Clinical Neurology Flashcards
Someone presents with a loss of sensation and pain bilateral upper limb. What do you suspect?
Syringomyelia: enlargement of the central canal of spinal cord
What are the recommended investigations for first seizure?
- Brain imaging (CT or MRI)
- EEG
- Blood tests: blood counts, serum glucose, electrolytes
- Urine toxicology screen
- CSF: if infection suspected
Where are LP and spinal anaesthesia performed?
Below the L1-2 level in the adult, so below the cord
What is Charcot triad of MS?
- Scanning speech
- Intention tremor
- Nystagmus (medial longitudinal fasciculus syndrome)
What cord segment is tested in the knee jerk muscle strech relex?
L2-L4
Where does the needle go in a epidural anaesthesia?
Outside the dura
What is a Wernicke aphasia?
Fluent, paraphasia, and impaired comprehension
What is the treatement of trigeminal autonomic cephalalgias in the ER?
OXYGEN
Someone takes out his tongue and it deviates. What nerve is injured?
Hypoglossal (CN XII)
What are the treatement of primary headaches?
- Identify trigger factors
- Non-pharmacological treatment
- Abortive treatment
- RIGHT when the headache stars but too frequent can cause rebound-headache
- Tylenol, Advil, ASA, Triptans (Serotonin agonists), Metoclopramide IV in ER
- Prophylactic (preventive) treatment
- Vitamin B2 (Riboflavin) 400 mg QD
- Magnesium 600 mg QD
- Cyproheptadine (Periactin) 4 mg TID for young kids < 10
What cord segment is tested in the triceps jerk muscle strech relex?
C7-8
How do venous infarction usually present?
Bilateral with mix of ischemia and hemorrhage
When DON’T we treat a first seizure?
- No risk factors for recurrence
- Normal exam
- Normal brain imaging
- Normal EEG
What vessels are the more at risk of stroke if you have chronic hypertension?
- Branches from the MCA
- Branches of the basilar artery
Someone presents with horizontal diplopia, what nerve do you suspect to be injured?
Abducens (CN VI)
What are the types of cerebral edema?
- Surrounding a tumour because of breakdown of BBB (vasogenic edema) –> responds to steroids
- Stroke
- Interstitial edema (caused by osmosis, usually related to hyponatremia)
Someone presents with unilateral frontal/retro-orbital headache with autonomic symptoms (pupils, tearing + redness of an eye and nasal secretion) that last 30-60 minutes. What’s your diagnosis?
Trigeminal autonomic cephalalgias
What is the best treatement for cerebral aneurysm?
Coiling is preferred to surgical clipping because it is less invasive (passing via the arteries, not the brain, to access the aneurysm).
What are the cardinal motor symptoms of Parkinson’s disease?
- Rest tremor
- Rigidity (Cogwheel)
- Bradykinesia
- Postural instability
Someone presents with facial numbness and pain (sharp, sudden, brief, electric-like). What nerve do you suspect to be injured?
Trigeminal (CN V)
- UMN below level
- Sensory loss below level
- Bladder Dysfunction
- No pain
What do you suspect?
Spinal Cord compression or injury
What are the most common causes of intraparenchymal Hemorrhage?
- Chronic Hypertension (deep hemorrhage in the brain)
- Cerebral Amyloid Angiopathy (superficial hemorrhage in the brain)
What cord segment is tested in the forearm jerk muscle strech relex?
C5-6
What are the elements of the ABCD2 score for stroke risk after TIA?
Age > 60
SBP >140 or DBP > 90
Clinical
- Weakness
- Language
Duration:
- > 60 minutes
- 10-59 minutes
Diabetes
Score > 2 21% and ≤ 2 4%
Someone comes it with ptosis and eyes not aligned. What nerve do you suspect to be injured?
Oculomotor (CN III)
Someone has an absent gag reflex. What nerve can be injured?
Glosso-pharyngeal (IX): afferent
Vagus (CN X): efferent
- Characteristic situation
- Prodromal symptoms
- Rapid recovery of consciousness and alertness
What do you think is the cause of this LOC?
Syncope:
- Orthostatic: hypovolemic
- Neurally-mediated: vasovagal
- No motor weakness
- Sacral (perianal) sensory loss
- Bladder Dysfunction
- No pain
What do you suspect?
Conus Medullaris problem (compression)
What are the components of the CHADS2 score for risk of stroke with A. Fib?
- CHF 1 point
- HTN 1 point
- Age > 75 1 point
- Diabetes 1 point
- S2 Prior* 2 points
Anticoagulate if ≥ 1
What are the differential diagnosis for seizures in children?
