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Neurology > 8th jan 24 > Flashcards

8th jan 24 Flashcards

1
Q

Ttt of restless leg syndrome

A

Non pharm:

Limit caffeine and alcohol
Regular exercise
Warm / cold soaks

Pharm ;

Supplemental iron if ferritin <75
Mild cases: Carbidopa levodopa
Daily s/s. : a2Delta ca channel ligand
(Gabapentin, pregablin)

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2
Q

RF for RLS

A

Iron def
Uremia
Pregnancy
DM (esp neuropathy)
Multiple Sclerosis
Parkinsons dx
Drugs: antidepressants , antipsychotics , antiemetics

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3
Q

Causes of peripheral neuropathy

A

DM
Hypothyroidism
B12 def

Toxic: Alcohol
Medicines - phenytoin ,disulfiram, platinum chemo
Heavy metals

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4
Q

Alcoholic neuropathy mechanism

A

Toxic neuropathy causes neurotoxicity by reducing no of small myelinated and unmyelinated fibers.
Concurrent thiamine def. results in concurrent demyelination.

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5
Q

Alcoholic neuropathy C/p

A

Symmetric distal polyneuropathy
Stocking and glove pattern
Parestheia
Burning pain
Numbness
Loss of DTR
Loss of light touch and vib
Gait ataxia

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6
Q

Vasculitic neuropathy

A

Polyarteritis nodosa (mononeuritis multiplex)
Patchy asymmetric neuropathy affecting several nerves

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7
Q

GBS c/f

A

Paresthesia
Neuropathic pain
Symmetric ascending weakness
Decreased absent DTR
Autonomic dysfunction (arrhythmia,ileus)
Resp compromise

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8
Q

How to diagnose GBS

A

Clinical dx
CSF: ⬆️protein, normal leukocytes
EMG
Nerve conduction
MRI. ( enhanced anterior nerve roots, cauda equina)

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9
Q

GBS RF

A

Recent Acute infection (GI or resp immune response that cross reacts -molecular mimicry)

Acute HIV (GBS occurs prior to onset of AIDS while there is still a robust response)
Can be Initial HIV presentation.

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10
Q

S/e of longterm metformin ttt

A

B12 def

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11
Q

C/P of b12 def

A

Sensory ataxia - stamping gait with positive romberg sign (dorsal column)

Upgoing plantars. - lateral CS tract

Lower extremity paresthesia - myelinated peripheral nerves

Neuropsych manifestations- irriation , mood changes -myelinated fibers in brain

Gait ataxia - Spinocerebellar tract

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12
Q

Pt with rash and pain /hyperesthesian in the same area of rash … h/o cancer with chemo and radio

A

Postherpetic neuralgia
Persistent pain > 4 Months
Reactivation of VZV causing pain due to inflammation if sensory nerve

C/f
Allodynia - pain on non painful stimuli
Anesthesia
Hyperesthesian

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13
Q

Ttt of post herpetic neuralgia

A

Gabapentin
Pregablin
TCA

➡️valacyclovir (stops active replication of virus ) can reduce risk of PHN
But once PHN develops antivirals have no role as PHN is not due to ongoing viral replication.

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14
Q

Patient with ascending paralysis no reflexes , no motor activity in one leg
With normal CSF

A

Tick paralysis.

Ttt: meticulous search for tick
With complete recovery in several days

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15
Q

Congenital CMV C/F

A

Hepatospleenomegaly
Jaundice
Periventricular calcifications
Microcephaly
Thrombocytopenia

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16
Q

Congenital CMV long term sequel

A

Sensorineural hearing loss

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17
Q

Cryptococcal meningoencephalitis C/P

A

Headache
N/V
Confusion
Abducens nerve palsy
Scattered umbilicated skin papules
Raised ICP

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18
Q

Ramsay hunt syndrome /herpes zoster oticus C/P

A

Ear pain
Vesicukar rash in EAC
Facial weakness

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19
Q

Hepes zoster oticus mechanism

A

Reactivation of latent VZV in GENICULATE GANGLION disrupting facial nerve function.
Vesicular rash in EAC (innervated by facial nerve) is classic.
Spread to vestibulocochlear nerve (8th) can lead to auditory and vestibular disturbance.
Reactivation mostly happens in adults but can occur in children too.

