Clerkship Flashcards
intention or kinetic tremors are most characteristic of damage to the _______
cerebellum
resting tremors due to damage of the ________
substantia nigra
toxic levels of phenytoin may evoke ______ in the eyes
lateral nystagmus
polymyositis shows weakness in (proximal/distal) muscle groups
proximal–to get out of a seat, person may have to pull himself up by arms
CN __ innervates stapedius muscle of middle ear. Paralysis of this muscle causes hyperacusis
CN VII facial
CN __ innervates tensor tympani, damage can cause inappropriate slack but no increased sensitivity
CN V trigem motor fibers
put warm water in one ear > indicates to the brain that the head is tilting toward that side. eyes deviate to the (same/opposite) side to maintain fixation of their target
same
mnemonic COWS for nystagmus and water in the ear
Cold-Opposite side, Warm-Same side
diseases affecting the ______ artery and the overlying sympathetic plexus do not produce anhidrosis, but do produce miosis and ptsosis (Horners)
internal carotid artery (dissection can lead to painful Horners after vigorous activity)
if you suspect subarachnoid hemorrhage and no blood is seen on CT scan, what is your next diagnostic step?
Lumbar puncture
tentorium cerebelli is a common site for the development of which type of tumor?
meningioma (it is a fold of meninges)
calcified masses appear as (high/low) density on CT without contrast enhancement
high density
highly vascular lesions appear dense on CT (after/before) contrast enhancement
after
two tumor types more common in NF2
meningiomas and bilat acoustic neuromas
NF2 arises from a deletion on the long arm of chr __
22
women with breast cancer and other gyn cancers are at an inc risk of developing what type of tumor?
meningiomas (sex steroid receptors on these tumors)
chr __ assoc with NF1
17
neglect and hemiparesis likely with (R/L) brain lesions
right
left frontal-parietal-temporal region is critical for _____
language
impaired naming, comprehension, and repetition, but patient has fluent speech
Wernicke aphasia
R sided occipital lesion causes a (R/L) homonymous hemianopia
Left
alexia without agraphia is a disconnection syndrome assoc with lesions involving the (R/L) occipital lobe and splenium of the _______
L occ lobe and corpus callosum
elevated ESR, periungual telangiectasias suggest _____
dermatomyositis
test to confirm a primary muscle disease (myopathy)
creatine phosphokinase
(poly/dermato)myositis: perifascicular muscle fiber atrophy, and inflamm infiltrate occurs in perimysial connective tissue rather than throughout the muscle fibers themsevles
dermatomyositis
(poly/dermato)myositis: extensive necrosis of muscle fiber segements with macrophage and lymphocyte infiltration
polymyositis
ascending paralysis with preserved sensation and sphincter control
Guillain Barre
CSF findings in Guillain Barre
markedly high protein, xanthrochromia
CSF findings in MS
elevation of gamma globulin
in order to accurately measure pressure in idiopathic inc in ICP assoc with pseudotumor cerebri, place pt in _____ position
lateral recumbent position
if you are concerned for stroke, but patient has elevated INR on warfarin and might have intracerebral hemorrhage, what do you do?
CT to rule out hemorrhage
what test is indicated if there is strong suspicion of aneurysm or vascular malformation
cerebral angiogram
ipsilateral ataxia and ipsilateral Horner, ipsi facial pain, ipsi impairment of corneal reflex, contralat pain and temp disturbances in limbs and trunk, dysphagia, dysphonia
Wallenberg/lateral medullary syndrome: CN V, nuc ambiguus, lateral spinothalamic tracts, inferior cerebellar peduncle, descending sympathetic fibers, vagus, glossopharyngeal nerves
most cases of lateral medullary infarction are caused by occlusion of the ______ artery
vertebral
the ____ artery supplies the entire posterior brain circulation
basilar
the _____ artery supplies the superior portions of the cerebellum
superior cerebellar
____ artery supplies portions of cerebellum and lower cranial nerves
AICA
MCC of lobar hemorrhage in elderly patients without hypertension
cerebral amyloid angiopathy aka congophilic angiopathy
treatment for focal seizure after an intracerebral or subarachnoid hemorrhage
antiepileptic drug such as levetiracetam (fast acting, unlike lamotrigine)
congenital disturbance that produces facial cutaneous angiomas, MR, hemiparesis or hemiatrophy, seizures
Sturge Weber aka encephalofacial angiomatosis
type of tumor assoc with sturge weber
leptomingeal angiomas
tumor assoc with von hippel lindau
telangiectasia of retina
tumor assoc with polycystic kidney disease
hemangioblastomas
_____ are very small, develop in pts with chronic HTN, commonly occur in lenticulostriate arteries
charcot-bouchard aneurysms
most common site for hematoma formation from rupture of charcot-bouchard aneurysm
putamen (because they occur in lenticulostriate arteries)
