2 ⼀NEUROLOGY II Flashcards
53
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]? (7)
- Retrograde amnesia ≥30min before injury
- [Vomiting ≥ 2]
- Seizure
- Severe HA
- AMSincluding LOC
- Neuro deficit
- GCS ≤14
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]? (2)
- depressed skull fx
- Basilar skull fx (CSF drainage, hemotympanum, [battle’s postauricular ecchymosis], periorbital hematoma)
Injury to the ⬜ causes ⬇︎ ability to Dorsiflex
[PF(common or deep) nerve]
________________
foot dropPED
✏️PF = [Peroneal⼀Fibular] - L4 (S1-S2)
Lennox Gastaut Dx?
Slow Spike-Wave EEG
________________
Lennox Gastaut
Lennox Gastaut CP-2
Lennox Gastaut
- Lala Land Retarded before 5 yo
- Generalized Tonic Clonic Seizures SEVERE
Levodopa is used to treat Parkinson’s Disease
Early SE?-3
_________________
Late SE?
Early SE (HAD) = Hallucinations/Agitation/Dizziness
_________________
Late SE (5-10 yrs post tx) = Involuntary mvmnts
[Dementia with Lewy Bodies (DLB)] Tx- 2
footnote
1. Rivastigmine AChinesterase inhibitor
- [2nd Gen Antipsychotic] for visual hallucination
* REMEMBER THAT DLB PTS ARE SENSITIVE TO ANTIPSYCHOTICS*
“DLB at the DMV “
List the difference between Primary and Secondary Generalized Tonic Clonic Seizures
________________
Seizure ATTaCK
Primary GTC occur when electrical discharge simultaneously comes from diffuse bilateral cortical areas (i.e. Absence)
vs
Secondary GTC comes from the spread of a [simple partial seizure]
List the sequence of events for a [GTC Seizure] - 5
Seizure ATTaCK
1st: Aura (nausea/dizziness) vs Simple Partial
2nd: Tonic: Sudden Stiffness–>Falling and cry out
3rd: [Time Out: aPNEA] –> Cyanotic, dusky face
4th: Clonic convulsions + oral involvement
5th: [Krazed: Postictal Amnesia (pt only recalls aura) + Lethargy + incontinence]
Pt just fell and started GTC seizing right in front of you!
How should you manage them? - 4
Seizure ATTaCK
1st: Roll pt onto side
2nd: Stabilize Head BUT NOT THEIR MVMNTS
3rd: KEEP THINGS OUT OF MOUTH OR AROUND PT
4th: ER if > 5 min
Main Features of TIA - 3
TIA(Transient Ischemic Attack) is
1. {Transient = [usually < 20m but ≤60m REQD]}
- {Ischemia (without infarction) is FOCAL(→ FOCAL neuro sx)}
- {Attack is [REVERSIBLE⼀NO residual sx⼀NO residual radio]}
🔎radio = radiomanifestations (⊝MRI)
Management for Epidural Spinal Cord Compression? -3
- [High Dose Dexamethasone IV]
- MRI
- Neurosurg consult
[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)]
Memantine
MOA
_________________
Indication
Blocks Glutamate from binding to NMDA Receptor
_________________
Moderate to Severe Alzheimer’s
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
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
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)
Mgmt of Epidural hematoma -3
- [Reduce ICP“Stop My Head Swelling!”]
a) SBP > 100
b) Mannitol IV
c) [Hyperventilate to pCO2 25-30]
d) Stress px(H2🟥, PPI)
_________________
2. Remove hematoma
_________________
3. Cauterize Dura (Electrocoagulate & Ligate middle meningeal a. of the dura arteries)
Name the 5 components of reducing Intracranial Pressure?
“Stop My Head Swelling (Cancer) !”
a) SBP > 100
b) Mannitol IV
c) [Hyperventilate to pCO2 25-30]
d) Stress px(H2🟥, PPI)
➜ e)+/- {CTS (for [CA|Trauma|Sickness_infxn] etx}
Most common side effects of INH isoniazid (2)
Injuries to
Nerves= Neuropathy (Pyridoxine B6 = tx/px)
and
Hepatocytes= Hepatitis - THIS IS SELF LIMITED AND RESOLVE WITHOUT INTERVENTION
4 most common symptoms of Heat Stroke
________________
HEAT
- Hyperthermia
- [Externally FLUSHED with Dry Skin]
- AMS(Confusion/HA/LOC/Dizziness)
- Tachycardia
________________
[⬇︎ core temp by 0.2C/minute] using [Augmentation of EVAPORATIVE COOLING]
Most common [1° CNS Tumors] in Adults (3)
GMS
[Glioblastoma astrocytoma] (GRADE 4 - MALIGNANT - 2nd MOST COMMON to Metastasis)
MeninGioma benign
SChWannoma
Brain Metastasis=MOST COMMON ADULT BRAIN CA
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)
Most Cryptogenic Stroke are ⬜ in origin. What is Cryptogenic Stroke ⬜ ?
Describe thew workup? -2
embolic;
ischemic stroke w/o obvious source on initial eval
________________
advanced cardiac imaging + ambulatory cardiac monitoring
to detect paroxysmal arrhythmia (afib)
Most seizures in young children with fever are benign (febrile seizure)
When is Lumbar Puncture indicated? (4)
- Nuchal rigidity
- HA
- bulging fontanelle
- prolonged AMS
Brachial Plexus damage of
[proximal median {C5⼀T1} n]
________________
clinical presentation? (2)
[PB F]
_________________
[+ thumb paralysis w thenar atrophy](if recurrent branch affected)
[PBF] = [Pope’s BlessingFISTING]
💡[Pope’s BlessingFISTING] = the official “Pope’s Blessing” antecdote.
Brachial Plexus damage of
[proximal median {C5⼀T1} n]
________________
cause
[anteroMedial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
[UCR “median claw”]
Brachial Plexus damage of
[distal median {C5⼀T1} n]
________________
clinical presentation? (2)
[UCR “median claw”]
_________________
[+ thumb paralysis w thenar atrophy](if recurrent branch affected)
=[Ulnar ClawResting] = the “median claw”
Brachial Plexus damage of
[proximal Ulnar {C8, T1} n]
________________
clinical presentation?
[UCF]
=[Ulnar ClawFisting]
Brachial Plexus damage of
[ULNAR (C8, T1) n]
________________
cause -3
- [FALL ONTO FLEXED ELBOW ➜ POSTERIOR PROXIMAL HUMERUS DISPLACEMENT]{→ PROXIMAL ULNA❌ = [UCF]}
- [MEDIAL EPICONDYLE]{→ PROXIMAL ULNA❌ = [UCF]}
________________ - [BICYCLIST HOOK OF HAMATE INJURY = GUYAN CANAL SYNDROME]{→ DISTAL ULNA❌ = [PBR “ulnar claw”]}
=[Ulnar ClawFisting]
=[Pope’s BlessingResting] = [the “ulnar claw”]
Brachial Plexus damage of
[distal ULNAR C8-T1 n]
________________
clinical presentation?
[PBR “ulnar claw”]
from [BICYCLIST HOOK OF HAMATE INJURY = GUYAN CANAL SYNDROME]
- ([hyperextension of 4th MCP and 5th MCP] + [flexion of 4th PIP and 5th PIP])*
=[Pope’s BlessingResting] = [the “ulnar claw”]
Myasthenia Gravis, LEMS and [Myopathies (polymyositis/dermatomyositis)] can be similar
How can you differentiate these based on reflexes?
Myopathies[polymyositis/dermatomyositis] and LEMS have ⬇︎ Reflexes.
Myasthenia is normal
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 accmp/by 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
Name 2 indications for a [Contrast Head CT]
intracranial abscess
intracranial mass
Name 4 Factors that differentiate [Lambert Eaton Myasthenic Syndrome] from Myasthenia Gravis
- [LEMS] improves with exercise/exertion during the day!
