1 ⼀NEUROLOGY I/II (6/10) Z Flashcards
A: MIOS seen in Younger pts indicates ⬜
B: MIOS seen in OLDER pts indicates ⬜
C: What is the purpose of the MLF
[MIOS-MLF Internuclear Ophthalmoplegia Syndrome]
1) Younger pts= Multiple Sclerosis
2) Older pts= [Pontine a. lacunar stroke]
________________
MLF coordinates CN3 with CN6
________________
Image: Left MIOS
CP for [MIOS-MLF Internuclear Ophthalmoplegia Syndrome] (3)
[MIOS-MLF Internuclear Ophthalmoplegia Syndrome]
*[Impaired ADDuction of affected eye]
+
[Normal ADDuction of affected eye during [near reflex convergence]
+
*[Nystagmus of UNaffected eye when attempting to ABduct]
Image: L MIOS
1st line tx for Heat Stroke is ⬜, which should be used to ⬇︎core body temperature by ⬜C/min .
Describe it
________________
List 3 adjunct Heat Stroke therapies
[augmentation of EVAPORATIVE COOLING] ; [0.2C/min]
(naked pt is sprayed with tepid (warm) water mist or pt is covered in wet sheet – while large fans circulate air ➜ ⇪ evaporative heat loss)
________________
ice water lavage / ice packs / cold IVF
3 main causes of pinpoint pupils
- Opiate OD
- Pontine lesion destroying sympathetic fibers
- Cholinergic eyedrops for Glaucoma
3 Main causes of Spinal Cord Compression
- DJD Disc Herniation (Smoking risk factor)
- [Epidural Staph a. Abscess (think IV drug user vs DM)]
- Tumor (Prostate/Renal/Lung/Breast/Multiple Myeloma mets)
Dx = MRI, Positive Straight Leg, Classic S/S
DJD=Degenerative Joint Disease
6 major causes of Syncope
MVC BSD
- ⬇︎ Cardiac Output (Valvular Dz/HOCM/Pulm HTN/PE/Tamponade/myxoma/aFib)
- Bradyarrhythmia (SA Node dysfunction/AV Block)
- [VANS - Vasovagal Autonomic Neurocardiogenic Syncope]
- Dehydration
- Stroke
- Metabolic (⬇︎Glucose vs ⬇︎Na+)
OBTAIN ECHOS ON ANY PT WITH SUSPICIOUS SYNCOPE!
A patient taking metoclopramide develops involuntary next flexion known as ⬜
Tx? (2)
[Torticollis Dystonia] ; [Benztropine IV 🆚 Diphenhydramine IV]
A pt complains of inabilty to recognize previously known faces
What is this called? ; Where is the lesion?
[ProsoPagnosia visual agnosia] ; BL Temporo-Occipital
a. Tx for PostFall syndrome (2)
_________________
b. What is PostFall syndrome?
a.
-URGENT PHYSICAL THERAPY
-URGENT BEHAVIORAL THERAPY
_________________
b. maladaptive fear of falling after a fall that ➜ restricted mobility and functional decline in the elderly
Describe the 3 main sx for [Brown Sequard Syndrome]
1.[DCP: Ipsilateral 2TVP loss]
2.[LateralCST: Ipsilateral [UMN (Weak MESH)]
3.[STT: Contralateral Pain/Temp loss 2 LEVELS BELOW ORIGINAL LESION]
|💡 Brown Sequard = SpinalHemisection
🖊2TVP-2point/Touch/Vibration/[Position Proprioreception]
Causes of [Brown Sequard Syndrome] - 3
- [(Extramedullary Tumor]
- Trauma
- [DJD Disc Hernation (Smoking risk factor)]
A: Describe Opsoclonus-Myoclonus Syndrome
B: What Childhood tumor is it associated with?
A: [Non-Rhythmic Conjugate Eye mvmnts] with myoclonus= “Dancing Eyes and Feet”
B: Neuroblastoma (onset 2 y/o)
Arises from Neural crest
PCiiH [Pseudotumor Cerebri Idiopathic Intracranial HTN] Dx - 3
1st: [CT to r/o space occupying lesion]
➜ 2nd: [Lumbar Puncture with opening pressure >250 mmH20 (from ⬇︎Arachnoid villi CSF absorption)]
3rd: [MRI +/- MRV revealing BL tortuous Optic N]
* _________________*
* This HA will make you go Blind!*
⊕Papilledema is a ctx to Lumbar puncture
When is ⊕Papilledema not a ctx to Lumbar puncture? Explain
[PCiiH (Pseudotumor Cerebri Idiopathic Intracranial HTN)];
As long as there are no signs of obstructive/noncommunicating hydrocephalus or mass, then it is ok
LP with CSF opening pressure > 250 mmH20 = PCIIH
[Pseudotumor Cerebri Idiopathic Intracranial HTN] Clinical Presentation - 4
PCiiH girls like to VAPE
- [Vision ∆ +/- papilledema]
- [Abducens CN6 palsy]
- Pulsatile Tinnitus
- [Eye-blinding HA (worst at sleeping times) & with head position ∆]
* This HA will make you go Blind!*
What is Wallerian Degeneration?
Degeneration of Axons after trauma, but in the setting of [preserved perineurium and epineurium] which later acts as scaffolding to allow axonal sprouting and regeneration within the PNS
Describe the Lacunar Syndrome CP
lenticulostriate vessels perfuse [bTIC]
1A: basal Ganglia–>Hemiballismus & involuntary writhing
1B: ThalamuS VPL –> Sensory Stroke CTL
1C: [Internal Capsule-POST limb/Corona Radiata]–> Motor stroke (ataxia vs. clumsy hand-dysarthria)
________________
- Lacunar Stroke= [Thrombotic HTN Arteriolosclerosis & Thrombotic microatheromas] of lenticulostriate vessels (bTIC) –> [cystic infarcts < 15 mm] –> Lacunar Syndrome*
- VPL=VentroPosteroLateral nc*
List the n. roots associated with Common Peroneal n.
L4-S2
foot is dropPED (Peroneal Everts & Dorsiflexes)
- Commonly caused by L5 Radiculopathy*
- Dx: Knee MRI vs EMG*
List the n. roots associated with Tibial n.
L4-S3 (Three)
can’t walk on TIPtoes (Tibial Inverts & Plantarflexes)
Commonly caused by L5 Radiculopathy
What are the functions of the Common Peroneal n. -2
L4-S2
foot is dropPED (Peroneal Everts & Dorsiflexes)
_________________
🔬 Commonly caused by L5 Radiculopathy
🩺 Knee MRI vs EMG
What are the functions of the Tibial n. (2)
L4-S3 (Three)
can’t walk on TIPtoes (Tibial Inverts & Plantarflexes)
Commonly caused by L5 Radiculopathy
CP of Craniopharyngiomas - 3
________________
Demographic?-2
- BiTemporal Hemianopsia
- HA
- Pituitary Hormonal Deficiencies (i.e. ⬇︎Libido)
Demographic: MOSTLY KIDS, but some adults
A: What is Cheyne-Stokes Breathing?
B: What is this breathing associated with? - 3
A: Cyclic breathing in which apnea is followed by [INC and then DEC tidal volumes] all the way up until the next apneic period
B:
- [Advanced CHF]
- [Comatosed BL metabolic encephalopathy]
- Elderly during sleep
[Myasthenia Gravis] Tx-4
P DDD F
1st: [Pyridostigmine AChesterase inhibitor]
2nd: Cyclosporine
3rd: Thymectomy
4th: **[Intubate + Plasmapharesis + IVIG + Steroids] if Crisis **
Pts with Myasthenia Gravis may develop Myasthenia CRISIS, which presents clinically as ⬜ !!!
What are precipitants of this?-3
P DDD F
Respiratory Failure!
Precipitants = FIS:
- Fluoroquinolones
- Infection
- Surgery
Crisis Tx: [Intubate + Plasmapharesis + IVIG + Steroids]
[LEMS - Lambert Eaton Myasthenic Syndrome] etx
[Autoimmune attack against (Presynpatic Ca+ channel)–> No ACh release]
[Myasthenia Gravis] Clinical Presentation (5)
“Give me Mya’s P DDD F”
[Ptosis
[Diplopia from Disconjugate gaze]
Dysarthria-bulbar dysfunction
Dysphagia w/nasal regurgitation-bulbar dysfunction
[FATIGABLE progressive Weakness Muscularly (Extraocular/RESP/Proximal/limbs/worst w/repetition/impvd with rest)]
Tx: Pyridostigmine AChesterase inhibitor
[Myasthenia Gravis] Dx-5
P DDD F
- ACh R Ab Assay
- MuSK (Muscle-Specific tyrosine Kinase) Ab Assay (only if #1 is neg)
- [Tensilon Edrophonium]–> Improves all sx
- Ice Pack to eyelids –> Improves Ptosis by inhibiting ACh breakdown at NMJ
- BE SURE TO GET CT CHEST AFTER DX TO COVER FOR THYMOMA, POSSIBLE THYMECTOMY!!!!
[LEMS - Lambert Eaton Myasthenic Syndrome] Clinical Presentation - 3
- Weakness of [Proximal limbs and trunk] mimicking myopathy, better with exercise
- Autonomic sx (Dry mouth /Orthostasis / Impotence)
- ⬇︎Deep Tendon Reflexes
[Myasthenia Gravis] etx
________________
Demographic?-2
Autoantibodies block and degrade [postsynpatic nicotinic ACh Receptors]] –> [⬇︎ motor end plate potential]
_____________________
[Women 20-30] [Men 60-80] yo
Migraine etx
________________
How are the Trigeminal nerves associated-2
________________
VTAP the migraine BEFORE it comes, and SEND it on its way when it does!
Genetic [GainOfFunction mutation in excitatory NMDA receptor]–>burst of cerebral activity when triggered—>hyperemia (usually occipital lobe)–> sx. Burst is followed by Cortical Depolarization tht has slow but deliberate forward advance –> Triggers Trigeminal pathway
Trigeminal afferents :
- send impulses–>[Brain Stem APCTZ] & hypothalamus–> Nausea/Photophobia/Phonophobia
- retroactively depolarize–>release of substance P –> neurogenic inflammatory pain + vasoDilation
A: Primary CNS Lymphoma is the ⬜ most common cause of ⬜ in HIV pts
B: What virus is this associated with?
C: What WBCs would you expect to see in the brain tissue
A: 2nd most common cause of ring enhancing lesions in HIV pts (1st = Toxoplasmosis Gondi)
B: EBV
C: B-lymphocytes
Basilar Artery occlusion CP
Locked In Syndrome!!! (preserved consciousness but with quadriplegia)
PCA occlusion CP-4
- [CTL Homonymous Hemianopiawith macular sparing (K in image)]
- Visual hallucinations
- [Alexia with NO agraphia]Dominant Hemisphere involvement
- [Down & Out Eye + Ptosis]Oculomotor CN3 involvement
ACA occlusion CP-3
- CTL Weakness worst in LE
- CTL Numb worst in LE
- Urinary Incontinence
AICA occlusion CP-4
Somewhat like [PICA Lateral Medullary Syndrome of Wallenberg]
- Hearing Loss
- FACE Paralysis (Similar to Bells Palsy)
- Ipsilateral ⬇︎Facial Pain/Temp
- CTL ⬇︎BODY Pain/Temp
PICA occlusion causes what syndrome?
what other vessel abnormality can cause the same CP?
This is AKA [PICA Lateral Medullary Syndrome of Wallenberg]
Intracranial Vertebral A occlusion = MOST COMMON CAUSE OF THIS!
ALL Elderly should be screened for “Falls “ ⬜ a year with ⬜. How do you manage patients with ⊕Fall screen? (2)
once; [inquiry on how many (if any) falls they’ve had]
_________________
▶if fall screen ⊕ → assess gait/balance with [psGUGT (postural stability “Get Up and Go” test)]
▶ … –(if psGUGT also ⊕)–> [extensive “fall” workup](image)
psGUGT: Without assistance, pt stands from armless chair, walks short distance, turns around, returns to chair and sits down again. [If unsteady/difficulty = ⊕ result]
ALL Elderly should be screened for “Falls “ ⬜ a year with ⬜.
