2018 Neurology 4% Flashcards
Migraine
F>M
Q few weeks
1/2 hr onset
Lasts hours to days
Frontal/temporal one or both sides
Throbbing
n/v/aura/photophobia, AM menarch, menses, weahter, stress, worse with movement
Tx: Tylenol/NSAID/ASA -> Sumatriptan->chloropromazine/metochlopramide
Prevention: BB, TCA, Vit B2 (riboflavin), CoQ 10, Topiramate, Botox
Cluster h/a
M>F
1-2/day
onset 2-15min
lasts 1/2 hr-2hrs
Orbital/one side
Excruciating
Rhinorrhea, ipsilateral Horner’s, Unilateral lacrimation
Tx: 100 OXYGEN, intranasal lidocaine, sumatriptan
Prevention: Verapamil, valproate, gabapentin
Tension h/a
F>M How often? Variable Onset Variable how long 1/2hr to 7 days Where: diffuse Non-throbbing Band like Tx: analgesics Prevention: BB, TCA
25yo F p/w chronic h/a x years noticed from puberty, mainly with waking up, several hours every few weeks, throbbing aw nausea and vom no auras - several tylenol and motrin didn’t help - acute pain would respond to….
Sumatriptan
25yo F with FLASHES of light moving across eyes for a few minutes wiht loss of visio nin one eye - left homonymous defect -normal after 45 min
Dx: Migraine
Young woman co wk in R arm and leg - PMHx migraines - feels better after couple hours - carotid US, MRI brain and TEE normal dx?
Migraines
DO NOT USE TRIPTANS with CAD or vasculitides
52yo M p/w moderately severe befrontal throbbing ha - aw nausea - had h/a for past few years - normal temp - BP 150/90, fundoscopy normla neck supple, pupils reactive no focal neur effects histor significant for CAD wtd?
NSAID with prochloroperazine
Acute migrain with nausea and vomiting fastest relief?
SQ Sumitriptan
Severe acute migraine not responding to sumatriptan or lasting >72hrs
IV dopamin antagonist (prochlorperazine.metoclopramide) + IV diphenyhydramine (prevent acute dystonic rxn)
Severe acute migrain x more than 72hrs - last sumatriptan >24hrs ago with little response - >
parental dihydroergotamine
Pregnancy with migraine h/ once a week
tylenol
Pregnancy with migraine h/a no response to Tylenol
Metoclopramide or Chloroproazine or ondeansetron
Migraine ppx for h/a’s how often?
2 times per week
PPX for migraine <15x/month
BB, amitriptyline, topiramate, sodium valproate
PPx for migraine >15/month
Topriamate-> botox
PPX migraines with asthma
Divalproex sodium, topiramate (no BB CI)
Prevention of menstrual h/a
mefenamic acid (Ponstel) … 2 days prior and up to end of menstruation
Migraine with Aura
OCP contraindicated!! Can cause DVT in brain. Progesterone only IUD.
Pt with migrain h/a takes NSAIDs and tylenol daily. now not working wth h/a daily from morning to evening
Analgesic induced h/a
d/c all analgesics
42yo F chronic non-throbbing h/a worse at end of day - band like around neck
Tension h/a
35yo F c/o excruciating Ice pick like retro-orbital h/a - h/o rhinorrhea, lacrimation, ipsilateral horner’s
Cluster h/a
Pt with recurrent h/a >5-6/day, lasting 15-20minutes, unilateral and retrooribtal
Chronic paroxysmal hemicrania
Tx: Indomethacin
32yo obese woman BMI>30 with daily h/a - horizontal diplopia - blurring of optic disc margins - wtd next?
CT scan (r/o) DVT in brain. IF neg --> MRV, if neg --> spinal tap (with incr pressure) Idiopathic Itracranial HTn (Pseudotumor cerebri)
Tx: Acetazolamide, lumboperitoneal shunt
Etio: obesity, Vit A toxicity, tetracycline, steroids, contraceptives, nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen, levothyroxine
Comoplications of pseduotumor cerebri
Peripheral visual field loss-> central visual field loss
Pt with known HTN with h/a and ataxia - CT scan large cerebellar bleed wtd?
surgery -or it may cause brainstem compression
65yo h/a ESR 75
Temporal arteritis
H/a with rhinorrhea
Cluster h/a
100% O2
Cluster h/a
H/a with zigzag wavy lines photophobia and aura
Migraine
Sumatriptan
Migraine, Cluster h/a
Thunderslap h/a, CT head neg, CSF xanthochromia
Subarachnoid hemorrhage
Chronic h/a inc’d with lying down
brain tumor
Young obese pt with headache and horizontal nysstagmus
Pseudotumor cerebri
Acetazolamide
Pseudotumor cerebri
50yo F seizure or focal weakness, h/a worse on coughing/lying down CT 4cm lesion, large edema, mass effect. No calcification..
Glioblastoma/astrocytoma
most common and aggressive primary brain tumor
Surgery primary therapy with chemo/radiation
dexamethasone
50yo h/a worse on coughing, lying down, CT INTRAVENTRICULAR tumor
Choroid plexius papilloma
slow growing benign tumor of ventricular system in choroid plexus - inc’d CSF production - inc’d OCP -> hydrocephalus
Tx: Surgery
50yo F h/o seizure d/o for 4 years - CTH 3cm tumor in sylvian fissure - diffuse enhancement with contrast
Meningioma Usually benign Arise from meninges Seizures or weakness Syvian fissure Inc'd ICP
Following tumors metastasize to brain
Breast, lung melanoma, lymphoma, renal
NOT prostate
45yo F lighting pain jabs in gums, cheek, chin, several times per day and last few seconds at a time - no focal neurolgical signs, oral exam normal. wtd?