- [LEMS] will show no imprvmnt with [Tensilon Edrophonium] injection OR ice pack
- {[LEMS] nerve testing shows [DEC DTR] but [INC Interactive Muscle responses✏️]}
- {[LEMS] has autonomic dysfunction(orthostasis, dry mouth, impotence)}
✏️[Interactive Muscle Response] = voluntary muscle initiated by host
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
{HA with [🅆orst after physical activity]} (2)
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
_________________
1. Mass
2. SAH
“{HA with [FRATwIPS] are Red Flags!}”
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
List DDx for this one:
{HA with [🄸NC Frequency or INC Severity]} (3)
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
_________________
1. M ass
2. S ub🄳ural hematoma
3. M ed overuse
“MSM always [INC frequency] or [INC SEVERITY]😈”
“{HA with [FRATwIPS] are Red Flags!}”
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
{HA with [🅃hunderclap⼀Sudden⼀“worst HA of life”]}
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
_________________
SAH
“{HA with [FRATwIPS] are Red Flags!}”
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
“{HA with [FRATwIPS] are Red Flags!}”
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
{HA with [🅁adical personality😵changes]} (4)
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
_________________
1. i ntracerebral hemorrhage
2. m ass
3. m eningitis
4. e ncephalitis
“i m me (“I am me!😭”: Radical Personality ∆)”
“{HA with [FRATwIPS] are Red Flags!}”
______________________________________________________________
intracerebral_hemorrhage:mass:meningitis:encephalitis
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
List DDx for this “{HA with [FRATwIPS]”} :
{HA with [🄰ge ≥50 yo]} (2)
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
_________________
- Mass
- Giant Cell Temporal Arteritis
“{HA with [FRATwIPS] are Red Flags!}”
“{HA with [FRATwIPS] are Red Flags!}”
List DDx for this [Headache Red Flag]:
{HA with [🄿apilledema]} (4)
⭐PAID⭐
_________________
▶“[HA with 🄿apilledema] and [HA with 🄵ocal neuro ∆ ] both come from getting…
PAID…which INC pressure…which hurt my HEAD”
▶▶(PAID causes → {[ICP] which → H.E.A.D.sx]}) 📄
📄[PAIDetx → {[ICP] → H.E.A.D.sx]})
PCIIH
AV Malformation
[INC CSF inproduced]
{[DEC CSF out([Mass vs [Cerebral Venous Sinus Thrombosis])_©️Brain MRI stat)]}
_________➜ ________
[ICP]
_________➜ ________
[HA (with focal neuro ∆ 🚩 | with Papilledema 🚩)]
[Eye vision ∆ + Papilledema]
[AMS]
[Doesn’t eat 2/2 NV]
“{HA with [FRATwIPS] are Red Flags!}”
List DDx for this [Headache Red Flag]:
{HA with [🄵ocal neuro changes]} (4)
⭐PAID⭐
_________________
▶“[HA with 🄿apilledema] and [HA with 🄵ocal neuro ∆ ] both come from getting…
PAID…which INC pressure…which hurt my HEAD”
▶▶(PAID causes → {[ICP] which → H.E.A.D.sx]}) 📄
📄[PAIDetx → {[ICP] → H.E.A.D.sx]})
PCIIH
AV Malformation
[INC CSF inproduced]
{[DEC CSF out([Mass vs [Cerebral Venous Sinus Thrombosis])_©️Brain MRI stat)]}
_________➜ ________
[ICP]
_________➜ ________
[HA (with focal neuro ∆ 🚩 | with Papilledema 🚩)]
[Eye vision ∆ + Papilledema]
[AMS]
[Doesn’t eat 2/2 NV]
“{HA with [FRATwIPS] are Red Flags!}” and need [⬜2 to r/o ⬜2]
List DDx for this [Headache Red Flag]:
{HA with [🅂ystemic Sx(fever, rash)]} (2)
▶{STAT [©️Brain MRI]}
▶{STAT [🅽HCT if c/f SAH)]} ;
_________________
▶▶mass intracranial;
▶▶[cerebral venous sinus thrombosis (DEC CSF outflow)]
_________________
_________________
- Encephalitis
- Meningitis
“{HA with [FRATwIPS] are Red Flags!}”
[Name the 4 EPS-ExtraPyramidalSymptoms]
(typically caused by [D2🟥] Rx)
EPS = TADD
{Tardive dyskinesia⬅︎ < [Valbenazine|DeuTetrabenazine] > }
{[Akathisia (restlessness)]⬅︎ < 1st⼀lower D2🟥 Rx dosage –(if persist)–> ⼀give BBB* 2nd >}
{Dystonia (sudden twisted posture worst with activity [Torticollis = dystonia of the “neck”])⬅︎ < bdIV >}
{[Drug-induced P|RKinsonism]⬅︎ < bAIV >}
(EPS is typically caused by [D2🟥] Rx)
🔎bdIV = [Benztropine IV] vs [Diphenhydramine IV]
🔎[D2🟥] = [D2 R Blocker]
_________________
🔎🔲 ⬅︎ < Treatment >
Tx for each EPS-ExtraPyramidalSymptom -4
EPS = TADD
{Tardive dyskinesia⬅︎ < [Valbenazine|DeuTetrabenazine] > }
{[Akathisia (restlessness)]⬅︎ < 1st⼀lower D2🟥 Rx dosage –(if persist)–> ⼀give BBB* 2nd >}
{Dystonia (sudden twisted posture worst with activity [Torticollis = dystonia of the “neck”])⬅︎ < bdIV >}
{[Drug-induced P|RKinsonism]⬅︎ < bAIV >}
🔎bdIV = [Benztropine IV], [Diphenhydramine IV]
🔎bAIV = [Benztropine IV], [Amantadine IV]
🔎D2B = [D2 R Blocker]
🔎{BBB* = Betablocker_propranolol, Benzo_lorazepam, [Benztropine IV]}
_________________
🔎X ⬅︎ < Treatment >
Name the 4 classic sx of [INC IntraCranial Pressure]- 4
HEAD
1.HA, Positional, worst at night/morning
2.[Eye papilledema & vision ∆ ]
4.AMS
5.[Doesn’t eat (NV)]
Name the Major UMN signs (5)
UMN signs = Weak MESH
Weakness
[Spastic Gait & Paralysis (partially from disproportionate Extensor weakness)]
[Exaggerated Reflexes (Babinski)]
Mental Status change
HemipLegia
Parinaud Syndrome etx
_________________
How does it clinically present?-5
[dorsal Midbrain SUP colliculi Pretectum]❌➜
“Parinaud LOSS his PUPAw”
________________
[Pupillary light reflex_LOSS]
[Upward Conjugate Vertical Gaze_LOSS (paralysis)]
Ptosis
Ataxia
[+/- water hydrocephalus 2/2 obstructive Pineal GlandGerminoma]
[(PUPAw) Parinaud Dorsal Midbrain syndrome]
📖etx =[Dorsal Midbrain SUP colliculi Pretectum] controls [conjugate vertical gaze]. if lesioned/ compressed (i.e. byPineal GlandGerminoma) → PUPAw/[Upward conjugate vertical gaze] paralysis
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 after physical activity
- [INC Freq or INC Severity]
- Papilledema
- [Systemic sx (fever/rash)]
HA diary should contain OPQRSSTAP
“{HA with [FRATwIPS] are Red Flags!}”
Name the Serotonergic Drugs -7
- SSRI
- SNRI
- TCA
- Tramadol
- MDMA
6. Linezolidabx
7. MAOIantidepressant
_________________
#6-7 = Serotonergic Honorable mentions(= C❌D with #1-5 due to ⇪ Serotonin Syndrome risk)
Neonatal Abstinence Syndrome
Classic Signs - 5
TYT Does Heroin
- Tremors
- Yawning
- Tachypnea
- Diarrhea
- High Pitched Cry
Caused by maternal opioid (Heroin) use during pregnancy
Neonate comes in with Hydrocephalus, delineated by bulging fontanelles
1st Diagnostic test you should obtain?
________________
Tx?
Head CT
________________
Ventricular Shunt
Nerve roots for Ankle Jerk Reflex
“1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight”
S1 - S2
Nerve roots for Patellar Reflex
“1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight”
L3 - L4
Nerve roots for Biceps Reflex
“1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight”
C5 - C6
Nerve roots for Triceps Reflex
“1, 2 buckle my shoe - 3, 4 kick the door - 5, 6 pick up sticks - 7, 8 lay down straight”
C7 - C8
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!
Neurofibromatosis Type 2
Clinical Presentation - 4
**[B** 2]<sup>4</sup>
- [**Bilateral** Acoustic Schwannomas➜ Bilateral DEAF]
- BL Cataracts
- [Belowpigment (*hypOpigmented*) Cafe Au Lait spots]
- Benign Multiple Meningiomas
Ocular Tonometry indication
Measures intraocular pressure(≥30 = ⊕Acute CAG!)