Patient has ⊕fall screen → ⊕psGUGT → requires elderly [extensive fall workup] now
Describe the 6-part differential that outlines elderly [extensive fall workup]
once; [inquiry on how many (if any) falls they’ve had]
_________________
All patients (especially elderly) s/p FALL require ⬜ by a ⬜ for the purposes of ⬜
[home safety assessment] ; occupational therapist
_________________
optimizing HOME safety and ADL
Altered Mental Status workup -7
GOT CLUB
- G[Glucose level ➜ Thiamine B1 f/b glucose admin (dextrose IV)]
- Oxygen level
- T3/T4 level
- B12 level
- Lumbar puncture
- [UDS/CMP/CBC]
- CT head
Although Parkinson’s disease is a clinical diagnosis < E + 2S - R - X >, what’s the most important supportive feature for confirming the diagnosis?
excellent response to dopaminergic tx (Levodopa/Carbidopa)
⊡established PD = < E + 2S - R - X >
[Parkinson’s Disease] is a ⬜ diagnosis
Diagnosing Parkinson’s Disease consist of 4 criteria blocks
Name them
clinical
_________________
< ESRX > critertion
1. {[Essential (for PD)] = AKA “PARKINSONISM” }
2. [Supportive (of PD)]
3. [RedFlags (atypical for PD)]
4. eXclusion (excludes PD dx)]
⊡established PD = < E + 2S - R - X >
[Parkinson Disease] = ⬜ diagnosis made of 4 criteria blocks < ESRX >
Describe the < E > criteria block (4)
clinical ;
_________________
< ESRX >
⭐[< E >ssential (for PD diagnosis)]
▶requires ([P or R]
▶requires (+ K)
▶ =AKA “parkinsonism”
Essential (for PD) = [ (P|R) +K ]
PARK =
-Pill Rolling resting tremor
-Areflexia posturally
-Rigiditiy cogwheel
-bradyKinesia
_________________
⊡established PD = < E + 2S - R - X >
[Parkinson Disease] = ⬜ diagnosis made of 4 criteria blocks < ESRX >
Describe the < S > criteria block (4)
clinical ;
_________________
< ESRX >
⭐[< S >upportive (of PD diagnosis)]
▶[Excellent response to levodopa/Carbidopa = MOST IMPORTANT SUPPORTIVE FEATURE]
▶Asymmetric limb findings (tremor, rigidity)
▶Olfactory dysfxn
⊡established PD = < E + 2S - R - X >
[Parkinson Disease] = ⬜ diagnosis made of 4 criteria blocks < ESRX >
Describe the < R > criteria block (7)
clinical ;
_________________
< ESRX >
⭐[< R >ed Flags (atypical for PD diagnosis)]
▶ [early Areflexia posturally (recurrent falls)
▶early SEVERE orthostatic hypOtension]
▶ [early bulbar dysfxn (dysarthria)]
▶ having NO [nonmotor signs] (i.e. having NO sleep ∆ is atypical fopr PD )
▶ Symmetric findings
▶Hyperreflexia
⊡established PD = < E + 2S - R - X >
[Parkinson Disease] = ⬜ diagnosis made of 4 criteria blocks < ESRX >
Describe the < X > criteria block (6)
clinical ;
_________________
< ESRX >
⭐[< X >clusionist (automatically eXcludes PD diagnosis)]
❌vertical palsy
❌[cerebellar sx (ataxia/nystagmus)]
❌sensory loss
❌aphasia
❌[pt currently taking dopaminergic rx (ie haloperidol)]
⊡established PD = < E + 2S - R - X >
[Parkinson Disease] = ⬜ diagnosis made of 4 criteria blocks < ESRX >
What is the diagnostic criterion arrangement neccessary to diagnose a patient with [ESTABLISHED Parkinson’s Disease] ?
clinical
_________________
< E + 2S - R - X >
[Parkinson Disease] = ⬜ diagnosis made of 4 criteria blocks < ESRX >
What is the diagnostic criterion arrangement neccessary to diagnose a patient with [probable Parkinson’s Disease] ?
clinical
_________________
< e + (s ≥r) - x >
Alzheimer’s Dz etx (4)
Alzheimers etx = aTPO
⭐accumlation of {β-amyloid (derived from [cleavage of chromo 21 t.A.P.P.]} in:
1.Temporal lobe early on ➜ [Neuritic Senile plaques]
2.[Parietal & occipital] lobe cerebral blood vessels ➜ [P\o Spontaneous Hemorrhages📷]
3.{hippOcampus & [Basal nc. of meynert]} ➜ defective [{O\B} Choline AcetylTransferase] ➜ [⬇︎ {O\B} ACh] ➜ {Alzheimer [CLAV ➜ HANDU]sx}
_________________
🖊{O\B} = {hippOcampus & [Basal nc. of meynert]}
🖊{P\o} = {[Parietal & occipital]}
🩺aTPO ↪ [CLAV ➜ HANDU]sx
👓t.A.P.P. = transmembrane Amyloid Precursor glycoProtein
An Unconscious, Unresponsive patient with unremarkable vitals and normal Deep Tendon Reflex presents c/f coma
▶How do you differentiate true coma from psychogenic coma?
▶ Explain (2)
obtain VCR
[⊕VCR = NO true COMA]
_________________
▶ [Vestibular Caloricstimulation Reflex] = tests’ [oculovestibular brainstem and cortex reflex] by irrigating auditory canal with cold water.
▶[⊕VCR = NO true COMA] =
irrigating auditory canal with cold water ➜ {[conjugate slow deviation of gaze to side of cold water (brainstem)] ➜ [saccadic correction to midline (cortex)]} = [COMATOSED BRAINS CAN NOT DO THIS] =[⊕VCR = NO true COMA] = [⊕psychogenic Coma]
[Parkinson Disease Tx] can cause psychosis due to ⬜
How do you manage this? -2
dopaminergic activation of mesolimbic pathway
_________________
{DEC [PD Tx] dosage (starting with least potent)}
–(if sx persist)–> [add D2 R Blocker (Quetiapine/Clozapine/PimaVanserin)]
Aside from CSF analysis revealing ⬜3, name the typical manifestations of [Herpes Simplex Encephalitis] (4)
[lymphocytic pleocytosis], [⇪ Protein], [⇪ RBC (from temporal lobe destruction)]
_________________
- AMS
- hemiparesis
- seizures
- aphasia
Atomoxetine Indication
NonStimulant ADHD Rx
Benzos can cause an uncommon SE known as Paradoxical Agitation. Describe this
[⬆︎Agitation, confusion and disinhibition] within a hour of benzo admin. GIVING MORE BENZOS WILL WORSEN THIS!
Benztropine & Trihexyphenidyl are in what class of drugs?
________________
How can pts on these develop Retro-Orbital HA during OD?
Anticholinergics; OD can –> Acute Glaucoma –> RetroOrbital HA
________________
Red as a beet, Dry as a bone, Hot as a hare, Blind as a bat, Mad as a hatter, Bowel & Bladder lose their tone, and the Heart runs alone
Between DM, Smoking and HTN, which carries the GREATEST STROKE Risk?
HTN
Both Mannitol and [Hypertonic Saline (3%/5%/23%)] are used to ⬇︎ ICP
List the differences in using Hypertonic saline? - 4
- HTS Anti-Inflammatory
- [HTS does NOT cross into interstitial space like Mannitol ( Mannitol causes Rebound Edema!) ➜
- ➜ HTS eventually expands systemic volume
- HTS ONLY given via Central line
HTS = Hypertonic Saline
Brachial Plexus damage of
[lower Trunk {(C8) (T1)}]
________________
clinical presentation?
[klumpke palsy claw hand]
Brachial Plexus damage of
[long thoracic {(C5)(C6)(C7)} n ]
________________
clinical presentation? -2
- [winged scapula]
- [inability to ABduct shoulder > 90º]
Brachial Plexus damage of
[Axillary {(C5)(C6)} n]
________________
clinical presentation?
[Deltoid paralysis]
Brachial Plexus damage of
[Radial {C5⼀T1} n]
________________
clinical presentation? -2
- [Saturday night palsy wrist drop]
- [No Tricep Reflex]
Brachial Plexus damage of
[Radial {C5⼀T1} n]
________________
causes -3
- [Crutches/Axilla damage]
- [anteroLateral⼀pFSF]
- Midshaft Humerus
👓{[anteroLateral⼀pFSF] = {[anteroLateral⼀proximal humerus displacement] iTSo [FOOSA Supracondylar Fx]}
Brachial Plexus damage of
[Axillary {(C5)(C6)} n]
________________
causes -3
- [Surgical NECK humerus]
- [ANTERIOR humerus displacement]
- Shoulder Injury
Brachial Plexus damage of
[long thoracic {(C5)(C6)(C7)} n ]
________________
causes -3
- STABS
- [MASTECTOMY]
- [AXILLARY NODE DISSECTION]
Brain Death is a clinical diagnosis and involves [absent cortex functions] and [absent brain stem functions]
What are the legal complications of disabling artificial life support for a pt who is newly diagnosed with Brain Death?
None - Brain death is a legally acceptable definition of death
Brain Death is a clinical diagnosis and involves absent cortical and brain stem reflexes
In correct diagnostic order, name the 5 Criteria Blocks used to diagnose Brain Death?
(“CNaPL”)
[5Clinical (evidence of _C_NS catastrophe, NO _C_onfounders, NO _C_hemicals-drug intox, >36_C_, _C_ore>100 SBP)]
[5Neuro exam(coma, NO cortex rflx, NO brainstem rflx, NO rooting/sucking rflx, spinal rflx ok)]
➜ [4ancillary testing if (C) (N) (P) inconclusive] = [EEG isoelectric line] vs [EEG NO SSensory activity] vs [EEG NO brainstem activity] vs [NO intracranial blood flow]
[3Pulmonary aPnea test (Preoxygenate ➜ disconnect ventilator = positive if NO spontaneous breath x 8m + PaCO2>60 + arterial pH<7.28]
[Local requirements]
Brain Death is a clinical diagnosis and involves [absent cortex reflexes] and [absent brainstem reflexes]
There are 5 Criteria Blocks (CNaPL) used to diagnose Brain Death
_________________
▶ Describe the [Clinical] criteria block (5)
(“CNaPL”)
[ 5Clinicalprerequisites]
- evidence of _C_NS catastrophe,
- NO _C_onfounders of CNS⼀sedatives/metabolic ∆
- NO _C_hemicals-drug intox/poisoning
- >36_C_,
- _C_ore>100 SBP)]
Brain Death is a clinical diagnosis and involves [absent cortex reflex] and [absent brainstem reflex]
There are 5 Criteria Blocks (CNaPL) used to diagnose Brain Death
_________________
▶ Describe the [Neuro exam] criteria block (5)
(“CNaPL”)
[5Neuro exam(coma, NO cortex rflx, NO brainstem rflx, NO rooting/sucking rflx, spinal rflx ok)]
Brain Death is a clinical diagnosis and involves [absent cortex functions] and [absent brain stem functions]
There are 5 Criteria Blocks (CNaPL) used to diagnose Brain Death
_________________
▶ Describe the [ancillary testing] criteria block (4)
(“CNaPL”)
➜ [4ancillary testing⼀if (C)| (N) |(P) inconclusive ] = (positive if)…
[EEG isoelectric line]
+
[EEG NO SomatoSensory activity]
+
[EEG NO brainstem activity]
+
[NO intracranial blood flow]
Brain Death is a clinical diagnosis and involves absent cortical and brain stem reflexes
There are 5 Criteria Blocks (CNaPL) used to diagnose Brain Death
_________________
▶ Describe the [Pulmonary aPnea test] criteria block (3)
_________________
▶▶What 3 factors prevent this test from being done?
(“CNaPL”)
[ 3Pulmonary aPnea test
- Preoxygenate
- ➜Pull vent ( disconnect ventilator)
- ➜ ➜ Positive = [(NO spontaneous breath x 8m) + PaCO2>60 + arterial pH<7.28] ]
_________________
❌if active drug intoxication
❌if heart disease
❌if lung disease
Brain Death is a clinical diagnosis and involves absent cortical and brain stem reflexes
There are 5 Criteria Blocks (CNaPL) used to diagnose Brain Death
_________________
▶ Explain the Order these criteria blocks should be followed when diagnosing brain death
On EEG, what is a [burst suppression pattern]?
_________________
What does it indicate? (2)
isoelectric periods punctuated by high amplitude activity
_________________
- Deep Coma
- Anesthesia
T or F: Positive Deep Tendon Reflexes means a patient is NOT Brain Dead
FALSE
_________________
- Brain Death is limited to Cortex and Brainstem.
Spinal Cord reflexes can still be functioning in Brain Death
Bromocriptine
MOA
_________________
Indication
[PostSynapticDopamine R Agonist (ergot)]
_________________
Parkinson’s
Carbamazepine side effects -3
- [bone marrow suppression (neutropenia)]
- SIADH hypOnatremia
- AntiCholinergic
[Carpal Tunnel Syndrome] etx
BILATERAL Median n Compression by the [Flexor Retinacular Transverse carpal ligament] –> Peripheral mononeuropathy + [ABductor pollicis brevis atrophy]
- [Flexor Retinaculum Transverse Carpal ligament] can be surgically incised for relief*
- CARPAL TUNNEL STARTS uL and –> BL*
Carpal Tunnel Syndrome Clinical Presentation - 6
- [Paresthesia vs Pain with Median n. Distribution worst at night]
- CARPAL TUNNEL STARTS uL and –> BL
- {[Thenar (ABP, FBP, O_P,)] atrophy [ABductor Pollicis Brevis] atrophy ➜ (⬇︎flexion/ ⬇︎ABduction/ ⬇︎Opposition)]}
- Tinel Sign (tapping over flexor surface ⬆︎ sx)
- Phalen Sign (flexing Wrist ⬆︎ sx)
- HOH Sign (Hand over Head ⬆︎ sx)
Pregnancy is associated with Carpal Tunnel
What should these particular pts also be worked up for?