Carbamazepine (Tegretol*) trigeminal neuralgia
Facial Palsy
Supranuclear (CVA) - Upper face spared
Infranuclear - both UPPER AND LOWER face Bell's palsy Accoustic Neuroma Ramsay Hunt syndrome Guillain-barre Lyme Dz Sarcoidosis
Motor Neuron Disease
Lower motor neuron (Infra-nuclear) - dec’d reflexes, dec’d muscle tone, +Fasciculations
Upper motor neurons (Supra-nuclear) - inc’d reflexes, inc’d muscle tone, NO fasciculations
30yo with erythema chronicum migrans 4 weeks ago now with left sided upper and lower face paralysis preceded by ha
Infranuclear lesion
55yo vesicular lesions on R side face with pain involving ear
Supra-nuclear lesion
65yo M with slurred speech and lower face paralysis
Suprnuclear lesion
55yo pw R sided facial paralysis of unknown etio
infranuclear lesion
60yo M sudden onlset R facial weakness, drooling of saliva inability to close R eye - mouth deviating to left side, unable to raise eyebrows - rest of neuro exam normal
Artificial tears, patch R eye at night, start PREDNISONE
fyi.. bilateral bells palsy can occur with lyme dz
Young woman co diplpia - closing one eye - diplopia persists dx?
Monocular psychogenic diplopia
CN III palsy
can’t look up, down or inward
Where is lesion?
posterior commuicating artery
Dx: MRA brain
Pt in MVA brought to ER with h/a - PE shows R pupil 2mm, left pupil 4mm - ptosis of R eye - wtd?
CT angio neck
dx: Carotid artery dissection
heparin –> surgery
Pt with acute onset diplopia h/o DM, Ptosis
Acute cranial mononeuropathy
Pt with hyperthyroid and exopthalmos - unable to completely abduct and has double vision - cause?
Thyroid opthalmopathy
Tx: steroids
R optic neuritis
MS with blindness in right eye
Tumor pressing on optic chiasma (acromegaly)
Bitemporal hemianopia
Left Optic tract
Right dense homonymous hemianopia
Left optic radiation (occipital lobe)
Right homonymous quadrantanopia
Stroke
Days
Throbotic - 50% preceeded by TIA
Embolic - more rapid onset
Hemorrhagic - HTN, amyloi angiopathy
Minutes
TIA -
Carotid artery syndrome -
Ipsillateral visual loss (amaurosis fugax)
Shadow in front of eye - contralateral motor or sensory changes
Vertebrobasilar syndrome DDD Dizziness, Diplopia, Dysarthria Sudden wk of legs -> dorp attacks B/l Wk Tx: ASA
Pt with TIA higher risk of stroke if…
Duration >10min (2pts) Speech disturbance (2pts) Age>60 (1 pt) DM (1pt) HTN (1pt)
……………… >3 score = admit. Score 0-3 (1% stroke risk), 4-5 (4.1%), 6-7 (8.1%)
Most important risk factor for stroke?
uncontrolled HTN
Pt with TIA , wtd next
Hopsital w/u - carotid dopper (r/o CAS), EKG/extended holter (r/o afib), CT brain, Coags/PTT (r/o LAS), TEE (r/o PFO)
If carotid shows >70% wtd?
Carotid endarectomy + ASA
If TIA and carotid 90% inoperable wtd?
Stent
Pt with TIA and cardid US with <50% wtd?
ASA + dipyrimadamole (Persantine*) OR plavix
Pt h/o TIA no PAD - best management
ASA - can also add ACE+/- indapamide to decrease recurrence
Pt has TIA on ACEi, ASA and statin
d/c ASA and start Plavix
don’t use both unless has CAD with stent also
Endartectomy vs stent
Endartectomy better mortality, less stroke, but worse with high carotid bifurcation…..
Stent better with high carotid bifurcation, but higher mortality/stroke
Pt with diplopia, dyarthria, dizziness - dx with verebrobasilar ischemia wtd?
ASA
Establish dx of vertebrobasilar ischemia dx with MRA posterior cranial vessels
Pt w/ treated vertebrobasilar ischemia has occasional epistaxis esp when sneezing dx?
vWF dz
TPA criteria
- Ischemic stroke with clearly defined sx onset
- No intracranial bleed on Head CT
- time from sx onset to delivery of tPA <270 minutes (4.5hrs), except if diabetic or age >80 then < 3 hrs.
Exclusion crtieria for TPA
- Rapidl improving sx….
- Stroke or head trauna/major 3 months/ Major surgery w/in 14 days….
- Suspected SAH despite normal CT head…
- SBP>185 or DBP >110…………
- on A/C……..
- PT>15 sec, plt<100,000, gluc <50 or >400
65yo M woke up in AM and THEN had stroke CT neg for bleed - presents within 3 to 4.5 hrs
TPA –> CTA for endovascular procedure
70yo M h/o afib pw sudden onset wk one side CT neg wtd?
TPA….. minimal improvement?? –> intra-arterial tPA
ASA 24-48 hrs later
65yo M found in AM in bed with stroke
NO TPA since duration unknown
Pt with ischemic stroke, time onset 60 min CT no bleed, BP 200/120 wtd?