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20
Q

Ttt of herpeszoster oticus

A

Corticosteroids
Antivirals

Early initiation <3days ass with improved recovery of facial nerve function

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21
Q

Herpes simplex encephalitis c/p

A

Acute in onset <1 week duration
Focal neurological findings
Fever
Behavior changes - hypomania ,kluver bucy syndrome (hyperphagia, hypersexuality) , amnesia

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22
Q

Herpes simple encephalitis dx

A

CSF: Lymphocytic pleocytosis
Inc erythrocytes
Elevated protein

MRI : Temporal lobe lesions

CSF PCR: Gold standard

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23
Q

Herpes simplex encephalitis ttt

A

I/V acyclovir

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24
Q

Pt with tremor worse with holding newspaper and drinking coffee

A

Essential tremor

BL action tremor of hands
No neurologic deficits
Improves with alcohol
Head tremor without dystonia
Slowly progressive
Hereditary

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25
Q

Physiologic tremor

A

Most common cause of action tremor
Worse with movement
Can be due to drugs , hyperthyroidism, anxiety, coffee(inc sympathetic activity)
Low amplitude not visible in normal conditions

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26
Q

Ttt of essential tremor

A

Propranolol. Bb
Primidone Anticonvulsant

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27
Q

B12 def C/p

A

➡️Anemia
➡️Macrocytosis elevated MCV
➡️Normal MCV if concurrent iron def anemia (in crohn dx due to bleeding)
➡️subacute combined degeneration

(Myelinated nerve fibres in Peripheral nervous system affected first hence lower extremity paresthesia comes first )

Demyelination of dorsal coulmn ( gait ataxia , reduced vib sensation)
Demyelination of lateral corticospinal tract (spastic paresis, enhanced reflexes)

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28
Q

B12 def dx

A

➡️Serum B12 levels initial
➡️Methylmalonic acid and homocysteine levels for inconclusive results

29
Q

What precipitates myasthenia crisis??

A

Infection
Surgery
Pregnancy/childbirth
Tapering immmunosuppressive drugs
Medicines- Aminoglycosides , BB

30
Q

S/S of myasthenia crisis

A

💩Inc generalised and oropharyngeal bulbar weakness (dysphagia, hypernasal speech)

💩Resp insufficiency

31
Q

Ttt myasthenia crisis

A

Intubation for worsening resp status

Plasmapheresis or IVIG plus steroids

32
Q

Red flags of unilateral facial weakness

A

▶️ upper face spared ( MRI for stroke)

▶️ focal neurological deficits ( MRI for stroke)

▶️ lyme endemic area, EM rash,flu like ill ess. (Lyme serology needed)

▶️ hearing loss, vertigo ( MRI for CPA tumor)

▶️ lower limb weakness , dec DTR
( do LP for GBS )

33
Q

C/P of bells palsy

A

▶️Mouth drooping
▶️Disappearance of nasolabial fold
Involvement of upper face (inability to close eye
Weakness raising eyebrow )

▶️Decreased tearing
▶️Hyperacusis
▶️Reduced taste over anterior 2/3 of tongue

34
Q

Ttt of bells palsy

A

Oral glucocorticoids

Antivirals

35
Q

Bells palsy causes

A

HZV,
HSV
Idiopathic
Parotid tumor
Lyme dx
Sarcoidosis

36
Q

Mechanism of bell palsy

A

Reactivation of neutrotropic virus (HSV)
Viral infection causes of inflamamtion and edema of facial nerve causing nerve compression and demyelination of nerve sheath.

37
Q

Myasthenia gravis C/P

A

🤓 fluctuating fatiguable proximal muscle weakness
BRO:
Ocular- diplopia , ptosis
Bulbar- dysphagia , dysarthria
Resp - myasthenia crisis

38
Q

Dx of myasthenia gravis

A

Ice pack test (Increases acetylcholine in NMJ by inhibiting its breakdown)
AChR Ab (specific)
CT chest (thymoma)

39
Q

Ttt of myasthenia gravis

A

▶️AChE inhibitor - pyridostigmine
▶️Immunotherapy (corticosteroids , Azathioprine)
▶️Thymectomy

40
Q

Myasthenia gravis mech

A

Autoantibodies against post synaptic nicotinic acetylcholine Receptors at NMJ

41
Q

Thymus and myasthenia

A

Thymus is involved in diff of Tcells and site of autoimmunization in MG

Thymoma and thymic hyperplasia is involved in pts with AChR antibodies

Even in the absence if thymoma thymectomy is beneficial to MG pts

Transient worsening of S/S (myasthenia crisis with Resp failure ) after thymenctomy treated with periopertaive pyridostigmine and immunosuppressants

DX : CT chest

42
Q

Pt with unilateral steppage gait and flexion of Rt hip and knee ?