Preeclampsia
CARPEL TUNNEL starts uL and then –> BL
[Carpal Tunnel Syndrome] dx
excluding clinical s/s
Nerve Conduction studies
EMG is not necessary for Carpal Tunnel Syndrome
[Carpal Tunnel Syndrome] tx - 5
- [WRIST SPLINT (sx < 10 mo)]
- Remove exacerbating factors
- NSAIDs
- CTS injection -IF MODERATE
- [Flexor Retinaculum Transverse Carpal ligament] can be surgically incised for relief - IF SEVERE
_________________
wrist splint maintains wrist in neutral position to avoid movements that narrow the tunnel more
Risk factors for Carpal Tunnel Syndrome - 4
- Obesity
- [Pregnancy (c/s Preeclampsia)]
- DM
- hypOthyroidism
CARPEL TUNNEL STARTS uL and –> BL
[Conus Medullaris Syndrome] etx
________________
Clinical Presentation - 7
(Compression of S2 - S4 n. roots @ Conus Medullaris) –>
________________
“RIM sara!?”
1. [Reflexia: HYPER]reflexia (Cauda Equina has hypOreflexia)
2. [Incontinence EARLY]
3. Motor weakness SYMMETRICALLY
4. saddle anesthesia
5. anocutaneous reflex loss
6. radiculopathy
7. [a MRI, CTS IV and Neurosurg consult = tx]
[cauda equina syndrome] etx
________________
Clinical Presentation - 7
(Compression of S2 - S4 n. roots @ Cauda Equina) –>
________________
“RIM sara!?”
1. [Reflexia: hypO]reflexia (Conus Medullaris has HYPERreflexia)
2. [Incontinence LATE]
3. Motor weakness Asymmetrically
4. saddle anesthesia
5. anocutaneous reflex loss
6. radiculopathy
7. [a MRI, (CTS IV) and Neurosurg consult = tx]
What Spinal Columns are affected in [Subacute Combined Degeneration]?-3
_________________
How do this manifest?-3
[SuBACute Combined Degeneration]
[Demyelinating lesions] in 3 Thoracic Spinal Columns:
- [Dorsal–> Loss of 2TVP]
- [Lateral CST –> UMN Weak MESH]
- [Spinocerebellar –>Ataxia]
* FriEdreich Ataxia affects the SAME 3 columns*
Causes of [Subacute Combined Degeneration] (3)
[SuBACute Combined Degeneration]
1) B12 Deficiency (demyelinates peripheral nerves also)
2. AIDS/HIV
3. Copper deficiency
* Affects Dorsal / Lateral CST / Spinocerebellar Tracts (Combined)*
B12 deficiency is common in the elderly
In the elderly B12 deficiency can present as ⬜ and [Subacute Combined Degeneration].
How do you address this?
Dementia ; SX REVERSIBLE WITH B12 SUPPLEMENTATION
_________________
SAC = Affects Dorsal / Lateral CST / Spinocerebellar Tracts (Combined)
Central Pontine Myelinolysis
dx (2)
_________________
tx (3)
- Brain MRI showing demyelinating lesions
- rapid sodium rise → delayed paralysis days later
- irreversible
- supportive care
- eye computer interface
Central Pontine Myelinolysis → ⬜ syndrome
Name the clinical features (6)
LOCKED IN SYNDROME
_________________
“CPM, you have the QB-VP but no HO for him”
⊕
✅[Quadriplegia w intact consciousness {LOCKED IN SYNDROME}]
✅[Blink reflex(upper CN intact)]
✅[Vertical EOM(upper CN intact)]
✅[Pupilllary reflex(upper CN intact)]
⊝
⛔[Horizontal EOM(lower CN paralyzed)]
⛔[Oral movements(lower CN paralyzed)]
Central Pontine Myelinolysis
etx (3)
- {[prolonged hypOnatremia≤120] x ≥2 days}
- rapid correction of hypOtonic hypOnatremia
- osmotic shock → oligodendrocyte death → demyelination → LIS*️⃣
️⃣ LOCKED IN SYNDROME = {[✅QB VP] but [⛔HO]}
Cerebral Palsy is a group of clinical syndromes generally characterized as ______
How does it present? - 3
Nonprogressive motor dysfunction (Prematurity>EtOH = RF) ;
“Cerebral Palsy is a young, *SAD** BUM”
- BL equinovarus club feet (image)
- {[UMN (Weak MESH)sx] LE >UE}
- Mental Retardation
Greatest RF = prematurity ( < 32 wks gestation)
Cerebral Palsy is a group of clinical syndromes generally characterized as ______
What are the 3 types? What’s the greatest risk factor for Cerebral Palsy?
Nonprogressive motor dysfunction ;
Cerebral Palsy is just SAD
- Spastic
- Ataxic
- Dyskinetic
Greatest RF = prematurity ( < 32 wks gestation) but EtOH is second
Cerebral Palsy is a group of clinical syndromes generally characterized as ______
If Cerebral Palsy is suspected, what diagnositc test should be obtained and why?
Nonprogressive motor dysfunction ;
brain MRI ;
look for etx (periventrivcular leukomalacia or malformation)
Classic signs of Fetal Alcohol Syndrome - 4
“FAS had drunk mama’s baby looking like a MULE”
1. Microcephaly
2. Upper THIN Lip
3. Long smooth Philtrum
4. Eyes have short Palpebral fissures
clinical course for Guillain Barre syndrome (3)
[ascending motor weakness progressive over 2 wks(+/- paralysis) ] ➜
[plateau x 2-4 wks] ➜
[spontaneous recovery over months]
________________
tx (plasma Xchange/ IVIG ) shortens course duration by 50%
Describe Pseudoexacerbation of Multiple Sclerosis
[SLUM SiiiN]
Infection in MS pt –>⬆︎ Body temp –> ⬇︎Conduction in [Remyelinated healed CNS areas] –> clinically APPEARS to be MS exacerbation BUT REALLY ISN’T!
Image: T1 MRI Black Holes Dx
Clinical Manifestation of Multiple Sclerosis (9)
Charcot classic triad of MS is a [SLUM SiiiN] !
Sensory sx (think BL Trigeminal Neuralgia)
Lhermittes sign = “electric tingling” down spine into arm & legs when chin is touched to chest
Uhthoff phenomenon (sx ⬆︎ during heat)
Motor sx
Scanning Speech
[Internuclear Ophthalmoplegia (MIOS)] / Intention Tremor / Incontinence
Neuritis Optic - (uL eye pain + vision loss + Marcus Gunn afferent pupillary defect) = ALSO RISK FACTOR
Demonstrate Sensory Innervation of the Hand
Ulnar nerve
________________
Median nerve
________________
Radial nerve
Subarachnoid Hemorrhage is most commonly due to ⬜
_________________
Clinical Presentation (6)
[Berry Saccular Aneurysm] rupture
_________________
- “worst HA of my life” ⼀sudden severe thunderclap HA different from previous
- Nausea
- Vomiting
- LOC
- meningismus
- [focal neuro ❌]
BSA most common location = {Circle of Willis ⼀ [junction of ACA & ACom]} (BSA can→ SAH/hemorrhagic stroke, [bitemporal hemianopia (compression of optic chiasm)]
Subarachnoid Hemorrhage
Risk Factors (5)
_________________
Xanthochromia= yellow tinted CSF due to hgb degradation products
Subarachnoid Hemorrhage
▶ ⬜ is the initial preferred test for SAH diagnosis
– - - - followed by secondary test ⬜ if initial test is negative. For secondary test, ⬜ confirms diagnosis of SAH
[Noncontrast Head CTwithin 6-12h sx] ;
[LP confirmatory>6h sx ⼀to document Xanthochromia if CT negative] ; XANTHOCHROMIA
_________________
Xanthochromia= yellow tinted CSF due to hgb degradation products
Clinical Presentation for Diabetic Ophthalmoplegia (3)
_________________
Etx?
DM –> [Oculomotor CN3 CENTRAL ischemia]
- Ipsilateral Down & Out Eye
- Ptosis (from Levator Palpebrae paralysis)
- NORMAL PERRL (since Parasympathetic fibers are spared)
transverse myelitis acute myelopathy
dx?
_________________
tx?
SURE
dx: MRIGadilinium
_________________
tx: [(CTSHD)]3d ⼀give for confirmed TMAM via MRI and if high suspicion for compressive CA myelopathy
* SURE sx*
Patient presents with Paralysis
what’s your Workup? (4)
Clinical presentation of
[transverse myelitis acute myelopathy] (4)
SURE
- Sensory level (demarcated sensory loss up to specific point)
- Urinary retention
- [Rapid developing LE weakness s/p URI/trauma/CA]
- Exam [hypOreflexia and flaccidity] ➜ [hyperreflexia and spasticity]
dx = MRIGad
clinical presentation of [Complex Regional Pain Syndrome] (6)
- patient S/P RECENT JOINT INJURY
- now p/w joint POOP
- joint burning
- joint edema
- joint skin ∆
- joint ⬇︎ROM
etx: INC sensitivity of sympathetic nerves
sx of Meningoencephalitis (5)
“MeningoEncephalitis Needs FAVOR”
Nuchal rigidity = Meningo-
FAVOR = -encephalitis
______________
FAVOR: Focal neuro ∆ , AMS, Vomiting, Ouch HA, Really hot fever
Viral Etiologies of Meningoencephalitis include (⬜3)
with
treatment (⬜2)
“MeningoEncephalitis Needs FAVOR”
PML Clinically Presents like Multiple Sclerosis
Describe PML-Progressive Multifocal Leukoencephalopathy
Opportunistic infection 2º to [John Cunningham PolyomaVirus]—-> [multiple white matter lesions] (Hyperintense Flair signal on radiology) –> Death vs. Severe Neuro injury
PML (Progressive Multifocal Leukoencephalopathy) Clinically Presents like Multiple Sclerosis
How is PML related to the drug, Natalizumab?
Also can be a Rare Side Effect of Natalizumab (MS drug) in pts who are also JC Virus positive
Usual Demographic: HIV pts (reversal of immunosuppresion stops JC Polyoma virus progression)
Concussion is defined as [⬜ -3]
[neuro disturbance(brief Confusion, Amnesia +/- LOC)] a/w mild TBI without intracranial structural injury
_________________
note: it is nml for concussion sx to wax/wane as pt returns to activity
Concussion = [neuro disturbance io\mild TBI with NO structural damage]
Concussion
Management? (2)
[REST ≥24H] ➜ [gradual return to activity with progression titrated to tolerance]
note: it is nml for concussion sx to wax/wane as pt returns to activity
Congenital Torticollis etx
Malpositioning of Head in Utero vs During birth –> constant contraction of SCM–>Lateral Neck swelling
Torticollis also possible in Adults
CP for Chemotherapy Peripheral Neuropathy - 4
- Stocking Glove symmetrical paresthesias starting at toes/fingers and spreading proximal
- Early loss of ankle jerk reflex
- Loss of Pain/Temp
- Motor weakness
Drug Culprits: Cisplatin / Paclitaxel / Vincristine
CP of Cerebellar Damage - 7
Cere is def on GRINDRR
Gait Ataxia IPSILATERAL
Rapid alternating mvmnt impairment
Intention tremor/Dysmetria IPSILATERAL
Nystagmus IPSILATERAL (medial AND Lateral Vermis)
Dysarthria (Lateral Vermis only)
Rebound phenomenon (pt hits themself in face if flexing bicep and examiner releases arm-image)
Reflex Pendular (knee swings >4x after Deep tendon reflex is elicited)
Vermis is midline
🧠[Cerebellar lesions = IPSILATERAL] because CorticoPontoCerebellar fibers decussate TWICE
Alcoholic cerebellar degeneration causes damage to the ⬜
________________
How can you differentiate Alcoholic cerebellar damage from other causes of cerebellar damage?
[Purkinje cells of cerebellar vermis (truncal ataxia & dysarthria)]
________________
Alcoholic cerebellar damage LEAVES LIMB COORDINATION INTACT (no intention tremor)
Cere is def on GRINDRR
cp of [Medial Medullary syndrome] -(3)
cp of [Lateral Medullary syndrome of Wallenberg] -(6)
VSINSY
Vestibular = [VDNV]sx
Spinal trigeminal = [IPL face pain/temp loss]
Inferior cerebellar Peduncle = ataxia
Nucleus ambiguus = diminshed gag reflex
Spinothalamic tract = [CTL BODY pain/temp loss]
YsYmpathethetic descending fibers = [IPL Horners]
VDNV = Vertigo/Diplopia/Nausea/Vomiting
Brachial Plexus damage of
[Upper Trunk {(C5)(C6)} n]
________________
clinical presentation?