Labetolol iv when BP <185/110, then TPA
Pt not taking HTN meds x 1 week - BP in office 240/130, h/a visual distrubances with hemianopsia, aura, cortical blindness MRI shows white matter edema in parieto-occiptal regions
Posterior Reversible Encephalopathy syndrome (PRES)
Started on nitroprusside - BP 140/90
-> taper nitroprusside
Pt with hemorrhagic stroke ….. when should anti-HTN be started
BP>180/100
Pt with uncomplicated ischemic stroke not eligible for TPA ….. when should anti-HTN be started
BP>220/120
Pt with ischemic stroke post tPA ….. when should anti-HTN be started
BP>170/100
ACA stroke
CL weakness leg/foot WITH sensory loss
urinary incontinence
Primitive reflexes, incr. DTR
MCA stroke
PARIETAL lobe (dominant) ... - acalculia, agraphia, Lt/Rt disorientation, finger agnosia, tactile agnosia, paresthesia TEMPORAL Lobe - aphasia PARIETAL Lobe Right (non-dominant) - spatial neglect, Unable to dress
PCA stroke
U/L homonymous hemianopia
I/L 3rd N palsy - WEBERS’ syndrome
contralateral sensory abn
Lateral Medullary Syndrome (wallengberg synd) PICA
I/L loss pain/temp from face/ CL pain/temp loss. body.
I/L palsy upper and lower face
I/L loss of lacrimationa nd salivation
I/L loss of taste anti 2/3 tongue
Vertigo, nystagmus, nausea, vomiting
Tending to fall to same side, wavy images
Hoarseness, dysphagia
Medial Medullary syndrome
Contralateral hemoparesis adn parastesia
affected eye looks down and toward nose
I/L tongue palsy
Basilar artery stroke
Hemiparesis, involutary shaking movement
Bulbar muscles involvement with loss of fxn in throat - unable to move tongue - only eye movements present and called LOCKED IN SYNDROME
Quadriplegia
Pt with right sided hemiplegia and sensory defeits - r hemianopsia and aphasia
L MCA
Pt with L foot and leg wk, urinary incontinence
R ACA
Pt with R side sensory abn, ptosis L eye, pupillary dilation
L PCA
Pt with diplopia, dysartria one sided wk with priorbital numbness and shakign/shivery moveemnts of affected limbs
Basilar artery
Pt with quadriplegia, cnat speak can’t put tongue out, eye movements ok
Basilar artery
Pt with dizziness, n/v, loss of pain/tmep sensation L half of face adn R side body, wavy lines, tends to fall to left while trying to sit up, hoarsemneess, dysphagia
Left Lateral Meduallary syndrome
32yo F no Pmhx p/w stroke - exam pain and tenderness over calk - etio?
PFO
45yo F lupus and Antiphospholipid syndrome with h/o DVT in past on warfarin PT 3.4 with TIA with R eye blury vision whic resolves in 10 min wtd?
Echo with bubble study
82yo M brought in with h/a and R wkness - CT hyperdense lesion in pareital area suggestive of subarachnoid hematoma BP 135/76 - no h/o trauma cause?
Amyloid angiopathy
Hepatopul syndrome
see bubbles q4 beats on TTE
Broca’s aphasia
non-fluent speech
CAN comprehend
Frontal lobe
MCA
Wernicke’s aphasia
fluent speech but non-sensical
Can’t comprehend
Temporal lobe
MCA
Conductive Aphasia
Can’t repeat
CAN comprehend and read
Global Aphasia
Sensory and motor aphasia
Branch of middle cerebral or internal carotid artery
Pure word blindness
can’t read - occipital lobe - PCA optic radiations
Thunderclap headache, hit by hammer headache, worst h/a of life nausea, vomiting, alter conciousness, neck stiffness, seizure, CNIII palsy wtd?
Subarachnoid hemorrhage —
CT head ->
If neg -> LP check for xanthochormia
LP neg? - MRA r/o reversible cerebral vasocontriction syndrome (tx’d with CCB)
Tx: Amlodipine
Best test to confirm prior to surgery for SAH: Cerebral angiogram
Complications of SAH
Rebleed 24hrs - 1 month
Vsaospasm 4 to 10 days
Hydrocephalus - late
CSW syndrome: decr. Na and BP
Best drug to tx vasospam
Nifedipine
Best time to do surgery
ASAP - clipping or coiling for causative aneursym
1 week after aneurysm surgery stroke develops - cuase?
vasospasm induced infarct
Vertigo - Central
Cause - brainstem/cerebellar dz, MS, cerebellar atrophy, basilar infarct, arnold chiari malformation
Nystagmus - Horizontal OR vertical
Visual fixation - NO inhibition of nystagmus
Hearing loss/tinnitis +-
N/V - Pos
Severity - severe
Vertigo - peripheral
Cause - vestibular neuritis, labrythnthitis, Menier’s dz, benign positional vertigo
Nystagmus - ONLY horizontal
Visual fixation - inhibition of nystagmus
Hearing loss/tinnitus - labyrinthitis (vestibular nerutis - ), Menier’s dz +
N/V - very bad
Severity - very bad
Pt with vertigo and horizontal nystagmus - on visual fixation nystagmus dissappears - dx?
peripheral vertigo
Pt with vertigo/horizontal nytagmus - visual fixation negates nystagmus - - inovlvmenet of vestbular portion of 8th nerve with diziness lasting hours to days - no deafness - URI 1 week ago dx?
