2025 – PAGE 408 – NEUROLOGY

LOWER MOTOR NEURON DISEASE

Findings of lower motor neuron lesions/disease include hypoactive or absent reflexes, atrophy of the muscle, and fasciculations.

HEAD TRAUMA

In cases of head trauma, if there is no focal neurological sign, no loss of consciousness, and the patient vomited only 0–1 times, it is OKAY to discharge from the ER WITHOUT any imaging. If required, order a CT, not an MRI.

PEARL: EPIdural hematomas can present days later after a “lucid period” and then have rapid deterioration and death. If a patient presents with a history of head trauma + loss of consciousness several days ago, STILL get the CT scan!

NEUROCARDIOGENIC SYNCOPE

Neurocardiogenic syncope usually occurs after prolonged standing or times of stress/anxiety. It is the most common etiology of syncope.

CEREBROVASCULAR ACCIDENT (AKA CVA or STROKE)

A cerebrovascular accident (AKA CVA or stroke) can present with a facial droop, slurred speech, or motor weakness on exam. Paresthesias are not specific. Could be seen in a chronically hypoxic patient with polycythemia, an African American or Mediterranean person with G6PD, or even in a patient with a carotid artery dissection from blunt force chest trauma (get carotid angiography). In general, the best diagnostic test for a stroke is an MRI. An MRI will show both a thrombotic stroke (most common) and a hemorrhagic stroke. Cerebral angiography would also be an appropriate choice. A regular CT of the head should NOT be ordered because it really only shows a hemorrhagic stroke.

PEARL: Regarding CT scans of the head, if you are ever specifically concerned about a head bleed (trauma, fall, history of an aneurysm, or coagulopathy), order the CT scan!

INTELLECTUAL DISABILITY

Intellectual disability, also known as general learning disability and formerly mental retardation (MR), is defined as an IQ < 70.

EPIDURAL HEMATOMA

A child can get an EPIdural hematoma from even mild trauma and may present with a rapid decline in mentation. There can be a LUCID PERIOD during which time the patient is fully conscious before the patient suddenly becomes unconscious again. Diagnose by getting a CT scan of the head and NOT by doing a lumbar puncture (contraindicated in suspected space occupying lesions due to possibility of herniation). If by chance a lumbar puncture was done, it will show RBCs in equal proportions in all tubes even in an atraumatic “champagne” tap.

PEARLS: Epidural bleeds are arterial and require STAT surgical intervention (burr hole). Some patients can have a traumatic event causing an epidural bleed. At the time of the insult there are concussive symptoms but then the patient improves, only to deteriorate AGAIN after an interval of time. This “lucid period” can last hours, or even DAYS. So, if you are presented with a patient who had head trauma, then lost consciousness (even a few days ago!) and is now presenting with ANY neurological complaint, GET A STAT HEAD CT!

SUBDURAL HEMATOMA (SDH)

Subdural hematomas (SDH) are caused by shearing of bridging veins between the dural sinuses and are associated with high-speed acceleration or deceleration. Mental status changes may be fast or slow in onset, and there is no lucid period. SDHs can turn into chronic SDHs. Evacuate the bleed if they show evidence of increased intracranial pressure (ICP), or if they show an increasing size on serial CT scans.

PEARL: In the world of pediatrics, if you see this in a baby, you should think shaken baby syndrome! The next step is to do a retinal exam to look for retinal hemorrhages!