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1
Q

Vascular territories

  1. contralateral arm>leg + gaze hemiparesis, aphasia
  2. aphasia, agnosia, apraxia
  3. diplopia / homonymous hemianopsia, vertigo, crossed facial & body findings
A
  1. middle cerebral artery
  2. anterior cerebral / carotid
  3. posterior / vertebrobasilar
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2
Q

dx?

rapidly progressive dementia, myoclonus, sharp, triphasic synchronous discharges on EEG

A

Creutzfeldt-Jakob

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3
Q 
MS treatments
1. for sx relief during acute attacks
2. disease modifying
INFb
Glatiramer
Natalizumab (fx?)
Gilenya
3. Immunosuppression (for progressive disease)
Mitoxantrone
cyclophosphamide / rituximab / cyclosporine / mtx
4. sx mgmt
fatigue
bladder dysfunction
spasticity
mood
A
  1. IV steroids (oral doesn’t work)
    2.
    INF-b: alters T cells and seals BBB
    Glatiramer = copaxone: synthetic polypeptide of myelin basic protein -> decoy, prevents activation of T cells
    Natalizumab = Tysabri: antibody -> prevents T cells from crossing BBB (fx = PML)
    Gilenya (Fingolimod): spingosine analogue -> hinders migration of lymphocytes from LN to periphery
    3.
    Mitoxantrone = Novantrone: antineoplastic (fx = cardiotox and myelosuppressive)
    4.
    fatigue: amantadine, modafinil (sympathomimetic)
    bladder: anticholinergic
    spasticity: baclofen (GABA agonist) or tizanidine (a2 adrenergic agaonist)
    mood: SSRI
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4
Q

Meningitis pathogens

  1. neonatal
  2. adults
A
  1. E. coli, listeria, GBS

2. Strep pneumo, n. meningitidis

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5
Q

viral vs. bacterial meningitis

A
  1. 1000 WBC
  2. normal glucose vs. low glucose
  3. normal protein vs. high protein
  4. lymphocytes vs. neutrophils
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6
Q

Meningitis abx coverage
Ampicillin
CTX
Vancomycin

A

Ampicillin: strep pneumo, n. meningitidis, listeria
CTX: gram(-), ampicillin-resistant Hib
Vanc: staph aureus (esp if recent neurosurgery)

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7
Q

Myopathies

  1. progressive proximal weakness w/o pain, LE > UE
  2. Muscle pain and stiffness in shoulder and pelvic girdle
  3. Skin rash and infalmmatory arthritis
  4. Rhabdomyolysis
  5. Hypothyroid features
A
  1. steroid-induced myopathy
  2. polymyalgia rheumatica
  3. inflammatory myopathies
  4. statins
  5. hypothyroid myopathy
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8
Q

Stroke localization

  1. pure unilateral motor weakness
  2. contralateral hemiplegia and ipsilateral CN
  3. isolated sensory pain w/ normal touch
  4. P&T deficit over ipsilateral face and contralateral body, ipsilateral bulbar muscle weakness, vestibulocerebellar impairment and Horner’s syndrome (motor spared)
  5. urinary incontinence, emotional disturbances
  6. ataxic hemiparesis, dysarthria / clumsy hand
A
  1. lacunar - internal capsule (posterior limb)
  2. vertebrobasilar - brainstem
  3. thalamic
  4. PICA - lateral medullar - Wallenburg
  5. anterior cerebral
  6. lacunar
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9
Q

Childhood seizures:

  1. what can it not be if >5yo
  2. 3Hz spike-wave EEG + triggered by hyperventilation
  3. shortly after awakening, triggered by sleep deprivation. Tx?
  4. nocturnal localized facila twitching and drooling
  5. absence w/ autonomic or tonic components
  6. absence like but w/ aura
A
  1. febrile seizure
  2. Absence
  3. Juvenile myoclonic - valproic acid
  4. benign Rolandic
  5. atypical absence, in cognitively challenged children
  6. complex partial
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10
Q

tx?