an aneurysm on the posterior communicating artery is especially likely to compress CN __
III oculomotor, leads to problems with pupil activity
what drug is used to prevent vasospasm as a complication of SAH (could cause a stroke)
niodipine
carotid endarectomy can reduce the risk of stroke in pts with symptomatic stenosis by __% or more and should be offered to all pts with symptomatic disease of internal carotid artery
70%
lesion of left inferior frontal gyrus
Brocas aphasia
isolated word finding deficit
anomic aphasia–diffuse brain dysf
_______ aphasia is similar to Brocas aphasia with the exception of preserved repetition
transcortical motor aphasia–left frontal white matter and spares overlying cortex
_______ aphasia is similar to Wernicke aphasia with the exception of preserved repetition
transcortical sensory aphasia–white matter underlying the cortex of Wernicke area
EEG pattern of 3Hz spike and wave pattern
generalized epilepsy
most helpful diagnostic test if someone presents with a simple partial seizure
MRI to look for focal brain lesion
greatest risk for alcohol withdrawal seizure occurs within ____ days after drinking cessation
1 day
delirium tremens occurs within ____ days after drinking cessation
2 to 4 days
mental dysf, mutliple seizure types, 1 to 2 Hz generalized spike wave discharges on EEG
Lennox-Gastaut
syndrome assoc with loss of language function and an abnormal EEG during sleep
Landau-Kleffner syndrome
relatively benign epilepsy syndrome with onset in late adolescence or early adulthood
juvenile myoclonic epilepsy
olfactory halluc (preseizure aura phenomenon) due to lesions of: _____
hippocampus
prophylactic phenytoin reduces incidence of (early/late) posttraumatic seizures
early (after TBI)
focal seizure activity that is primarily motor and spreads, often secondarily generalizes
Jacksonian march aka sequential seizure (hand is a common site for the start)
seizure type that occurs when the pt is waking up, may be triggered by light flashes or loud sounds
myoclonic seizure, most commonly seen in benign juvenile myoclonic epilepsy
EEG abnormalities all over the cortex simultaneously, always lose consciousness, may be confused after the seizure
generalized tonic-clonic
seizure that lasts 30 minutes or a series of seizures over a 30 minute period without the patient regaining full consciousness between them
status epilepticus
condition of persistent focal motor activity, distal hand and foot most commonly affected, seizures may persist for hours or months
epilepsia partialis continua
tx for complex partial seizures without secondary generalization
levetiracetam (low side effect profile)
tx for West syndrome (infants)
ACTH
lesion to reticular activating system
coma
lesion to mamillary bodies
Wernicke Korsakoff (thiamine def)
lesion to superior colliculi and name of syndrome
paralysis of upward gaze, Parinaud syndrome
lesion to amygdala
Kluver Bucy syndrome
lesion to frontal lobe
disinhibited, poor concentration, poor logic, poor judgment
lesion to cerebellar hemisphere
intention tremor, ataxia-fall toward side of lesion
lesion to parietal lobe, non dominant (usually Right side)
hemispatial neglect–ignore the other side of the world
lesion to dominant parietal lobe (usually left), and syndrome name
agraphia, acalculia, finger agnosia, L/R disorientation (angular gyrus–Gerstmann Syndrome)
lesion to cerebellar vermis (midline)
truncal ataxia, dysarthria
lesion to subthalamic nucleus
hemiballismus
lesion to PPRF
eyes away from lesion
non dominant broca aphasia
inability to EXPRESS emotion in speech
non dominant Wernicke aphasia
inability to COMPREHEND emotion in speech
lesion to arcuate fasciculus
cannot repeat. that is what connects Wernicke’s area to broca’s
occlusion of posterior cerebral artery
damage to occipital lobe
which artery: Broca’s OR Wernicke’s aphasia
MCA
which artery: unilateral lower extremity sensory and/or motor loss
anterior cerebral
which artery: unilateral facial and army sensory and/or motor loss
MCA
provides taste to anterior 2/3 of tongue
CN VII facial
provides taste to posterior third of tongue
CN IX glossopharyngeal
provides motor to tongue
CN XII hypoglossal
(classic/common) migraine: preceded by an aura of neurological dysf, usually visual
classic
classic migraines and basilar migraines are more common in (men/women)
women
(classic/basilar) migraine: visual change may develop into blindness, irritability may develop into psychosis, transient quadriplegia, stupor, coma for several hours
basilar
symptomatic trigem neuralgia often assoc with what disease
MS
paroxysmal, lancinating pains in face
trigem neuralgia
constant, deep pain in face
atypical facial pain–often tx with antidepressants
(abortive/prophylactic) migraine tx: amitriptyline HCl, propranolol, verapamil, valproate
prophylactic
(abortive/prophylactic) migraine tx: metoclopramide HCl, ergotamine, sumatriptan
abortive
sudden onset of a very severe headache with no apparent structural cause