- Sandifer’s syndrome: GERD after eating
- Breath holding spells: after crying, associated with iron deficient anemia
- Febrile seizures: occurring with fever in the absence of CNS infection or electrolyte imbalance (6 months and 6 years)
- Absence seizures: NO aura, short and no post-Ictal fatigue
- Epilepsy
ALWAYS INVESTIGATE IF FOCAL
- Papilledema
- Projectile vomiting
- Sinus bradycardia
- Hypertension
- Decreased level of conscouiousness
What’s your diagnosis?
ICP –> cerebral edema
- Patchy motor weakness
- Patchy sensory loss
- Possible bladder Dysfunction
- Possible pain
What do you suspect?
Cauda Equina problem
What is the major cause of optic nerve (CN II) impairment?
Increased intracranial pressure
When should you order a CT scan for a headache?
- New
- Age > 40
- Abnormal exam
- Change
- Thunderclap Headache
Where does the needle go in a lumbar puncture?
Subarachnoid space
In what curcumstances would you suspect an Olfactory (CN I) injury?
- Head trauma
- Fronto-basal tumor
What is a Broca aphasia?
Impaired fluency but intact comprehension
Someone has diploplia when looking down (ex. when going down the stairs). What nerve do you suspect to be injured?
Trochlear (CN IV)
What cord segment is tested in the ankle jerk muscle strech relex?
S1
What is the most important thing to do to diagnose seizures?
A good history (focal onset or not?)
What is the Monroe-Kelley Hypothesis?
Increased ICP is due to either increase normal components (CSF, brain, blood) or addition of new components (tumor, pus, extravascular blood)
Dysarthria, dysphagia and hoarseness are signs of damage of which nerve?
Vagus (CN X)
What is the cause of Wernicke-Korsakoff Syndrome?
Thiamine deffciency (chronic alcoholism or bariatric surgery)
What is Syringomyelia?
There is a “central canal” of the spinal cord that is a potential space in adults. It can expand, usually either because of a developmental abnormality or post-trauma.
Can cause numbness and tingling of limbs in suspended sensory loss (not below sensory level)
A child presents with abrupt onset of irritability and lethargy, mental status change and seizures with an history of recent infection. What’s your diagnosis?
Acute disseminated encephalomyelitis: a demyelinating disease
What cord segment is tested in the bicepts jerk muscle strech relex?
C5-6
Someone presents with Bell’s palsy, what nerve is injured?
Facial (CN VII)
- UMN lesions
- Scanning speech
- Intention tremor
- Nystasgmus
What’s your diagnosis?
MS
- Past cardiac history, older person
- Often provoked, usually by exertion or physical activity
- Associated cardiac symptoms may occur (palpitations)
- Sudden and no warning (unlike syncope) and no seizure-like manifestations
What do you think is the cause of this LOC?
Cardiac cause:
- Cardiac
- Aortic stenosis
- Arrhythmias
A patient presents with decreased lower extremity reflexes with rapidly evolving symetrical ascending muscle weakness and paresthesia without fever. What’s your diagnosis?
Guillain-Barré Syndrome
What nerve is responsible for the corneal reflex?
V1 (ophtalmic) part of trigeminal (CN V)
What is the most important risk factor for stroke?
Hypertension
What are the obvious symptoms of Parkinson’s disease that can help you diagnose it?
◼ Masked facies, reduced eye blink
◼ Change in voice
◼ Trouble arising from chair
◼ Difficulty turning in bed
◼ Trouble buttoning shirt
◼ Flexed posture with loss of arm swing
◼ Sialorrhea (hypersalivation)
◼ Change in handwriting
What are the red flags that indicate that the patient with a Parkinson’s disease diagnosis DOES NOT actually have Parkinson’s disease?
◼ Symmetrical presentation
◼ Rapid disease progression
◼ Poor response to levodopa
◼ Prominent, early speech or swallowing difficulties
◼ Pyramidal, cerebellar, autonomic signs
◼ Early gait disorder and falls
◼ “wheelchair sign”
What are the 2 common clinical presentations of a ruptured aneurysm (causing SAH)?
“Sentinel bleed” with headache
- Sudden onset
- Maximal at onset
- “Worst headache of my life”
- Constant for many hours
“Full” Rupture
- Loss of consciousness
- Seizure
- Why? Not ischemic or pressure
- Vocalization, tonic stiffening, clonic movements for 1-2 minutes
- Prolonged post-ictal period; unconscious then confuse
- Urine incontinence, tongue biting
What do you think is the cause of this LOC?
