to be slowly titrated over weeks to avoid side effects, and there is no specific dose, jut increase to efficacy.  You will need to monitor blood levels, CBC, and LFTS.  Other agents included gabapentin, pregabalin, or even baclofen.  In the acute setting such as in the ED try infusing Fosphenytoin (not iv dilantin) 1000 mg x1.  It should stop the attack and allow the pt to be comfortable for a few days, but may need to be repeated before the carbamazepine is effective.  For refractory cases, refer to neurosurgery for trigemnial nerve ablation vs. decompression.

Michael Leddy, MMS, PA-C is an Associate Medical Educator for Certified Medical Educators and works in a busy Neurology practice.  Visit his profile by clicking here and feel free to email an additional neurological clinical pearls questions to CME@CertMedEd.com


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