Clinical Medicine Flashcards
1-30 LMNL and disorders of peripheral nerves 31-48 Spinal Cord Disorders 49-66 Disorders of Neuromuscular Junctions 67-82 Ischemic and Hemorrhagic Strokes 83-100 UMNL and Localization of Cortical Lesions 101-122 Cerebellar and Balance Disorders 123-162 Increased Intracranial Pressure 163-208 Movement Disorders 209-220 Sleep Disorders 221-263 Infections in CNS 267-320 Headache 321-335 Delirium 336-355 Neurological Disorders affecting Vision
1
Q
What are some causes of UMNL?
A
Stroke
MS
2
Q
What are some causes of LMNL?
A
Polyneuropathy
GBS
Early UMNL
3
Q
What are the signs of LMNL?
A
Flaccidity
Decreased DTR
Present atrophy
Fasciculation
Weakness pattern: [Distal > Proximal, Flexors = Extensors]
4
Q
What are the signs of UMNL?
A
Spasticity
Increased DTR
Clonus
Absent Superficial reflexes
Positive Babinski
Positive Hoffman
Disuse atrophy
Weakness pattern: [UL: Extensors > Flexors, LL: Flexors > Extensors]
5
Q
What are the 4 phases of spinal shock and its duration?
A
Areflexia [0-1 day]
Initial reflex return [1-3 days]
Hyperreflexia [1-4 weeks]
Hyperreflexia, spasticity [1-12 months]
6
Q
What is the cause of spinal muscular atrophy?
A
Genetic - AR
7
Q
Describe the clinical presentation of Spinal Muscular atrophy
A
Progressive muscle weakness and atrophy
LMNL
8
Q
Treatment of Spinal Muscular Atrophy?
A
ASO- antisense oligonucleotide
9
Q
What is ALS?
A
Neurodegenerative disease affecting motor neurons in cerebral cortex, brainstem and anterior horn of SC
10
Q
Describe the presentation of ALS?
A
Progressive weakness that spreads one limb to the other and eventually patients die due to respiratory failure
Mixed UMNL and LMNL
11
Q
Prognosis of ALS?
A
Fatal in 3-5 years
12
Q
What is an example of sensory neuronopathy?
A
Herpes zoster [الحزام الناري]
13
Q
Describe presentation of plexopathy?
A
Weakness and numbness depending on parts of plexus affected
14
Q
What are some causes of plexopathy?
A
DM
Focal mas - Pacoast
15
Q
What is a hereditary cause of peripheral neuropathy?
A
Charcoat Marie Tooth disease
16
Q
What is mononeuropathy?
A
One peripheral nerve is affected
17
Q
What are some examples of mononeuropathy?
A
CN7 palsy
Carpal tunnel syndrome
18
Q
What causes carpal tunnel syndrome?
A
Median nerve entrapped in flexor retinaculum
19
Q
What are the symptoms of carpal tunnel syndrome?
A
Numbness in lateral 3 ½ digits +/- weakness
20
Q
What are the clinical exams for carpal tunnel syndrome?
A
Tinel sign
Phalen sign
21
Q
How is carpal tunnel syndrome diagnosed?
A
Clinical diagnosis
Nerve conduction study
22
Q
What is used to treat Carpal tunnel syndrome?
A
Wrist splint/NSAIDs
Steroid
Surgery
23
Q
What is mononeuropathy multiplex?
A
Several peripheral nerves affected simultaneously or sequentially
24
Q
What are some causes of mononeuropathy multiplex?
A
Vasculitis of vasa nervorum
Sarcoidosis
DM
25
What is polyneuropathy?
Generalized symmetric and length dependent [Longest fibers affected first]
26
What is the commonest cause of polyneuropathy?
DM
27
How is polyneuropathy diagnosed?
Clinical diagnosis
Nerve biopsy [if necessary]
Nerve conduction study [to confirm diagnoses and classify it]
28
What are the types of polyneuropathy?
Demyelinating
axonal
29
What are the causes of axonal neuropathy?
Metabolic /endocrine [DM]
Hereditary
Drugs
Vasculitis
Vitamin toxicity
Alcohol
30
What are the causes of demyelinating neuropathy?
GBS
Hereditary
Arsenic toxicity
Lymphoma
31
Describe the presentation of Anterior Spinal Artery Syndrome
Areflexia + flaccid paralysis at lesion [anterior horn destruction]
Anhidrosis + loss of vasomotor tone
Loss of bladder + bowel control but with preservation of reflex emptying
Paralysis of respiration in cervical segments
Bilateral horn syndrome
32
What structures are affected in Anterior Spinal artery Syndrome?
Anterior ⅔ of SC, with sparing of posterior columns and horns
33
In what order are the structures affected in Syringomyelia? What is the correlating presentation?
Anterior horn cells → LMNL patterns
Corticospinal tract → caudal UMNL signs
2nd order Spinothalamic fibers as they decussate anterior to anterior ventral commissure
34
Describe the clinical presentation of Syringomyelia
Cape sensory deficit / sacral sparing
35
What are the causes of Syringomyelia?
Hemorrhage
Trauma
Tumor of SC
Chiari I malformation
36
Describe the presentation of Combined system degeneration?