(≥30 mmHg = ⊕Acute Closed Angle Glaucoma! → OpHtho consult + Timolol/CTS/Acetazolamide STAT)
Normal Retina consist of ____, _____ and ______
Papilledema occurs when ⬜ , and this is commonly caused by what 3 conditions?
normal [RetinaDSL] = DSL: [Disc margin sharp /Small veins linear /Large vessels sharp]
___________________________
{PCM causes [INC ICP(H.E.A.D.) sx]→ transmitted to (Optic CN2) → (papilledema[RetinaDSL]} ;
______________________________
“
“PCM causes Papilledema”
1. PCIIH
2. [CSF❌[(⬇︎CSF out⼀CVST✏️) vs (⇪CSF in/made) ]
3. Mass intracranial
_________________
✏️CVST = [CErEbral Venous Sinus Thrombosis ( → ⬇︎CSF outflow)]
Parkinsonism is often caused by ____ or _____
Name 2 rare causes of Parkinsonism
Common =
✔︎ {DIRECT Striatum[Substantia nigra pars compacta degeneration (2/2 idiopathic “LABS” accumulation)}
vs
✔︎ [D2🟥]Rx
_________________
rare =
-CO2 toxicity
-ManGanese toxicity
_________________
🔎LABS = [Lewy α-synuclein BodieS]
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
L
MOA (2)
_________________
Complications (3)
“Eat SALADS after you Park”
{🔧[L + C ]
🔧with [ (E vs T)</sup> ]}
—–--
_________________
⊗ arrhythmia: (Levodopa can → peripheral catecholamine formation → arrhythmia)
⊗dyskinesia involuntary mvmts]: chronic Levodopa can → [dyskinesia involuntary mvmts] after admin = “on/off phenomenon”
⊗akinesia: between doses
🔎 = [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 (Benztropine)]➜ treats [Parkinsons “P|R toxic cholinergism”]} ✏️
- [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
_________________
📝Parkinson dz = {[loss of dopamine] + [“P|R toxic cholinergism”]}. Anticholinergics“Benztropine” treat toxic cholinergism (Pill rolling tremor + Rigidity cogwheel only)
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?
Patients s/p recent [ischemic CVA/TIA] have ⇪ risk for what 3 complications following [ischemic CVA/TIA]?
Because of this, CVA/TIA pts should undergo ⬜ within 24 hours
pts s/p [ISCHEMICCVA/TIA]… have ⇪ risk for developing:
1. [(within 3d)hemorrhagic conversion]
2. [(within 3d)cerebral edema]
3.[(WITHIN 30d)REPEAT STROKE]
[BALTIC(post ischemic stroke mgmt)] STAT
patients with undetermined [altered mental status] should RECEIVE which 3 drugs on arrival? -3
Not Thinking Great
- Naloxone
- [Thiamine B1 ➜
- [Glucose /Dextrose IV)]
Patients with [late-life major depression onset > 65 yo] are at INC risk for developing what 2 conditions?
Alzheimer’s
Vascular dementia
PE is common cause of early death in recovering 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
[Pineal gland tumors] p/w ⬜ syndrome, and some [Pineal gland tumors] are ⬜ that secrete ⬜
Describe cp for this syndrome -5
[PUPAwParinaud’s dorsal midbrain syndrome] ;
Germinomas ; HCG
________________
[(PUPAw)]
[Pupillary light reflex_LOSS]
[Upward Vertical Gaze_LOSS (paralysis)]
Ptosis
Ataxia
[+/- water hydrocephalus 2/2 obstructive Germinoma]
“Parinaud LOSS his PUPAw”
✏️PPDMS can also occur with any [Dorsal Midbrain SUP Colliculi Pretectal]❌
PKU-Phenylketonuria S/S (4)
PKU smells a MESS!
Musty Odor
Eczema
Seizures
Slow mentally (retard)
Postconcussive syndrome can persist anytime from ⬜ to ⬜ post TBI, and involves what 8 major sx?
hours to ≥6 months after TBI
_________________
postconcussive from ADAM’S VHS
Amnesia
Difficulty concentrating/multitasking
Anxiety
Mood alteration
Sleep ∆
Vertigo dizziness
HA
So CONFUSED
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 = CorticoBulbar and CorticoSpinal
- 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?
“spastic” UMN(Corticospinal Pyramidal Tract) lesions
Spasticity causes Scissors Gait
Pts are recommended to employ ⬜ during the prodromal phase of VANS to abort the syncopal episode
_________________
Name two examples (2)
[physical counterpressure maneuvers]
_________________
[crossing legs while tensing body muscles] or [clenching fist while tensing arm muscles]
these improve venous return and cardiac output
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 - fcm]
- Hypothalamus
- Passes as hypothalamospinal tract in lateral medulla
- [IML C8-T1 Cilospinal Center of Budge] = SNX1 ⼀→ exits @ T1 and travels
_________________ - Under Subclavian Artery as [sympathetic chain trunk]
- Lung Apex
-
SUP cervical ganglion near carotid bifurcation *(= SNX2)
_________________ - facial Sweat Glands
- carried with CN5B1 thru cavernous sinus & then SUP orbital fissure to Pupil Dilator
- [muller’s superior tarsal muscle] innervation
_________________
_________________
✏️2 / 3 / 5 / 6 / 8 are most common sites of Horner’s syndrome
🔎SNX = Synapse
What are the most common causes of Horner’s Syndrome? - 5
- Lateral Medullary syndrome of Wallenberg
- [spinal cord lesion above T1 (Brown Sequard hemisection/syringomyelia)]
- Lung Apex tumor
- Neck Carotid Trauma
- Cavernous Sinus Thrombosis
_________________
[HPI - ULS - fcm] 2 / 3 / 5 / 6 / 8 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 -3
“Having Sciatica makes you break LAWS”
1. NSAIDs
2. APAP
3. Self-Limited
NSAIDs + APAP = 1st line tx 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)
Seizures and Syncope are difficult to differentiate
Name features that help differentiate Seizures from Syncope - 4
Seizures has…
- Postictal confusion
- Postictal lethargy
- Triggered by flashing lights
- Tongue laceration
beware: Clonic jerks can occur during syncope associated w/cerebral hypoxia!!
Serotonin Syndrome Clinical Presentation (8)
“Serotonin gave me the 🆂HI🆅🅴RS!”
🆂hivering
[Hyperreflexia & Myoclonus]
INC Temp
[🆅itals Unstable (tachycardia vs. tachypnea vs. HTN)]
[🅴ncephalopathy (Confusion vs. Agitation)]
Restlessness
Sweating
_________________
🆂🆅🅴 = Serotonin Syndrome triad
SIDS is sudden infant death that can’t be explained
What are 4 major ways to ⬇︎ risk of SIDS?
- Supine Sleeping position
- NO second hand smoke
- Use Pacifier during sleep
- ROOM sharing (NOT bed sharing)
Negative Cremasteric reflex could be caused by ⬜ (3)
- Testicular Torsion
- [L1-L2 spinal cord damage (will be accompanied by loss of hip Flexion & loss of hip ADDuction)]
- Diabetic neuropathy
“L1, L2…his testicles move”* Cremasteric reflex 🅽 roots
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]
Step-Wise Tx to Restless Leg Syndrome - 4
1st: NonPharm (Leg Massage/Heat/Exercise/Iron Supplement)
2nd:[NonErgotPostsynpatic Dopamine🟢] ✏️
3rd: Gabapentin (if pt also has insomina vs chronic pain)
4th: Opioids
✏️examples: Pramipexole|Ropinirole
-Gabapentin MOA= [α2-delta Ca+ channel ligands]
[STURGE Weber Syndrome] Clinical Presentation -6
STURGE
💊1.[Stain_Red(Nevus Flammeus Port Wine Stain) along CN5B1|B2 vs (congenital uL cavernous hemangioma) ](tx= Argon Laser)
2.[Tramline gyrification calcifications on CT]
3.Unilateral
4.Retardation
💊5.[{Glaucoma IPL] + [CTL Homonymous Hemianopia]}(tx=⬇︎IOP)
💊6.{⭐⭐ EPILEPSY ⭐⭐(tx=anti-Epileptics)}
Sturge Weber Syndrome Tx -3
💊{<sub>[**S**tain_Red<sup>*✏️*</sup>]</sub>**(tx= Argon Laser)**}
💊{<sub>[{**G**laucoma IPL] + [CTL Homonymous Hemianopia]]</sub>**(tx= ⬇︎IOP)**}
💊{<sub>[⭐⭐ **E**PILEPSY ⭐⭐]</sub>**(tx= antiEpileptics)**}
## Footnote
✏️[**S**tain_Red<sup>*([Nevus Flammeus Port Wine Stain]|uL cavernous hemangioma)*</sup>]
#**STURGE**<sub>sx</sub>
Name the Lower Motor Neuron signs - 4
LMN signs (FAAW) - Fasciculations / Atrophy & Areflexia / Weakness
Tetanus takes ⬜ days to onset after exposure to endospores
________________
Tx? - 5
2 days;
- Tetanus IgG Immune Globulin
- Tetanus Vaccine
- Abx
- Diazepam
- Mechanical ventilation ICU
Comes from puncture wound vs burn
The criteria for Status Epilepticus is ⬜ or ⬜
_________________
How do you manage Status Epilepticus (5)
CP of VertebroBasilar TIA - 5
Labyrinths: DIZZINESS
_________________
[Brainstem( → “crossed” signs)] : DIPLOPIA,
DYSARTHRIA
_________________
Cerebellum: BL Clumsiness
_________________
Spinal Cord: BL Weakness
Tourette Syndrome CP -2
Tics - BOTH MOTOR AND VOCAL AT SAME TIME!