[Erb Palsy Waiter’s Tip]
Brachial Plexus damage of
[Upper Trunk {(C5)(C6)} n]
________________
cause
[Baby Delivery lateral neck pull]
DDx for Clostridium Botulinum - 4
Also consider…
- Myasthenia Gravis
- Atypical Guillain Barre
- Tick Paralysis
- Brain Stem infarct
Adult tx: Equine Heptavalent Antitoxin (passive immunity)
DDx of Neuromuscular Weakness has 5 origins
Describe Upper Motor Neuron causes of Neuromuscular weakness - 4
DDx of Neuromuscular Weakness has 5 origins
Describe Anterior Horn Cell causes of Neuromuscular weakness - 4
Deficiency of what INC risk for Restless Leg syndrome?
_________________
unpleasant LE sensation at night or rest, relieved by moving
IRON
(dx = FerriTin ≤75 )
_________________
- other RF: Pregnancy/Uremia/DM/MS/[anti:MDD|Psychotics|Emetics]*
- 1st line tx = Gabapentin*
Define Coma (6)
Unarousable, Unresponsive Sleep State in which only [brainstem reflexes] and [Spinal reflexes] are testable.
2/2 diffuse cortical depression
Can progress to vegetation, full recovery or brain death
DELIRIUM IS A MEDICAL EMERGENCY
Based on consciousness, how do you differentiate Delirium from Dementia ?
Delirium = CONSCIOUSNESS RAPIDLY FLUCTUATES
_________________
Dementia = consciousness intact
note: return of Primitive reflexes is normal in Dementia
Describe Athetosis ; What disease is it seen in?
Slow, writhing mvmnts of hands & feet often occuring with Chorea (Choreoathetosis) ; Huntington’s
What are the TRAUMATIC LUMBAR PUNCTURE CSF lab ranges
Glucose
Protein
WBC count
RBC count
GPW-R
G ⇪
P ⇪
W ⇪
RBC 6K < Traumatic LP (without xanthrochromia)
_________________
xanthochromia = discoloration of CSF 2/2 hgb breakdown that appears within 2-12h of SAH
What are the Normal CSF lab ranges
Glucose
Protein
WBC count
RBC count
GPW-R
Glucose: 40-70
Protein: <40
WBC: 0-5
RBC: < 6K < Traumatic LP
Describe CSF analysis for TB meningitis
Glucose
Protein
WBC
[G low < 45]
[P High 100-500]
[W High 100-500]
Describe CSF analysis for Cryptococcal Neoformans meningitis
Glucose
Protein
WBC
[G low< 40]
[P Up >40]
[W Up <50 (Lymphocytes)]
_________________
+ CSF opening pressure > 250 || Occurs in advanced HIV || Dx = India Ink Prep or Antigen test
Describe CSF analysis for Bacterial meningitis
Glucose
Protein
WBC
[G low< 40]
[P High >250*]
[W UBER HIGH >1,000]
_________________
*G might be higher & P might be lower if pt s/p abx pretx
Describe CSF analysis for Guillain Barre:
Glucose
Protein
WBC count
[P UBER HIGH 45-1,000]
_________________
normal G / W
Describe CSF analysis for Viral meningitis
Glucose
Protein
WBC count
[P HIGH<150]
[W HIGH 10-500 (Lymphocytes)]
_________________
normal G
Note: HSV = ⬆︎Protein and ⬆︎ RBC also from temporal lobe destruction
Dementia with Lewy Bodies (DLB) CP - 3
DLB at the DMV
- Dementia confusion periodically
- MichaelJFox Parkinsonism (PARK + hamp) tht does NOT respond to dopaminergic tx
- Visual Hallucinations
Lewy Body= [LABS (Lewy α-synuclein BodieS)] that are Eosinophilic intracytoplasmic accumulations
Pts with [Dementia with Lewy Bodies (DLB)] are extremely sensitive to _____ and it may cause what side effects?-3
DLB at the DMV
ANTIPSYCHOTICS
________________
- Dementia INC
- MichaelJFox PARK INC
- autonomic dysfunction
Describe En-Bloc Gait
_________________
What type of ataxia is this?
Minimal mvmnt of head while walking w/staggering gait
_________________
Vestibular Ataxia
Will be accompanied w/Vertigo & Nystagmus
Describe Physiologic Tremors (4)
-benign [12-14 Hz high freq] tremor
-occurs posturally (i.e. when holdings arms out),
-activated w/emotion
-activated w/caffeine
Describe the “Clasp Knife” phenomenon
________________
What disease is this related to?
Rapid SPASTIC RESISTANCE to passive mvmnt of limb
________________
UMN (Weak MESH) Pyramidal Tract dz
- Pyramidal Tract = Corticospinal and Corticobulbar*
- Pronator Drift also indicates Pyramidal Tract Dz*
Px for Migraine HA - 4
VTAP the migraine BEFORE it comes, and SEND it on its way when it does!
- Verapamil
- Topiramate
- Amitryptyline
- Propranolol
Tx for Acute Migraine HA - 4
VTAP the migraine BEFORE it comes, and SEND it on its way when it does!
- Sumatriptan
- Ergots (Bromocriptine)
- NSAIDs
- D2 R Blockers (Metaclopramide/Prochlorperazine)
Describe the Character for the HA:
Migraine
Cluster (3)
Tension (2)
Migraine = POUND = [Pounding/One Day-3 day Duration/Unilateral/Nausea/Disabling] + photo vs. phonophobia & [flashing dots aura]
Cluster = [Excruciating, sharp & steady] (100% O2 tx)
Tension = Dull & tight
Describe the Duration for the HA:
Migraine
Cluster
Tension
Migraine = POUND = [Pounding/One-3 Day Duration /Unilateral/Nausea/Disabling] + photo vs. phonophobia & [flashing dots aura]
Cluster = 15 - 90 MINUTES (100% O2 tx)
Tension = 30 min to 7 DAYS!!!! (Tammy’s Entire Work Week)
Describe tube presentation of a traumatic CSF lumbar puncture
Elevated RBC in 1st tube, followed by declining numbers of RBC with each successive tube
Frontotemporal Pick’s Dementia
Sx -2
Prounouced Frontal & Temporal lobe atrophy –>
[Socially inappropriate Behavior] + aphasia
OCCURS MORE IN FEMALES!!!
Demographic of Frontotemporal Pick’s Dementia?
________________
Mode Of Inheritance
50-60 yo Females
________________
AUTO DOM
Alzheimers >60 yo
Socially inappropriate behavior + aphasia
Describe Neuroleptic Malignant Syndrome - 5
RARE SE of Any Dopamine Blocker (Antipsychotics vs. GI meds) that –> FEVER
- [Fever > 40C]
- Encephalopathy (Confusion)
- Vitals unstable (INC HR / RR / BP from autonomic dysfunction)
- Enzymes ⬆︎ (CPK)
- [Rigitidy lead pipe] (Tremor)
Diagnostic Criteria for Febrile Seizure - 5
- 6 mo - 6 yo
- Temp > 38C
- No hx of Afebrile seizures
- No CNS infection
- No acute metabolic cause of seizure (pt would have dehydration)
Tx = Reassurance only!
Diagnostic criteria for Nightmare Disorder - 4
- Makes recurrent awakenings
- reMembers their nightmare
- Manageable (CAN be consoled) upon awakening
- Mind is alert upon awakening
-NightMares occur during REM
-NightMares are developmentally normal for kids
Diaphragmatic paralysis can be easily confused with ⬜ because they both cause ⬜ . What’s the most common cause of bilateral diaphragmatic paralysis?
CHF; orthopnea
_________________
ALS
Subarachnoid Hemorrhage
Dx (5)
1st: [NONCONTRAST HEAD CT (ideally within 6-12h of sx)]
1b. CT⊕ ➜ Cerebral angiography to identify bleeding source
_________________
2nd: CT⊝ ➜ REQUIRES [Lumbar Puncture confirmation (ideally >6h from sx)]**
2b. LP⊕ =[xanthochromia = CONFIRMS DIAGNOSIS] but other findings= [⇪ opening pressure]/[⇪ RBC in all 4 CSF tubes]
2c. LP⊝ = r/o SAH
Subarachnoid Hemorrhage
Why do negative [Noncontrast Head CT] have to be followed with a negative ⬜ before SAH can be exclusively ruled out
_________________
Ideally when should this subsequent test be done and why?
[Lumbar Puncture confirmatory (ideally >6h from sx)]**
**(some bleeds are outside ideal 6-12h CT window and/or are too small for CT)
_________________
perform LP > 6h from sx onset since..
[CSF blood can take up to 6h to degrade and form Xanthochromia = LP ideal>6h from sx]
Dx for Creutzfeldt Jakob disease - 6
- [PRNP prion protein] genetic testing
- EEG Biphasic vs Triphasic sharp wave complexes
- Postmortem brain biopsy
- ⬆︎CSF 14-3-3 proteins
- MRI Cortical Ribbons
- MRI basal ganglia hyperintensity
Dx for VitB12 deficiency - 3
- [⬆︎ Methylmalonic Acid levels]
- CBC showing Macrocytic Anemia
- Serum Vitamin levels
Which drugs are used to treat Multiple Sclerosis Exacerbation?-2
1st: High Dose IV Methylprednisolone
2nd: (Refractory): Plasmapheresis
Which drugs are used to treat Multiple Sclerosis maintenance?-3
Maintenance:
1. [β-interferon]
2. [Glatiramer acetate]
3.Natalizumab
Dx for Multiple Sclerosis - 5
_________________
Which diagnostic is the preferred test for MS?
Which diagnostic is the backup test (used in equivocal cases) for MS?
- T2 MRI: [Periventricular white matter demyelinating plaques with lipid laden macrophages] = PREFERRED TEST
- [CSF Oligoclonal IgG bands = backup test]
_________________ - T1 MRI Black holes
- Clinical (SLUM SiiiN)
- Visual conduction velocity test
Sx will be disseminated in time and space
What do [Pregnant MS⊕] and [Pregnant MS⊝] patients have in common?
_________________
How do they differ? (2)
MS: Multiple Sclerosis
SAME TREATMENT for MS Exacerbation ⼀[Methylprednisolone IV High Dose] is used for MS Exacerbation in Pregnant patients with or without MS
_________________
- [Pregnant MS⊕] have INC risk for [assisted delivery (cesarean/vacuum/forceps)]
- [Pregnant MS⊕] have INC risk of their infant developing MS as well
[Pregnant MS⊕] typically have {[⬜ lower | HIGHER] MS activity} during pregnancy and {[⬜ lower | HIGHER] MS activity} during postpartum
MS: Multiple Sclerosis
lower; HIGHER
Normal Pressure Hydrocephalus Sx (3)
_________________
Which is earliest to present?
⬇︎CSF absorption –> Wacky, Wobbly & Wet!
Wacky (memory loss)
[ Wobbly magnetic frontal gait apraxia] = EARLIEST CLINICAL FINDING]
Wet (Urinary Incontinence from compressing periventricular cortico-cortical white fibers traveling to sacral micturition center)
Normal Pressure Hydrocephalus characteristics - 4
Wacky, Wobbly & Wet!
- Idiopathic
- Episodic
- Elderly
- Does not ⬆︎ SubArachnoid space volume
Etx: ⬇︎Arachnoid villi CSF Absorption vs obstruction
What’s the only imaging modality for diagnosing Alzheimer’s Disease?
________________
Which areas does it reveal this in? - 3
CLAV –> HANDU
PET scan revealing [PIB-Pittsburgh Compound B] binding to β-amyloid and being taken up in
- PreFrontal
- Temporal
- Parietal
Early Findings of Alzheimer’s - 4
CLAV –> HANDU
Cognitive PROGRESSIVE ⬇︎
Language ⬇︎
Anterograde immediate memory loss
Visualspatial disorientation (loss in ur own neighborhood)
Onsets after 60 yo
aTPO = [CLAV ➜ HANDU]sx
Clinical Criteria for diagnosing Alzheimer’s -5
Diagnosing Alzheimer requires the [WONG Criteria]
1. GOE 2 Cognitive deficits
2. Worsening Memory
3. Consciousness intact
4. Onsets after 60 yo
5. No other Systemic/Neuro DO to cause cognitive defects
aTPO = [CLAV ➜ HANDU]sx
Late Findings of Alzheimer’s - 5
CLAV –> HANDU
Hallucinations
Agnosia (unable to recognize things via 5 senses)
Neuro ∆ (seizure/myoclonus)
Dyspraxia (unable to do things from before)
Urinary Incontinence
Onsets after 60 yo
aTPO = [CLAV ➜ HANDU]sx
Alzheimer’s tx - 7
_________________
Which medication should be used last?