  1. status
  2. persistent status despite initial tx
A
  1. benzo / phenytoin

2. midazolam / PB

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11
Q

AEDs

  1. after 1st seizure
  2. generalized
  3. partial
A
  1. none
  2. valproate (teratogen, wt gain), ethosuximide
  3. phenytoin (gingival hyperplasia), carbamazepine (agranulocytosis, hyponatremia), lamotrigine (SJ), topiramate (nephrolithiasis, “dope-iramate = lowers IQ”), levetiracetam (Keppra rage), lacosamide
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12
Q

Types of headaches:

  1. episodic headache
  2. gradually worsening -> think about?
  3. persistent headache w/o change -> think about?
  4. chronic daily headache w/ episodic exacerbations
  5. before and after orgasm
  6. intense pain radiating from behind ear to temples w/ scalp sensitivity
  7. migraines -> daily less severe headaches punctated by severe migraines
A
  1. acute recurrent
  2. chronic progressive -> increased ICP
  3. chronic daily -> CVT
  4. mixed headache
  5. post coital cephalgia
  6. occipital neuralgia
  7. transformed migraines (overuse of pain relievers)
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13
Q

Migraine tx:

  1. abortive
  2. ppx (when to start?)
A
  1. ibuprofen, acetaminophen, triptans, antiemetics (chlorpromazine, prochlorperazine, metoclopramide), ergotamine
  2. BB, TCA, anticonvulsants (topiramate, valproate), antihistamines, CCB. Start if >3 attacks/mo
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14
Q

Developmental milestones:

  1. gross motor -> if problem think?
  2. social -> think?
  3. global -> think?
  4. cognitive
A
  1. cerebral palsy
  2. hearing problem
  3. autism
  4. perinatal injury / genetics
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15
Q

Stroke types:

  1. no unilateral weakness or numbness
  2. ataxia, nystagmus, facial weakness, occipital headache and neck stiffness
  3. contralateral motor and sensory deficits + homonymous hemianopsia
  4. contralateral motor and sensory deficits + gaze away vs. towards lesion
  5. contralateral motor and sensory deficits + seizure
  6. upgaze palsy
  7. reactive vs. nonreactive pinpoint pupils
  8. coma & total paralysis
  9. hypertensive
A
  1. cerebellar
  2. cerebellar
  3. basal ganglia (putamen, caudate, globus subthalamic nucleus, substantia, nucleus accumbens) or occipital lobe
  4. basal ganglia or occipital vs. thalamus
  5. cerebral (motor = frontal; sensory = parietal)
  6. thalamus
  7. pons vs. thalamus
  8. pons
  9. putamen of basal ganglia
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16
Q

med fx:

  1. somnolence, confusion, hallucinations in older patients, dyskinesia
  2. dry mouth, blurred vision, constipation, nausea & urinary retention
  3. ankle edema and livedo reticularis
  4. insomnia and confusion in elderly patients
A
  1. dopaminergic (levodopa, bromocriptine, pramipexole, ropinirole, entacapone or tolcapone)
  2. anticholinergic (trihexyphenidyl, benztropine)
  3. amantadine
  4. MAOB inhibitor (selegiline)
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17
Q

Contents of cavernous sinus (top to bottom)

A
  1. chiasm and internal carotid
  2. pituitary
  3. III, IV, VI, V1, V2
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18
Q

Tremors

  1. Resting tremor, better w/ mvmt
  2. Resting tremor, worse w/ mvmt
  3. Action tremor
  4. End-action tremor (target directed = intention tremor)
  5. Head tremor
  6. leg involvement vs. no leg involvement
A
  1. Parkinson
  2. Physiologic
  3. Essential
  4. Cerebellar
  5. Essential
  6. Parkinson vs. essential
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19
Q

tx for ET

A

propranolol (avoid if asthma or diabetes), primidone (anti-convulsant), alcohol -> botox -> Deep brain stimulation

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20
Q

functions of ACh

A

parasympathetic and NMJ

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21
Q

Tx:

  1. GBS
  2. trigeminal neuralgia
  3. MG
  4. MG crisis
  5. Restless leg syndrome
  6. ALS
  7. persistent post LP headache
  8. AD
  9. Lewy body dementia
  10. optic neuritis
  11. acute disseminated encephalomyelitis
  12. infantile botulism
  13. Herpes zoster oticus
  14. dermatomyositis
  15. tourette
A
  1. IVIG or plasmapheresis
  2. carbamazepine
  3. pyridostigmine -> immunotherapy
  4. PEX or IVIG + steroids
  5. Fe or pramipexole or gabapentin
  6. Riluzole (glutamate inhibitor)
  7. epidural blood patch
  8. acetylcholinesterase inhibitors (donepizil)
  9. acetylcholinesterase inhibitors (rivastigmine, galanthamine), avoid neuroleptic agents
  10. IV steroids
  11. steroids
  12. antitoxin
  13. acyclovir and steroids
  14. steroids and immunosuppressants
  15. DA blocking agents
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22
Q

Cushing reflex

A

bradycardia + HTN + decreased RR (sign of high ICP)