Loss of motor function below lesion
Loss of position sense below lesion
Loss of vibratory sensation below lesion
37
What structures are affected in combined system degeneration?
Lateral corticospinal tract
Dorsal Columns
38
What structures are affected by Vit. B12 deficiency?
Diffuse involvement of dorsal columns and lateral corticospinal tracts
Optic nerve, cerebellum, peripheral nerves and cerebral hemisphere
39
What are the causes of Combined system degeneration?
Vitamin B12 deficiency
Hypocupremia myelopathy
40
What structures are affected in Tabetic syndrome?
Large posterior fibers of dorsal roots that later form the posterior column
41
What are the causes of Tabetic Syndrome?
Tertiary neurosyphilis
DM
42
Describe the presentation of Complete transection
Decreased in respiration if above C5
Spasticity below lesion [UMNL]
Decreased voluntary bowel and bladder control
43
What are the causes of complete transection?
Transverse myelitis [post-infectious or demyelinative]
Corticospinal tract
Dorsal column
44
What are the structures affected in Complete transection?
Anterolateral spinothalamic tract
Dorsal columns
45
Describe the clinical presentation of hemisection syndrome
Ipsilateral sensory loss below the lesion
Contralateral motor loss [LMNL]
46
What structures are affected in hemisection syndrome?
Anterolateral spinothalamic tracts
Dorsal column
47
What is another name for Brown-sequard syndrome?
Hemisection syndrome
48
What are the causes of hemisection syndrome?
Trauma
Compression
MS
49
What is the cause of Myasthenia Gravis?
Antibodies against N1 Ach Receptors [Post-synaptic]
50
What is the cause of LEMS?
Antibodies against VGCC [Pre-synaptic]
51
What is the cause of Botulism?
C. Botulism neurotoxin [Pre-synaptic]
52
What is the cause of Organophosphate Exposure?
Irreversible inhibition of AchE → ↑↑Ach stimulation [Synaptic]
53
Describe the onsets of Botulism, MG, and LEMS
Botulism: Rapid onset
MG + LEMS: Progressive onset
54
What conditions are associated with MG?
Autoimmune diseases [Hyperthyroidism]
Lymphoma [10%]
55
What conditions are associated with LEMS?
Small cell cancer
56
Describe the clinical presentation of MG
Fatigability with repetitive contraction with diurnal variation
Ptosis & Diplopia [in 2/3]
Descending weakness
Facial Weakness
Snarl Smile
Dysarthria & Dysphagia
Proximal Muscle Weakness
Respiratory Muscle weakness [MG Crisis]
Normal sensation & Reflexes
57
Describe the clinical presentation of LEMS
Ascending weakness
Slow progressive leg weakness & fatigue
Dry Mouth
Constipation
Post-Exercise Facilitation
Eye & Bulbar symptoms [in 30%]
Absent Deep Tendon Reflex
58
Describe the clinical presentation of Botulism
Dilated Pupils
Dry mouth
Constipation
Descending weakness
59
Describe the clinical presentation of Organophosphate Exposure
Proximal Muscle Weakness
Respiratory Muscle weakness
Confusion, Anxiety
Coma
Diarrhea
Vomiting
Sweating
60
Diagnostic tests for Botulism?
Incremental response
Toxin Isolation
61
Diagnostic Tests for LME?
Incremental response w/↑ frequency stimulation
CT chest for SCLC
Antibodies against VGCC in 95% of patients
62
Diagnostic Tests for MG?
Decremental response w/↓ frequency stimulation
CT chest for Thymoma
AchR-Ab in 85% of patients
MuSK-Ab in 50% of patients who test -ve for AchR-Ab
Tensilon Test [IV Tensilon causes temporary and rapid improvement of symptoms]
63
Treatment of OE
Atropine
Pralidoxime
64
Treatment of Botulism
Penicillin G
Botulinum Toxin
Toxin Removal [Gastric Lavage + Wound cleaning]
65
Treatment of LEMS
3,4-DAP [potassium channel blocker]
66
Treatment of MG
Pyridostigimine [temporary symptomatic treatment]
Glucocorticoids → Steroid-spacing mechanisms
Thymectomy
IV Ig
PE
67
What is a stroke?
Sudden focal neurological deficit caused by interruption of blood flow to a specific region of the brain
68
What are the two types of strokes?
Hemorrhagic
Ischaemic
69
What are the common types of stroke?
Ischaemic [85%]
Intracerebral hemorrhage [15%]
SAH [5%]
70
What is the most common cause of emboli in ischemic stroke?
Atrial Fibrillation
71
What is a Transient Ischemic attack?
Focal deficit that resolves completely and spontaneously within 24 hours
[60% have evidence or brain infarction]
72
What are the risk factors for stroke?
HTN
Smoker
DM
Dyslipidemia
Previous history of TIAs
Heart disease
Hypercoagulopathy
Sickle cell/ Increased RBCs
Obesity
Carotid Bruit
Afib
Snoring
Cocaine
73
What is the most common artery implicated in strokes?
Middle Cerebral Artery
74
Describe the presentation of MCA occlusion?