CLAV –> HANDU
- Donepezil - AChnesterase inhibitor
- Tacrine - AChnesterase inhibitor
- Rivastigmine - AChnesterase inhibitor
- Galantamine - AChnesterase inhibitor
- Memantine - NMDA R Blocker: USE LAST
- Respite Care for Caregivers (ex: Adult day program)
- Atypical antipsychotics - Olanzapine vs Risperidone (for acute psycosis)
aTPO = [CLAV ➜ HANDU]sx
[early Neurosyphilis] typically presents during the ⬜ syphilis stage. How does it present? -3
2nd;
[MeningoVascular (Meningitis+CVA)] | Uveitis | Tinnitus
prodrome ➜ MUT ➜ DAT
[LATE Neurosyphilis] presents during the ⬜ syphilis stage. How does it present? -3
3rd ; Dementia |Argyll Robertson Pupils | TDPCD
TDPCD: Tabes Dorsalis Posterior Column Disease
prodrome ➜ MUT ➜ DAT
Explain [Relative Afferent Pupillary Defect]
partial optic n vs retinal lesion –> pupils BOTH constrict when light is shown in normal eye BUT when light is swung to lesioned eye BOTH eyes Dilates since lesioned eye has ⬇︎ afferent input
Recall the Pupillary pathway beginning with light entering the eye (8)
Edinger Westphal nucleus provides ⬜ to the ⬜ ganglion
CP of a pt with R damaged EW nucleus
PreGanglionic [ParaSympathetic efferent OUTflow] to ciliary ganglion
R (Ipsilateral) FIXED DILATED pupil not reactive to light
Essential Tremor is a [ (BUE/Head/Voice) Action Tremor worst w/Action]
What are the exacerbants of Essential Tremor? - 5
- Hyperthyroid
- Lithium
- Valproic Acid
- Action
- holding a position
Etx of Parkinsons Disease
[LABS (Lewy α-synucleinBodieS)] accumulation in [substantia nigra pars compacta] –>degeneration –> ⬇︎Dopamine release and ⬇︎ stimulation of Striatum which –> allows [Globus pallidus internal] to continuously inhibit [VA/VL Thalamus from stimulating motor cortex]
The Basal Ganglia consist of what 5 things?
Recall the 🔲 Basal Ganglia pathway for movement starting at Cortex
a. DIRECT (5)
b. InDirect (5)
“Can Pretty Gays Sound Smart?”
-Caudate
-Putamen
-Globus Palidus
-Subthalamic nucleus
-Substantia Nigra
Explain how a Physician should approach the discussion of [Brain Death Diagnosis] and [Organ Donation]
1st: [Brain Death Dx] = Physician
________________
Later: [Organ Donation] = [OPO (Organ Procurement Organization)]
Explain how collateral blood flow to a “complete” circle of willis help prevent ischemic CVA/TIA?
[External Carotid: Opthalmic A] can retrogradedly perfuse Circle of Willis when Internal Carotid is blocked
Fall has 3 main etiologies ( ⬜ , ⬜ or ⬜ )
_________________
What are the 10 crucial points of medical history to work up Fall?
Mechanical 🆚 Syncope 🆚 Seizure
_________________
HANDSTAMPED
Hx Syncope?
Associated symptoms
Number of episodes
Duration
Setting
Time until recovery
Acknowledged/Witnessed?
Medical hx
Prodrome?
Epilepsy hx
Drug use?
Febrile seizures present day ⬜ of illness, are a common complication of high fever a/w ⬜, and onset between ⬜ y/o
_________________
What is the prognosis for children with febrile seizure (3)
1 ; viral infection ; [3 months - 6 yo]
_________________
-typically [benign course (does not require tx)]
- but 30% will have ≥1 recurrence
- and 30% will also have INC risk for Epilepsy
Usually Simple Partial Seizures originate in a single hemisphere
Simple Partial Seizures may present as what 3 things?
- Motor ∆ (head turning) - no LOC
- Sensory ∆ (paresthesias)- no LOC
- Autonomic ∆ (sweating)- no LOC
For cp, what are 2 ways to differentiate Sleep Terrors from [RSRBD]?
RSRBD = REM Sleep Related Behavioral Disorder
[Sleep Terror = NRSAD (NonREM) = abrupt hyperarousal from sleep] |
[RSRBD= REM = “acting out dreams”]
NRSAD = Non-REM Sleep Arousal Disorder
RSRBD = REM Sleep Related Behavioral Disorder
The 3 types of dream disorders are ⬜, NRSAD and ⬜
_________________
Describe characteristics of NRSAD (3)
NRSAD = Non-REM Sleep Arousal Disorder
RSRBD | NRSAD | NightMareDisorder
_________________
NRSAD
1. recurrent incomplete awakenings from NonREM sleep
2. [+plus Sleepwalking] or [+plus SleepTerrors]
3. Dream Amnesia (NO DREAM RECALL)
Sleepwalking and SleepTerrors are both qualifiers for NRSAD
NRSAD = Non-REM Sleep Arousal Disorder
RSRBD = REM Sleep Related Behavioral Disorder
What is the clinical progression of [NRSAD ⼀ Sleep Walking and Sleep Terrors]? (3)
NRSAD = Non-REM Sleep Arousal Disorder
onset 4-12 yo ➜ RESOLVES SPONTANEOUSLY ≤ 2 YEARS FROM ONSET –(if SEVERE = low-dose benzo qhs)
It is common for AIDS pts with Cryptococcal n. meningitis to develop ⇪ ICP due to ⬜ ➜ ⬜ sx
For pts with recurrent sx of ⇪ ICP from [Cryptococcal n meningitis], how is this treated?
[high CSF fungal burden clog arachnoid villi] ➜ ⬇︎ CSF outflow ➜ ⇪ ICP ; [HA/NV/papilledema]
_________________
[serial LP until sx resolve]
Friedreich Ataxia involves Degeneration of the ⬜ , ⬜ and ⬜ spinal columns]
FriEdreich Ataxia involves Degeneration of the [Dorsal, Lateral CST and SpinoCerebellar spinal columns]
- FriEdrecih is Fratastic! He’s your fav. twisted frat brother, always studdering and falling, but has a sweet, big heart*
- SuBACute Combined Degeneration affects SAME 3 columns*
Functions of the Obturator n.-2
- MOTOR Leg ADDuction
- SENSORY medial thigh
________________
usually from pelvic trauma or surgery
GCS(Glasgow Coma Scale) predicts Prognosis of what 4 things?
________________
The 3 components are EVM (Eyes/Verbal/Motor)
Describe the [Verbal Response] component (5)
- GCS prognosis’* Brain CHIT
1. Coma
2. Hemorrhage (SAH)
3. Infection (bacterial meningitis)
4. Trauma
________________
EVM = Eyes / Verbal / Motor
GCS(Glasgow Coma Scale) predicts Prognosis of what 4 things?
________________
The 3 components are EVM (Eyes/Verbal/Motor)
Describe the [Eyes] component (4)
- GCS prognosis’* Brain CHIT
1. Coma
2. Hemorrhage (SAH)
3. Infection (bacterial meningitis)
4. Trauma
________________
EVM = Eyes / Verbal / Motor
GCS(Glasgow Coma Scale) predicts Prognosis of what 4 things?
________________
The 3 components are EVM (Eyes/Verbal/Motor)
Describe the [Motor] component (6)
- GCS prognosis’* Brain CHIT
1. Coma
2. Hemorrhage (SAH)
3. Infection (bacterial meningitis)
4. Trauma
________________
EVM = Eyes / Verbal / Motor
What’s the marker for [Glioblastoma astrocytoma]?
GFAP
What Dx should you suspect in a Young HIV Pt witih Dementia?
________________
Pgn?
AIDS Dementia= slow cognitive & behavioral decline with POOR PGN . Note: This presentation is Similar to [SuBACute Combined Degeneration]
HIV LeukoEncephalopathy is the same thing but with White matter instead
Homocystinuria tx -2?
auto recessive [Cystathionine synthase] deficiency –> Thromboembolism–> Stroke
tx = [Pyridoxine B6] + AntiCoag
Homocystinuria dx-2
auto recessive [Cystathionine synthase] deficiency –> Thromboembolism–> Stroke
[Homocysteine⬆︎] and [Methionine⬆︎]
Homocystinuria Clinical presentation-5
auto recessive [Cystathionine synthase] deficiency –> Thromboembolism–> Stroke
- Marfanoid habitus (elongated limbs, arachnodactyly, scoliosis) - MH
- Ectopia Lentis - MH
{3. Retarded -h}
{4. Fair Hair & Eyes -h}
{5. Stroke -h}
________________
- MH = MARFAN and HOMOCYSTINURIA*
- h = homocystinuria only*
[transverse myelitis] and [Guillain Barre Syndrome] both p/w LE paralysis
How do they differ in ______
a. Motor
b. Sensory
[transverse myelitis] and [Guillain Barre Syndrome] both p/w LE paralysis
How do they differ in ______
a. autonomics
b. Cranial Nerves
c. EMG/nerve conduction velocity
[transverse myelitis] and [Guillain Barre Syndrome] both p/w LE paralysis
How do they differ in ______
a. MRI
b. CSF
How is Carotid Artery Dissection associated with Horner Syndrome?
Carotid A Dissection –> Partial Horner (Ptosis + Miosis only) 2/2 postganglionic sympathetic fiber damage
Name the most important things to do when administering tPA to a stroke patient? (3)
1.STRICT IV BP CONTROL{[< 180/110 before tPA] [< 180/105 after tPA ]
(avoid HTN to ⬇︎risk of hemorrhagic conversion but avoid hypOtension to maintain perfusion to the ischemic penumbra)
_________________
3.wait ≥24h before ANY BLOOD THINNER
Why is a [rapid bedside dysphagia screening] required for Acute Stroke patients?
Stroke patients (especially if +dysarthria) have ⇪ risk for oropharyngeal dysphagia and aspiration = CAN NOT RECEIVE ANY MEDS BY MOUTH (like ASA) until [rapid bedside dysphagia screening performed]
How do you manage
Ischemic Stroke? (4)
prior to diagnosing Dementia, reversible causes of Cognitive impairment must be r/o
How do you workup Cognitive impairment ? (10)
How is the [Oculocephalic Dolls eye Reflex] used to assess brainstem function?
Eyes should remain stationary and fixed as head is rotated = normal brain stem function
“Dolls Eyes a NORMAL GUY” (Dolls Eyes = Brainstem intact)
How long does it take pts with Subdural hematoma to have sx? Why is this a problem for elderly?
1-2 days; Elderly may have insidious subdural bleeds for weeks after injury –> Confusion/Somnolence/HA/FOCAL Neuro ∆
Image: L Chronic Subdural Hematoma
DDx for patient p/w 1/2 facial paralysis (without forehead sparing)?
[Lyme serology 1st] ➜ [Bells palsy (dx of exclusion!)]
What causes [Lateral ventricle frontal horn] enlargement in Huntington’s disease?
**Gross Caudate atrophy**
[AUTO DOM [Chromo 4 CAG repeats]] —> Degeneration of (Caudate nc. inside the ((I)ndirect Striatum w/ [Gross Caudate atrophy] ) –> [⬇︎ GABA release]
“Hunting 4 food is way too aggressive & dancey”
Huntington’s Dz Clinical Presentation (2)
- “Hunting 4 food is way too aggressive & dancey”*
1st: Aggressive Dementia w/ strange behavior
2nd: Dance-like Choreoathetosis (dancing/writhing movements) - AUTO DOM = Affects BOTH sexes equally!!*
Etx of Huntington’s Disease
[AUTO DOM [Chromo 4 CAG repeats]] —> Degeneration of (Caudate nc. inside the ((I)ndirect Striatum w/ [Gross Caudate atrophy] ) –> [⬇︎ GABA release]
“Hunting 4 food is way too aggressive & dancey”
Identify ; Which are Lenticulate and which are Striatum?
“Gay People Cook!” = Basal Ganglia
Gay People=Lenticulate // People Cook= Striatum
- eg = Globus Pallidus
- es = Putamen
- d = Caudate
The 3 types of dream disorders are ⬜, NRSAD and ⬜
_________________
Name the primary characteristics of [NRSAD: Sleep Terrors] ?
RSRBD | NRSAD | NightMareDisorder
_________________
Sleep terrors are :
- NRSAD (NonREM)
- accompanied with recurrent incomplete awakenings
- can NOT be consoled upon wakening
- Seems to forget the dream = Dream Amnesia/No Dream Recall
NRSAD = Non-REM Sleep Arousal Disorder
identify (12)
identify (21)
A: Identify Boxes (4)
B: Clinical Presentation for lesion at A? B? C? D?
A: Identify Boxes (4)
B: Clinical Presentation for lesion at E? F? G? H
C: Explain how [H] is special (*** )?