Vestibular neuritis (Labyrinthitis) Tx: Meclizine
35yo recurrent dizzziness and tinnitius and sensation fullness in ear for months aw n/v - exam horizontal nystagmus disappears with visual fixation - audiogram with hearing loss dx?
Meniere’s dz (tinnitus, hearing loss, vertigo)
Tx: Salt restriction, diuretics, surgical ablation
70yo M with new onset dizziness x 2 hours, BP high wtd?
MRA posterior vessels r/o brainstem stroke
Dx of benign positiional vertigo?
Dix halpike maneurver
Pt with vertigo, unilateral tinnitus, progressive hearing loss dx?
Accoustic Neuroma
Etio - Schwann cells
Dx test - MRI
Pt with vertigo while turing in bed, getting in and out of bed, bending over and straightening up, extending neck to look up, epsisoes >30s NO hearing loss dx?
Benign positional vertigo - Dx with Dix halpike maneuver
Tx: Epley otiolith manuever -> Vestibular rehab
Pt with vertigo, dysarthria, diplopia, ataxia dx?
Vertebral bulabar insufficiency
Duration of vertigo
Seconds: BPPV, TIA
Minutes: Migraine, orthostatic hyptension, TIA
Minutes to Hours: Migraine, Meniere’s
Hours to Days: Migraine, Labryrinthitis, Meneire’s
Days to Weeks: Labryrinthitis
Hearing testing
Normal: Webber - tuning fork on forehead - both ears hear same, Rhinne test AC>BC b/l ears
Unilateral air conduction deafness - Webber - hear better in affected ear (from forehead) - BC>AC Rhinne test
b/l conductive deafness/otosclerosis - webber - both ears hear equally, BC>AC both ears (rhinne)
Unilateral sensory deafness - no bone or air conduction from rhine test - webber test on forehead - only normal ear hears
b/l sensory deafness - both rhine and webber no hearing either ear…
Vertigo with fluctuating hearing loss, tinnitis lasting hours to days
Meniere’s dz
Vertigo with progressie hearing loss and tinnitus, whisper test decreased - tuning for non left mastoid without response - tuning for on forehead with better hearin gon right
Acoustic neuroma (unilateral sensory hearing loss) - lateralize to good ear
Vertigo lasting 30 s and wakes up pt no hearing loss
Benign positional vertigo
Vertigo with sudden onset dizziness, dysarthria, diploppia and weakness
Vertebrobasilar ischemia
Vertigo post URI, horizontal nystagmus dissappears on visual fixation
Vestibular neuritis - labryrinthitis)
MCC vertigo
Benign positional vertigo
Tinnitis with gradual onset hearing loss, whisper test decreased - tuning for on mastoid doesn’t elicit resposne - tuning for on forehea dwith no loaclization - audiology with high freq hearing loss
Presbycusis
MCC dementia
Alzheimer’s dz
60yo cognitive impairment, poor short term membory, can’t name names
paranoit delusions
CT/MRI - brain atrophy - dilated ventricles
inc’d B amyloid precursuor protein - inc’d presenilin activity, APo protein E4
Neurofibrillary tangles - protein Tau (microtubule)
Treatment dementia
MMSE 21-25 - cholinergic augmentation (anticholinesterase), donepezil, galantamine, rivastigmine
MMSE 11-20 - cholinergic augmentation plus NMDA antagonist (memantine)
MMSE <11 - severe dementia - consider palliative care - d/c meds
Effect of cholinesterase inhibitor
Improvement of neuropsychiatric score
Pt with alzheimers - family asks about memantine - advice?
SLOWS progression of dementia
Pt with alzheimer’s on donepezil - has hip surgery - post surgery agitated and confused - dx?
Post op delirium
82yo M with alzheimers for several years - has been getting donepezil and memantine, chlorthalidone for HTN, metformin for DM and nortriptylinefor depression getting more agitated - wtd?
d/c anti-cholinergics
what is going to delay nursing home placement? –> enroll the wife in support group (decreased care giver burden)
Donepezil, galantamine and rivastigmine are choinesteras inhibitos used to treat dementia - aw?
Syncope, bradycardia w/ increased pacemaker placement, hip fracture
Who is more likely to experience sever disability in performance of daily living - cancer or dementia pt
Advanced dementia
62yo sales exective pw forgetfullness - MMSE 27/30 father with alzheimers dx?
Mild cognitive impairment
wtd? Neuropsych eval
Reasess in 1yr - rate of progression to alheimers 15%/yr
Tx: improve cognitive fxn with 6 month program physical activity and cognitive training
S/E Ginkgo
inc’d bleeding time. ginkgo does not work
75yo Pt brought in by son - father behaving irrationally - father thinks son is imposter and beign kept in prison - looks like home - gets lost in mall freqently now doesn’t go - mild tremor soem rigidity - urinary and fecal inctinecne in recetn months - CTH brain atrophy and dilation of ventricles dx?
Alzheimer’s dz
tx: not very effective
Acetylcholinesterase inhibitor, NMDA rct antagonist
Pt with dementia, parkinsonian sx of brady kinesia and postual instability, VISUAL HALLUCINATIONS, no resting tremor, extreme regidity, cytoplasmic inclusion bodies alpha-synuclein protein in subcortical tissue
Dementia with lewy bodies (seeing and doing inapprop things)
35yo pt with dementia father with dementia at age 40 dx?