Contralateral face
Aphasia [if on left]
Contralateral sensory loss
Cortical sensory loss [non-dominant hemispheres]
Contralateral visual field defect
Gaze deviation ipsilateral to lesion
75
Describe the presentation of Internal Cerebral artery occlusion
Ipsilateral retinal ischemia
Sensorimotor dysfunction similar to MCA
76
Describe the presentation of ACA occlusion
Contralateral leg weakness
Contralateral leg sensory loss
Apraxia
Abulia
77
Describe the presentation of PCA occlusion
Contralateral homonymous hemianopia
Visual agnosia
Cognitive dysfunction
78
Management of Suspected Stroke cases
CT angiogram
EEG
Neurological screening assessments
IV with normal saline
79
When should CT scan be done?
Within 25 minutes of arrival
80
Management of Hemorrhagic Strokes?
Mannitol to lower ICP
Nimodipine for SAH
81
Management of Ischemic strokes
Consider fibrinolytic [tPA] therapy or Aspirin
82
Secondary prevention of TIAs?
Evaluate for embolism or carotid stenosis
Aspirin / Clopidogrel
83
What structures are affected in capsular hemiplegia?
Corticospinal tracts
Corticobulbar tracts
84
Occlusion of which artery may lead to capsular hemiplegia?
MCA
85
What is a characteristic finding of capsular hemiplegia?
Ipsilateral facial nerve palsy, with sparing of the upper half
86
Signs of UMNL in the Internal Capsule?
Contralateral hemiplegia
Hemisensory loss
UMN signs
87
Signs of UMNL in Midbrain?
Crossed hemiplegia
Ipsilateral oculomotor palsy
Contralateral hemiplegia
88
Signs of UMNL in Pons?
Contralateral hemiplegia
Ipsilateral CN 6, CN 7 palsy
89
Signs of UMNL in Medulla?
Ipsilateral CN 9, 10, 11, 12 palsy
Contralateral hemiplegia
90
Signs of UMNL in the cervical area?
Ipsilateral hemiparesis
91
What determines the dominant hemisphere?
Localization of speech and mathematical ability
92
When is cerebral dominance established?
1st few years of life
93
What would produce primitive reflexes?
Bilateral lesion of frontal cortex
94
What are the functions of the Frontal lobe?
Planning ahead
Monitoring
Sustained attention
Goal orientated behavior
Working memory
Problem solving
95
What are the functions of the parietal lobe?
Receives and processes sensory information
Transmits info to other parts and coordinates
Visual attention
Spatial reasoning
96
Tests for Parietal lobe?
Sterogeneis test
Point discrimination test
Graphesthesia test
97
What are the functions of the temporal lobe?
Hearing
Compression of Language
Memory retrieval and formation
98
What would a lesion in Wenicke’s area produce?
Affects language comprehension, response would also be gibberish
99
Lesion of which structure would produce homonymous hemianopia?
Optic tracts
100
Lesion of which structure would produce homonymous hemianopia with macular sparing?
Cerebral cortex
101
What is the function of the anterior cerebellar lobe?
Regulates muscle tone
102
What is the function of the posterior cerebellar lobe?
Coordination of voluntary motor activity
103
What is the function of the flocculonodular lobe?
Maintenance of posture and balance
104
What are the characteristics of cerebellar disease?
Hypotonia [rag-doll appearance and inebriated]
Disequilibrium
Dyssynergia
Dysmetria [past-pointing]
Ataxia
Dysarthria
Intention tremor
Dysdiadochokinesia
Nystagmus
105
What is dysdiadochokinesia?
Inability to perform rapid alternating movements
106
How can we check for rebound?
Flex forearm at elbow against resistance, then suddenly release, positive if it hits chest or face
107
Describe decomposition of movements?
Breakdown smooth muscle act into jerky parts
Rebound
108
Cause of Anterior Vermis Syndrome
Alcohol abuse [commonly]
109
Presentation of Anterior Vermis Syndrome
Gait, trunk and leg ataxia
110
Presentation of Posterior Vermis Syndrome
Gait ataxia
111
What Structure is affected in Posterior Vermis Syndrome?
Flocculonodular lobe
112
What are the common causes of Posterior Vermis Syndrome?
Brain tumors in children, ex:
Medulloblastoma
Ependymoma
113
What are the causes of Cerebellar hemispheric syndrome?
Brain Tumor
Brain abscess
114
Presentation of Cerebellar Hemispheric Syndrome?
Ipsilateral Leg/Arm, Truncal and Gait ataxia
115
Cause of Anterior Lobe Syndrome?
Malnutrition associated with chronic alcoholism
116
Manifestation of Anterior Lobe Syndrome?
Ataxic gait
Gait instability
Loss of coordination
Fails heel-shin test
Dysarthria
117
Cause of Posterior Lobe Syndrome?
Strokes
Tumor
Trauma
Degenerative disease
118
Manifestation of Posterior Lobe Syndrome
Decreased muscle tone
Intention tremor
Loss of coordination of voluntary movements
Explosive speech
Dysmetria
Dysdiadochokinesia
119
Manifestation of Floculondular Lobe Syndrome?