(Motor & Vocal -shoulder shrugs/blinking/grimacing/[coprolalia swearing])
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)
_________________
“Catatonia is WIMPEN around”
Sx of Catatonia - 6
“Catatonia is 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 ➜
= [posi⊕ive patient rxn(pt relieved within 5 min)] = ⊕Catatonia dx
= [negative or no pt rxn] = inconclusive
________________
note: a negative response does NOT rule out catatonia
“Catatonia is WIMPEN around”
Tx for Essential Tremor - 6
Propranolol > [PAT - Primodone vs Anticonvulsants vs Topiramate] > Benzo > Surgery
socially relieved by EtOH
Onsets at 45 yo and 50% cases are AUTO DOM
tx for Guillain Barre syndrome -2
________________
when is this tx indicated?
plasma EXCHANGE
or
IVIG
________________
nonambulatory pts should receive tx if their sx have been present < 4 wks
________________
ambulatory pts recover on their own
Tx for Single Brain Metastasis (likely from ⬜ primary) - 3
[Lung NonSOLC]
_________________
SURGERY>SRS>[Whole Brain Radio]
✏️ ⭐ [(SRS) Stereotactic RadioSurgery(Use SRS 1st in non-surgical pts) ]]
Tx for Multiple Brain Metastasis (likely from ⬜ primary)
Whole Brain Radio
Likely from [Lung NonSOLC] primary
Tx of Pediatric Migraine - 3
- Dark Quiet Room +
- NSAID
- Triptans (refractory)
Triggers = stress/lights/odors/foods
Typical sx of dementia are ⬜3 ; and although most cases are caused by ⬜ , 20% dementia patients have reversible causes
“Dementia is Geriatrics Losing Cognition”
- Gait
- Language
- [Cognition MMSE < 24]
_________________
Alzheimer’s
r/o [VhSreversible dementia] prior to [Alzheimer dementia] dx
What are the 3 reversible causes of dementia??
▶VhS
[VitB12 deficiency] | hypOthyroid| [Sad(MDD “Pseudodementia”)]
🔎MDD = Major Depression Disorder
r/o [(VhS)reversible dementia] prior to [Alzheimer dementia] dx
_________________
“Dementia is Geriatrics Losing Cognition”
[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-5?
“Leaning on Elbows at desk(P). hamate fracture(d)”
1.[numb IPL 4th and 5th digits][distal | PROXIMAL] ❌
2.[weak “clumsy” IPL hand][distal | PROXIMAL] ❌
_________________
3.[numb IPL hypOthenarPROXIMAL❌ only]
4.[DEC IPL wrist flexionPROXIMAL❌ only]
5.[DEC IPL hand gripPROXIMAL❌ only]
PROXIMAL Ulnar n is especially vulnerable to❌at as it runs posterior to medial epicondyle_elbow. ⬇︎IPL hypOthenar sensation, ⬇︎IPL wrist flexion and ⬇︎IPL hand grip = cp
May also occur at forearm in DM pts
What are the UpToDate clinical recommendations for
[Vitamins & Dietary Supplements] in [pts with new dx Dementia]?
NOT RECOMMENDED
(no clinical evidence they help)
Valproic Acid
side effects -3
Val hated Baby Liver Plates!
1. Baby = Teratogenic Neural Tube Defects
2. Liver = hepatotoxic
3. Platelet drop = thrombocytopenia
* pts should be monitored for these side effects*
VertebroBasilar insufficiency affects the (⬜4) of the CNS and occurs because of (⬜3)
Labyrinths: DIZZINESS
[Brainstem( → “crossed” signs)] : DIPLOPIA, DYSARTHRIA
Cerebellum: BL Clumsiness
Spinal Cord: BL Weakness
_________________
[emboli, thrombus, arterial dissection]
What 2 conditions is Tourette syndrome associated with?
ADHD
Obsessive Compulsive Disorder
What are Risk factors for PCiiH [Pseudotumor Cerebri Idiopathic Intracranial HTN] - 4
- [OOOO (Overweight Ogles{Women} On OCP (will usually have Empty Sella Turcica))]
- Tetracyclines
- Vitamin A OD (Isotretinoin)
- Growth Hormone
This HA will make you go Blind!
What are the 2 most important clinical values to monitor for Guillain Barre syndrome?
________________
cross reacting abs against peripheral nerves
Negative Inspiratory Force
Tidal Volume vital capacity
________________
assess’ respiratory status
What are the 7 major complications of Newborn Prematurity
Less than 32 weeks gestation specfically
“Premies stay BURPPIN”
Bronchopulmonary Dysplasia
UcantBreathe (Neonatal Respiratory Distress Syndrome)
Retinopathy
Patent Ductus Arteriosus
Palsy CEREBRAL
Intraventricular Hemorrhage
Necrotizing Enterocolitis (⬆︎gastric residual volume with abd distension)
[Oculomotor CN3] palsy CP? -4
eye is DOPe
[Down & Out] + Ptosis + [eye dilated]
What are the causes of [Oculomotor CN3] palsy?-5
“Third Palsy Causes DOPe Presentation”
- TUMTL herniation
- PCA occlusion
- Cavernous Sinus Thrombosis
- [DM oculomotor CN3 central ischemia (no eye Dilation)]
- POST communicating artery aneurysm
DOPe
What are the functions of [Oculomotor CN3]? -7
E. .SUP Orbital fissure ➜
e1. Upper
▶[SUP rectus (D)]
▶[LPS (P)]
_________________
e2. Lower-a
▶[inf Oblique]
▶[inf rectus]
▶[Medial rectus (O)]
_________________
e2. Lower-(b)
▶ < ciliary branch: {ciliary ganglion}: [CPM (e)] + [ciliary m]>
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
- [ciliary m = contracts ciliary m]
Recite the pathway of the [Oculomotor CN3], starting with its nucleus (which houses the ⬜ ganglion) in the ⬜ ? -8
[EW ganglion]; midbrain
_________________
a.{[Oculomotor CN3 nucleus] of 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 4 most common causes of excessive daytime sleepiness?
POND
- Periodic Limb Movement
- OSA
- Narcolepsy
- Depression
dx = Polysomnography
Late neurosyphilis can present with Dementia, ARP and TDPCD
What are the primary manifestations of TDPCD? (2)
TDPCD = Tabes Dorsalis Posterior Column Disease
ARP = Argyll Robertson Pupils
- Sensory ataxia (from loss of dorsal root/DCP 2 TVP)
- lancinating radiculopathy (face, back, extremities)
🔎Sensory ataxia = inability to “sense” legs
What are the Risk Factors for Alzheimer’s Dz - 6
CLAV–> HANDU
- > 60 yo
- Female
- Family hx
- Head Trauma
- ⊕[Apolipoprotein E4]“ApoE4 is BAD 4U!”
- Down’s Syndrome (they have ⬆︎ [chromo 21 transmembrane amyloid precursor glycoprotein])
What are the major functions of [Vagus CN10] - 5
VAGUS
Vocal Cord Phonation
[ALG :motor and sensory]
[Gag reflexE ➜FFerent limb] (loss of Gag = [Glossopharyngeal CN9] problem)]
[U‘ll COUGH reflexa←fferent limb]✏️
[Swallowing & Palate Elevation(VagusCN10❌ → Uvula deviates OPPOSITE lesion)]
✏️vagus CN10 sends cough sensory information TO nc
Image: {Left [Vagus CN10] palate dysfunction}
___________________________x____________________________________
🔎ALG = Aortic & Heart*(baroreceptor/chemoreceptor)* , Lungs_bronchi, GI:
{EFFerent.afferent.}</sub>
[VANS] is categorized into what 3 sub-types?
With these sub-types in mind:
Name all the common triggers of [VANS]? -8
[VANS = (Vasovagal Autonomic Neurocardiogenic_reflex-Syncope)]
“the VANS are VCS”
1.VEMOTION
2.VPAIN
3.V[Prolonged Standing(via VagusCN10 Aortic Baroreceptors)]
_________________
4.CCarotid Massage
_________________
5.SCoughing
6.SMeals
7.SDefecation
8.SUrination
these →parasympathetic SPIKE = [vasoDilation, ⬇︎HR]→ ⬇︎brain perfusion
VANS is preceded by nausea, sweating and dizziness
_________________
🔎
V= [Vasovagal ⼀VANS]
C = [Carotid⼀VANS]
S = [Situational⼀VANS]
a. What are “crossed signs” ?
