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CaseFiles Flashcards

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
Q

dx? ECG w/ U waves, flat and broad T waves, premature ventricular beats

A

hypokalemia

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26
Q

iatrogenic causes of pseudotumor

A

GH, TCA, excessive vit A

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27
Q

fx of primidone?

A

acute intermittent prophyria (abd pain + hallucinations)

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28
Q

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
A
  1. Alzheimer
  2. Vascular
  3. Frontotemporal
  4. Lewy body
  5. NPH
  6. CJD
  7. Parkinson, Alzheimer
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29
Q

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
A
  1. embolic
  2. hemorrhagic
  3. hemorrhagic
  4. thrombotic
  5. subarachnoid
  6. subarachnoid
  7. subarachnoid
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30
Q

dx?

HIV patient w/ focal neurological deficits and multiple non-enhancing lesions

A

PML

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31
Q

Gait disorders

  1. ataxic
  2. magnetic
  3. short shuffling steps
  4. foot drop, slapping
  5. falling to one side
A
  1. cerebellar
  2. NPH/frontal
  3. Parkinson
  4. Neuropathy
  5. vestibular (labyrinthitis, meniere)
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32
Q

dx? young woman w/ bilateral trigeminal neuralgia

A

MS

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33
Q

dx? progressive ascending paralysis hrs vs. wks

A

Lyme vs. GBS

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34
Q

dx? cape distribution of sensory loss + areflexic weakness in upper extremities

A

Syringomyelia

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35
Q

dx? Parkinson pt w/ othostatic hypotension, impotence, incontinence

A

multiple system atrophy

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36
Q

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
A
  1. dystonia; benztropine or diphenhydramine
  2. akathisia; benztropine
  3. parkinsonism
  4. tardive dyskinesia
  5. cluster headache; 100% O2
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37
Q

Horners in:

  1. stroke
  2. headache
  3. neck injury
A
  1. lateral medullary
  2. cluster
  3. carotid dissection
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38
Q

w/u for:

  1. ET
  2. SAH
  3. new seizures
  4. seizure in known epilleptic
  5. infantile botulism
  6. CNVI palsy
  7. demyelinating polyneuropathy
A
  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
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39
Q

Imaging findings for:

  1. ET
  2. Parkinson
  3. AD
  4. Lewy body
  5. supranuclear palsy
  6. HIV dementia
  7. CJD
  8. melanoma brain mets
A
  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
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40
Q

Histology findings for:

  1. ET
  2. Parkinson
  3. AD
A
  1. Purkinje cell abnormality in cerebellum
  2. Substantia nigra (loss of cholinergic DA cells)
  3. Nucleus basalis of Meynert (loss of cholinergic cells)
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41
Q

Medical ddx for tremor

A

hyperthyroidism

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42
Q

What is Westphal variant?

A

childhood huntington, which looks more like Parkinson; lesion in neostriatum

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43
Q

dx and mgmt

twisting and repetitive mvmts w/ abnormal posture

A

dystonia -> MRI -> Primary (mutation, torsin A) vs. secondary (trauma, drugs, infections, anoxia) -> DA / anticholinergic, benzos / botox, deep brain stimulator in GPi

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44
Q

where is the substantia nigra

A

midbrain and basal ganglia

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45
Q
  1. what is lewy body? Diseases?
  2. what is neurofibrillary tangles? Diseases?
  3. what is amyloid plaques? Diseases?
A
  1. intracellular alpha-synuclein - Parkinson, Lewy body dementia
  2. intracellular tau - Alzheimers, supranuclear palsy, FTD
  3. extracellular amyloid (presenilin mutation)- Alzheimers
46
Q

Familial parkinson

A

parkin gene, AR, no Lewy bodies

47
Q

dx? Looks like Parkinson but:

  1. w/ limb dystonia / alien limb
  2. downgaze palsy and jerk nystagmus
A
  1. Corticobasal ganglionic degeneration

2. supranuclear palsy

48
Q

tx for Parkinsons

  1. DA
  2. DA agonist
  3. MAOB inhibitor
  4. sx relief
    a. tremors
    b. levodopa-induced dyskinesia
  5. surgery
A
  1. levodopa + carbidopa / entacapone / tolcapone
  2. bromocriptin, pramipexole, ropinirole
  3. selegiline
    4a. anticholinergics (trihexyphenidyl), Amantadine
    4b. Amantadine
  4. DBS
49
Q

spinocerebellar ataxia vs. ALS

A

multiple abnormalities w/ prominent ataxia and abnormal cerebellar MRI vs. pure motor weakness w/ normal MRI

50
Q

What is ADSCA?

