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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
Physiologic tremor
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
26
Ttt of essential tremor
Propranolol. Bb Primidone Anticonvulsant
27
B12 def C/p
➡️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)
28
B12 def dx
➡️Serum B12 levels initial ➡️Methylmalonic acid and homocysteine levels for inconclusive results
29
What precipitates myasthenia crisis??
Infection Surgery Pregnancy/childbirth Tapering immmunosuppressive drugs Medicines- Aminoglycosides , BB
30
S/S of myasthenia crisis
💩Inc generalised and oropharyngeal bulbar weakness (dysphagia, hypernasal speech) 💩Resp insufficiency
31
Ttt myasthenia crisis
Intubation for worsening resp status Plasmapheresis or IVIG plus steroids
32
Red flags of unilateral facial weakness
▶️ 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
C/P of bells palsy
▶️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
Ttt of bells palsy
Oral glucocorticoids Antivirals
35
Bells palsy causes
HZV, HSV Idiopathic Parotid tumor Lyme dx Sarcoidosis
36
Mechanism of bell palsy
Reactivation of neutrotropic virus (HSV) Viral infection causes of inflamamtion and edema of facial nerve causing nerve compression and demyelination of nerve sheath.
37
Myasthenia gravis C/P
🤓 fluctuating fatiguable proximal muscle weakness BRO: Ocular- diplopia , ptosis Bulbar- dysphagia , dysarthria Resp - myasthenia crisis
38
Dx of myasthenia gravis
Ice pack test (Increases acetylcholine in NMJ by inhibiting its breakdown) AChR Ab (specific) CT chest (thymoma)
39
Ttt of myasthenia gravis
▶️AChE inhibitor - pyridostigmine ▶️Immunotherapy (corticosteroids , Azathioprine) ▶️Thymectomy
40
Myasthenia gravis mech
Autoantibodies against post synaptic nicotinic acetylcholine Receptors at NMJ
41
Thymus and myasthenia
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
Pt with unilateral steppage gait and flexion of Rt hip and knee ?
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
B/l steppage gait causes
Sensory ataxia (B12 def , compressive myelopathy) Wide based stappage gait Worse in dark Positive romberg Loss of proprioception vib
44
Meningovascular syphilis
Meningitis. Plus ischemic stroke with H/o multiple sexual partners
45
Meningovascular syphilis dx
Brain imaging; Focal segmental arterial narrowing of MCA LP : confirms the dx Positive VDRL
46
MV syphilis ttt
Iv penicillin 10-14 days
47
MV syphilis C/P
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
Tabes dorsalis C/P
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
Tabes dorsalis vs B12 def
B12 def does not involve dorsal nerve roots and is not ass with Argyll Robertson pupils
50
Early neurosyphilis
Meningitis Eyes: optic neuritis , uveitis Ear. : hearing loss tinnitis Meningovascular (with stroke)
51
Late neurosyphilis
Progressive dementia Tabes dorsalis
52
Causes of brain abscess
▶️Acute otitis media direct spread ▶️Acute mastoiditis direct spread ▶️Infective endocarditis Hematogenous spread ▶️Sinusitis Direct spread
53
Organism for brain abscess
Staph aureus Strept pneumo Viridans strept Anaerobes
54
C/P of brain abscess
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
DX of brain abscess
MRI brain or CT CT guided aspiration or surgical biopsy of lesion
56
Ttt of brain abscess
Empirical AB Metronidazole Ceftriaxone Vancomycin Aspirate the lesion
57
Cryptococcal meningitis c/p
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
Cryptococcal meningitis dx
LP : encapsulated yeast capsular polysaccharide with india ink stain Low glucose Inc protein Lymphos Brain imaging normal
59
Ttt of crytococcal meningitis
Antifungals IV
60
Herpes encephalitis mech
HSV 1 travels retrograde along trigeminal nerve to attack temporal lobe Blood in CSF
61
Viral (mumps) meningitis
Slight ⬆️ protein Normal glucose ⬆️ cell count lymphs
62
TB meningitis CSF
Low glucose ⬆️ protein ⬆️ cell count with lymphos Elevated adenosine deaminase (Like fungal) CSF acid fast bacilli is diagnostic
63
Tuberculous meningitis dx
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
TB meningitis CP
Slow progressive in weeks Subacute SS of meningeal irritation Fever Nuchal rigidity Headache CN palsy Stroke (due to vasculitis)
65
Meningitis in children organism
Strept pneumo Neisseria
66
Bacterial meningitis paeds C/F
Fever Age <1 : Bulging fontanelle , irritability, poor feeding Age > 1 : Signs if inc ICP , meningeal signs
67
Dx of meningitis
CSF culture
68
Bacterial meningitis ttt
Vancomycin + ceftriaxone +/- dexamethasone
69
Bacterial meningitis Complications
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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