* * *
b. What do they indicate? Explain.
a. {[IPL Cranial Nerve deficits] with [CTL Body deficits]} ⼀example: Lateral Medullary syndrome of Wallenberg
* * *
b. Brainstem Stroke:
because brainstem is where most cranial nerves originate and also where many motor and sensory fibers CROSS MIDLINE, brainstem strokes characteristically create “crossed signs”
What causes Hemiballismus
▶[(BTiC)Lacunar Stroke] damage
▶▶to {[Basal GangliaSubthalamic nc ( = modulates Basal Ganglia output)]}
▶▶▶→ [CTLHemiBallismus & involuntary writhing]}
Note: Basal Ganglia is in Subcortical nuclei
What hallmark sign of encephalitis discerns it from meningitis?
⭐AMS⭐
(specific to encephalitis)
encephalitis sx = FAVORS
What is Akathisia?
________________
How do you treat it? -2
restlessness (typically 2/2 [D2 R Blocker] Rx)
________________
[attempt dosage DEC 1st (if 2/2 [D2 R Blocker] medication)] ➜ [propranolol 2ND]
Describe Essential Tremor-2
________________
What is it socially relieved by?
- [ (BUE/Voice/Head) Action Tremor worst w/Action]
-
No additional neuro ∆
_________________
relieved with EtOH
✏️[e❌acerbated by : HYPERthyroid | Lithium | Valproic Acid]
✏️ Onset at 45 yo
✏️50% cases are AUTO DOM
What is Pseudodementia?
Severe Depression in Elderly tht mimics Alzheimers dementia.
“Elderly c/o SLEEP PROBLEMS, memory loss and attention problem, but really have depression”
Tx = SSRI
r/o [(VhS)reversible dementia] prior to [Alzheimer dementia] dx
What is [Sensory receptive aprosody]?
________________
How does it occur?
Inability of pt to understand prosody/vocal inflections by other people
________________
Damage to [NonDominant Cortex opposite to Wernicke’s area]
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
In Brain Death dx, {⊕ancillary= [(⬜) with (⊝IC Blood Flow>⬜min )]}
Name 3 diagnostic modalities you can use to determine (IC Blood Flow) during Brain Death dx
[⊕EEG = isoelectric & NO bstem & NO SS]
_________________
- [Radioisotope brain scan]
vs - [TransCranial Doppler]
vs - [Carotid AngioCTA/MRA]
⭐{⊕ancillary= [(⊕EEG3 ) with (⊝IC BFlow >10m)]}
💡(⊝IC Blood Flow) is typically 2/2 associated brain edema
What is the femoral nerve responsible for? -5
- MOTOR:EXTENDS KNEE
- REFLEX:KNEE
- SENSORY:Anteromedial thigh
- SENSORY:medial leg
- SENSORY:arch of foot
What is the tx for [Cryptococcal Neoformans] meningoencephalitis? (4)
[(Amphotericin B) + (Flucytosine)]GOE2w (sx abate/CSF sterile)
➜ {[HD Fluconazole]8w (+ start HAART)}
➜ [LD Fluconazole]1y
_________________
Cryptococcal n. meningitis = {[Elevated CSF opening >250] + [lymph WBC <50]} in pt with CD4<100
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 Therapeutic hypOthermia often used for?
________________
How low of temp can you go?
Prevents hypoxic Brain injury in pts with [out of hospital cardiac arrest]
________________
32C
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 is [Post Intensive Care Syndrome]?
_________________
What are the risk factors? (3)
pt s/p ICU, now c/o [⬇︎QOL 2/2 sustained residual physical-psych-neurodeficits primarily developed io\ “(MAD)” ICU experience]
_________________
MAD
1. Mechanical ventilation prolongation
2. ARDS
3. Delirium
🔎QOL = Quality Of Life
Explain how certain drug class cause EPS?
Which drug class cause EPS the most?
inadvertantly[Blocking (Nigrostriatal D2 R )];
[FGA(Haloperidol/Fluphenazine) ]
🔎FGA = First generation Antipsychotics
What other condition is [LEMS - Lambert Eaton Myasthenic Syndrome] associated with?
“LEMS has a good SOLC(soul)”
SOLC-Small Oat cell Lung Carcinoma
What other condition is [Myasthenia Gravis] associated with?
Thymoma (thymic hyperplasia)
What pCO2 (mmHg) should pts with INC intracranial pressure be hyperventilated to?
25-30
what role does Steroids play in Intracranial Bleeding?
NONE
“Stop My Head Swelling !”
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
Name the two 1st line Rx groups for treating Dementia? (2)
[AChE inhibitors] > [NMDA Glutamate R Blocker]
_________________
AChE inhibitor = Acetylcholinesterase inhibitor
What’s the most common Brain CA in adults?
METASTATIC
_________________
(from another primary ⼀like Lung NonSOLC)
What’s the best way to approach treatment for [Neuroleptic Malignant Syndrome]-2
Treat [Rigiditiy lead pipe] with Dantrolene (inhibits Ca+ release from sk. muscle sarcoplasmic reticulum)
+
supportive care
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]
When should epidural hematoma be evacuated ideally?
before Transtentorial herniation
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 Leg]
L5 Radiculopathy can also cause Foot dropPED
Where do most Medulloblastomas occur?
________________
How does this present clinically?
[infratentorial Cerebellar VERMIS]
________________
[Truncal ataxia]
Describe Features of BENA (Brocas Expressive NonFluent Aphasia) -4
1.❌[Nonfluent speech]
2.❌[Right Hemiparesis]
3.❌Impaired Naming
4.❌Impaired Repetition
Describe Features of Wernickes Aphasia - 4
1.❌ [Noncomprehensive speech]
2.❌ [R “pie in sky”(R SUP homonymous quadrantonopia) ]
3.❌impaired Repetition
_________________
4.✔︎ [fluent speech]
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
Which 3 conditions is Valproic Acid used to treat?
_________________
Why do Women need greater precaution when taking Valproic Acid?
Epilepsy | Juvenile Myoclonic Epilepsy| Bipolar disorder
_________________
Valproic Acid is teratogenic ➜ Neural Tube Defects
[MAOI antidepressant] and [Linezolid abx] are 2 drugs that are contraindicated with the ____ class of drugs
Seroternergic
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
Which CA metastastize to the spinal cord? -5
- Breast
- Lung
- NonHodgkins lymphoma
- Renal
- Prostate
Which 3 CNS tumors affect Spinal Cord?
_________________
Tx?-2
- Meningioma benign
- Ependymoma (usually 4th Vt)
- Metastasis (Prostate/Renal/Lung/Breast/Multiple Myeloma)
Tx = Radiation + Dexamethasone
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 disorder results in a Waddling gait and why?
Muscular dystrophy; Gluteal m weakness
Waddling Gait = walks like Penguin from Batman
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
1. NHCT
2. [CTA/MRA_head-neck]📸
3. Carotid Cervical US
4. TTE
| **BALT(I)C**
which medication is given for Cluster HA px?
Verapamil
Which Second Generation Antipsychotics are most associated with causing
[Extrapyramidal (TADD)] sx -2
Risperidone > Lurasidone
“Risper, Lura.. and stop being so extra”
Loss of Gag Reflex indicates what cranial nerve damage
IPL[Glossopharyngeal CN9]
Dysphagia indicates what cranial n. damage (2)
[Glossopharyngeal CN9] and [Vagus CN10]
Dysphonia/Hoarseness indicates what cranial n. damage
[Vagus CN10]
fx = V.A.G.U.S.
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 hemianopia w/Macular sparing]
- [Oculomotor CN3]–> IPL[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 does Fluoxetine need __ weeks to washout before starting a MAOI?
5
________________
SSRI + MAOI ➜ SEROTONIN SYNDRONE (SHIVERS)
Why is Altered mental status in a pt who had a large ischemic stroke 2 days prior alarming? - 3
pts s/p [ISCHEMICCVA/TIA]… have ⇪ risk for developing:
⭐1. [(within 3d)hemorrhagic conversion]
⭐2. [(within 3d)cerebral edema]
3.[(WITHIN 30d)REPEAT STROKE]
because of this BALTIC should be started STAT
Why is Heparin NOT USED in pts with Acute Stroke?