Truncal Ataxia- Paraxial muscles
120
What produces appendicular ataxia?
Lesion of cerebellar hemispheres
121
Causes of Intention Tremors?
MS
Midbrain infarction
122
Ataxia mimicers
Hydrocephalus → damages frontopontine pathways
Lesion of prefrontal cortex
Pons/Cerebellar peduncles → cerebellar input or output
123
What does Monro-Kellie rule state?
An increase in one element [Blood, CSF, Brain Tissue] must occur at the expense of others, which will increase ICP
124
What is the normal ICP in adults?
8 - 18 mmHg
15 - 22 cmH20
125
What is the normal ICP in children?
10 - 20 cmH20
126
What is the leading cause of Increased ICP in kuwait?
Idiopathic intracranial HTN, associated with obesity
127
What is the formula for CPP?
CPP = MAP - ICP
128
What is the normal CPP?
80-100 mmHg
129
What is the formula for MAP?
MAP = DP+ ⅓(SP-DP)
130
What is the most reliable indicator of increased ICP?
Decreased LOC
131
What is the earliest sign of ↑ICP? Late sign?
Early sign: Decreased LOC
Late sign: Fixed and dilated pupil
132
What is cushing’s triad?
Bradycardia
Change in breathing pattern
↑BP
133
What causes cushing’s triad?
Ischemia or pressure on brainstem
134
Describe decorticate posturing
Flexion of UL and extension of LL
[Plantar flexed
Internally rotated
Flexed arm, elbow and hands
Adducted shoulders]
135
Describe decerebrate posturing
Extension of UL + LL
[Plantar flexed
Extended elbow
Pronated forearm
Flexed hand]
136
What is a sign of ↑ICP in infants?
Bulging fontanelle
137
What are signs of ↑ ICP?
Headache
Vomiting
Abnormal posturing
Papilledema
Poor pupillary response to light
138
What respiratory changes are associated with diffuse cortical lesions?
Cheyne-stokes respiration
139
What is Cheyne-stoke respiration?
Apnea alternating with hyperventilation
140
What respiratory changes are associated with Midbrain lesion?
Central Neurogenic Hyperventilation
141
What is Central Neurogenic Hyperventilation?
Sustained regular and rapid, deep breathing
142
What respiratory changes are associated with pons lesion?
Apneustic breathing
143
What is Apneustic breathing?
Prolonged pause at end of inspiration
144
What respiratory changes are associated with medullary lesion?
Ataxic breathing
145
What is ataxic breathing?
Rapid and shallow breathing
146
Describe pupillary changes associated with brainstem lesion
Midbrain: Mid-sized pupils
Pons: Pin-point pupils
147
What are the types of brain edema?
Vasogenic
Cytotoxic
Interstitial
148
What is the most common type of brain edema?
Vasogenic
149
What is Vasogenic Edema?
Increased permeability of brain capillary endothelial cells , follows white matter distribution
150
Cause of Vasogenic Edema?
Tumor
Abscess
Hemorrhage
Infarction
Contusions
151
What is Cytotoxic Edema?
ATP failures, increasing cell size, follows gray matter distribution
152
Cause of Cytotoxic Edema?
Hypoxic-ischemic injury
Osmolar injury
Toxins
Secondary injury following head trauma
153
What is interstitial edema?
Increase of water content of periventricular matter due obstruction of CSF flow
154
Herniation Syndrome due to increased ICP?
Transtentorial herniation
Subfalcine herniation
Central herniation
Upward transtentorial herniation
Tonsillar herniation
155
What structures are compressed in transtentorial herniation?
Ipsilateral Oculomotor
PCA
Rarely- Contralateral Oculomotor nerve + Cerebral peduncle
156
What is transtentorial herniation?
Medial temporal lobe squeezed under tent
157
What is Subfalcine herniation?
Cingulate gyrus pushed under falx cerebri
158
What structures are compressed in subfalcine herniation?
ACA [→ infarction of paramedian cortex]
159
Treatment of Increased ICP
Removal of causative
Hyperventilation [→ hypocapnia → vasoconstriction]
Removal of CSF
Fluid restriction
IV mannitol
Steroids
160
What is Upward Transtentorial herniation?
Infratentorial mass compresses brain stem → upward movement of cerebellum
161
Presentation of Central Herniation:
Hernites both temporal lobes → damage to midbrain:
Decerebrate posturing
Pupils fixed in mid positions
→ Loss of brainstem reflexes/cessation of respirations/brain dead
162
What are the indications for corticosteroids as treatment for ↑ICP?
Brain tumor
Abscesses
163
What are the classes of hyperkinetic disorders?
Tics
Myoclonus
Ballismus
Dystonia
Chorea
Atherosis
Tremor
164
What are the classes of hypokinetic disorders?
Parkinsonism
165
What is most common major movement disorders?
Parkinson’s disease
166
What is the typical age of onset of parkinsons?
50-60 yrs
167
What are the cardinal features of PD?
Bradykinesia
Rigidity
Instability [postural]
Tremor [Resting]
168
What are the symptoms of Parkinson’s?