A

Common fibular nerve neuropathy

Compression at fibular neck sensory loss on dorsum of feet and impaired dorsiflexion and eversion

Negative Romberg

Pt flexes hip and knee to avoid dragging foot

Foot drop

Other cause of unilateral steppage gait
L5 radiculopathy

43
Q

B/l steppage gait causes

A

Sensory ataxia
(B12 def , compressive myelopathy)

Wide based stappage gait
Worse in dark
Positive romberg
Loss of proprioception vib

44
Q

Meningovascular syphilis

A

Meningitis. Plus ischemic stroke with H/o multiple sexual partners

45
Q

Meningovascular syphilis dx

A

Brain imaging;
Focal segmental arterial narrowing of MCA

LP : confirms the dx
Positive VDRL

46
Q

MV syphilis ttt

A

Iv penicillin 10-14 days

47
Q

MV syphilis C/P

A

H/o multiple sexual partners

Meningitis ( headache NV neck stiffness)
For 2 weeks followed by;
Ischemic stroke
(U/L weakness hypereflexia)

Diffuse maculopapular rash involving extremeties palms soles trunk

48
Q

Tabes dorsalis C/P

A

Years ➡️ decades after initial infection

Sensory ataxia (dorsal column)

Lancinating pains (dorsal nerve root)
Brief periods of shooting burning pain in face back extremities

Positive Romberg test

Neurogenic Urinary incontinece

ArgylRobertson pupil

49
Q

Tabes dorsalis vs B12 def

A

B12 def does not involve dorsal nerve roots and is not ass with Argyll Robertson pupils

50
Q

Early neurosyphilis

A

Meningitis
Eyes: optic neuritis , uveitis
Ear. : hearing loss tinnitis
Meningovascular (with stroke)

51
Q

Late neurosyphilis

A

Progressive dementia
Tabes dorsalis

52
Q

Causes of brain abscess

A

▶️Acute otitis media direct spread
▶️Acute mastoiditis direct spread
▶️Infective endocarditis Hematogenous spread
▶️Sinusitis Direct spread

53
Q

Organism for brain abscess

A

Staph aureus
Strept pneumo
Viridans strept
Anaerobes

54
Q

C/P of brain abscess

A

Progressive headache
Resistant to analgesics

Nocturnal headaches due to inc ICP
(Supine position)

Vomiting

Fever

Focal neurological deficits

Fleeting pains ,myalgias , subconjuctival ,hemmorrhages, Murmur
(IE)

Rhinorrhea congestion fever (sinusitis)

Seizures

Bulging perforated erythematous TM
Irritability
(AOM)

Tender mastoid swollen and erythematous , opacification of mastoid air cells on MRI/CT (mastoiditis)

55
Q

DX of brain abscess

A

MRI brain or CT

CT guided aspiration or surgical biopsy of lesion

56
Q

Ttt of brain abscess

A

Empirical AB
Metronidazole
Ceftriaxone
Vancomycin

Aspirate the lesion

57
Q

Cryptococcal meningitis c/p

A

Immunocompromised pt
Transplant pt
On immunosuppressant meds
AIDS CD4 <100
Signs if Inc ICP
Capsular polysaccharides clogs arachnoid villi causing CSF obstruction

Headache 
N/V
Confusion
Diplopia 
Lateral gaze palsy

Abducens nerve palsy (lateral gaze palsy) and diplopia due to inc ICP

Umbilicated skin lesions

58
Q

Cryptococcal meningitis dx

A

LP : encapsulated yeast capsular polysaccharide with india ink stain

      Low glucose 
      Inc protein
      Lymphos

Brain imaging normal

59
Q

Ttt of crytococcal meningitis

A

Antifungals IV

60
Q

Herpes encephalitis mech

A

HSV 1 travels retrograde along trigeminal nerve to attack temporal lobe

Blood in CSF

61
Q

Viral (mumps) meningitis

A

Slight ⬆️ protein
Normal glucose
⬆️ cell count lymphs

62
Q

TB meningitis CSF

A

Low glucose
⬆️ protein
⬆️ cell count with lymphos
Elevated adenosine deaminase
(Like fungal)

CSF acid fast bacilli is diagnostic

63
Q

Tuberculous meningitis dx

A

Imaging : basilar meningeal enhancement and hydrocephalus
(Hydrocephalus due to obstruction of CSF outflow by tubercular proteins and vasculitis due to cerebral artery inflammation)

CSF counts

CSF AFB smear

64
Q

TB meningitis CP

A

Slow progressive in weeks
Subacute SS of meningeal irritation
Fever
Nuchal rigidity
Headache
CN palsy
Stroke (due to vasculitis)

65
Q

Meningitis in children organism

A

Strept pneumo
Neisseria

66
Q

Bacterial meningitis paeds C/F

A

Fever
Age <1 : Bulging fontanelle , irritability, poor feeding
Age > 1 : Signs if inc ICP , meningeal signs

67
Q

Dx of meningitis

A

CSF culture

68
Q

Bacterial meningitis ttt

A

Vancomycin + ceftriaxone
+/- dexamethasone

69
Q

Bacterial meningitis Complications

A

Sensorineural hearing loss
( Most common - inflammation if cochlea leads to fibrosis and then ossification of cochlea can quickly follow leading to permanent profound hearing loss )

Behavior disability

CP

Epilepsy

All patients with bacterial meningitis should undergo audiologic testing asap before discharge

Neurology (19 decks)

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