⬆︎Bleeding Risk if stroke turns out to be Hemorrhagic
Why should all patients with Parkinson’s disease be screened for Major Depression Disorder?
Many ParkDZ sx overlap with [MDD (a possible comorbidity of ParkDZ)] and if Sad and/or [Interest loss] is present ➜ Antidepressant tx
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?
🅽onContrast Head CT; [ARTtPA thrombolysis]IV✏️
________________
WITHIN 4.5 HOURS OF SX ONSET!
✏️[Alteplase |Reteplase |Tenecteplase]tPA thrombolysis
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
_________________
What part of the brain is likely damaged in [Acalculia or Agraphia] ?
difficulty with Arithmetic or Writing
LEFT
_________________
[Dominant inferiorParietal]
[90% R handed] and [60% L handed] people have [⬜ (R | L)] Hemisphere dominance for speech and language
_________________
What part of the brain is likely damaged in Construction apraxia?
Can NOT copy simple line drawings
LEFT = DOMINANT
_________________
[NonDominant Parietal]
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
_________________
What part of the brain is likely damaged in Aphasia?
unable to speak
LEFT
_________________
[Dominant temporal]
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
_________________
What part of the brain is likely damaged in Dressing apraxia? (2)
difficulty donning clothes
LEFT
_________________
[NonDominant Parietal] or [BL Parietal]
[90% R handed] and [60% L handed] people have [⬜ (R | L)] hemispheric dominance for speech and language
_________________
What part of the brain is likely damaged if patient unable to discern Right from Left ?
LEFT
_________________
[Dominant inferior Parietal]
DysLaterality
[Amyotrophic Lateral Sclerosis] (Lou Gehrig’s)]
clinical presentation? -3
- ❌[UMN Weak MESH❌ (especially motor nc 5/9/10/12)]progressive
- ❌[LMN FAAWS ❌] progressive
- ✔︎ [cognition/ocular/bowel/bladder]intact
[Amyotrophic Lateral Sclerosis] (Lou Gehrig’s) etx - 2
- Rare = [Superoxide Dismutase gene mutation] –> copper-zinc dysfunction —>[Upper AND Lower Motor Neuron Disease!]
- Common = Idiopathic
UMN Dz includes loss of neurons in motor nc. 5/9/10/12
Treatment
P7BP (3)
[Peripheral facial CN7 Bells palsy]
[CTS within 3d onset] + [EYE artificial tears] + [EYE patch]
recovery within 1-6 mo of sx onset
[Central facial Stroke palsy] and [Peripheral facial CN7 Bells palsy] both present with ⬜ and ⬜
_________________
What are 3 ways to discern them from one another?
CSP|P7BP
- Nasolabial fold loss
- Lower Lip droop
_________________
❌[⊕Sparing(forehead & eyebrows) = ⊕Stroke]
❌{[⊕SHUTS EYE CLOSED] = [⊕Stroke]}
🔎CSP = [Central_facial Stroke palsy]
🔎P7BP = [Peripheral_facial CN7 Bells palsy]
[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)
[Creutzfeldt Jakob Dz] etx
PrP (prion protein), normally in neurons as [α -helical structure] converts–> [INFECTIOUS Beta pleated sheets] –> Protease resistance –>
Vacuoles in [Gray Matter Neurons & Neutrophils] develop –> Cyst = [Spongiform Gray Matter]
[Creutzfeldt Jakob Dz] CP - 3
[RAPIDLY Progressive Dementia] + [STARTLE Myoclonus] –> DEATH
Can be Acquired vs. Inherited
[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)
[Juvenile Myoclonic Epilepsy] cp? -2
________________
EEG findings? -2
- [Teenage UE myoclonus → GTC +/- Absence]
- frequently within the 1st hour of waking
________________
a. [interictal BL polyspike]
+
b. [interictal slow wave discharge]
[Juvenile Myoclonic Epilepsy] tx
Valproic Acid
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] ultimately ➜ [1 of 3 herniation = [sO/ mO / mOm]
-⭐{eventually .. [(fetal αFP) and (fetal AChE)] leak into amniotic fluid and finally maternal serum}
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 [remote hx 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
[T or F] Incidentally discovered lesions in the sella are fairly uncommon
FALSE
_________________
small lesions in the sella are incidentally discovered all the time = follow closely with Pituitary gland also
[T or F] patients with Parkinson disease often have underlying depression, and this is managed by increasing their Parkinson Meds’ dosage
FALSE
TREAT WITH SSRI
psychomotor retardation and sadness are hard to see in Parkinson’s so BE ON THE LOOKOUT FOR MDD
[Thiamine B1] deficiency causes ⬜ and BeriBeri 2/2 to ⬜
________________
Describe BeriBeri (3)
[Wernicke Korsakoff Syndrome] and [BeriBeri] ; [impaired glucose metabolism → ATP depletion]
________________
[BeriBeri falls into 3 subtypes (WET, DRY, BOTH)] :
1.[High Output Dilated HF + edema] = WET
2.[Symmetrical Peripheral Neuropathy + muscle wasting] = DRY
3.[WET and DRY](BOTH)
Think ATP: [Thiamine B1] is needed to make ATP with:
[α-ketoglutarate dehydrogenase (TCA)],
[Transketolase (HMP shunt)],
[Pyruvate dehydrogenase (TCA)]
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
▶Cryptococcus ⬜ is a yeast that can cause opportunistic meningoencephalitis in patients CD4 ⬜
▶▶In addition to CNS sx, specific skin findings such as ⬜ may also appear.
▶Neoformans ; <100
▶▶[central umbilicated papules (resembling molluscum contagiosum)]
Since ⬜ overdose produces ⬜ sx which mimics brain death, how do you differentiate it from actual brain death?
Baclofen; [complete atonia, aReflexia +/- fixed Dilated pupils] ;
_________________
[Baclofen OD ➜ Loss of Bicep (Spinal) Reflexes]
Brain Death has intact Spinal Reflexes
📖Baclofen MOA = GABA-B agonist
⬜ treats ALS. What the MOA?
________________
Amyotrophic Lateral Sclerosis
Riluzole ; [DEC neuron Glutamate secretion]
________________
progressive weakness + UMN AND LMN deficits + [cognition/ocular/bowel/bladder preservation]
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] when 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 FAAW(Fasciculations / Atrophy & Areflexia / Weakness)]
A: List the 6 stages of Sleep
B: List their associated EEG waveform
The Limbic system contains 5 organs and has 6 functions
a. Name the 5 organs that make up the Limbic system
b. Name the 6 functions of the Limbic system
a. CHAMP
_________________
b. [“famous”6 F’s]
CSF is returned via ⬜ into the ⬜, which ultimately dumps into the ⬜
arachnoid granulations; [SUP sagittal sinus] ; [Internal Jugular Vein]
💡[SUP sagittal sinus(found in dura) ] = main location of CSF return
CSF is made by [⬜ of the ⬜] and then reabsorbed by ⬜
ependymal cells; [Lateral Ventriclechoroid plexus];
[arachnoid villi granulations] (which dumps CSF into the dura’s [SUP sagittal sinus] → Internal Jugular Vein)
Describe CSF path from Lateral Ventricles to Subarachnoid Space (9)
💧{[(CSF made by Ependymal cells) of Choroid Plexus ]OF LAT VT}
🧠LAT VTCSF
💧 –(InterVt Foramen of Monro)–>
🧠3rdVT
💧 –(Cerebral Aqueduct of Sylvius)–>
🧠4thVT
💧 {–([Foramen Luschka *(Laterally)*] or [Foramen Magendie *(Medially)*] )–>}
🧠Subaracnoid space
difference between
[Communicating Hydrocephalus] vs [NONCommunicating Hydrocephalus]
COMM: [arachnoid scarring (post meningitis, etc)] → [⬇︎arachnoid granulation CSF reabsorption] → [ ⇪CSF accumulation = ICP/papilledema/herniation]
_________________
NComm: ventricle structural blockage(i.e. [CAS stenosis] vs [FOM colloid cyst]) → [ ⇪ CSF accumulation = ⇪ ICP/papilledema/herniation]
🔎CAS = Cerebral Aqueduct of Sylvius
🔎FOM = Foramen of Monro
Spinal Muscular Atrophy etx and CP
[ANT Horn Cell degeneration] from [Chromo 5 SMN1 and 2 gene mutations]–> LMN signs of FAAW- Weakness/[atrophy & areflexia] /Fasciculations
⭐2 onsets: [Infantile Werdnig HoffmanFATAL] vs [AdultNONFatal]
Spinal Muscular Atrophy
What’s the difference between Infant type and Adult type
Infantile onset = (Werdnig Hoffman) –> [Auto Recessive FATAL condition –> Floppy Baby from diffuse [Distal muscle atrophy]
________________
adult/child onset types = [Non-fatal Chronic Disability]
Describe Friedreich Ataxia (8)
FriEdreich is Fratastic! He’s your fav., twisted, frat brother, always studdering and falling, but has a sweet, big heart
FriEdreich = [Vitamin E Deficiency] mimics it
Fratastic has 9 letters = [Chromo 9 Auto Recessive GAA repeat]
twisted = Kyphoscoliosis @ childhood
frat = [frataxin (iron binding protein) defect]
studdering = Dysarthria
falling = [Falls & Ataxia + (Pes Cavus High Foot Arch)]
sweet = DM
big heart = Hypertrophic Cardiomyopathy = COD
Involves Degeneration of [Dorsal, Lateral CST & SpinoCerebellar]
Loss of Gag Reflex indicates what cranial nerve damage
Glossopharyngeal CN9 Ipsilateral
Dysphagia indicates what n. damage (2)
[Glossopharyngeal CN9] and [Vagus CN10]
Dysphonia/Hoarseness indicates what n. damage
[Vagus CN10]
Atomoxetine Indication
NonStimulant ADHD Rx
What are the Afferent and Efferent nerves for Corneal Reflex?