Stooped posture
Masked facial expression
Forward tilt of trunk
Rigidity
Flexed elbows and wrists
Slightly flexed hips and knees
Shuffling, short stepped gait
Trembling of extremities
169
What is the most disabling symptom of PD?
Bradykinesia
170
What is the earliest sign of PD?
Resting tremor
171
Define resting tremor
Tremor that presents at rest and improves when a motor task is performed
172
Describe resting tremors in PD?
Begins unilaterally as “pill-rolling” tremor in hands
Earliest sign of PD, present in 70% of patients
173
What sign is indicative of advanced stage of PD?
Postural instability and gait disturbances
174
Describe the postural instability seen in PD?
Flexion of neck and trunk
175
Describe gait disturbances seen in PD?
Low gait with short stride length
Inability to turn quickly
Reduced arm swing
176
What rigidity is seen in PD patients?
Lead pipe [sustained] rigidity
Cogwheel [intermittent] rigidity
[lead pipe + tremor]
Seen in 90% of patients
177
What signs are common in parkinsonisms?
Rigidity
Bradykinesia
178
How do you diagnose PD?
History & clinical examination
2 out of 4 cardinal features
Laboratory tests and imaging
To exclude secondary parkinsonism
Diagnosis supported by response to Dopaminergic drugs
179
What is the treatment of PD?
Dopamine replacement
Amantadine
MAO-B inhibitors
DBS
180
Classification of Parkinsonism?
Primary
Secondary
Atypical
181
What are the causes of atypical parkinsonian syndromes?
Corticobasal degeneration [CBD]
Progressive Supranuclear palsy [PSP]
Multiple System Atrophy [MSA]
182
What are tics?
Sudden, repeated, brief movement or sounds, which can be voluntarily suppressed
183
What is the clinical criteria for Tourette Syndrome?
≥2 motor
≥ 1 vocal
\> 1 year
184
What is coprolalia?
Profanities
185
What is echolalia?
Repeat what others say
186
What is palilalia?
Repeats own words
187
What is dystonia?
Sustained involuntary muscular contraction → fixed posture / repetitive twisting movements
188
Divisions of Dystonia?
Focal
Generalized
Task specific
189
What is torticollis?
Dystonia of neck
190
What are the task specific dystonias?
Writer’s cramp
Musician dystonia
Throwing a ball
191
What is sensory trick?
Purposeful movement that suppresses dystonia
192
What medications may cause dystonia?
Dopamine receptor blockers
193
Define myoclonus
Brief shock-like jerks
194
What is an example of negative myoclonus?
Asterixis
195
What can myoclonus indicate?
Lesion in cortex, subcortex, brainstem, spinal and peripheral nerves
196
Define tremors
Rhythmic oscillation of a body part by alternating contraction of antagonist muscles
197
What structures are affected by tremors?
Hands
Head
Jaw
Voice
Tongue
LL
198
What are the causes of resting tremors?
PD
199
How are tremors classified?
Resting tremor
Postural tremor
Action tremor
200
What is the commonest movement disorder?
Essential tremor
201
How are essential tremors diagnosed?
Spiral test
202
What are the treatment options of Essential tremor?
Medications [propranolol]
Deep brain stimulation
203
What is chorea?
Irregular, involuntary, non-rhythmic and unsustained movements that flow from one side to another
204
What are the classic examples of chorea?
HD
Sydenham’s chorea
205
What are two hereditary causes of chorea? Its pattern of inheritance?
HD - [dominant]
Wilson’s disease [recessive]
206
What is ballismus?
Large amplitude choreic movements of proximal limbs
207
What is the commonest cause of hemiballismus?
Stroke
208
What is athetosis?
Slow continuous stream of sinuous, writhing movements [typically of hands]
209
What is the most common sleep disorder?
Insomnia
210
Define Acute Insomnia?
Few days - 3 months, usually results of stressful events
211
Define Chronic Insomnia?
\> 3 months
212
What is Restless leg syndrome?
Urge to move legs, accompanied/caused by uncomfortable sensations in legs, worsening during periods of rest and is relieved by movement
213
What are the supportive features of Restless leg syndrome?
Dopaminergic responsiveness
Positive family history
Presence of periodic limb movements in sleep/wakefulness
214
Clinical manifestations of Narcolepsy
Narcoleptic sleep attacks
Distrubed night sleep
Cataplexy
Hallucination/Automatic behaviors
Sleep paralysis
215
Comorbid conditions associated with Narcolepsy?
Periodic limb movements
Sleep Apnea
Rem sleep behavior disorder
Eating disorders
Increased BMI
DM
216
What is narcolepsy?
Irresistible desire to fall asleep at inappropriate times
217
Pathophysiology of narcolepsy?
Depletion of hypocretin neurons in lateral and prefrontal region of hypothalamus
218
Diagnostic test of narcolepsy?
Decreased hypocretin 1 in CSF
HLA-DQB1-0602 in Ch.6
219
Presentation of Narcolepsy?
Agr 15-30, runs in family 1-2 of first degree relatives
220
What are parasomnias?
Abnormal movements that occur in sleeper during arousals from sleep, with preserved sleep architecture
221
In general, how do infectious microorganisms cause disease in the CNS?
