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Neurology > 18 Jan 24 > Flashcards

18 Jan 24 Flashcards

1
Q

Pt with cauda equina syndrome and recent spinal anasthesia , anticoagulant history ?

A

Spinal epidural hematoma due to epidural

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2
Q

Spinal epidural hematoma Management

A

MRI spine
Urgent Surgical decompression (laminectomy)

Bleeding is venous so symptoms are slowly progressive in days.

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3
Q

Spinal epidural hematoma CF

A

Pts taking anticoagulants or thrombocytopenia
Epidural block recent
Spinal point tenderness
Neurologic deficits
Slowly progressive hematoma expansion in days as bleeding is venous

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4
Q

Common site of epidural hematoma

A

Fracture of pterion ( junction of frontal parietal temporal sphenoid bones )

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5
Q

Initial immediate ttt for cerebral edema

A

Hypertonic saline.

Osmotic therapy decreases the parenchymal volume by creatjng osmolar gradient that draws water out of edematous brain.

Hypertonic saline is prefrred over mannitol.

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6
Q

Interventions to lower ICP

A
  1. Decrease brain parenchymal volume:
              Hypertonic saline mannitol
  2. Decrease cerebral blood volume :
      Head elevation to increase venous outflow 
  Sedation to decrease metabolic demand 
  Hyperventilation to dec PaCO2
  3. Decrease CSF volume;
     CSF removel (External ventricular drain)
  4. Increase Cranial volume ;
      Decompressive craniectomy
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7
Q

Shaken baby syndrome. CF

A
  1. Subdural bleeding due to shearing of bridging veins
  2. Coup- countercoup injury as brain impacts skull
  3. Subdural hem presenting as incr HC, bulging/tense anterior fontanelle , papilledema , AMS
  4. Vitreoretinal traction
  5. Retinal hemorrhages
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8
Q

Management of non accidental trauma

A

Ensure immediate safety
Skeletal survey
CT head
Fundoscopy

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9
Q

Epidural hematoma pt becomes obtunded with BTN bradycadia and bradypnea (cushing triad ) Dx

A

Uncal herniation

First sign fix , dilated pupil due to oculomotor nerve compression.
(Oculomotor muscles paralysis comes later and leads to ptosis and down and out position of IL eye)

CL hemiparesis

CL homonymous hemianopia with macular sparing (comp of PCA)

IL hemiparesis. (Kernohan phonemenon)

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10
Q

Post concussion syndrome CF

A

Charaterized by prolonged >4 week concussion syndrome.

Common SS tension like headache with phonophobia.
Dizziness
Sleep disturbance
Mood changes
Poor conc

Most pts improve in 3 months.

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11
Q

Orbital floor fracture CF

A

Weakest area of bony orbit (orbital floor ,medial orbital wall)

🤪Herniation of orbit in maxillaty sinus
🤪Entrapment of inferior rectus muscle
🤪Entrapped IR keep orbit in downward position causing diplopia on upward gaze. Despite normal visual acuitu.
🤪Prolonged entrapment causes ischemia,fibrosis , permanent dysfunction.

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12
Q

Brain death clinical criteria

A

Known cause TBI stroke
Evidence (clinical , neuroimaging) of devastating CNS event.
Exclusion of confounding conditions (electrolyte abnormality, intoxication, paralytics)
Core temp >36 (96.8) , SBP > 100

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13
Q

Brain death clinical exam

A

🛖Coma
🛖Brainstem reflexes absent
🛖Apnea test : no resp response to PaCO2 >60mmhg
🛖 DTRs still present as they origin in spinal cord.

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14
Q

What is apnea test of brain death?

A

Preoxygenate and disconnect from ventilator.