thunderclap headache
trauma to nerves in extremities may give rise to ____, a disturbance in sensory perception characterized by hypesthesia, dysesthesia, and allodynia
causalgia
claw deformity
ulnar n
trauma to elbow leads to damage of which nerve
ulnar n
which nerve is damaged with fractures of the humerus
musculocutaneous
saturday night palsy nerve
radial>wrist drop
what med to give after spinal cord injury within 8 hours of injury
methylprednisone
most common sequela of encephalitis lethargica
Parkinsonism
acquired by ingesting material contaminated with fecal matter from sheep or dogs, encephalic hydatidosis, cysts, cyst behaves like a tumor
echinococcus
tx for T gondii
sulfadiazine and pyrimethamine
both HIV and CMV infxns in the brain characteristically produce ____
microglial nodules
type of EEG seen with HSV encephalitis
bilat periodic epileptiform discharges over temporal regions
where do brain abscesses usually form
gray white junction
MC sx with brain abscess
headache
tx for listeria
amp plus genta
MC site of primary cancer that mets to the brain
lung (2/3 of cases)
type of primary brain tumor only seen in AIDS patients
primary brain lymphoma
what type of herniation occurs with tumor of posterior fossa?
transtentorial
one of the MC CNS tumors of childhood, develops in cerebellum, causes ataxia, hydrocephalus
medulloblastoma
optic gliomas seen in NF (1/2)
NF1 (also in NF1: cafe au last spots, bone cysts, sphenoid bone dysgenesis, precocious puberty, pheochromocytoma, syringomyelia, cortical dysgenesis)
girl with headaches, diplopia, impaired upward gaze, lid retraction, convergence-retraction nystagmus. pupils react on convergence but not to light
pineocytoma–dorsal midbrain in the region of the superior colliculus (Parinaud syndrome)
in context of cancer: lethargy, weakness, areflexia, coma and convulsions can occur
hypercalcemia from paraneoplastic disease or bone destruction
polyneuropathy in context of monoclonal gammopathy on serum protein electrophoresis and plasma cell dyscrasia on bone marrow biopsy
multiple myeloma causing paraproteinemic polyneuropathy
dz in which accumulation of glucosylceramide produces HSM and may cause lethal CNS disease
Gaucher-def of glucocerebrosidase in fibroblasts or leukocytes
a pt with progressive chronic liver failure for 5 years would show changes in what type of CNS cell at death?
astrocytes (alzheimer type II astrocytes)
tx for restless leg syndrome
L-dopa
most sensitive test for B12 def
methylmalonic acid
tx for benzo and alc withdrawal
chlordiazepoxide
vitamin deficiency in people who drink and smoke causing injury to optic nerve
deficiency amblyopia
pellagra-what’s deficient?
nicotinic acid aka niacin
obesity assoc with hypersomnia and sleep apnea, sleep attacks during the day
Pickwickian
young woman with optic neuritis
consider MS
Alzheimer disease: (neuronal loss in cerebral cortex/demyelination in cerebral cortex/pigmentary degeneration in hippocampus)
demyelination in cerebral cortex
patients who undergo ventriculoperitoneal shunting for NPH may suffer major complications such as (subdural/epidural) hematoma and infections
subdural. occurs because reduction in ICP brought on by shunting may cause the brain to pull away from the covering meninges, stretching and potentially rupturing the riding veins
general paresis, chronic meningoencephalitis, dementia, delusions, dysarthria, tremor, myoclonus, seizures, spasticity. Dx-monocytic pleocytosis
neurosyphilis
GI complaints, seizures, myoclonus, ataxia, supra nuclear gaze disturbances, hypothalamic dysfunction, dementia. oculomasticatory myorhythmia is pathognomonic
whipple disease due to T whippelli
dopaminergic drugs may unmask (intention tremor/chorea)
chorea
three areas that may be involved in parkinsonism
globus pallidus, subthalamic nucleus, thalamus
Lewy bodies are intra (nuclear/cytoplasmic) inclusions
intracytoplasmic
tx for parkinsonism caused by psych drugs
trihexyphenidyl (anticholinergic)
form of focal dystonia characterized by blepharospasm, forceful jaw opening, lip retraction, neck contractions, tongue thrusting. can occur idiopathically
Meige syndrome. tx with botox
tx for MS flare
corticosteroids
tx to prevent MS flare (2)
glatiramer and interferon beta 1B
MS affects 1 in ___ people
1000
common S/E of corticosteroid tx for MS flare and how to tx it
gastric disturbance–give ranitidine
infant who develops extensor posturing and regression around 6 months of age, myoclonic seizures may develop, defect in N-acetylaspartic acid metabolism
Canavan disease
young man with centrocecal scotoma, other family members also have it
Leber optic atrophy
demyelinating disorder affecting children who become symptomatic during the first months of life, but may live into their 30s. sudanophilic leukodystrophy, mostly affects males
Pelizaeus-Merzbacher
newborn with cystic swelling at base of spine covered with hyper pigmented skin and coarse hair. what’s most likely?