Direct invasion of neuronal tissue
Production of neurotoxin
Immune response incited by pathogen
222
Infection by which microorganisms present acutely?
Viral and Bacterial [mostly]
223
Infection by which microorganisms present sub-acutely/chronically?
Mycobacterium
[+Neurosyphilis]
Fungal
Parasitic
Spirochetal
224
What signs and symptoms indicate meningitis?
Fever
Neck Rigidity
Headache
Vomiting
225
What signs and symptoms indicate encephalitis?
Seizures
Altered sensorium
226
What are the causes of infectious encephalitis?
Viral [Commonest]
Bacterial
Fungal
Autoimmune
Para/Post-Infectious
227
What are the clinical features of focal encephalitis?
Changes in :
Consciousness
Alert
Behavior
Personality
Focal seizures
228
What are the clinical features of generalized encephalitis?
Generalized seizures
Altered sensorium
Confusion
Coma
Irritability
Confusion
Disorientation
Prodrome [Fever, headache, Body aches, and N &V]
229
What is the most serious cause of encephalitis and its pathogenesis?
HSV 1 , Through the olfactory nerves
230
Describe the clinical presentation of Generalized encephalitis?
Acute onset
Generalized seizures
Neurological deficit [possible]
231
Describe the clinical presentation of Focal encephalitis
Subacute onesie
Focal seizures
Neurological deficit
232
What are the clinical features of Generalized encephalitis?
Headache
Fever
Vomiting
Agitation
Restlessness
Altered sensorium
Unconsciousness
233
What are the clinical features of Focal encephalitis?
Conscious with behavioral or personality changes
234
What are the investigative tests for encephalitis?
Routine lab tests
Blood Cultures
CSF exam
PCR
Serology by detection of antibodies in CSF
CT/MRI
EEG
235
What does CSF of an encephalitic patient show?
CSF analysis
↑ protein
Normal glucose
Lymphocytic pleocytosis
236
What viral causes of encephalitis are treatable?
VCZ
HSV
CMV
237
What is the empirical treatment for encephalitis?
Acyclovir
238
When is acyclovir withdrawn in encephalitis patients?
If HSV+ VCZ excluded
239
What is the symptomatic management of encephalitis?
Mannitol for cerebral edema
Anticonvulsants for seizures
Steroids
240
What are the complications of Encephalitis?
Brain edema
Personality changes
Memory problems
SIADH
Intellectual disorders
Lack of muscle coordination
Paralysis
Epilepsy
Hearing or vision defects
Speech impairment
Coma
Death
241
What is the common etiology of Generalized encephalitis?
Viral, short-lived
242
What is the common etiology of Focal encephalitis?
HSV
Autoimmune
243
What is the cause of HSE?
Reactivation of virus lying dormant in trigeminal ganglion
244
What investigations are used to diagnose HSE?
CSF analysis
HSV PCR
CT: uni/bilateral temporal lobe lesion
EEG
Repeat all investigation after 4 days if initially negative
245
Prognosis of HSE
Mortality \> 70% with severe long term neurological sequelae
W/treatment ~30% but with severe disabilities
246
Describe the clinical presentation of viral meningitis
Acute onset and symptoms may follow a preceding flu-like symptoms
Fever and severe headache
Meningeal irritation, N &V, rashes
Less common: Diarrhea, myalgia, cough
247
What are the most common causes of viral meningitis?
Enterovirus
HSV 1
HSV2
248
CSF analysis of Viral meningitis
Normal/ ↑ protein
Normal glucose
Lymphocytic pleocytosis
Normal or slightly elevated opening pressure
249
When is IV acyclovir indicated in viral meningitis?
HSV 1/HSV 2
VCZ
250
What is the prognosis of viral meningitis?
Self limited infections, with adults making a complete recovery within 7-10 days
251
Sequelae of Viral meningitis in children?
Seizures
Hydrocephalus
Sensorineural hearing loss
Cognitive/behavioral abnormalities
252
Describe the presentation of acute bacterial meningitis in elderly patients
Possibly atypical with no signs of meningeal irritation, just non-specific confusion
253
What investigations are used to diagnose bacterial meningitis?
CSF exam [gold standard]
CT- possible sulcal effacement
MRI-
T2- hyperintensity in sulci
T1- enhancement of leptomeninges within sulci
DWI- diffusion restriction in sulci
254
What does CSF examination in bacterial meningitis patient reveal?
↑ protein
↓↓ glucose
Pleomorphic pleocytosis
255
What is the empirical treatment of acute bacterial meningitis?
Vancomycin
Ceftriaxone / Cefotaxime
Dexamethasone
256
Prognosis of bacterial TB?
Mortality /Morbidity 18-40%
257
Who has a poor prognosis in bacterial meningitis?
Extreme ages
Immunocompromised
Late onset seizures [\> 4 days]
Long duration before starting treatment
258
What are the immediate complications of bacterial meningitis?
Coma
Loss of airway reflexes
Seizures
Cerebral edema
Vasomotor collapse
DIC
Respiratory arrest
Dehydration
Pericardial effusion
Death
259
What are the delayed complications of bacterial meningitis?