No spontaneous respirations for 8-10mins with PaCO2 >60 or >20 above baseline and arterial pH <7.28
Declares brain death (after meeting legal req)

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15
Q

Carotid artery dissection cause

A

Trauma
HTN
Smoking
Connective tissue dx

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16
Q

Carotid artery dissection CF

A

UL head n neck pain
Transient vision loss
IL partial Horner syndrome
Ptosis miosis without anhidrosis
Signs if cerebral ischemia (focal weakness)

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17
Q

Cause of partial horner in Carotid artery dissection

A

Distention of symoathetic fibers that travel along internal carotid lead to partial horner syndrome. (Ptosis miosis)

Anhidrosis does not occur as its sympathetic fibers travel along external carotid artery.

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18
Q

Ttt of carotid artery dissection

A

CT or MRA
Manage like ischemic stroke

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19
Q

Complication of carotid artery dissection

A

Injury to arterial intima allows blood to flow into vessel wall leading to formation of false lumen Aneurysm) or intramural hematoma.
This leads to arterial obstruction or thromboembolic events.
Cerebral ischemia or TIA is commin complication.

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20
Q

Child with hemiparesis And aphasia after injury to posterior pharynx

A

Carotid artery dissection due to trauma.

Intimal injury to ICA causes dissection or thrombus formation which occurs in hours to days and extends into MCA and ACA.

SS
Neck pain
Thunderclap headache
Ischemic stroke

Dx
CT or MRA

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21
Q

BHS age

A

Benign
Onset 6 mo to 2Y
Completely resolve by age 5
Represent a variant of Vasovagal syncope due to autonomic dysfunction.

Cyanotic. Child becomes cyanotic and crying related

Pallid. Child becomes pale and diaphoretic , related to minor injury.
Confused and sleepy afterwards for few mins.

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22
Q

New memory impairment and cogniyive decline patient who takes medication for rhinitis.

A

Always review drug history for drugs with anticholinergic properties.

Prior to pursuing workup discontinue non essential medications.

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23
Q

Lead poisoning in adults CF

A

Aborbed through lungs
Stored in skeleton
Released slow and exerts pathologic effect in decades

GIT. ;

     Abd pain , constipation , anotexia

Neurologic ;

                        Cognitive deficits 
                        Peripheral neuropathy 
         (Impaired dorsiflexion) 
                        Short term memory loss

Hematologic :

                        Microcytic Anemia 
                        Basophilic stippling 
                        Hyperuricemia (impaired purine metabolism)

Neuropsych : Psychosis

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24
Q

Lead poisoning ttt

A

EDTA

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25
Q

Short term complications of delirium

A

Disorientation , falls
Immobility , pressure ulcers
Poor intake , dehydration
Aspiration pneumonia
Prolonged hospitalisation

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26
Q

Long term complications of delirium

A

Persistent delirium
Nursing home placement

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27
Q

Permanent complication of delirium

A

Cognitive decline (even a single episode puts at risk)

dementia

Death:
20% mortality at 6mo

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28
Q

Delirium CF

A

Fluctuating noctural disorientation and agitation in the setting of medical illness (hip fracture, surgery)

Worse at night

Fluctuating SS allows pts to seem lucid in the day (hence under diagnosed)

Hyperactivity(agitation) classic Symptom

Hypoactive delirium (common in elderly)

29
Q

Non convulsive status epilepticus CF

A

Ongoing or intermittent seizure without convulsions

Fluctuating level of consciousness

Catatonia

Automatisms

Eye deviation

30
Q

Aminoglycoside ototoxcity CF

A

Damage hair cells in cochlea (hearing loss)
Vestibular system ( imbalance)

Varying CF:

BL (but not necessarily symmetrical hearing loss hence positive whisper test need audiogram.

Imbalance and oscillopsia (sensation if objects moving) BL vestibular system affected - in true vertigo only one side is affected

Positive head thrust : evaluates vestibuloocular reflex
Affected in peripheral vestibulopathy
(Not central)

31
Q

RF for aminoglycoside toxicity

A

Bacteremia
Renal dysfunction
Hepatic dysfunction
Use with other ototoxic drugs.

