TGA Checklist

RISK FACTORS:

  • Past history of TGA
  • Advanced Age
  • Migraneous Headaches

EXAMINATION:

  1. full neuro exam (CN, sensory, motor, cerebellu, reflexes)
  2. memory exam (explicit memory loss, intact implicit memories)
  3. test immediate (intact) vs delayed recall (impaired)
  4. test attention span with serial 7’s WORLD backwards (intact)
  5. test procedural memory (intact)
  6. MMSE

TGA – all symptoms should resolve under 24 hours.

DIAGNOSTICS:

  1. if no resolution in 24 hours – requires broader investigation (MRI/CT, LP, EEG)
  2. imaging:  MRI preferred over CT unless suspicion of acute ischemic stroke
  3. EEG to r/o seizures
  4. work-up patients with no witness at onset, <50 years old (rarer), high risk (immunocompromised, drug / ETOH use, abnormal VS)

TREATMENT:

  1. thiamine if h/o ETOH abuse
  2. hold meds that can cause amnesia (benzos)
  3. observe in ED OBS UNIT or inpatient x 1-2 days until resolution of symptoms
  4. serial neuro exams until patient returns to normal

 

REFERENCE:  http://emdidactic.blogspot.com/2017/04/transient-global-amnesia.html

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TGA Differentials

  • Seizure/transient epileptic amnesia 
(lasts < 1 hour)
  • Stroke (rarely presents as isolated amnesia)
  • Atypical migraine
  • Head injury/occult trauma/concussion syndrome 
(Manage as Head Injury)
  • Medication and recreational drug side effect
  • Herpetic encephalitis 
(fails to resolve in <24hrs)
  • Early neurosyphilis
  • HIV dementia
  • Alcohol psychosis
  • Alcohol blackout

Describing Aneurysm Sizes

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Encephalopathy Work-up

Screening tests

  • Serum glucose, electrolytes, calcium/phosphorus, uric acid, lactate and pyruvate, liver, renal and thyroid function tests, blood gasses
  • Prolactin levels (10 to 20 min after suspected seizure, diagnosis seizure vs. psychogenic nonepileptic seizure)
  • Serum CK
  • ANA, ENA, ANCA, RF, complement, ACE, anti-thyroglobulin and anti-thyroperoxidase antibodies (Hashimoto disease), autoantibody panel (thyroid antimicrosomal, antiparietal),  immunoglobulins
  • Serum ceruloplasmin and copper, 24h urinary copper, slit lamp, liver biopsy (WD)
  • CBC, ESR, CRP, plasma fibrinogen
  • Coagulation profile (protein C and S, ATIII, Factor Leiden V, APLS, anticardiolipin)
  • Serum vitamin B12 and folic acid
  • RPR, TPHA
  • Serum cortisol, PTH and osmolality.
  • Serology: HIV, HSV, adenovirus, CMV, Coxsackie, polio, echovirus, hepatitis (A,B,C), parvovirus B19, mycoplasma, toxoplasma, VDRL, cysticercosis
  • Blood and urine organic acids and carnitine
  • Chest X-ray
  • PPD
  • Echocardiogram
  • EEG (non-convulsive status epilepticus), VEP, EMG/NCVs
  • Brain MRI, MRA
  • Conventional angiogram (CNS vasculitis)
  • serum ammonium

CSF

  • Besides routine analysis (chemistry, cell count, smear and stainings): lactate and pyruvate (mitochondrial disease), oligoclonal bands, IgG index, VDRL, viral (measles titer), fungal, PCR (T. Whippleii, JC virus, HSV, CMV, VZV), Ziehl staining, repeated cytology,
  • anti-thyroglobulin and anti-thyroperoxidase antibodies (Hashimoto disease).

 

Specific investigations

Blood/serum

  • 14-3-3 protein (CJD) (stable at room temperature and can be sent by regular mail)
  • Aminolevulinic acid, porphobilinogen, uroporphyrins, coproporphyrin
  • Antineural nuclear antibodies (ANNA-1(=Anti-Hu), ANNA-2 (=anti-Ri), ANNA-3, Purkinje cell cytoplasmic antibodies (PCCA-1 (=anti-Yo), PCCA-2, PCCA-Tr and mGluR1), plasma membrane cation channel antibodies (CV2/CRMP-5, Ma1, Ma2/Ta, amphiphysin, striational, voltage gated calcium channels (VGCC) and voltage gated potassium channels (VGKC), anti-NMDA-R (NR1 and NR2) antibodies.
  • Methylmalonic acid, VLCFA, arylsulphatase, homocysteine

 

Biopsy

  • Conjunctiva (sarcoidosis),
  • Small bowel (Whipple disease)
  • Skin (SLE, vasculitis, CADASIL)
  • Brain biopsy

 

Reference:

“Acute Encephalopathy Work-Up.” Neuroweb.us. http://www.neuroweb.us/Chapters/acute%20encephalopathy/work_up.htm, 2017. Web. 18 Aug. 2017.

Neurogenic Stress Cardiomyopathy

Proposed Mechanism for HCP causing Takotsubo:

Sympathetic control of the heart is mediated by hypothalamic nuclei that abut the walls of the third ventricle.  Specifically, dysfunction of PVN and DMN has been linked to catecholamine-induced myocardial necrosis.  Hydrocephalus may disrupt these centers, although intracranial hypertension may not be necessary for this to occur.

 

hypothalamus-2-14-638.jpg

Figure-1-A-schematic-representation-of-the-hypothalamic-nuclei-and-the-distribution-of

*Paraventricular nucleus (PVN):   TRH release, CRH relesase, oxytocin release, vasopressin release, somatostatin release

**Dorsomedial nucleus (DMN): BP, HR, GI stimulation

 

Reference:

Gharaibeh, Kamel, Jackie Scott, and Nicholas A. Morris. “Neurogenic Stress Cardiomyopathy Precipitated By Acute Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage.” Neurocritical Care (2017): n. pag. Web. 14 Aug. 2017.

“Hypothalamus.” En.wikipedia.org. N.p., 2017. Web. 14 Aug. 2017.

Transphenoidal Cushing

Cushing’s disease:

 

Check labs:

  • AM cortisol and ACTH levels 6am and 6pm post-op day 1 and 2 (off steroids).

Treatment:

  • Avoid starting steroids until biochemical evidence of hypocortisolemia or clinical evidence of adrenal insufficiency.
  • Pt is deemed to be in early remission if morning cortisol level ≤5mcg/dl on postoperative day 1 or 2, necessitating glucocorticoid replacement.
  • Check BP q 2 hours. If BP<90/60 or nausea/vomiting/dizziness, immediately draw cortisol and ACTH levels and start Dexamethasone 0.5mg BID or HC 25mg daily (if on wards)
  • Assuming BP stable, start Dexamethasone 0.5 mg BID or HC 10mg AM and 5mg PM second post-op day 2
  • Send home on Dexamethasone 0.5 mg BID o HC 10mg AM and 5mg PM and have endocrinologist potentially adjust at 2 week post-op visit. Stress importance of this medication.
  • Subsequent assessments of corticotroph function are performed at a minimum of 3, 6, and 12 months after surgery. If successful surgery, unable to be weaned off of glucocorticoid replacement for at least 6-12 months after surgery.

 

ABCD2 Score

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TIA Prognosis and Key Mx Considerations by National Stroke Association

 

Reference:

Stroke.org. (2017). [online] Available at: http://www.stroke.org/sites/default/files/resources/tia-abcd2-tool.pdf?docID [Accessed 31 Jul. 2017].