C: [H] is actually {[K]-{CTL Homonymous Hemianopiawith macular sparing} if [PCA occluded]
identify (14)
In regards to Carpal Tunnel, the ⬜ n. courses between the ⬜ and ⬜ muscles before crossing under the ⬜ inside the carpal tunnel
In regards to Carpal Tunnel, the Median n. courses between the [Flexor Digitorum superficialis] and [Flexor Digitorum Profundus] before crossing under the [Flexor Retinaculum transverse carpal ligament] inside the carpal tunnel
Although [minor head trauma] does NOT usually indicate [nHCT]
these 3 “special” groups do…
[HIGH RISK: subjects | symptoms | signs]
_________________
Name the [HIGH RISK subjects]? (6)
subjects AKA “patients”
1. age ≥65
2. Coagulopathic
3. IntoxicationDrug/EtOH
4. [PHM([ped vs auto])]
5. [PHM( [vehicular ejection])]
6. [PHM([Fall from height])]
| PHM = Patients with High-Risk Mechanism
[minor head trauma] does NOT usually indicate [noncontrast Head CT].
Although [minor head trauma] does NOT usually indicate [noncontrast Head CT], there are 3 “special” groups that do…
[HIGH RISK: subjects | symptoms | signs]
_________________
Name the [HIGH RISK symptoms]? (4)
- Retrograde amnesia ≥30min before injury
- [Vomiting ≥ 2]
- Seizure
- Severe HA
Minor head trauma does NOT usually indicate [noncontrast Head CT].
There are 3 groups that require [noncontrast Head CT] after Minor head trauma..
[HIGH RISK: subjects | symptoms | signs]
_________________
Name the [HIGH RISK signs]? (5)
- GCS ≤14
- depressed skull fx
- Basilar skull fx (CSF drainage, hemotympanum, [battle’s postauricular ecchymosis], periorbital hematoma)
- AMSincluding LOC
- Neuro deficit
Injury to the ⬜ causes ⬇︎ ability to Dorsiflex
[Common Peroneal nerve]
________________
foot dropPED
L4-S2
Main Features of TIA - 3
- Transient ( No more than 1 day long but typically < 20 min)
- NO residual deficits
- NO residual radiomanifestations
[Medial Midbrain Syndrome of Weber] etx
________________
CP-2
PCA infarct ➜ damage to –>
- [Oculomotor CN3] → [iPL DOPe]
- [Crus CerebriCST & CorticoBulbar)] → [CTL Hemiparesis→ Face, UE, LE]
_________________
DOPe = [(Down & Out eye) + Ptosis + (eye dilated)]
Memory depends on a BL 4-way circuit
What is this circuit?-4
“Having Fun Memories Around”
[Hippocampus temporal lobe] –> Fornix –> [Mamillary Bodies] —> [ANT Thalamus]
Meniere’s Disease etx
⬆︎endolymphatic fluid in inner ear–> Membranous labyrinth swelling and rupture –> [KRE- K+ Rich Endolymph] leak into [Na+ rich perilymph] –> abnormal hair cell function –> VTNH sx
**Very Terrible Nystagmus & Hearing **
_________________
same sx as Acute Labyrinthitis
Acute Labyrinthitis CP - 4?
**Very Terrible Nystagmus & Hearing **
- Vertigo
- Tinnitus
- Nystagmus
- Hearing loss which –> Permanent eventually
same sx as Meniere’s Disease
Meniere’s Disease tx - 5
1st: Diet(restrict Na+, caffeine, Nicotine, EtOH)
2nd: [antihistamines ⼀Benzo ⼀antiemetics]
3rd: DiureticsLong Term
_________________
Sx = VTNH (Vertigo, Tinnitus, Nystagmus, Hearing loss)
MeningoVascular syphilis infects ⬜ , which can present as stroke (2/2 to ⬜) , and is confirmed via ⬜
What is the tx?
[subarachnoid space vessels] ; intracranial arteritis ; [CSF VDRL]
_________________
PCN
Most common [1° CNS Tumors] in Pediatrics-3
________________
what’s the only one that’s supratentorial?
PEDs
Pilocytic Astrocytoma = MOST COMMON and can be Supratentorial OR infratentorial
Ependymoma (found in 4th Vt)
meDulloblastoma PNET = 2nd most common
Ependymoma and meDulloblastoma are infratentorial POST fossa(image)
Brachial Plexus damage of
[proximal median {C5⼀T1} n]
________________
clinical presentation? (2)
[Pope’s BlessingFISTING] = “Pope’s Blessing”
[+ thumb paralysis w thenar atrophy]if recurrent branch affected
Brachial Plexus damage of
[proximal median {C5⼀T1} n]
________________
cause
[anterMedial⼀pFSF]
👓{[anteroMedial⼀pFSF] = {[anteroMedial⼀proximal humerus displacement] iTSo [FOOSA Supracondylar Fx]
Brachial Plexus damage of
[distal median {C5⼀T1} n]
________________
cause (2)
- carpal tunnel
- wrist laceration
Brachial Plexus damage of
[distal median {C5⼀T1} n]
________________
clinical presentation? (2)
[median clawresting] = “median claw”
[+ thumb paralysis w thenar atrophy]if recurrent branch affected
Brachial Plexus damage of
[proximal Ulnar {C8, T1} n]
________________
clinical presentation?
[median clawFISTING]
Brachial Plexus damage of
[ULNAR C8-T1 n]
________________
cause -3
- [FALL ONTO FLEXED ELBOW ➜ POSTERIOR PROXIMAL HUMERUS DISPLACEMENT]PROXIMAL ULNA
- [MEDIAL EPICONDYLE]PROXIMAL ULNA
* * * - [BICYCLIST HOOK OF HAMATE INJURY = GUYAN CANAL SYNDROME]DISTAL ULNA
________________
[Pope’s Blessingresting] = [“ulnar claw”]
Brachial Plexus damage of
[distal ULNAR C8-T1 n]
________________
clinical presentation?
[Pope’s Blessingresting] = [“ulnar claw”]
- ([hyperextension of 4th MCP and 5th MCP] + [flexion of 4th PIP and 5th PIP])*
Myotonia Dystrophy Clinical Manifestation - 6
My Tonia, My Toupee, My TV Viewers, My Throat, My Ticker, My Testicles,
Tonia = MyoTonia = [⬇︎ relaxation after volitional muscle contraction with Weakness & Atrophy] (cant let go of doorknob)
Toupee = Frontal Balding / daytime sleepiness
TV viewer = Cataracts / Ptosis
Throat = SEVERE DYSPHAGIA –> Aspiration PNA
Ticker = Arrhythmia
Testicle = Testicular Atrophy
[AUTO DOM CTG Repeat]
How does [Congenital Myotonia Dystrophy] present? (6)
My Tonia, My Toupee, My TV Viewers, My Throat, My Ticker, My Testicles,
- presents at birth with*
- ________________*
hypoTonia profoundly
cataracts
inverted V-shaped upper lip
feeding intolerance
respiratory distress
contractures
________________
[AUTO DOM CTG Repeat]
how is Myotonia Dystrophy initially diagnosed?
[AUTO DOM CTG Repeat]
_________________
My Tonia, My Toupee, My TV Viewers, My Throat, My Ticker, My Testicles
[HA with Papilledema] is a [HA Red Flag]; and warrants minimum [⬜ to rule out (⬜2)]
Name DDx for this [Headache Red Flag]:
[worst with physical activity] (2)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- Mass
- SAH
- *
- FRATwIPS*
[HA with Papilledema] is a [HA Red Flag]; and warrants minimum [⬜ to rule out (⬜2)]
Name DDx for this [Headache Red Flag]:
[INC Frequency or INC Severity] (3)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- Mass
- subdural hematoma
- Med overuse
- FRATwIPS*
[HA with Papilledema] is a [HA Red Flag]; and warrants minimum [⬜ to rule out (⬜2)]
Name DDx for this [Headache Red Flag]:
[Thunderclap⼀Sudden⼀“worst HA of life”]
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
SAH
- FRATwIPS*
Although other dx exist, [HA with Papilledema] is a [HA Red Flag]; and requires ⬜ to r/o ____ and/or _____
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ; mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
- FRATwIPS*
[HA with Papilledema] is a [HA Red Flag]; and warrants minimum [⬜ to rule out (⬜2)]
Name DDx for this [Headache Red Flag]:
[Radical Personality😵changes] (3)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- Mass
- CNS infection
- Intracerebral hemorrhage
- FRATwIPS*
[HA with Papilledema] is a [HA Red Flag]; and requires ⬜ to r/o (⬜2)
Name DDx for this [Headache Red Flag]:
[Age ≥50 yo] (2)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- Mass
- Giant Cell Temporal Arteritis
- FRATwIPS*
[HA with Papilledema] is a [HA Red Flag]; and requires ⬜ to r/o (⬜2)
Name DDx for this [Headache Red Flag]:
[⊕Papilledema] (3)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- MASS
- PCiiH
- AV MALFORMATION
- FRATwIPS*
[HA with Papilledema] is a [HA Red Flag]; and requires ⬜ to r/o (⬜2)
Name DDx for this [Headache Red Flag]:
[⊕Focal neuro] (3)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- MASS
- PCiiH
- AV MALFORMATION
FRATwIPS
[HA with Papilledema] is a [HA Red Flag]; and requires ⬜ to r/o (⬜2)
Name DDx for this [Headache Red Flag]:
[⊕Systemic Sx(fever, rash)] (2)
STAT [©️Brain MRI (or 🅽HCT if c/f SAH)] ;
mass intracranial; [cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
- Encephalitis
- Meningitis
* * *
FRATwIPS
Name the classic sx of IntraCranial Hypertension - 4
HEAD
1.HA, Positional, worst at night/morning
2.[papillEdema & vision ∆ ]
4.AMS
5.Dont eat (NV)
Parinaud Syndrome etx
How does it clinically present?-5
[Parinaud Dorsal Midbrain syndrome (PUPAw)]
“Parinaud LOSS his PUPAw”
Direct Compression of [Dorsal Midbrain Pretectum SUP Colliculi] (possibly from Germinoma) –>
________________
[Pupillary light reflex_LOSS]
[Upward Vertical Gaze_LOSS (paralysis)]
Ptosis
Ataxia
[+/- water hydrocephalus 2/2 obstructive Germinoma]
Name the most common pineal gland tumor
and how it clinically manifest (2)?
Germinoma
- [Parinaud Dorsal Midbrain syndrome (PUPAw)]
- [Pituitary hypothalamic dysfunction (if in suprasellar region)]
Name the red flags that indicate a HA may be malignant (8)
[FRATwIPS] cause malignant HA
- Focal neuro ∆
- Radical Personality ∆
- Age ≥50
- [Thunderclap⼀Sudden⼀”worst HA of life”]
- worst w/physical activity
- [INC Freq or INC Severity]
- Papilledema
- [Systemic sx (fever/rash)]
HA diary should contain OPQRSSTAP
Genetic etx of Neurofibromatosis Type 1
[17q11 mutation] ➜ suppression of [NTS-GAP] ➜ [(CLAP ON) tumor sx]
________________
[NTS-GAP] = [NeuroFibroMin Tumor Suppressor-GTPase Activating Protein]
Characteristics of Neurofibromatosis Type 1 (6)
“CLAP ON type 1!”
- [Cafe Au Lait HYPERpigmented spots ≥ 6]
- Lisch nodules
- [Acoustic Schwannoma uL ➜ HA/Tinnitus/Vertigo]
- Pheochromocytoma
- Optic N glioma
-
Neurofibroma PLEXIFORM
* Note: NF1 in Newborns will present w/Macrocephaly, ⬇︎Feeding ,learning disabilities*
Identify disease
Lisch nodules seen in Neurofibromatosis TYPE 1
CLAP ON type 1!
Ocular Tonometry indication
Measuring intraocular pressure in acute [closed angle glaucoma]
Image: Acute [Closed Angle Glaucoma]
Normal Retina consist of ____, _____ and ______
Papilledema has 4 characteristics on fundoscpopy
Papilledema occurs when ⬜ , and this is commonly caused by what 4 conditions?
normal = DSL: [Disc margin sharp /Small veins linear /Large vessels sharp]
_________________
[elevated ICP is transmitted to (Optic CN2)] ;
- Mass intracranial
- [Cerebral Venous Sinus Thrombosis (DEC CSF outflow)]
- INC CSF production
- PCiiH
Parkinsonism is often caused by ____ or _____
Name 2 rare causes of Parkinsonism
Common = [Substantia nigra pars compacta degeneration] vs [D2 R Blockade]
rare = Toxic levels of CO2 or ManGanese
P|RK & hamp
Parkinsonism Clinical signs (8)
PARK & hamp
[Pill Rolling Resting 4-6 Hz unilateral Tremor] worst with Rest & Mental Task
[AReflexia posturally (should have late onset)] –>Shuffling Gait/Fall when turning or stopping
[Rigidity Cogwheel]
BradyKinesia
+
- hypOphonic speech
- autonomic ⬇︎ (constipation / bladder problems / orthostatic hypOtension)
- micrographia
-
poker masked face
P|RK([P or R ]+ K)= primary signs
Parkinson’s Disease Tx = SALADS
Describe the MOA of
L(2)
“Eat SALADS after you Park”
{[L + C ] with [ (E vs T)</sup> ]}
—–--
[Levodopa(Dopamine Precursor) + (Carbidopa)]
with
[(Entacapone or Tolcapone)]
Parkinson’s Dz Tx - 6
“Eat SALADS after you Park”
- {[Levodopa(Dopamine Precursor)+ Carbidopa] with [Entacapone|Tolcapone]}
- Amantadine
- Anticholinergics
- [Dopamine PostSynaptic R Agonist](NonErgot: Ropinirole vs. Pramipexole) & (ergot:bromocriptine)
- Selegiline
-
Surgery
- Pallidotomy: Destructive of [Globus Pallidus:internal]
- SubThalamic nuc. inhibition with electrode
- ANT Choroidal a ligation
Patient with c/f meningitis has received antibiotics prior to having lumbar puncture
How may this affect CSF analysis? (4)
Abx pretreatment can cause CSF:
- Glucose HIGHER than expected
- Protein lower than expected
- [Gram Stain] yield lower than expected
- [Gram Culture] yield lower than expected
Patient presents with lower extremity paralysis with paresthesia
workup?