32
Q

Ttt of AG toxicity

A

Discontinue

33
Q

4 month old with twisting limb and body movements
HO cephalhematoma

A

Bilirubin induced neurologic dysfunction
BIND

34
Q

BIND pathphys

A

🦷Excess free Unconj biliribin crosses the BBB
🦷deposition of bilirubin in BG and brainstem nuclei
🦷 neuronal damage , necrosis & atrophy

35
Q

RF BIND

A

Prematurity
Hemolysis (G6PD)
Birth trauma (cephalhematoma)
Exclusively BF with excessive weight loss.

36
Q

BIND Acute encephalopathy

A

💄Reversible (ttt : phototherapy , exchange transfusion)
💄CF :

       Lethargy or inconsolability 
       Hypotonia (early)  hypertonia 
       (Late)
       Apnea/resp failure , feeding diff ,        seizures
37
Q

BIND chronic encephalopathy

A

💄 irreversible
💄 CF ;

        Development delay 
        SNHL
        Choreoathetoid movements 
        Upward gaze palsy
38
Q

BIND prevention

A

Serial examinations
Bilirubin monitoring in early neonatal period
Early ttt of hyperbili (phototherapy)

39
Q

Lithium toxicity causes

A

Acute;

                Intentional

Chronic :

                Dec Renal perfusion (dec   clearance )
                Dehydration 
                Thiazide , NSAIDs,  ACEInhibtr
40
Q

Lithium toxicity CF

A

Acute ;

GIT : NV , diarrhea
Late neurologic features

Chronic :

Lethargy, confusion , agitation, slurred speech 
Ataxia , tremor/fasciculations,seizures
QT interval prolongation , bradycardia
41
Q

Lithium toxicity Dx and ttt

A

DX.: Serum lithium levels (<1.5mEq/L)

Ttt : Hydration
Hemodialysis

42
Q

TCA side effects reasoning

A

Muscrinic receptors : Anticholinergic symptoms(dry mouth , constipation, urinary retention)

Histamine receptors: Lethargy

Alpha adrenergic receptors :

                  Orthostatic hypotension
43
Q

Orthostatic BP measurement

A

Systic BP decline > 20mmhg
Diastolic BP decline > 10mmhg

44
Q

Ttt of decompression sickness

A

Emergency care :
IV hydration
Trendelenburg position
100% oxygen (causes absorption of nitrogen gas from blood))

Definite ttt:
Hyperbaric oxygen therapy.

45
Q

Confusion Assessment method to identify delirium

A
  1. acute change (hours to days) and fluctuating course (intermittent)
  2. Inattention (easy distractibility)
  3. Disorganized thinking (confusion)
  4. Altered consciousness (daytime somnolence)
46
Q

Non pharm measures for delirium

A

Reduce night time noise and disturbance
Freq verbal orientation
Reassurance
Interaction with family members
Presence of trained sitter at bedside.
Early mobilization and avoid restraints
Avoid polypharmacy

47
Q

When should low dose haloperidol not be used for delirium ?

A

Lewy body dementia
(Neuroleptic hypersensitivity)
Severe parkinsons and impaired consciousness with neuroleptic administration.

48
Q

Causes of delirium

A

Dementia
Parkinson
Prior stroke
Advanced age
Sensory impairment

49
Q

CF of CO poisoning

A

Mild / moderate :

    1.  Headache , confusion 
    2.  Malaise , dizziness , nausea

Severe:

    1.   Seizure , syncope, coma
    2.   MI , arrhythmia
50
Q

DX : of CO posioning

A

🛞ABG
AGMA due to lactic acidosis from tissue hypoxia

🛞ECG + _ cardiac enzymes
🛞MRI characteristic of hypoxia:
BL basal ganglia hyperintensity

Pulse oximetry is normal in CO poisoning as pulse oximetre cannot diff between oxyhemoglobin and carboxyHb

51
Q

Ttt of CO poisoning

A

High flow 100% O2
Intubation /hyperbaric O2

52
Q

Sydenham chorea neurologic and psych features.