meningocele
female carriers of fragile X have MR in __% of cases
about half. mild MR
17 month old boy who started having progressive gait problems at 13 months old. pt is spastic, yet nerve conduction studies show slowed motor and sensory conduction velocities. CSF protein is elevated, MRI shows white matter abnormalities. def arylsulfatase A. what disease? what test will give useful diagnostic info?
metachromatic leukodystrophy. do a nerve biopsy to look for sulfated in schwann cells
5 yr old boy with MR, homonymous hemianopsia, hemiparesis. He had infantile spasm and still has epilepsy. Head CT shows calcifications in cerebral cortex in a railroad track pattern
sturge weber syndrome
erythrocytosis with cerebellar signs, microscopic hematuria, and HSM
von Hippel Lindau
eye finding in von Hippel Lindau
telangiectasis in the fundi on retina exam
MOI of tuberous sclerosis
autosomal dom with incomplete penetrance
sebaceous adenomas found in what dz
found in 90% of patients with tuberous sclerosis
gliomatous tumors that require no tx and are a principal criterion for dx of tuberous sclerosis
retinal phakomas
calcifications seen on CT scan of pt with tuberous sclerosis usually represents calcified (meningeal adhesions/astrocytomas/granulomas/subependymal glial nodules)
subependymal glial nodules
asymptomatic dandy walker formation prognosis
may not affect life whatsoever
percent of tuberous sclerosis pts with MR
65%. of those, half are severely retarded
intellectual functioning in DMD
slightly impaired
man with difficulty relaxing grip, hyper somnolence, premature baldness, testicular atrophy, cataracts
myotonic dystrophy
EMG pattern displayed in myotonic dystrophy
dive bomber pattern–characteristic sound when action potentials are heard. repetitive discharges with minor stimulation
75 year old man with elevated ESR, anemia, weight loss, malaise
polymyalgia rheumatica–arteritis of the elderly
MC site of CNS atrophy assoc with chronic alcoholism
superior vermis
lethal neurologic complication of organophosphate poisoning
severe UMN and LMN motor polyneuropathy
______ inhalation by coal miners produces a clinical picture similar to that seen with hepatolenticular degeneration (Wilson dz). Parkinsonism is most predominant feature, axial rigidity and dystonia may develop
Manganese
how does ciguatoxin (produced by dinoflagellates which are consumed by reef fish) cause food poisoning sxs and neurological sxs
acts on voltage gated sodium channels, leading to increased permeability to sodium and increased excitability
MC form of retinal degeneration, hereditary, optic disc pallor seen later in disease, develops along with abetalipoproteinemia (Bassen-Kornzweig dz)
retinitis pigmentosa
visual loss is usually substantial in (papilledema/papillitis)
papillitis (often early sign of MS)
marcus gunn pupil
problem with afferent (optic nerve) in one eye, so pupils actually dilate when the flashlight is swung toward that eye, but both constrict when the light is in the other eye
marcus gunn pupil commonly develops in people with _______ and is a sign of ______
MS, sequela of optic neuritis, sign of optic atrophy
visual loss in retinal degneration, vitamin A def, color blindness
nyctalopia (night blindness)
scintillating scotomas are the classic signature of the _____
migraine aura
injury to the _____ results in signif loss of visual acuity, with preservation of peripheral vision
macula
segmental narrowing of arterioles, arteriolar straightening, arteriolar-venular compression (nicking) seen in _____
long standing HTN
injury to CN __ produces a lateral rectus palsy
CN 6
an abducens dysf with lateral rectus palsy in a child may develop due to increased ICP or direct damage to the ______
brainstem (like a brainstem glioma)
child with one sided facial pain and blurry vision, CN 6 lateral rectus palsy
Gradenigo syndrome d/t osteomyelitis (infection) of petrous pyramid as a result of chronic ear infections
CN most at risk of injury with trauma to the orbit or the full face
CN 4 –will induce a slight head tilt to compensate for impaired intorsion of the affected eye
CN affected by VZV
CN 4 bc it shares a sheath with CN V, where VZV is harbored
initial sign of injury to the third nerve (usually by aneurysm)