A

trinucleotide repeat expansion:
Presents in adulthood, no non-neuro involvement
I: +cognitive impairment
II: +pigmentary macular dystrophy, myoclonus
III: pure cerebellar

51
Q

Tardive dyskinesia

  1. RFs?
  2. if patient on metoclopramide
  3. TD vs. dystonia
A
  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
Q

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
A
  1. Brown-sequard
  2. anterior cord
  3. central cord (leg motor fibers run more laterally and are thus spared)
53
Q

hyponatremia following head trauma?

A

SIADH

54
Q

Head trauma:

  1. fluctuating cognition
  2. persistent confusion/memory deficit after 15 min
  3. brief convulsion @ time of initial head injury
A
  1. delirium
  2. concussion
  3. no AED needed
55
Q

Todd’s paralysis

A

post-ictal paralysis

56
Q
  1. agnosia

2. apraxia

A
  1. can’t recognize things

2. can’t do things

57
Q

mgmt post SAH

A

minimize vasospasms through nimodipine + triple H: HTN, hypervolemic, hemodilution

58
Q

Locations of aneurysms:

  1. 3rd nerve palsy
  2. kidney cysts
A
  1. Pcomm

2. Acomm

59
Q

catamenial epilepsy

A

seizures associated w/ menstrual cycles

60
Q

most common seizure in adults?

A

complex partial

61
Q
  1. pseudoseizure vs. malingering
  2. signs of pseudoseizure
  3. organic disease associated w/ pseudoseizure
A
  1. conversion vs. faking
  2. tonic-clonic activity w/o LOC, pelvic mvmts, rotatory head mvmts, no electrical abnormalities
  3. asthma
62
Q

med trigger of acute glaucoma

A

anti-cholinergic drugs

63
Q

fx of triptans

A

n/v, paresthesias in toes and fingers; contraindicated in patients w/ CAD or HTN

64
Q

Midrin

A

acetaminophen, dichloralphenazone (muscle relaxant) and isometheptene mucate (vasoconstrictor) for migraine

65
Q

pseudodementia vs. AD

A

“I don’t know” vs. near misses

66
Q

lab findings in B12 deficiency

A 
high methylmelanyl CoA
high homocysteine (also seen in folate def)
67
Q

dx? spastic ataxia, loss of joint position sense

A

subacute combined degeneration / B12 def

68
Q

B12 def vs. MS?

A

peripheral vs. central

69
Q

medical causes of optic neuropathy

A

ethambutol and amiodarone

70
Q

pupils in optic neuritis?

A

APD = Marcus Gunn pupil

71
Q

facial myokymia

A

wormlike movement of muscles felt by patients w/ MS

72
Q
  1. MR modalities?

2. imaging modality for MS?

A 
1.
T1: white is white, gray is gray (cortical), dark CSF
T2: reverse of T1
FLAIR: T2 but dark CSF
2.FLAIR
73
Q

CSF findings in MS

A

oligoclonal bands (also in SLE, SSPE, sarcoidosis, SAH, syphilis, CNS lymphoma)
high IgG
high myelin basic protein

74
Q
  1. dx? viral / vaccine in genetically susceptible patient -> HA, n, confusion, spinal cord compromise
  2. hyperacute form?
  3. may not be differentiable from?
A
  1. acute disseminated encephalomyelitis (inflammatory demyelination)
  2. acute necrotizing hemorrhagic encephalomyelitis
  3. MS
75
Q

most common cause of viral meningitis

A

enterovirus (Coxsackie, echo)

76
Q

mgmt of meningitis

A

abx -> imaging -> +/- mannitol -> LP

77
Q
  1. botulism vs. GBS
  2. botulism vs. MG
  3. botulism vs. polio
A
  1. descending vs. ascending weakness
  2. hyporeflexia vs. normal reflexes
  3. symmetric vs. assymetric
78
Q

dx? behavioral changes / memory / attention / slow thinking w/ normal neuropsych tests, tripping / falling / apraxia / akinetic mutism (decreased motor and verbal activity)

A

HIV associated dementia

79
Q

HIV pt w/ depression -> screen for?