A

🧠Chorea (involuntary jerky movements worse while awake and with action)
🧠Hypotonia
🧠Milk maid grip (weak hand grip)
🧠Tics
🧠Emotional lability , anxiety , irritability , Obsessive compulsive behaviors

53
Q

Pathophys of sydenham chorea

A

➡️Preceding GAS
➡️Molecular mimicry between Anti GAS antibodies and neuronal antigens in BG

54
Q

Ttt of sydenham chorea

A

Chronic Antibiotics (penicillin G)
Symptomatic (haloperidol)

55
Q

Dx of sydenham chorea

A

GAS testing; Throat culture
ASO
Anti DNAase B titres

Cardiac testing :
Echo
ECG

56
Q

Causes of wernicke encephalopathy

A

Chronic Alcoholic
Short gut syndrome
Anorexia / malnutrition
Hyperemesis gravidarum

57
Q

CF of wernicke encephalopathy

A

Triad ;
Ophthalmopegia
Ataxia
Confusion

CF:

Ataxia (wide based gait)
Encephalopathy (lethargy, disorientation)
Oculomotor dysfunction (nystagmus, gaze palsy)

58
Q

What is korsakoff syndrome

A

Late complication of WE

Significant retrograde and anterogrdae amnesia
Confabulation
80% in ppl with WE due to alcohol.
Less freq in WE with other causes

59
Q

Ttt of WE

A

IV thiamine followed by glucose

60
Q

Alcohol withdrawal mech

A

Alcohol is CNS depressant
Enhances GABa (inhibitory)signal and reduces NMDA (excitatory) signaling

Reduced alcohol consumption leads to rebound CNS overexcitation

Happens in 6-24 hrs of alcohol cessation.

61
Q

Alcohol withdrawal CF

A

Alcohol hallucinations ;

      Visual hallucinations (animals and insects

Delirium tremens ;

      Rapid onset delirium
      Agitation
      Extreme autonomic instability 
      Fever 
      Sinus tachycardia 
      HTN
      Diaphoresis

Withdrawal seizures:

      Gen tonic clonic that often occur in rapid succession
62
Q

Indications of emergent DIALYSIS

A

AEIOU

Acidosis :

        Metabolic acidosis 
        PH <7.1 refractory to ttt

Electrolyte abnormalities :

       Symptomatic Hyperkalemia
       Severe hyperkalemia ref to ttt >6.5

Ingestion:

       Toxic alcohols (methanol, ethylene glycol) 
       Salicylates 
       Lithium
       Sodium valproate 
       Carbamazepine

Overload :

       Volume overload ref to diuretics

Uremia :

       Encephalopathy
       Pericarditis 
       Bleeding
63
Q

Ttt of tourette syndrome

A

🚑Habit reversal training /behavior suppressive therapy

🚑Antidopaminergic drugs :

VMAT2 inhibitors: tetrabenazine (pref)
Antipsychotics. : risperidone

Alpha 2 agonist. : guanfacine , clonidine
If comorbid ADhD

64
Q

RF for heat stroke

A

Strenuous activity in hot weather
Dehydration
Lack of physical fitness , obesity
Medicines ;

Anti psychotics
Antihistamines
Phenothiazines
Anticholinergics
TCAs

65
Q

CF of heat stroke

A

⛱Core temp > 104
With AMS , Seizure

⛱Organ or tissue damage :
Rhabdomyolysis
Renal/hepatic failure
DIC
ARDS

66
Q

Ttt of heat stroke

A

ABC

🍔Rapid cooling :
Ice water immersion
Ice wet towel rotation
Evaporative cooling

🍔Fluid resuscitation

🍔Management if end organ complications

🍔No role of antipyretic

67
Q

Ttt of alcoholic withdrawal

A

🧇Long acting BZ (chlordiazepoxide)

reduces recurrent withdrawal or seizures

🧇Eletrolytes and fluid replacement

68
Q

Workup for WE

A

Clinical Dx
Blood thiamine levels and LFTs
MRI
Degeneration of mamillary bodies

Neurology (19 decks)

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