Seizure disorder
Focal paralysis
Subdural effusion
Hydrocephalus
Intellectual deficits
Sensorineural hearing loss
Ataxia
Blindness bilateral adrenal hemorrhage
Death
260
Define Chronic meningitis
Meningitis lasting longer than a month without improvement
261
What are the common causes of Chronic meningitis?
Chronic bacterial or fungal infections
TB
Cryptococcal
Syphilis
Cysticercosis
Lyme
262
What conditions are commonly seen in patients with TBM?
Mild anemia
Hyponatremia
Subcortical strokes
263
What is tuberculous vasculopathy?
A complication of TB
Multiple or bilateral lesions in territories of MCA perforating vessels
264
What investigations must be done to diagnose TBM?
MRI
PPD [possible]
CSF analysis
↑ protein
↓ glucose
Lymphocytic pleocytosis
PCR
Culture
265
Treatment for TBM?
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
Dexamethasone [initial phase]
266
What are the neurological sequelae associated with TB?
Developmental delay in children
Seizures
Hydrocephalus
CN palsies
267
Prognosis of TBM?
Death in 50% of cases
268
Mortality of TMB
Greatest in \>5 yrs or 50 yrs\< or illness longer than 2 months
269
What are the causative microorganisms of brain abscess?
Streptococci [60-70%]
Bacteroides
Enterobacteriaceae
Staphylococcus aureus
S. milleri
270
What are the rare causative microorganism of brain abscess?
Nocardia
Listeria
271
What is the treatment for brain abscesses?
Ceftriaxone
Metronidazole [anaerobes]
Surgical drainage
[If \>2.5 cm
If neurologically unstable
If decreased consciousness]
272
What are the causes of subdural empyema?
Extension of sinusitis
Otitis media
273
What is the treatment for subdural empyema?
Ceftriaxone
Metronidazole [anaerobes]
Surgical drainage
274
What are the pain-sensitive intracranial structures?
Blood vessels [vasodilation is painful]
Meninges
Nerves
275
What are the pain-sensitive extracranial structures?
Scalp
Joints
Muscles
Teeth, Eyes and Ears
276
What is the prevalence of headaches?
96-99%
\>90% are benign
277
What are the 5 mechanisms of Headaches?
Traction on major vessels or meninges
Distension of arteries
Inflammation near pain-sensitive structures
Direct pressure on cranial arteries or cervical nerves
Sustained contraction of scalp/neck muscles
278
How do you differentiate between primary and secondary headaches?
History [onset, severity, systemic features]
279
What are the redflags for secondary headaches?
Systemic symptoms
Secondary risk factor
Neurological symptoms
Onset
Older age [new onset or progressive pain]
Pregnancy
Postural aggravation
Papilledema
Previous history of headache
Precipitated by valsalva
280
What condition is associated with older onset of headaches ?
Giant cell arteritis
281
What are some vascular causes of headaches?
Stroke
SAH
Intracerebral hemorrhage
282
What are some infectious causes of headaches?
Meningitis
Sinusitis
Post-herpetic neuralgia
283
What are some inflammatory causes of headaches?
Temporal arteritis
284
What are some drug-related causes of headaches?
Nitrates
Caffeine withdrawal
Sympathomimetics
285
What are some metabolic / systemic causes of headaches?
Anemia
Hypercalcemia
Renal Failure
Hypoxia
Hypercarbia
286
What are some ophthalmologic causes of headaches?
Glaucoma
Ischemia
287
What are some conditions that cause decreased ICP and headaches?
Post-Lumbar puncture
Spontaneous Intracranial hypotension
288
What are some conditions that cause increased ICP and headaches?
Mass
Hypertension
Pseudotumor/Idiopathic Intracranial hypertension
289
What are the primary headache disorders?
Migraine
Tension
TACs [Cluster, Paroxysmal Hemicrania, SUNCT and Hemicrania continua]
Others [Trigeminal Neuralgia and Occipital neuralgia
290
What is associated with Migraines?
Nausea and Vomiting
291
What type of migraine is common?
Without aura
292
What is the severity of Migraine headaches?
Moderate to severe intensity
293
What are the auras of migraines?
Photophobia
Phonophobia
Osmophobia
294
What is the commonest aura of migraines?
Photophobia
295
What are the complications of migraine?
Stroke
Seizures
Status migrainosus [\>72hrs]
Chronic migraines
Persistent migraine w/o infarction
296
What is the clinical presentation of Childhood Migraines?
Benign Paroxysmal Vertigo
Cyclic Vomiting
Abdominal migraines
297
What is used to treat acute migraines?
Analgesia
Triptans
298
How can we educate Migraine patients?
Avoid triggers
Diary documenting their headaches [timings, frequency, relation to menses]
Patients shouldn’t abuse analgesic treatments
299
T/F: There are no preventative treatments for Migraines.
False, there are some preventative methods such as monoclonal antibodies against CGRB
300
What is the commonest reported headache? Commonest primary headache?
Reported: migraine
Primary: Tension
301
What are Tension headaches?
Tight band on the head
302
What conditions are associated with Tension headaches?
Stress
Depression
Associated with medication-overuse headaches
303
What is the severity of Cluster headaches?