Huntington’s dz
Memantine
Alzheimer’s dz
Loss of interest, disinhibition, urinates in neighors lawn, hypersexual. abnormal agressive behavior
Fronto-temporal dementia
Contacminated corneal transplants and growth hormone
Creutzfeldt-jakob dz
EEG intermittent sharp waves with slow background
Creutzfeldt-jakob dz
65yo M chronic HTN, hx CVA 3 ya with rapid onset dementia no problem naming names ataxia nd diplopia, extensor reflex, no sensory loss - CT scan multiple no-enhancing hypodense lesions
Multi-infarct dementia
tx: optimize CVA prevention (smoking cess, statins, ASA etc)
65yo M onset of memory loss noticed by family, difficulty naming names, no motor sx - paranoid delusions
Alzheimer’s dz
80yo F pw dementia, urinary incotinence wid based gait, CT scan enlarged ventricles and sulci NOT enlarged
Normal pressure hydrocephalus
tx: VP shunt
55yo M onset of dementia with RAPID deterioration, myoclonic jerks, NO incontinence
Creutzfeldt-jakob dz
Pt sees roaring lions/bears, stiffness, tremor
Dementia with Lewy bodies
motor features of parkinson’s
bizarre visual hallucinations
Tx: sx tx of parkinsonian sx, anti-psycotics
Multiple Sclerosis
Demyelination of white matter in brain and spinal cord…..
Demyelination - plaques in the white matter on MRI w/GAD
Brain- Optic nerve - optic neuritis
Medial longitudinal fasciculus - Internuclear ophthalmoplegia - one eye can’t pass midline (both eyes can’t look same way)
Spinal cord - > Dorsal columns: Sensory changes, vibration and position sense loss
-> corticospinal tracts - MOTOR sx - wk, spacsiticy, hyperreflexia
Optic Neuritis
Inflammation of Optic Nerve
Subacute decrease in vision +- periocular pain
Visuion blurry post excerc or heat/smoking or stress
Relative afferent pullilary defect
Tx: IV methylprednisone
Other presentations of MS
Bladder dysfxn Bowel dysfxn Sexual dysfxn Trigeminal neuraligia Cognitive dysfxn (thinning of corpus callosum Spasticity - carbamazepime helps Fatigue - tx with Amantadine NO seizures No aphasia No h/a
Dx of MS
Clinical presentation
Best imaging - Flare - MRI inc’d T2 signal dec’d T1 signal
Enhancement with Gad in active lesions
If MRI inconclusive - evoked potential studies - conduction velocities
CSF: Cells<10. > 2 IgG oligoclonal bands suggestive of MS
Tx of MS
Acute Relapses -
InterNucOph, Optic Neuritis, fxn impairment -> IV methylprednisolone 1g qd x 3-5 days and taper
Active dz or to prevent relapse:
IFN Beta 1a (avonex), IFN Beta 1b (betasone), IFN Beta 1c (copaxone*)
Fatigue - amantadine
What causes acute relapse in MS
Infections
before high dose steroids always r/o infection
Young women shoudl be on contraception to avoid teratogencity on IFN tx. if inadvertentently becomes pregnant on interferon therapy, NO need for therapeutic abortion.
MC presentation of MS
spasticity
Blurry vision, diplopia
MS
Methylprednisolone IV 1g/day for x 5 days then taper
Acute MS relapse
Alpha interferon
NOT Tx for MS
B interferon
MS PPx for relapse
Amantadine
Tx for MS fatigue
Optic Neuritis in MS
Better prognosis
Sensory sx in MS
Better prognosis
Relapsing remitting in MS
Better prognosis
Progressive relapsing MS
Worse prognosis - d/c B infn
Age>40 at dx of MS
worse prognosis
32yo with intermittent diplopia - numbness/paraesthesia - attempted adduction affected eye -> horizontal nystagmus - Visual acuity - 20/20
internuclear ophthalmoplegia
etio - Medial longitudinal fasciulus - MS
Young woman develops “thick tongue” blurry vision after hot showser - after exc or after hot weather - dx?
Optic neuritis
Pt with MS not responding to B interferon
start mitoxantrone
Parkinson’s dz
Movement d/o 2/2 decrease DOPAMINE from SUBSTANTIA NIGRA
Clinical Dx
Cl Fts RRRR
R esting tremor 4-7 Hz - pill rolling - pronation/supination
R igidity - cog wheel regidity - dec’d arm swing
R etarded movement - bradykinesia and dyskinesia
R eflex lost - postural reflex lost-> frequent falls
When to treat Parkinson’s
Only start when sx have negative impact on functioning status
1. REPLETE DOPAMINE IN BRAIN - - -
Levodopa (peripheral effects not needed) so add carbidopa (prevents periopheral effect of levodopa)
2. DOPAMINE AGONISTS (start in pt <70 yo): pramipexole, ropinirole bromocriptine
3. INHIBITORS OF DOPAMINE BREAKDOWN - selegiline, tolcapone - allows higher doses of L dopa to cross BBB
4. ANTI-CHOLINERGICS TO decr. s/e of levodopa (trihexyphenidyl, Benztropine)
Complications of Treatment
L-Dopa side effects
Involuntary movements - fascial lingual dystonia, chorea, athetosis
Psychiatri symptoms - confusion, depression hallucinations psychosis
on-off phenomenon - alternative hyperkinesia-hypokinesia
55yo M p.w slow shuffling gait - resting tremor and brdykinesia - ADL with difficulty - cogwheel rigidity and spacticity of muscles - now would start…
Levodopa and carbidopa
Pt started on levodopa-carbidopa c/o nausea wtd?