PE is common cause of early death in Stroke patients, so DVT px is needed
How is DVT px determined for Acute Ischemic Stroke patients? (2)
if patient received
[thrombolytics | dual antiplatelet | therapeutic anticaogulation] ➜ IPC
________versus_________
[ASA only] ➜ [IPC + SQ Prophylactic Heparin]
IPC = Intermittent Pneumatic Compression
Prolactin level of ⬜ = Prolactinoma
________________
Tx? -2
> 200
________________
[Dopamine R agonist (bromocriptine ergot vs cabergoline)] <
1cm < [Surgery for MACROademona]
_________________
tx ⬇︎tumor size (even visual sx) within few days. Surgery rarely indicated
Pronator Drift is a good indicator of what type of disease?
UMN Pyramidal Tract Dz (think stroke)
- Pyramidal Tract = Corticospinal and Corticobulbar*
- Clasp Knife phenomenon also indicates Pyramidal Tract Dz*
Pt has advancing foot crossing over opposite foot similar to closing scissor blades
What causes Scissors Gait?
UMN (Corticospinal Tract spasticity) lesions
Spasticity causes Scissors Gait
Pts with Cerebellum lesions have _____ (ContraLateral vs Ipsilateral) Hemiataxia. Why is this? ; Why are Cerebellar hemorrhages so dangerous?
IPSILATERAL ; CorticoPontoCerebellar fibers decussate TWICE ; May extend down into brainstem –> Coma & Death
Image: L Cerebellar hemorrhage –> L hemiataxia
Recall the Oculosympathetic Horner’s pathway - 9
[HPI - ULS - fci]
- Hypothalamus
- Passes as hypothalamospinal tract in lateral medulla
- [IML C8-T1 Cilospinal Center of Budge]
- Under Subclavian Artery as sympathetic trunk
- Lung Apex
- SUP cervical ganglion near carotid bifurcation
6A. Facial Sweat Glands
6B. carried with CN5B1 thru cavernous sinus & then SUP orbital fissure to Pupil Dilator
6C. Innervates [Muller’s superior tarsal muscle]
2 / 5 / 6 / 6B are most common sites of Horner’s syndrome
What are the most common causes of Horner’s Syndrome? - 4
- Lateral Medullary syndrome of Wallenberg
- Lung Apex tumor
- Neck Carotid Trauma
- Cavernous Sinus Thrombosis
_________________
[HPI - ULS - fci] 2 / 5 / 6 / 6B are most common sites of Horner’s syndrome
Sciatica
etx
_________________
Clinical Presentation - 3
“Having Sciatica makes you break LAWS”
- [Lower Back pain w/radiation down POSTERIOR thigh –> lateral foot]
- Ankle jerk reflex ABSENT (this can occur naturally with age!)
- Weak Hip Extension
- [S1 n PosteroLateral compression at L4-5 or L5-S1] –> UMN signs
Sciatica tx -2
“Having Sciatica makes you break LAWS”
NSAIDs + APAP = 1st line as Sciatica sx are self limited
Sciatica
dx? -2
“Having Sciatica makes you break LAWS”
Dx = CLINICAL
(Only use MRI for confirmation of disc herniation if sensory/motor deficit, cauda equina syndrome sx or epidural abscess r/o)
Negative Cremasteric reflex could be caused by ⬜ (3)
- Testicular Torsion
- [L1-2 spinal cord damage (will be accompanied by loss of hip Flexion & loss of hip ADDuction)]
- Diabetic neuropathy
Testicular Torsion and Acute Epididymitis
what do they share?
________________
How do they differ?
Sim = Both have [Acute Testicular Pain]
________________
Differences =
- TT has [High Riding testes] and [NEGATIVE cremasteric reflex]
- [AE has Fever, Pyuria & CORD TTP]
Sturge Weber Syndrome Clinical Presentation -5
- SEIZURES
- Red Facial Lesion (Port Wine Stain vs Red Nevus along CN5 territory = congenital UL cavernous hemangioma)
- GlaucomaiPL
- Homonymous HemianopsiaCTL
- Hemiparesis
Tramline Gyriform Calcifications on CT
Sturge Weber Syndrome Tx -3
- Seizure control
- [GlaucomaiPL] control (⬇︎Intraocular pressure)
- [Red Facial lesion] control with Argon laser
________________
- Tramline Gyriform Calcifications on CT*
- Red Facial Lesion = Port wine stain vs Red nevus along CN5 territory*
Tetanus takes ⬜ days to onset after exposure to endospores
________________
Tx? - 4
2 days;
- Mechanical ventilation ICU
- Human Tetanus Immune Globulin
- Abx
- Diazepam
Comes from puncture wound vs burn
The criteria for Status Epilepticus is ⬜ or ⬜
_________________
How do you manage Status Epilepticus
CP of VertebroBasilar TIA - 5
Labyrinths: DIZZINESS
Brainstem: DIPLOPIA, DYSARTHRIA
Cerebellum: BL Clumsiness
Spinal Cord: BL Weakness
Tourette syndrome tx (7)
haloperidol FGA
pimozide FGA
Risperidone SGA
Aripiprazole SGA
[Alpha 2 R agonist]
Tetrabenazine
[CBT habit reversal therapy]
Tuberous Sclerosis Clinical Presentation (12)
HAMARTO(MAS)ss
[Hamartomas benign]
[AngioMyoLipoma in Kidney]
Mitral Regurgitation
[Ash Leaf Macules]
[Rhabdomyoma Cardiac –> Valvular Obstruction]
Tuberous Sclerosis
auto dOm
Mental Retard-triad ⭐
[Angiofibroma on Face-triad] - ⭐ image
[Seizures-triad - ORDER EEG] ⭐
SEGA (SubEpendymal Giantcell Astrocytoma)
[Shagreen forehead patches]
Patients with Tuberous Sclerosis must receive a ⬜ test; especially since (⬜2) is the leading cause of death in these patients
EEG ; [SEIZURES and associated CNS decline]
_________________
HAMARTOMAsss
Tx for Catatonia - 2
Lorazepam
and/or
ECT
________________
consider Lorazepam challenge = Lorazepam 2 mg IV ➜ observe result (if pt relieved within 5 min = catatonia)
Sx of Catatonia - 6
”..had Catatonia always WIMPEN around”
WAXY FLEXIBILITY
Immobility
Mutism
Posturing
[EchoLalia/EchoPraxia]
Negativism
“ WIMPEN sx “
________________
consider Lorazepam challenge = Lorazepam 2 mg IV ➜ observe result (if pt relieved within 5 min = catatonia)
How do you diagnose Catatonia?
Lorazepam challenge =
[Lorazepam 2 mg IV] ➜ observe patient ➜ if pt relieved within 5 min = catatonia.
________________
note: a negative response does NOT rule out catatonia
“ WIMPEN sx “
Tx for Single Brain Metastasis (likely from ⬜ primary) - 2
[SURGERY ➜ [(SRS) Stereotactic RadioSurgery]] vs Whole Brain Radio
- Likely from [Lung NonSOLC] primary*
- Use SRS first in non-surgical candidates*
Tx for Multiple Brain Metastasis (likely from ⬜ primary)
Whole Brain Radio
Likely from [Lung NonSOLC] primary
[Ulnar Nerve Syndrome] typically occurs at the ⬜ , usually from what scenario?
ELBOW (where ulnar n lies at medial epicondylar groove before passing thru cubital tunnel) ; Leaning on Elbows at desk
May also occur at forearm in DM pts
[Ulnar Nerve Syndrome]
CP-3?
“Leaning on Elbows at desk”
- numbness over medial forearm
- numbness over 4th and 5th digits
- Weak Grip of ipsilateral hand (Atrophy of hypothenar vs 1st dorsal interosseous m)
May also occur at forearm in DM pts
[Oculomotor CN3] palsy CP? -4
eye is DOPe
[Down & Out] + Ptosis + [eye dilated]
What are the causes of [Oculomotor CN3] palsy?-5
- POST communicating artery aneurysm
- TUMTL herniation
- PCA occlusion
- Cavernous Sinus Thrombosis
- {DM [Oculomotor CN3] central ischemia (will NOT have eye dilation)}
________________
DOPe
What are the functions of [Oculomotor CN3] ?-6
E. .SUP Orbital fissure ➜
e1.
▶[SUP rectus (D)]
▶[LPS (P)]
_________________
e2a.
▶[inf Oblique]
▶[inf rectus]
▶[Medial rectus (O)]
_________________
e2b.
▶ < ciliary branch: {ciliary ganglion}: [CPM (e)] >
DOPe = Oculomotor CN3 palsy sx
- [inf oblique]EWG
- [inf rectus]EWG
- [SUP rectus]EWG : D
- [medial rectus]EWG : O
- {[Levator Palpebrae Superioris]EWG = elevates eyelid} : P
- {[Constrictor pupillae m (ciliary branch) ]cg ←EWG = constricts pupil} : e
Recite the pathway of the [Oculomotor CN3], starting with its nucleus (which houses the ⬜ ganglion) in the ⬜ ? -8
[EW ganglion]; midbrain
_________________
a.[{EWG} of [Oculomotor CN3 nucleus] in midbrain]
B. SCA
c. PCA
d. Cavernous Sinus
E. .SUP Orbital fissure
e1-Upper. ➜ [SUP rectus (D)] / [LPS (P)]
e2-lower-a. [inf Oblique (D)] / [Medial rectus (O)] / [inf rectus]
e2-lower-b. < ciliary branch: {ciliary ganglion}: [CPM (e)] >
DOPe = Oculomotor CN3 palsy sx
▶ LPS = . {[Levator Palpebrae Superioris]EWG = elevates eyelid} : P
▶cPM= {[constrictor Pupillae M (ciliary branch) ]cg ←EWG = constricts pupil} : e
What are the major functions of [Vagus CN10] - 5
VAGUS
Vocal Cord Phonation
[Aortic baro/chemoreceptor Parasympathetics]
[Gag reflex - EFFerent (loss of Gag = CN9 problem)]
U‘ll COUGH reflex- when vagus receives signal afferently
[Swallowing & Palate Elevation]
Image: Left Ipsilateral CN10 palate dysfunction
What are triggers of VAN (Vasovagal Autonomic Neurocardiogenic) Syncope? -8
- EMOTION
- PAIN
- Carotid Stimulation
- Prolonged Standing
- Coughing
- Meals
- Defecation
- Urination
VAN Syncope is preceded by nausea, sweating and dizziness
What causes Hemiballismus
Lacunar Stroke damage to [Subthalamic nc. of the Basal Ganglia] (important in modulating basal ganglia output) –>
CTL Hemiballismus
Note: Basal Ganglia is in Subcortical nuclei
What is the action of the Inferior Oblique m?
________________
What is the action of the Superior Oblique m?
IOUO SODO
InferiorOblique = Up and Out
SuperiorOblique (innervated by Trochlear CN4) = Down and Out
What is the ancillary test used to assess for [NO intracranial blood flow] during Brain Death diagnosis?
Radioisotope brain scan revealing NO cerebral blood flow > 10 min (typically 2/2 brain edema)
What is the most common cause of Fatal Sporadic Encephalitis in the U.S.?
_________________
Should you use CT or MRI for dx?
Herpes Encephalitis
_________________
MRI (and then CSF PCR=Gold Standard Dx)
What is the most common cause of Lateral Medullary Syndrome of Wallenberg?
_________________
2nd most common?
Intracranial Vertebral a occlusion ;
PICA occlusion
What is the [ARAS (Ascending Reticular Activating System)] important for?
________________
Lesions of the ⬜ where ARAS is located leads to what? - 2
ARAS “Always Retaining Awake State” = keeps you awake!
________________
lesions of upper brain stem –> Somnolence or Coma
What is unique about [Trochlear CN4]?