What are the Afferent and Efferent nerves for Lacrimal Reflex?
What are the Afferent and Efferent nerves for Jaw Reflex?
What are the Afferent and Efferent nerves for Pupillary Reflex?
[optic CN2] –(Pupillary Reflex)–> [oculomotor CN3]
cp for [Trigeminal CN5] motor lesion (3)
✔︎ causes [IPL pterygoid m paralysis] ➜
✔︎ unopposed contralateral pterygoid muscle contraction →
✔︎ jaw deviates **TOWARD** lesion
## Footnote
*"I lick my wounds at 5, 11 and 12"*
uvula cp for [Vagus CN10] lesion (2)
✔︎weak side relaxes and uvula points away from lesion
cp for [spinal accessory CN11] lesion (2)
✔︎ shoulder droops toward lesion“I lick my wounds at 5, 11 and 12”
✔︎weakness turning head CTL
💡[hypoglossal CN12] also points toward lesion(2/2 weakened IPL tongue muscles)
✏️“I lick my wounds at 5, 11 and 12”
🛑[postgang sympathetic pupillary fibers] travel with CN5B1
Cavernous Sinus syndrome is caused by ⬜3
- Pituitary mass
- carotid-cavernous fistula
- [infectious cavernous sinus thrombosis (facial|dental infxn uses facial veins and spreads into cavernous sinus)]
Cavernous Sinus syndrome
clinical presentation (8)
a. [CN3/4/6 → (IPLDO3P/ophthalmoplegia)]
b. [CN5B1 → IPL DEC corneal reflex]
c. +[sympathetic pupillary fibers (travels with CN5B1)]→ [IPLHorner’s_MAP] → [IPLCavernous_doMAP]
d. {[CN5B2 → [ IPL DEC Maxillary sensation]}
e. proptosis
f. papilledema
g. Vomiting
h. HA
📖causes:
1. Pituitary mass
2. carotid-cavernous fistula
3. [infectious cavernous sinus thrombosis (facial|dental infxn uses facial veins and spreads into cavernous sinus)]
_________________
🔎DO3P(“DOPe” Oculomotor CN3 Palsy) = [down/out + Ptosis + (eyeDilated-myDriasis)] = [SPECIFIC TO IPLOculomotor CN3❌]
🔎[Horners_MAP] = [Miosis+Anhidrosis+Ptosis] = SPECIFIC TO [IPLSYMPATHETIC CHAIN❌]
🔎[Cavernous_doMAP] = [down/out + Miosis + Anhidrosis + Ptosis] =SPECIFIC TO [IPLOculoSYMPATHETIC CHAIN❌(likely within Cavernous Sinus) = [CAVERNOUS SINUS SYNDROME]]
Which mastication muscles
close the jaw? (3)
_________________
open the jaw?
Masseter/teMporalis/Medial_pterygoid
_________________
Lateral pterygoid
“Munch your jaw closed, then Lower it open”
What are some triggers of Primary GTC Seizure? - 9
Seizure AT(Ta)CK
- Flashing lights
- Sleep Deprivation
- Hyperventilation
- EtOH
- Infection
- Cocaine
- Whole Brain Anoxia
- [Rapid Na+⬇︎]
- [Rapid Glucose⬇︎]
ATTaCK
👓▶Seizures = sync high freq neuronal firing{(partial focal [simple vs complex]) vs (GZD [MATTA])}
▶Epilepsy = DO of recurrent seizures
2 categories of seizures, Partial focal vs GZD diffuse.
[GZD diffuse] seizure
what are the subtypes? (5)
✔︎5 subtypes MATTA
1. [Myoclonic (quick jerky mvmts)]
2. [Atonic (LOSS of “stiff” Tone“just drops to floor”)]
3. [Tonic-Clonic_grand mal (stiff ↔mvmt)]
4. [Tonic (just stiff Tone)]
5. [Absence_petit mal (blank stare\3hz\No postictal confusion)]
Tonic = stiff // Myoclonus: mvmt jerky
👓▶Seizures = {sync⼀high freq⼀neuronal firing{(partial focal [simple vs complex]) vs (GZD [MATTA]}
▶Epilepsy = DO of recurrent seizures
✔︎ Seizure ATTaCK
2 categories of seizures, Partial focal vs GZD diffuse.
Partial focal seizure
clinical features (6)
✔︎ affect single area of brain (but can secondarily proceed to GZD diffuse
✔︎ typically originates in medial temporal lobe
✔︎(maps) = motor/sensory/autonomic/psychic
_________________
✔︎ 2 types:
⚡[simplepartial focal = ⊕consciousness]
⚡[complexpartial focal = ⊝ consciousness]
👓▶Seizures = sync high freq neuronal firing{(partial focal [simple vs complex]) vs (GZD [MATTA])}
▶Epilepsy = DO of recurrent seizures
✔︎ Seizure ATTaCK
Bethanechol
MOA
_________________
Indication (2)
activates bowel/bladder[Muscarinic🟢Direct cholinomimetic]
_________________
-ileus
-urinary retention
“BethanE makes you pee!”
resistant to AChE
Carbachol
MOA
_________________
Indication
[Muscarinic🟢Direct cholinomimetic] = constricts pupil → ⬇︎IOP
________________\
[Cglaucoma]
[closed angleglaucoma]
[glaucoma] = [closed angleglaucoma]
Pilocarpine
MOA (3)
_________________
Indication (2)
[Muscarinic🟢Direct cholinomimetic] =
1. stimulates tears/sweat/saliva
2. [contracts ciliary muscle→ open angle glaucoma tx]
3. [contracts pupillary sphincter → closed angle glaucoma tx]
_________________
-#2 → open angle glaucoma tx
-#3 → closed angle glaucoma tx
resistant to AChE
Methacholine
Indication
challenge test for diagnosing asthma
[Muscarinic R agonistDirect cholinomimetic] = induces bronchoconstriction → “”
Edrophonium
MOA
(short acting)[AChE inhibitorIndirect cholinomimetic] = ⇪ ACh
historically for: diagnosis of myasthenia gravis
Neostigmine
MOA
[AChE inhibitorIndirect cholinomimetic] = ⇪ ACh
NO CNS BBB Xng
Physostigmine
MOA
_________________
Indication
(BBB Crossing) [AChE inhibitorIndirect cholinomimetic] = ⇪ AChcentrally
_________________
treats [Muscarinic R Blockade (atropine/Jimson Weed/anticholinergic)] TOXICITY
“Physo phyxes atropine OD”
Pyridostigmine
MOA
_________________
Indication
(LONG acting)[AChE inhibitorIndirect cholinomimetic] = ⇪ ACh
_________________
Myasthenia Gravis
“PyRido Rids of Myasthenia Gravis”
NO CNS BBB Xng
Hyoscyamine
MOA
_________________
Indication
Μ🟥antispasmodic
_________________
IBS
(same as Dicyclomine)
Tropicamide
MOA (2)
_________________
Indication
[Muscarinic🟥myDriasis + cyclopLegia ]
_________________
pupil dilation
Atropine & Homatropine = similar Eye application
Solifenacin
MOA
_________________
Indication
(⬇︎Bladder spasms)Muscarinic🟥
_________________
Urge incontinence
(same as Oxybutynin & Tolterodine)
Scopolamine
MOA
_________________
Indication
(CNS)Μ🟥
_________________
Motion Sickness
Μ = Muscarinic
Glycopyrrolate
MOA
_________________
Indications (3)
Μ🟥
_________________
IV: ⬇︎ PreOp airway secretions
PO: ⬇︎drooling
PO: ⬇︎peptic ulcer
Μ = Muscarinic
Atropine
MOA
competitiveΜ🟥
▶[Organophosphate/Parathion/Muscarinic R agonist OD /Cholinomimetic Tox] → DUMBBELSS
▶Atropine bl🛑cks DUMBBELSS
▶[Atropine tox/anticholinergic tox/Jimson Weed tox] → Blind\bat, Dry\bone, Hot\hare, Mad\hatter, Red\beet, Bowel + Bladder\loses tone, Heart\alone
Homatropine
MOA (2)
_________________
Indication
(myDriasis + cyclopLegia)[Muscarinic🟥]
_________________
pupil dilation
Atropine & Tropicamide = similar Eye application
i.Toxicity of [Drugs A(Cholinomimetic, ⬜, ⬜ or ⬜)] → ⬜sx
ii.[Drug B(⬜)] bl🛑cks these sx
iii.but OD of Drug B can → [⬜sx]
iv. which would then require [Drug C(⬜)] to correct
i.Toxicity of [Drugs A(“COPS”)] → [DUMB BELSSsx]
_________________
ii.[Drug B(Atropine Alice)] bl🛑cks these sx
_________________
iii.but OD of [Drug B(Atropine Alice )] can → [Blind\bat, Dry\bone, Hot\hare, Mad\hatter, Red\beet, Bowel + Bladder\loses tone, Heart\alonesx]
_________________
iv. which would then require [Drug C(Physostigmine)] to correct
_________________
_________________
▶COPStoxicity →
Cholinomimetic
Organophosphate
Parathion Pesticide
[Shit/Sex ⼀Feed/Breed ⼀Muscarinic R agonist]→
_________________
“i.toxic COPS inevitably → [DUMB BELSS], smh.