A

HIV dementia

80
Q

dx? lancinating pain, ataxia, hyporeflexia, CN abnormalities, impotence or incontinence

A

tabes dorsalis

81
Q

CSF: elevated protein and IgG

A

MS or syphillis

82
Q

different forms of neurosyhillis

A

asymptomatic -> meningovascular -> general paresis -> tabes dorsalis

83
Q

dx? syphilitic patient w/ headaches, cognitive changes and CN abnormalities

A

syphilitic meningitis

84
Q
  1. unresponsive pupil w/ impaired corneal sensation and hyporeflexia in legs
  2. vermiform movements when redilating
A
  1. Homes-Adie

2. ciliary ganglion dysfunction

85
Q

Homes Adie vs. 3rd nerve

A

yes accomodative pupils vs. no

86
Q

papilledema w/ brain tumors in adults vs. children

A

no vs. yes

87
Q

CNVI palsy in young vs. old

A

malignant vs. benign

88
Q

dx? facial paralysis w/ ear pain and vessicles

A

Herpes zoster oticus = Ramsay Hunt syndrome

89
Q
  1. bilateral facial paralysis -> think?

2. incomplete facial palsy -> think?

A
  1. Lyme, GBS

2. Parotid gland tumor

90
Q

Ramsay Hunt vs. Bells

A

zoster vs. simplex

91
Q

blown pupil and/or ptosis -> what type of herniation?

A

uncal

92
Q

tests for MG

A

tensilon = edrophonium, cooling (both improves)

93
Q

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
A
  1. labyrinthitis
  2. Meniere -> low salt diet
  3. BPPV -> canalith repositioning procedure
  4. vestibular migraine
  5. vertebrobasilar insufficiency -> antiplatelet
  6. vestibular neuritis
94
Q

triggers for BPPV

A

aspirin, phenytoin, alcohol

95
Q

dx? slow version of GBS

A

chronic inflammatory demyelinating polyneuropathy

96
Q

CSF finding in demyelinating polyneuropathy

A

albuminologic dissociation (high protein, normal cells)

97
Q

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
A
  1. AIDP
  2. Miller-Fisher
  3. Acute motor axonal neuropathy
  4. acute motor sensory axonal neuropathy
  5. acute panautonomic neuropathy
98
Q

cutaneous features of dermatomyositis vs. SLE

A

heliotrope rash vs. malar
Gottron papules over joints vs. between joints
Shawl sign

99
Q

inclusion body vs. polyomyositis vs. dermatomyositis

associated w/ malignancy?

A

polymyositis

100
Q

dx? degeneration of both upper(increased tone) and lower (atrophy, fasciculations) motor neurons in a single limb

A

ALS

101
Q

common mimic of ALS

A

cervical myelopathy

102
Q

nerve roots of peroneal nerve

A

L4-L5

103
Q

complex (vs. simple) febrile seizure

A

focal, >15min and recurs within 24 hrs

104
Q

most common pathogen associated w/ febrile seizures

A

Herpes 6

105
Q

migraine and epilepsy

A

both doubles the risk for the other

106
Q

other system manifestations of

  1. DMD
  2. BMD
A
  1. heart failure, low IQ

2. cardiomyopathy

107
Q

features of tics

A

suggestible and temporarily suppressible

108
Q

language in autism

A

regresses

109
Q

metastatic brain tumor

  1. mass effect?
  2. location
  3. enhancement?
  4. tx?
A
  1. yes, 2/2 edema
  2. 80% supratentorial @ G-W junction
  3. ring
  4. radiation
110
Q
  1. dx? 2. pathophys?

profound hypotonia and weakness in an infant who is alert and attentive

A
  1. spinal muscular atrophy type 1

2. overzealous pruning of motor neurons during development

111
Q

recurrent seizures, infantile spasms, severe mental retardation, dysmorphic craniofacial features

  1. dx?
  2. spectrum?
  3. chromosome?
A
  1. Lissencephaly (smooth brain)
  2. Miller-Dieker > isolated lissencephaly
  3. 17

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