Take with low protein meal or carbidopa 30 min prior to levodopa
Pt with long standing parkinson’s dz on Levodopa-Carbidopa now c/o wkness and bradykinesia … what happened?
On-off phenomenon - inc dose/freq +/- selegiline/rasagiline (inhibits levodopa breakdown)
70yo F parkinson’s dz on levodopa and carbidopa did well for several years now with inc’ing sx - > dosage of levo/carbidopa inc’d-> psychsis wtd?
start atypical antipsychotic - quetiapine or clozapine
Pt with refractory schizophrenia started on clazapine - 3 weks later develops agranulocytosis WBC 500 wtd?
d/c clozapine and never use again
Pt with Parkinson’s dz hospitalized with PNA confused, agitated at night -
start lorazepam
Parkinson’s related dementia
Quetiapine (seroquel*) or clozapine
Parkinson’s related DELIRIUM
Lorazepam or Quetiapine
Pt pw bradkinesia, abn gait, inc’d muscle tone and mild dementia - exam reveal erect posture with hyperextension of neck no tremor, vertical ophthalmoplegia; trouble walking downstairs, eating or reading
Progressive Supranuclear palsy
(Slow movements, problem with voluntary eye movement, diplopia while reading (hard to get eyes close together)
Tx: TCA (amitripline)
Essential or Familial/Kinetic Tremor
Autosomal dominant, mainly hands/head
Intention tremor at 7-10hz (physiogic >9)
Aggrevated by anxiety, anteropost flapping hands
Gets better at rest
dec’d with etoh
Tx with propranolol -> primadone
Pt with creepy-crawly sensations, itchiness, pain, parestesias, jerky movement every 20-40 s while sleeping - fatigue during day
Sx transiently relieved with movement or walking - can occur with or wihtout Parkinson’s
A/W Iron def anemia
Dx: Restless leg syndrome
-established by H&P
If IDA - iron therapy - if not better in 12 wks start dopamin agonist
No iron def - dopamin agonist (perfolide, pramipexole, ropinrole or gabpentin
periodic limb movementd/o with jerky movements during sleep dx by?
Polysomnography
Pt while writing, hand goes into spasm - phalen/tinel’s neg, serum Ca 9mg
Acute dystonic rxn
Pt get phenothiazine for n/v - coupel hours later - pt eyes are stuck in particular gaze (left or right) wtd?
Diphenhydramine
Other manifestations of Acute Dystonia..
Torticollis - fixed flexion of neck
Blepharospams
Writers cramp
18yo M with twitching of face, grimacing and movements of neck
Tourette’s syndrome
Tx: CBT then neuroleptics
Tremor best seen at rest
Parkinson’s
Tremor aggrevated by anxiety
Essential/kinetic
Tremor dec’d by rest
Essential/Kinetic or Cerebellar
Tremor relieved by etoh
Essential/Kinetic
Tremor activated by action
cerebellar > essential/kinetic > parkinson
Tremor in head/voice tremors
Essential/kinetic
Chin tremors
Essential/Kinetic or parkinsons
Familial tremors
essential/kinetic
Tremor on fexion-extension
Essential/kinetic
Tremor on pronation/supination
Parkinson’s
Tremor at rest and on movment ***
Parkinsons
Neuromuscular dz
Myasthenia gravis
Autoimmune
Ab to POST-synaptic Ach rct’s
Low level of Ach rct
Cl ft:
WEAKNESS as day PROGRESSES (repetive acts) reflexes normal
Extraoc/oc muscles-> Ptosis, diplopia
Facial muscles-> diff chewing, dysartria
BUlabar muscles - diff swallowing
Prox limb muscles - wk brushing hair
Intercostal an diaphragmatic wk -> resp failure (Myasthenic crisis)
Edrophonium challenge test (Tensilon test) -> Ptosis should get better
Ach rct ab + in 90% gen MG, 50% ocular MG
neuromuscular diseases … .Dipolpia
+Ptosis + wkness –> MG
+INO –> MS
+dysarthria + ataxia + dizziness –> Verterobasilar TIA
+cauda equina –> Leptomeningial metastaisis
Pt with diplopia, fatigue at end of day difficulty brushing hair, recently while eating regurg thru nose, diplopia, ptosis in both eyes. wtd to get dx?
Ach receptor Ab test
35yo prox muscle wk, ptosis, diplopia, EOMI intact, vision intact, DTR intact. wtd next
Repetive nerve stim studies
MS - gets weaker with repeated stim
Eaton lamburt - stronger with repeated stim
***Single fiber electromyography (SFEMG) is more sensitive than nerve stimulation studies (100% SFEMG vs 65% NCS) but SFEMG is operator dependent.
Pt dx with MG wtd next
CT chest r/o thymoma - if present resect
40yo F works on farm lately gets tired - diplopia on exam - pupils ok refelxes ok vision ok - dx?
MG - reponsd to physostigmine
(not organophosphate - pupils would be constricted) this exam you go with presentation
30yo smoker with diplopia - tired at end of day - difficulty swallowing, chewing, nasal regurg - develops progressive wk and goes into resp facilure - dx?
MG
What makes MG wkness worse?
aminoglycoside abx Antiarrythmics BB Infxn Electrolytes d/o ***
Pt with myasthenic crisis wtd?
admit to ICU,
Plasma exhange,
Immunglob/steroids,
Elective intubation for vital capacity <21 ml/kg
Pt with MG on pyridostigmine now with acute exacerbation wtd?
immunoglobulin/steroids
Eaton Lambert syndrome
Autoimmune/Oat cell CA Antibody to PRE-synaptic rct's Weakness BETTER with repetitive action HYPO-reflexia no ptosis no diplopia
Pt with wk, inabilit to get up form chair, BETTER with excercise - h/o chronic smoking, 30 pack years- DECREASED reflexes, no ptsosis, repetitive nerve stim with incremental INCREASE with continuing potentials dx?