ii. Atropine Alice happily cleans up those DUMB BELSS…
iii. but too much of Atropine Alice can → [Blind\bat, Dry\bone, Hot\hare, Mad\hatter, Red\beet, etc.]
iv. so PhysoStigmine sticks around to Phyxe too much Atropine Alice”
Neostigmine
Indication (4)
- postop ileus
- postop urinary retention
- myasthenia gravis
- reversal of NMJ blockade
[AChE inhibitorIndirect cholinomimetic]
NO CNS BBB Xng
A: What are the 7 Steps of Visual Pathway starting with light entering eye?
B: Light Entering Eye:
TEMPORAL Retina Fields pass _____ [crossed/uncrossed]
vs.
nasal retina fields pass ____ [crossed/uncrossed]
A: Pathway of Visual Info from Retina [RN CT L DV]
“RN Can Try Learning Direct Vision”
1. Light enters —> hits Retina
2. Travels in Optic Nerve
3. Optic Chiasm[NRts Axons CROSS HERE]
4. Optic Tract
5.[Lateral Geniculate Nucleus of Thalamus]
6. [Optic RaDiations(Meyer’s Temporal Loop vs. Parietal direct path)]
7. [Area 17 -Calcarine Primary Visual cortex]
B: Light Entering Eye:
TEMPORAL Retina Fields pass UNcRossed
vs.
nasal retina fields pass crossed @ Optic Chiasm
🔎NRts = [Nasal Retina field⼀Temporal Sight]
A: Although Visual Perception begins in ______, collateral visual info enters ____ via Pretectal Area= for ___ _____ and _____ _____ for ________
B: Pretectal Area uses ___ nuclei of _____ for ___ _____ and projects both ipsilateral & contralateral via ____ _____
A: Although Perception of vision begins in [Area 17 CPVC] collateral visual info enters Brainstem via Pretectal Area=FOR PUPILLARY REFLEX and [SUP Colliculus]=For head&eye movement
B: Pretectal Area uses [Edinger-Westphal nuclei] of midbrain for PUPILLARY REFLEX and projects both ipsilateral & contralateral via POSTERIOR commissure
What would occur if there was a Lesion in …
1. R Optic N. —->
- Optic Chiasm —–>
- R Optic Tract—>
- R [meyer’s loop-inferior Optic Radiation] –>
- R [Lateral Geniculate nucleus of thalamus]–>
- R [Dorsal Parietal-SUPERIOR OPTIC RADIATION]
- R [Area 17 CPVC]
B: Which 2 lesions present the same Visual sx?
Lesion in … (using R side damage as example)
- R Optic N. —-> BLIND RIGHT EYE
- ————————————————————————————- - Optic Chiasm —–> [Bitemproal hemianopia] (both temporal fields knocked out)
- ————————————————————————————- - R Optic Tract—>[CTL homonymous hemianopia] {Lose L-eye Temp} and {R- eye nasal}
- ————————————————————————————- - R [meyer’s loop iOR (“pie in sky”)] –> “Pie in the Sky Lesion’ = [CTL homonymous upper quadrantanopia]
- ————————————————————————————- - R [Lateral Geniculate nucleus of thalamus]–>[CTL homonymous hemianopia]
- ————————————————————————————- - R [Dorsal Parietal SOR (“pie on floor”)]–>[CTL homonymous LOWER quadrantanopia]
- ————————————————————————————- - R [Area 17 CPVC]–> [CTL homonymous hemianopia with macular/fovea sparing]
- ————————————————————————————-
Lesions of Optic Tract and [Lateral Geniculate Nucleus of thalamus] PRESENT SAME VISUAL SX!
CTL = Contralateral (or L in this case)
How does [Pupillary Light Reflex] present when there is..
A. [Optic CN2] damage? why?
B. [Oculomotor CN3] damage? why?
PUPILLARY LIGHT REFLEX io\
A. [Optic CN2] Damage—-> BL PUPIL FREEZE = EQUAL PUPILS that do NOT REACT AT ALL becuz signal is NEVER sent to [Edinger-Westphal nucleus]= NO accomodation on either side
vs.
B: [Oculomotor CN3] damage—>
✔︎{[IPL (side with CN3 damage) pupil freeze]
with
✔︎{[CTL (side with NO CN3 damage) pupil constriction]
✔︎ {[IPL (side with CN3 damage) pupil freeze]
= [⊕optic N relay] but [⊝ oculomotor CN3 accomodation] → pupil freezes/never changes}
plus
✔︎{[CTL (side with NO CN3 damage) pupil constriction]
= [⊕ optic N relay] and [⊕ oculomotor CN3 accomodation] → pupil constricts appropriately}
A: In order to change gaze & focus on very close objects you need the ____ REFLEX which involves what 3 things?
B: Why does this reflex also involve the [Visual association cortex]?
C: How does your body know when this needs to be activated? [2]
In order to change gaze & focus on very close object you need the ACCOMMODATION REFLEX which involves..
- eye convergence via [medial recti m.]
- Ciliary m. constriction —>Lens thicken
- Constriction of both pupils–>DEC light entering due to greater reflectance from close object
C: *[Visual Association Cortex] realizes something is “out-of-focus”–>sends signals (via internal capsule) to [supraoculomotor nuclei]—>generates motor control that bilaterally sends signals to Oculomotor complex
**Oculomotor complex uses [Edinger-Westphal nucleus] to control [ciliary ganglion]–>sends short ciliary n. to [ciliary m.] and iris sphincter
Oculomotor neurons control [medial recti m.]
Optic Radiation is AKA the _____ ______
Optic Radiation is AKA [Geniculocalcarine tract]
A: The [Pupillary Light Reflex] involves a ⬜ reflex and ⬜ reflex. Describe each?
B: After light is shone thru 1 eye, BOTH pupils constrict becuz ⬜
C: What part of the brain facilitates [Pupillary Light Reflex]?
A: DIRECT reflex = light is shone thru R pupil and the R pupil constricts
CONSENSUAL reflex= light is shone thru R pupil BUT L pupil constricts also
_________________
B:
▶both pupils constrict becuz
▶ IPL [Optic CN2] fibers synapse at IPL [rostral midbrain’s SUP colliculus pretectal olivary nc] which send →
▶BILATERAL connections to each [Edinger-Westphal nucleus] (which houses and communicates with each own’s respective [Oculomotor CN3 nc]
)
▶= activates each respective [Oculomotor CN3] nc
▶which sends respective [Oculomotor CN3] fibers to each’s respective Ciliary ganglion—>
▶CG sends [Parasympathetic short ciliary nerves] to —> ▶constrict respective [sphincter pupillae m.]
C: [Rostral Midbrain SUP colliculus]
pt presents with Ptosis
Recite DDx algorithm for Ptosis -4
cavernous sinus, sympathetic, Horners