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23
Q

heat + AMS vs. no AMS

A

heat stroke (thermoregulation failure) vs. heat exhaustion (inadequate fluid and salt replacement)

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24
Q

dx? weakness and muscle cramps -> paralysis leading to hyporeflexia

A

hypokalemia

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25
dx? ECG w/ U waves, flat and broad T waves, premature ventricular beats
hypokalemia
26
iatrogenic causes of pseudotumor
GH, TCA, excessive vit A
27
fx of primidone?
acute intermittent prophyria (abd pain + hallucinations)
28
Dementia types 1. insidious short term memory loss 2. stepwise decline 3. personality changes 4. Visual hallucinations w/ parkinsonism, fluctuating 5. Ataxia, incontinence and dilated ventricles 6. rapidly progressive w/ myoclonus, seizures 7. loss of smell
1. Alzheimer 2. Vascular 3. Frontotemporal 4. Lewy body 5. NPH 6. CJD 7. Parkinson, Alzheimer
29
thrombotic vs. embolic vs. hemorrahgic vs. subarachnoid? 1. maximal @ start 2. signs of increased intracranial pressure 3. seizure 4. stuttering progression w/ periods of improvement 5. WHOML 6. neck stiffness 7. no focal deficits
1. embolic 2. hemorrhagic 3. hemorrhagic 4. thrombotic 5. subarachnoid 6. subarachnoid 7. subarachnoid
30
dx? | HIV patient w/ focal neurological deficits and multiple non-enhancing lesions
PML
31
Gait disorders 1. ataxic 2. magnetic 3. short shuffling steps 4. foot drop, slapping 5. falling to one side
1. cerebellar 2. NPH/frontal 3. Parkinson 4. Neuropathy 5. vestibular (labyrinthitis, meniere)
32
dx? young woman w/ bilateral trigeminal neuralgia
MS
33
dx? progressive ascending paralysis hrs vs. wks
Lyme vs. GBS
34
dx? cape distribution of sensory loss + areflexic weakness in upper extremities
Syringomyelia
35
dx? Parkinson pt w/ othostatic hypotension, impotence, incontinence
multiple system atrophy
36
dx? and tx? 1. sudden sustained contraction 2. restlessness 3. tremor, rigidity, bradykinesia 4. dyskinesia of mouth, face and extremities months after D2 blockade 5. stabbing pain in eye w/ tearing, ipsilateral Horner's, runny nose
1. dystonia; benztropine or diphenhydramine 2. akathisia; benztropine 3. parkinsonism 4. tardive dyskinesia 5. cluster headache; 100% O2
37
Horners in: 1. stroke 2. headache 3. neck injury
1. lateral medullary 2. cluster 3. carotid dissection
38
w/u for: 1. ET 2. SAH 3. new seizures 4. seizure in known epilleptic 5. infantile botulism 6. CNVI palsy 7. demyelinating polyneuropathy
1. MRI 2. CT -> if negative, LP 3. MRI, EEG 4. AED levels 5. fecal 6. MRI to look for vascular / demyelinating causes 7. EMG, CSF, nerve biopsy
39
Imaging findings for: 1. ET 2. Parkinson 3. AD 4. Lewy body 5. supranuclear palsy 6. HIV dementia 7. CJD 8. melanoma brain mets
1. PET showed increased activity in thalamus 2. none 3. temporal atrophy 4. occipital atrophy 5. midbrain atrophy 6. diffuse cerebral atrophy 7. normal or cortical ribboning / thalamic hyperintensity 8. hyperintense on T1, hypointense on T2
40
Histology findings for: 1. ET 2. Parkinson 3. AD
1. Purkinje cell abnormality in cerebellum 2. Substantia nigra (loss of cholinergic DA cells) 3. Nucleus basalis of Meynert (loss of cholinergic cells)
41
Medical ddx for tremor
hyperthyroidism
42
What is Westphal variant?
childhood huntington, which looks more like Parkinson; lesion in neostriatum
43
dx and mgmt | twisting and repetitive mvmts w/ abnormal posture
dystonia -> MRI -> Primary (mutation, torsin A) vs. secondary (trauma, drugs, infections, anoxia) -> DA / anticholinergic, benzos / botox, deep brain stimulator in GPi
44
where is the substantia nigra
midbrain and basal ganglia
45
1. what is lewy body? Diseases? 2. what is neurofibrillary tangles? Diseases? 3. what is amyloid plaques? Diseases?