Eaton Lambert 2/2 small cell lung CA
Better with repetition
Eaton labert
Worse with repetition
MG
Hyporeflexia
Eaton lambert
Normal relfex
MG
Abx infxn worse
MG
Small cell CA
Eaton labert
Thymoma
MG
Pre-synaptic Ab
Eaton lambert
Post-synaptic anti-acetychoie rct ab
MC
Ptosis/diplopia
MG
Muscle wkness
MG and Lambert-Eaton
60yo M pw complaints of pain in shoulders, tired at end of day acan’t keep head up - recently choked on food, slurring speech - has had diffuctly wearing pants /shirt - exam mild wk neck muscles- twithcing of shoulder - spasticity of muscles, hyper reflexia - sensory exam ok dx?
ALS
dx - EMG
tx: Anti-glutamic acid = Riluzole
Spinal cord
Myelopathy - Upper motor neuron
Radiculopathy - Lower motor neuron
Cervical spondylitis
Compression of cervical Cord - UMN with sensory changes
UMN changes: Spasticity, hyper-reflexia of deltoid, beceps, triceps, extensor plantars
Sensory changes - Loss of position and vibration sense in lateral arm/lateral 3 fingers
Dx: MRI/myelogram
Tx: Steroids
Syringomyelia
Cavitation of central spinal cord -> LMN with sensory changes
LMN changes - weakness of upper limbs; start with hands and proceeds proximally to shoulders
Sensory chages - Lateral column changes: temperature and pain sensation lost - touch and vbration preserved
Dx: MRI
Tx: Monitor if progresses - > surgery
Pt with wk of hand now progresses to shoulder - pain/temp sensation lost but touch and vibration preserved - MRI cavitary lesion of spinal cord
Syringomyelia
Pt with deep ache in buttocks and thighs when standing, disappears on sitting
Spinal stenosis
Pt with pain in thoracic area - flu one week ago or SLE - Now with wk of legs and bladder disturbances - getting worse - hyperreflexia (UMN)
Transverse myelitis
Pt with stock and glove distribution of tingling sensation, pt confused has ataxia, spasticity and clonus
Subacute combined degenration of spinal cord
Pt with loss of vibration in lateral three fingers, hyper reflexia of deltoid, bicepts and triceps
Cervical Spondylitis
L5 Radiculopathy
= +foot drop, can’t evert OR invert foot
…. while Peroneal nerve injury has + foot drop, can’t evert, but CAN invert foot
L5 vs S1 radiculopathy / reflex presetnation
L5 - dec’d dorsiflexion, NO ankle jerk
S1 - dec’d plantar flexion - dec’d ankle jerk
Elderly pt with c/o back pain inc’d with walking - expecially down hill and standing with numbness in legs It decreased while sitting, shaking leg makes it better. MRI would show?
Spinal stenosis
… hypertrophy of Ligamentum flagum.. TX = PT
55yo M after lifting weights - lower back pain - leg raise >45 deg with pain - anal sphincter tone good, dorsiflexion R foot slightly dec’d, ankle jerk dec’d
Sciatica with herniated disc… wtd? analgesics and activity as tolerated
If anal sphincter tone lost or bladder dysfxn (wet or soiled), wtdd?
MRI - r/o cauda equina syndrome
Sensory loss on Lateral aspect of thigh what spinal segment?
L2
One of most common causes of mononeuritis multiplex
PAN
Polyneuropathy - Guillan barre
Guillain Barre - inflammation of nerves with segmental demyelination
LMN - ascending paralysis
CSF - in’c protien, normal WBC
Nerve conducion - slow conduction
tx: IVIG-> plasma phereisis
Elective intubation if reps muscles invovled
Botulism -
Descending paralysis
blurred vision, diplopia, dysarthri, dysphagia
diarrhea/vom in young pt with dilated pupils
Labs; toxin in serum or stool
Tx: botulism anti-toxin
Cyclist with paresthesia in little finger adn inability to adduct little finger and index finger - hypothenar wasting
Ulnar neuropathy
Nocturnal awakening with pain and paraesthesias
Median nerve
Alcoholic with diplopia and weakness of the right hand
Radial neuropathy
Difficulty standing on toes, reflexes dec’d
Sciatica
Wrist drop -
Radial neuropathy
Foot drop
Peroneal nerve comopression
Antibody induced acute polyneuropathy - occurs in
Guillain-barre syndrome…..
occurs over wks to months
Young pt with ankle sprain - takes NSAIDs - extreme tenderness when bed sheet touches - exam bluish discoloration - dx?
Complex regional pain syndrome (formerly reflex sympathetic dystrophy)
If pt with patchy demineralization, bisphosphonates are effective - treatment even in absense of osteoporosis**
19yo playing football has a sudden impact and falls to ground - appears confused upon immediate exam - no LOC, 15 minute later normal cognition and vision and finger -nose test - wtd?
Remove from play –> licensed healthcare provier will decide on case by case basis whne to return to play..