Only cranial nerve to exit DORSAL midbrain and then decussate and innervate CTL Superior Oblique muscle
IOUO SODO
What dx should you suspect in a pt who has doMAP? _________________
explain
doMAP = [down & out eye + Miosis⼀Anhidrosis⼀Ptosis]
Cavernous Sinus Compression!
_________________
[Oculomotor AND sympathetic (Horner’s)] fibers cross thru Cavernous Sinus and if compressed ➜
doMAP [(down & out eye) + Miosis⼀Anhidrosis⼀Ptosis]
What would a [R Partial Retinal lesion] manifest as
R Monocular scotoma
Lesion at which letter would result in [R Nasal Hemianopia]
D
Lesion at which letter would result in [L Pie on the Floor (Homonymous INF quadrantanopia)] lesion
G
In order from Most to least common, name sites of Berry Saccular Aneurysm? - 4
SAH occur usually in Suprasellar Cistern
[ANT communicating] > [POST communicating (will result in CN3 palsy)] > MCA > [POST Circulation]
What’s the most common cause of SubArachnoid Hemorrhage?
________________
What’s the 2nd?
Usually in the Suprasellar Cistern
Trauma > [Berry Saccular Aneurysm]
In order from Most common to least common, Name the 5 most common origins of Brain Metastasis?
_________________
Which of these present as MULTIPLE (not solitary) brain metastasis?-2
Most common= [LUNG NonSOLC]
> Breast > unknown>Melanoma>Colon
[Lung NonSOLC] & Melanoma –> multiple
_________________
rare = Oropharyngeal
Where are Brain Metastasis typically found? - 2
Gray White Junction vs Watershed Zones
✏️ Brain metastases are multifocal and spherical
_________________
✏️Most common= [LUNG NonSOLC]> Breast > unknown>Melanoma>Colon
Where do most disc herniations occur? - 2
_________________
Risk factor for disc herniation?
between
- L4-5 OR
- L5 - S1
SMOKING = Risk factor
_________________
Positive Crossed Straight Leg = Lumbar Disc herniation
What 4 locations is pain radiated to in L5 Radiculopathy?
- Lower Back
- Butt
- Lateral Thigh
- LateralAntero Calf
L5 Radiculopathy can also cause Foot dropPED
Describe Features of BENA (Brocas Expressive NonFluent Aphasia) -4
- Right Hemiparesis
- Impaired Speech Fluency
- Impaired Naming
- Impaired Repetition
BENA = Dominant Inferior Frontal
Describe Features of Wernickes Aphasia - 3
- R SUP homonymous quadrantanopia
- Impaired Comprehension “Word Salad”
- Impaired Repetition
Wernicke = pt will sound like a “jumbled “Word salad”
Conductive AND Wernicke Area = Dominant SUP Temporal
Describe Features of CONDUCTION Aphasia
VERY POOR Repetition
This is in addition to Fluent but many phonemic errors
cp for conduction aphasia?
What areas of the brain are involved in CONDUCTION Aphasia? - 4
⛔[VERY POOR Repetition](CAN NOT REPEAT phrases such as “No ifs, ands or buts”) but
✔︎ intact speech fluency
✔︎ intact comprehension
- Arcuate Fasciculus = MOST COMMON
- Supramarginal Gyrus
- Auditory Cortex
- Large Posterior Perisylvian area
Which 3 Neuro Diseases Cross the Corpus Callosum?
- Gliomas (AGE - i.e. Glioblastoma)
- Multiple Sclerosis
- CNS Lymphoma
Which areas of the brain are affected by [HSE-Herpes Simplex Encephalitis]? - 2
- Medial temporal
- Inferior frontal
Brainstem strokes cause [IPL Cranial Nerve deficits] and [CTL Body deficits]
Which Cranial Nerve nuclei originate from the midbrain? (3)
Brainstem strokes cause [IPL Cranial Nerve deficits] and [CTL Body deficits]
Which Cranial Nerve nuclei originate from the Pons?
Brainstem strokes cause [IPL Cranial Nerve deficits] and [CTL Body deficits]
Which Cranial Nerve nuclei originate from the Medulla?
Which grade Astrocytoma is this? How can you tell? CP?
LOW grade astrocytoma; it has NO CONTRAST ENHANCEMENT ; Seizures
Which imaging should be obtained for CVA/TIA w/u? - 4
- NonContrast Head CT
- TTEchocardiography (evaluate for cardioembolism)
- Carotid cervical US
- CTA/MRA (CTA shown in image-evaluate for Vertebrobasilar abnormalities)
Which Second Generation Antipsychotics are most associated with causing
[Extrapyramidal (TADD)] sx -2
Risperidone > Lurasidone
Loss of Gag Reflex indicates what cranial nerve damage
Glossopharyngeal CN9 Ipsilateral
Dysphagia indicates what cranial n. damage (2)
[Glossopharyngeal CN9] and [Vagus CN10]
Dysphonia/Hoarseness indicates what cranial n. damage
[Vagus CN10]
Which 3 vessels are affected by [TUMTL-Transtentorial Uncal Medial Temporal lobe] Herniation?
________________
What manifestations result from this?
[TUMTL Hernation–> Compression of [POP- PCA / Oculomotor CN3 / Paramedian Pontine vessels] –>
Compression of:
- [PCA] –> Occipital lobe infarct –> CTL homonymous hemianopsia w/Macular sparing
- [Oculomotor CN3]–> [Ipsilateral DOPe ⼀”Down & Out” Eye + Ptosis + eye dilated]
- [Paramedian Pontine vessels] –> Duret Hemorrhage
Why are competitive weight lifters at risk for Orthostatic Syncope? (2)
▶[competitive weight lifters] often use [diuretics and fluid restriction] to rapidly lose weight for lighter weight category
▶▶[diuretics and fluid restriction] → hypOvolemia → orthostatic syncope
GET [DIURETIC URINE ASSAY] + ORTHOSTATIC BP = Dx
Why are Multiple Sclerosis pts at risk for BL Trigeminal Neuralgia
Demyelination may occur at Trigeminal nucleus –> BILATERAL neuralgia
Sx will be disseminated in space and time
Why is Altered mental status in a pt who had a large ischemic stroke 4 days prior alarming? - 2
Within 3-5 days (below) can develop:
- Hemorrhagic conversion of infarct
- Brain Edema
You suspect a pt had an ischemic Stroke
After FIRST, ruling out Hemorrhagic stroke with ⬜ , what thrombolytic therapy should be given?
________________
When should you give it?
NonContrast Head CT; [AlteplaseIV]
________________
WITHIN 4.5 HOURS OF SX ONSET!
[Cavernous Sinus Thrombosis] Presentation (6)
Infection of face vs teeth spreads thru facial veins –> cavernous sinus
*doMAP
*[CN3 / 4 / 6 / 5B1 and 5B2]IPL
* [Proptosis]
* HA
* Papilledema
* NV
doMAP =
[do: down/out (eye)]
[MAP: Miosis/Anhidrosis/Ptosis]
Treatment for [Peripheral facial CN7 Bells palsy] ? (3)
[CTS within 3d onset] + [EYE patch] + [EYE artificial tears]
recovery within 1-6 mo of sx onset
[Central facial Stroke palsy] and [Peripheral facial CN7 Bells palsy] both present with ⬜ and ⬜
_________________
What are 2 ways to discern them from one another?
- Nasolabial fold loss
- Lower Lip droop
_________________
❌Stroke Spares forehead and eyebrows
❌Stroke Shuts the eye completely
[Central venous sinus thrombosis] occurs in ⬜ states (pregnancy), and p/w which 3 major symptoms?
_________________
Tx?
prothrombotic;
HA / ICP / [focal deficits from venous stroke/hemorrhage]
_________________
Heparin (this is safe even with intracerebral hemorrhage)
[Excessive daytime sleepiness] is mostly 2/2 ⬜ but in young people it may be a sign of Narcolepsy
________________
DSM5 Clinical criteria for Narcolepsy?
________________
Confirmatory Dx?
insufficient sleep
________________
[sleep ∆ ➕ ≥ 3x/week ➕ ≥3 mo]
with
([Cataplexy] or [CSF hypOcretin-1 deficiency] or [REM latency ≤ 15 min] )
________________
- Dx = POLYSOMNOGRAPHY*
- *
(sleep ∆ = sudden or recurrent sleep lapse/napping multiple times a day)
hypnoGOgic /hypnopompic hallucinations also common sx
Cataplexy presents as ⬜, and indicates Narcolepsy
Tx for Narcolepsy?
________________
What’s the specific treatment for Cataplexy? -4
(Conscious, Brief, Sudden, BL)Muscle tone loss precipitated by intense laugh/joking
________________
Modafinil = Narcolepsy
- ________________*
- Cataplexy tx:*
1. SNRI
2. SSRI
3. TCA
4. Sodium Oxybate (rarely used)
There are 3 types of Neural Tube Defects [sO/ mO / mOm]
etx for [Neural Tube Defect] (3)
-[folate B9 deficiency before&during pregnancy]
-➜ failure of caudal neuropore (at 4WG) to fuse closed ➜ [lower vertebral column defect] =
-⭐{leakage of [(fetal αFP) and (fetal AChE)] into amniotic fluid and maternal serum}
-with 1 of 3 herniation:
There are 3 types of Neural Tube Defects [sO/ mO / mOm]
etx for [Neural Tube Defect] involves failure of ⬜ fusion/closure due to ⬜ deficiency during pregnancy → 1 of 3 types of NTD herniation:
❓ Describe the 3 types of NTD herniation
[caudal neuropore (precursor to lower vertebrae)] ; [folic B9]
-with 1 of 3 herniation:
1▶ {[Meninges ⊝] ⼀ [NeuralTissue ⊝] = [sO ( dura intact/normal αFP/ +/- hair tuft or skin dimple))]}
_________________
2▶ [Meninges ⊕] ⼀ [NeuralTissue ⊝] = mO [dura meninges TORN]/⇪ αFP
_________________
3▶ [Meninges ⊕] ⼀ [NeuralTissue ⊕] = mOM →{dura meninges TORN/neural tissue ❌/ ⇪ αFP} = [NEUROGENIC BOWEL AND BLADDER
how do you screen for Neural Tube Defects i.e. ( [Spina Bifida Occulta/Meningocele/Meningomyelocle]] ? -2
[⇪ alpha fetoprotein] on maternal screen ➜ prental US confirmation
[T or F]
Patients with [ hx remote opioid use disorder, currently Abstinent x months], will require HIGHER-than-usual doses of opioids for acute pain control
FALSE
_________________
Abstinent patients with hx OUD LOSE ALL OPIOID TOLERANCE WITHIN MONTHS of cessation = if hx remote, treat with normal dose opioids
[T or F]
If you give opioids to [abstinent patients with hx of opioid use disorder] it requires a discussion of risk /benefits First (unless it’s in the setting of obvious and severe pain)
_________________
Why or why not?
FALSE
_________________
Even if they’re in severe pain, in [now-abstinent (hx) opioid users] you MUST FIRST DISCUSS risk (such as life threatening relapse)/benefit with patient before giving opioids
[T or F]
Patients on maintenance/chronic opioid therapy require HIGHER-than-usual doses of opioids for acute pain control
TRUE
Amaurosis Fugax CP -4
_________________
etx
- monocular vision loss
- nonpainful,
- [transient ( < 10 min)]
- “curtain descended over eye”
_________________
[Central Retinal artery occlusion] from [Carotid Artery atherosclerotic emboli]
▶ In Multiple Sclerosis patients, muscle spasms are a common disabling Motor sx; usually occurring in the ⬜.
▶Name the1st line tx options for [MS muscle spasms]? (2)
▶ adjunct tx? (2)
▶LE
_________________
▶[Baclofen PO or Tizanidine PO]
▶physical therapy, stretching
In ischemic Stroke, ⬜ is the most severe potential complication of [tPA thrombolysis]
hemorrhagic conversion
_________________
reverse with Antifibrinolytics vs Cryoprecipitate
How do you reverse [tPA thrombolysis] if the greatest complication of [tPA thrombolysis] ( __?__ ) … occurs? -3
hemorrhagic conversion
_________________
- [aminocaproic acid Antifibrinolytic (inhibits Plasminogen activators)]
- [transexemic acid Antifibrinolytic]
- [Cryoprecipitate (fibrinogen, factor8, vWF): (replaces clotting factors)]
Syringomyelia
clinical features (4)
🔴cystic cavity formation within (usually C8-T1) spinal cord
🔴(2/2 brain herniation during Chiari 1 vs trauma vs tumor)
🔴damages ANT commissural fibers first → [UE CAPE-LIKE BL PAIN/TEMP LOSS]
🔴Eventually Ventral Horns are destroyed also –> LMN signs (FAW) - Fasciculations / Atrophy & Areflexia / Weakness
A: List the 6 stages of Sleep
B: List their associated EEG waveform
The Limbic system is composed of ⬜, and is responsible for what 5 things?
CHAMP ; [“famous”5 F’s]