impaired depression
occlusion of the retinal (vein/artery) produces engorged tortuous veins and streaky linear retinal hemorrhage, visual loss is variable
vein
occlusion of the retinal (vein/artery) produces painless visual loss, cherry red fovea, cloudy grayish yellow retina, vessels appear to have segmented columns of blood
artery
amaurosis fugax
fleeting loss of vision, can be caused by emboli traveling through the internal carotid that exit to the ophthalmic artery and cause obstruction before they break up
otherwise healthy young woman with poorly responsive, dilated pupils and absent Achilles tendon reflexes bilaterally
Adie tonic pupil, benign tonic pupillary dilation
medication that may induce a syndrome resembling HTN encephalopathy, “reversible posterior leukoencephalopathy,” headache, visual dysf, confusion, seizures
cyclosporine toxicity
MCC of acute monocular blindness, painless, HTN and DM are risk factors
ischemic optic neuropathy (posterior ciliary artery is involved)
field cuts from a lesion impinging on the optic chiasm from one side
field cut in the contralateral field of the contralateral eye, upper quadrant preferentially affected. ipsilateral eye may exhibit a centrocecal scotoma
MCC of hearing loss in the elderly, high frequency perception is impaired because of sensorineural damage, spiral ganglion neurons of the cochlea most likely affected, normal Rinne test (means that middle ear deafness is not present)
presbycusis
girl with mastoiditis which expands into the ______ lobe, develops fluent aphasia
temporal (damage to wernicke area in superior temporal lobe gyrus)
what is damaged with the sound of an explosion? high or low tone sensorineural hearing loss?
cochlea–causes high tone sensorineural hearing loss
artery with medial branches supplying the brainstem (occlusion leads to vertigo due to vestibular nuclei), and lateral branches, lateral branches may induce vertigo by injury to cerebellar flocculonodular lobule injury
PICA
med that may exacerbate tinnitus
aspirin
where is the olfactory cortex located
lateral olfactory gyrus- prepiriform area
areflexia and flaccidity assoc with spinal shock usually evolve into hyperreflexia and spasticity within ____ (time period)
3 days to 3 weeks
what type of motion of the lumbar spine during car accidents causes vertebral fracture
extreme flexion (if not restrained by a shoulder belt)
artery of _____ is a major anterior radicular artery and supplies the lower two-thirds of the spinal cord. at risk of occlusion during AAA repair
Adamkiewicz
abnormal collection of fluid resulting in an expansion of the central canal
syrinx
first dorsal interosseous muscle is innervated by the ____ nerve, which originates at the __ and __ nerve roots
ulnar. C8 and T1
where is the decussation of the pyramids?
junction of medulla and spinal cord
MCC of mononeuropathy multiplex
DM
what type of injury is most likely to cause an injury limited to the upper brachial plexus?
birth trauma
Friedreich disease is linked to a defect on chr __
9
the peripheral neuropathy seen in a patient with Friedreich develops in part because of degeneration in _____
dorsal root ganglia
tx for Guillain Barre
plasma exchange and IVIG
recurrent attacks of ab pain, gastroparesis, constipation due to autonomic neuropathy, psychosis, axonal motor neuropathy, autonomic instability
acute intermittent porphyria
DM is a common cause of CN __ palsy via nerve infarction
CN III, sparring the pupillomotor parasympathetics
periorbital ecchymosis, ecchymosis over the mastoid region, hemotympanum, or CSF rhinorrhea should be considered evidence of a ______ skull fracture
basilar
(hypo/hyper) thermia has been shown to reduce cerebral injury from ischemia in its with traumatic brain injury
hypo. by decreasing cerebral metabolism, reducing acidosis, attenuating change in the BBB, inhibiting release of excitatory neurotransmitters
bladder dysf in MS is a consequence of corticospinal tract disease, causing an UMN lesion leading to a spastic bladder. therefore use _____ as a tx
oxybutynin, also TCAs like imipramine
______ response: an expanding intracranial mass produces an elevated BP and a slow heart rate
Cushing response