1. intracellular alpha-synuclein - Parkinson, Lewy body dementia 2. intracellular tau - Alzheimers, supranuclear palsy, FTD 3. extracellular amyloid (presenilin mutation)- Alzheimers
46
Familial parkinson
parkin gene, AR, no Lewy bodies
47
dx? Looks like Parkinson but: 1. w/ limb dystonia / alien limb 2. downgaze palsy and jerk nystagmus
1. Corticobasal ganglionic degeneration | 2. supranuclear palsy
48
tx for Parkinsons 1. DA 2. DA agonist 3. MAOB inhibitor 4. sx relief a. tremors b. levodopa-induced dyskinesia 5. surgery
1. levodopa + carbidopa / entacapone / tolcapone 2. bromocriptin, pramipexole, ropinirole 3. selegiline 4a. anticholinergics (trihexyphenidyl), Amantadine 4b. Amantadine 5. DBS
49
spinocerebellar ataxia vs. ALS
multiple abnormalities w/ prominent ataxia and abnormal cerebellar MRI vs. pure motor weakness w/ normal MRI
50
What is ADSCA?
trinucleotide repeat expansion: Presents in adulthood, no non-neuro involvement I: +cognitive impairment II: +pigmentary macular dystrophy, myoclonus III: pure cerebellar
51
Tardive dyskinesia 1. RFs? 2. if patient on metoclopramide 3. TD vs. dystonia
1. old, female, pre-existing brain damage 2. switch to domperidone (doesn't cross BBB) 3. spasms of neck & back vs. no spasms; worse w/ anticholinergic vs. better; late onset vs. acute onset
52
Spinal cord injuries 1. ipsilateral motor and vibration + contralateral P&T 2. bilateral motor and PT, normal vibration 3. bilateral motor UE>LE and PT, normal vibration
1. Brown-sequard 2. anterior cord 3. central cord (leg motor fibers run more laterally and are thus spared)
53
hyponatremia following head trauma?
SIADH
54
Head trauma: 1. fluctuating cognition 2. persistent confusion/memory deficit after 15 min 3. brief convulsion @ time of initial head injury
1. delirium 2. concussion 3. no AED needed
55
Todd's paralysis
post-ictal paralysis
56
1. agnosia | 2. apraxia
1. can't recognize things | 2. can't do things
57
mgmt post SAH
minimize vasospasms through nimodipine + triple H: HTN, hypervolemic, hemodilution
58
Locations of aneurysms: 1. 3rd nerve palsy 2. kidney cysts
1. Pcomm | 2. Acomm
59
catamenial epilepsy
seizures associated w/ menstrual cycles
60
most common seizure in adults?
complex partial
61
1. pseudoseizure vs. malingering 2. signs of pseudoseizure 3. organic disease associated w/ pseudoseizure
1. conversion vs. faking 2. tonic-clonic activity w/o LOC, pelvic mvmts, rotatory head mvmts, no electrical abnormalities 3. asthma
62
med trigger of acute glaucoma
anti-cholinergic drugs
63
fx of triptans
n/v, paresthesias in toes and fingers; contraindicated in patients w/ CAD or HTN
64
Midrin
acetaminophen, dichloralphenazone (muscle relaxant) and isometheptene mucate (vasoconstrictor) for migraine
65
pseudodementia vs. AD
"I don't know" vs. near misses
66
lab findings in B12 deficiency
``` high methylmelanyl CoA high homocysteine (also seen in folate def) ```
67
dx? spastic ataxia, loss of joint position sense
subacute combined degeneration / B12 def
68
B12 def vs. MS?
peripheral vs. central
69
medical causes of optic neuropathy
ethambutol and amiodarone
70
pupils in optic neuritis?
APD = Marcus Gunn pupil
71
facial myokymia
wormlike movement of muscles felt by patients w/ MS
72
1. MR modalities? | 2. imaging modality for MS?
``` 1. T1: white is white, gray is gray (cortical), dark CSF T2: reverse of T1 FLAIR: T2 but dark CSF 2.FLAIR ```
73
CSF findings in MS
oligoclonal bands (also in SLE, SSPE, sarcoidosis, SAH, syphilis, CNS lymphoma) high IgG high myelin basic protein
74
1. dx? viral / vaccine in genetically susceptible patient -> HA, n, confusion, spinal cord compromise 2. hyperacute form? 3. may not be differentiable from?
1. acute disseminated encephalomyelitis (inflammatory demyelination) 2. acute necrotizing hemorrhagic encephalomyelitis 3. MS
75
most common cause of viral meningitis
enterovirus (Coxsackie, echo)
76
mgmt of meningitis
abx -> imaging -> +/- mannitol -> LP
77
1. botulism vs. GBS 2. botulism vs. MG 3. botulism vs. polio