Severe to very severe
304
Describe the state of patient with Cluster headaches
Suicidal and unable to sleep
305
What is the duration of Cluster headaches?
15-180 min
306
What is used to treat Cluster headaches?
Abortive and prophylactic treatment [oxygen mask]
307
What is the severity of Paroxysmal hemicrania?
Moderate pain
308
What is used to treat Paroxysmal hemicrania?
Indomethacin
309
What is the duration of Paroxysmal hemicrania?
2-30 minutes , episodic or chronic
310
What type of headache is very rare and difficult to treat?
SUNCT headaches
311
What does SUNCT stand for?
Short lasting
Unilateral
Neuralgiform headache w/
Conjunctival injection and
Tearing
312
What is the duration of SUNCT headaches?
1-600 sec
313
What is the severity of Hemicrania continua?
Mild to moderate pain
314
What type of headache is associated with autonomic features?
Hemicrania continua and other TAC headaches
315
What autonomic features are associated with TAC headaches?
Ptosis
Miosis
Facial swelling
Tearing
Nasal Congestion
316
What is the duration of hemicrania continua headaches?
Continuous
317
Define Neuralgia
Very sharp pain in seconds that can happen several times a day
318
What structures are affected in Trigeminal Neuralgia?
Maxillary [V2] and Mandibular [V3] divisions of the trigeminal nerve [CN5]
319
What is used to treat Trigeminal Neuralgia?
Carbamazepine
320
What structure is affected in Occipital neuralgia?
C2- Occipital region of head
321
Onset of AD?
\>65 yrs.
322
What pathological findings of AD?
Extracellularly: aB
Intracellularly: Tau
323
What are the risks of AD?
Vascular
TBI
Sleep Disturbances
TREM2
ADOE E4 alleles
324
What factors may reduce the risk of AD?
Increased formal education
Physical activities
Social engagement
325
What is the hallmark findings of Early onset AD?
Disproportionately decreased repetition of sentences
326
Presentation of Posterior Cortical Atrophy
Progressive and Disproportional loss of visuospatial and visuoperceptiual
327
Differences of presentation of Early onset and Late onset Ad?
Early onset has better memory recognition score and semantic memory compared to late onset
328
Pathological differences between Early onset and Late onset Ad?
Early onset: Posterior Cingulate
Late onset: Medial temporal lobe
329
What is the second most common cause of Early-onset AD?
Posterior Cortical Atrophy
330
What are the core clinical features of Lewy-body dementia?
Fluctuating cognition
Recurrent Visual Hallucination
REM Sleep Behaviors
Cardinal Features of Parkinsonisms
331
What are the supportive clinical features of Lewy-body dementia?
Hypersomnia/Hyposomnia
Hallucination
Systemic Delusions
Apathy
Severe Autonomic Dysfunction
Repeated Falls/Postural Instability
Syncope
Severe sensitivity to Antipsychotic agents
332
What is the hallmark of Delirium?
Acute impairment of cognition with fluctuating course
333
Criteria for Delirium
Acute Onset + Fluctuating course
Inattention
Disorganized Thinking
Altered levels of Consciousness
334
Criteria for Persistent Vegetative state?
1 month
335
Criteria for Permanent Vegetative state?
3 months
6 months in TBIs
336
What is the afferent limb for light reflex?
Optic nerve
337
What is the efferent limb for light reflex?
Oculomotor nerve
338
What findings are consistent with total loss of afferent limb of light reflex?
No direct or consensual reflex in affected eye
339
What findings are consistent with partial loss of afferent limb of light reflex?
Partial constriction
Both eyes dilate
340
Findings of Optic Neuritis
Central Scotoma
Optic Disc swelling [2/3 retrobulbar]
341
Causes of Mydriasis?
CN 3 Palsy
Cocaine
Atropine
342
Causes of Miosis?
Horner's Syndrome
Tertiary Syphilis
Morphine
Pilocarpine
343
Where is a lesion located if patient say he sees a "pie on the floor"?
Parietal lobe
344
Where is a lesion located if patient say he sees a "pie in the sky"?
Temporal lobe
345
Complete loss of vision in one eye
Optic nerve
346
Bitemporal hemianopia
Optic Chiasma
347
Homonymous Hemianopia
Optic tract
348
UR Quadrant hemianopia
Lower fibers in temporal lobe
349
LR Quadran hemianopia
Lower fibers in parietal lobe [anterior]
350
Homonymous Hemianopia w/macular sparing
Lower fibers in parietal lobe [posterior]
351
Lesion in Pontine/Midbrain would produce?
eyes deviate toward hemiparesis [wrong way gaze]
Vertical gaze [midbrain]
Abducent nerve [pontine]
352
Lesion in Hemisphere would produce?
away from hemiparesis
353
What structure is affected in Internuclear Opthalmoplegia?
MLF
354
What are some causes of Internuclear Opthalmoplegia?
MS
Brainstem infarcts
355
Findings in Internuclear Opthalmoplegia?
Side of lesion is the same side that fails to adduct:
1- Abduction [normal]
2-Adduction [eye on side of lesion fails to adduct]
3- Normal eye nystagmus
4- Affected eye fails to adduct