***dont give steroids for traumatic brain injury
Seizures
Generalized
1. Tonic Clonic - valproate, lamotrigine, levetiracetam, topriamate
2. Absense/Petit mal:
without aura or post ictal sx, 3 sec spike and wave patternon EEG
tx: ethosuximide, valproate, lamotrigine
Partial
1. SIMPLE- focal seizure affects small volume of cortex, no LOC (psychic sensation, deja vu
- COMPLEX- involves large enough cortex to cause loss of conciousness
tx: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin(adjunctive)
DONT START ANTI-SEIZURE MEDICATION ONSTROKE PATIENT UNLESS THEY HAVE SEIZURES
Medications that cause seizures
Imipenem, tramadol, bupropion, haldol, meperiridine, PRBC
Partial: Carbamazepine, phenytoin, valproate, levetiracetam, lamotrigine, gabapentin
other causes of seizures: cocaine, alcohol w/d, hypoglycemia, syncopal convulsions, pseudoseizures
SEIZURE –> DECR. HCO3.
Best Anti-sz med for elderly
Lamotrigene
Best anti-Sz med for with liver dz
Keppra (Levetrcetam) (ALSO BEST FOR HIV)
Best anti Sz medication in pregnancy
Carbamapezine
What antiseizure medication causes kidney stones
Topiramate
After the first seizure - best dx imaging is…
CT –> if neg –> MRI
Then do EEG (epileptiform spike +/- slow waves
NORMAL EEG does NOT r/o seizure d/o
Pt makign presentation to supervisor slumps over in chair, diaphretic, has jerks of arms nad legs several times - completely recovers in 30 sec and has pallor, BP normal, cardiac/neuro exam normal dx?
Syncopal convulsions
Pt in dental chair passes out andhas jerky movement o arms and legs, completely recovers in 30 sec - diaphoretic - similar episode once before
neurocardiogenic syncope (P waves w/o QRS? decr. HR)
22yo h/a, smells of burnign rubber, feels strange, no convulsions seen dx?
partial seizure/psychomotor epilepsy
Pt has generalized seuzures not better with dilantin - serum Ca low, ca cl injections don’t help wtd?
Iv Mg SO4
22yo with weird sensation in stomach followed by sudden freezing, swallowing chewing, lip smacking - minute later she starts talking and doesn’t recall eepsode
Partial seizure (doesnt recall = complex partial)
30yo F brought to office - say having recurrent spells of starting for several seconds the haveing intense familiarity with surrounding sand strangers most likely affected lobe is?
Temporal lobe
Young woman with epigastric rising sensation - most likely dz?
simple partial seizure temporal lobe (deja vu)
22yo F with husband and narrating complaint then her leg starts jerking which gets wors and on /off x several minutes - then SOB, then holds head tight afte r3 min jerking stops and feels dizzy and has headache dx?
Pseudoseizure
dec’d Ca+
55yo brought in by family - having episodes when staring blankly for several seconds then shakes hand repeately fo rfew minutes then feels tired - no focal neuro deficits, MRI normal wtd?
Sleep deprived EEG
dx: Complex partial
Pt with onset of seziure of left arm and then spreads to left leg - after episode wk of left arm and leg dx?
Jacksonian seizure
frontal lobe
starts at arm and marches toward leg in terms of sx (begin with fingers - end with legs) - NO LOC
Treatment of status epilepticus (sz >30min or LOC between 2 mor more seizures
- IV glucose + 100mcg thiamine ….
- Lorazepam ….
- Loading dose Phenytoin 10mg/kg or Fosphenytoin (Cerebyx* all of it at once)
- Maximize Phenytoin –> 10mg/kg more
- Phenobarb (Luminal) or Midazolam (Versed)
- General anaestheia and neruomuscular blockade
Pt with new monset seizure - post ictal state recommendation?
No driving
No swimming
Pupils
- Mid dilated - glaucoma ..
- Mid constricted - uveitis (iridocylitis) or compression of sympathetic chain (CXR or CT-A to r/o dissec.) ..
- BL dilated - anti-cholinergics, botulism, cocaine/barbituates OD, anoxia. ..
- UL dilated - CN III compression (MRA lesion –>PCA)
- BL constriction - Opiates, pontine infarct, organophosphate poisoning
MRI/CT findings in different diseases.. infarct?
hypodense area - no enhancement
MRI/CT findings in different diseases.. bleed?
hyperdense area, no need for contrast CT
MRI/CT findings in different diseases.. Multi-infarct dementia?
Mulitple hypodense areas, no enhancement
MRI/CT findings in different diseases.. Tumor?
Enhancing lesion
MRI/CT findings in different diseases.. Brain abscess
Ring enhancing lesion
MRI/CT findings in different diseases.. Toxoplasmosis
Multople ring enhancing lesions
MRI/CT findings in different diseases.. Cerebral atrophy
Dilated ventricles AND dilated sulci
MRI/CT findings in different diseases.. Normal pressure hydrocephalus
Dilated ventricles, sulci NOT dilated** MRI
MRI/CT findings in different diseases.. Multiple Sclerosis
White matter plaques, enhance with active dz
MRI/CT findings in different diseases.. Alzheimer’s
dilated ventricles**+ Brain atrophy, Periventricular white matter lesions
Neuro imaging for headache shouldbe ……
MRI, not CT. If stroke, hemorrhage, and head trauma suspected then non contrast CT
Pt w/ vertigo while turning in bed/getting in aand out of bed, bending over and straightening up, extending neck to look up, episodes last about 30secs. Denies hearing loss. dx? tx?
benign paroxysmal positional vertigo… dx w/ dix-hallpike
tx.. epley-otolith maneuver