1. descending vs. ascending weakness 2. hyporeflexia vs. normal reflexes 3. symmetric vs. assymetric
78
dx? behavioral changes / memory / attention / slow thinking w/ normal neuropsych tests, tripping / falling / apraxia / akinetic mutism (decreased motor and verbal activity)
HIV associated dementia
79
HIV pt w/ depression -> screen for?
HIV dementia
80
dx? lancinating pain, ataxia, hyporeflexia, CN abnormalities, impotence or incontinence
tabes dorsalis
81
CSF: elevated protein and IgG
MS or syphillis
82
different forms of neurosyhillis
asymptomatic -> meningovascular -> general paresis -> tabes dorsalis
83
dx? syphilitic patient w/ headaches, cognitive changes and CN abnormalities
syphilitic meningitis
84
1. unresponsive pupil w/ impaired corneal sensation and hyporeflexia in legs 2. vermiform movements when redilating
1. Homes-Adie | 2. ciliary ganglion dysfunction
85
Homes Adie vs. 3rd nerve
yes accomodative pupils vs. no
86
papilledema w/ brain tumors in adults vs. children
no vs. yes
87
CNVI palsy in young vs. old
malignant vs. benign
88
dx? facial paralysis w/ ear pain and vessicles
Herpes zoster oticus = Ramsay Hunt syndrome
89
1. bilateral facial paralysis -> think? | 2. incomplete facial palsy -> think?
1. Lyme, GBS | 2. Parotid gland tumor
90
Ramsay Hunt vs. Bells
zoster vs. simplex
91
blown pupil and/or ptosis -> what type of herniation?
uncal
92
tests for MG
tensilon = edrophonium, cooling (both improves)
93
Vertigo: 1. (days) hearing loss, tinnitis, n/v 2. (minutes) aural pressure, low pitch tinnitus and hearing loss 3. (sec) rotatory nystagmus and reverses w/ standing and fatigues on repeat 4. (min) migraine 5. (min) speech and swallow problems 6. (days) viral infection
1. labyrinthitis 2. Meniere -> low salt diet 3. BPPV -> canalith repositioning procedure 4. vestibular migraine 5. vertebrobasilar insufficiency -> antiplatelet 6. vestibular neuritis
94
triggers for BPPV
aspirin, phenytoin, alcohol
95
dx? slow version of GBS
chronic inflammatory demyelinating polyneuropathy
96
CSF finding in demyelinating polyneuropathy
albuminologic dissociation (high protein, normal cells)
97
subtypes of GBS: 1. ascending paralysis 2. areflexia, ataxia, CN>extremities, anti-GQ1b ganglioside ab 3. purely motor, in children 4. in adults 5. dysarrythmias
1. AIDP 2. Miller-Fisher 3. Acute motor axonal neuropathy 4. acute motor sensory axonal neuropathy 6. acute panautonomic neuropathy
98
cutaneous features of dermatomyositis vs. SLE
heliotrope rash vs. malar Gottron papules over joints vs. between joints Shawl sign
99
inclusion body vs. polyomyositis vs. dermatomyositis | associated w/ malignancy?
polymyositis
100
dx? degeneration of both upper(increased tone) and lower (atrophy, fasciculations) motor neurons in a single limb
ALS
101
common mimic of ALS
cervical myelopathy
102
nerve roots of peroneal nerve
L4-L5
103
complex (vs. simple) febrile seizure
focal, >15min and recurs within 24 hrs
104
most common pathogen associated w/ febrile seizures
Herpes 6
105
migraine and epilepsy
both doubles the risk for the other
106
other system manifestations of 1. DMD 2. BMD
1. heart failure, low IQ | 2. cardiomyopathy
107
features of tics
suggestible and temporarily suppressible
108
language in autism
regresses
109
metastatic brain tumor 1. mass effect? 2. location 3. enhancement? 4. tx?
1. yes, 2/2 edema 2. 80% supratentorial @ G-W junction 3. ring 4. radiation
110
1. dx? 2. pathophys? | profound hypotonia and weakness in an infant who is alert and attentive
1. spinal muscular atrophy type 1 | 2. overzealous pruning of motor neurons during development
111
recurrent seizures, infantile spasms, severe mental retardation, dysmorphic craniofacial features 1. dx? 2. spectrum? 3. chromosome?
1. Lissencephaly (smooth brain) 2. Miller-Dieker > isolated lissencephaly 3. 17

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