Seizure (neurologic cause)
What are the IMPORTANT non-motor symptoms of Parkinson’s disease?
Psychiatric disturbance
- Anxiety
- Depression
- Apathy
Autonomic disturbance
- Constipation
- Erectile dysfunction
- Urinary frequency
- Orthostatic hypotension
- (Pain)
Cognitive Impairment
- Dementia
- Hallunications
Sleep disturbance
- Hyposomnia
- REM sleep behaviour disorder
- Excessive daytime sleepiness
- Migraine
- OCP
- Smoking
What are you worried about?
STROKE
Where does the needle go in a spinal anaesthesia?
Subarachnoid space
Someone presents with pain when eating. What nerve do you suspect to be injured?
Glosso-pharyngeal (CN IX)
What region in the brain regulates conciousness?
The reticular activating system
What are the 3 categories of coma etilogy?
- Structural (hemorrage, ischemia, herniation…)
- Diffuse neuronal dysfunction (drugs, toxins, endocrine…)
- Psychogenic unresponsiveness
What type of herniation can cause a third nerve palsy?
Uncal herniation
What are the important aspects of coma history?
- Onset (hyperacute, acute, subacute, chronique)
- Underlying medical conditions (epilepsy, liver, diabetes, anticoagulation)
- Preceding symptomes (fever, seizures, neck stiffness, dysuria)
- Medication (changes, antichilinergics, sedatives)
- Recreational drug and alcohol use/withdrawal sttes
- Tauma
- Travel
- Baseline cognitive function
What are the elements in the GCS?
- Eye response
- Verbal response
- Motor response
*minimum score is 3 (1 for each category)
What are the components of a coma neurological exam?
- Level of consciousness (LOC)
- Pattern of breathing
- Pupils (equality and reactivity)
- Fundoscopy (ICP, hemorrhage)
- Occular positions and movements
- Brainstem reflexes (corneal, gag)
- Motor responses
Cheyne-Stokes pattern of breathing is associated to what lesions?
- Bilateral hemispheric
- Elevated ICP
- Cardiopulmonary dysfunction (OSA…)
Hyperventilation is associated to what lesions?
- Metabolic encephalopathy
- High brainstem
Apneusis pattern of breathing is associated to what lesions?
Bilateral pons lesions
Ataxic/cluster pattern of breathing is associated to what lesions?
Pontomedullary lesions
Apnea is associated to what lesions?
Bilateral medullary lesions
What can cause pinpoint pupils?
- Opioids
- Pons lesions
If you have a seasure in the RIGHT frontal lobe, where will your eyes deviate?
To the left
If you have a stroke in the RIGHT frontal lobe, where will your eyes deviate?
To the right
What are the basic investigations to do in a comatose patient?
- Glucose
- CBC (WBC?)
- Electrolytes
- Renal function
- Liver function
- Blood gas
- Toxicology screen
What is the imaging of choice in a comatose patient?
Head CT and MRI is you see nothing
What are the criteria of brain death?
- Irreversible etiology
- Deep coma with no movement arising from the brain
- Brainstem reflexes absent
- Apnea
What can cause coma?
- Bilateral cerebral hemispheres
- Bilateral thalami
- Reticular activating system
What is Epilepsy?
At least TWO unprovoked seizures occurring more than 24h apart
OR
ONE unprovoked seizure and probability of recurrent seizure superior to 60% over the next 10 years
OR
Diagnosis of an epilepsy syndrome
What are the 3 types of syncope?
- Neurogenic or “reflex syncope”
- Vasovagal
- Situational
- Carotid sinus hypersensitivity
- Orthostatic hypotension
- Medication
- Volume
- Neuropathy
- Cardiac
- Arythmias
- Valvulopathy
- PE
What is the first thing you give to a patient having a 1st seizure?
Benzodiazepine
What differentiates essential tremor from intention tremor?
Both happen with movement, but the intention tremor gets WORST when approaching the target
What are the red flags that indicate a secondary headache?
- New onset > 40
- Thunderclap (worst headache of my life)
- Fever
- Focal neurological deficits
- Progessive nausa and vommitting
What is the only type of primary headache for which you order brain imaging?
Cluster headache (subtype of trigeminal autonomic cephalgia): brain MRI
You are a primary physician and you suspect your patient has a a cord compression, what do you do?
- Give corticosteroids (dexamethasone)
- X-ray
- MRI
- Refer
What do you need to rule out if you suspect Myastenia Gravis?
Thymoma
What is the most common cause of Eaton-Lambert syndrome?
Paraneoplastic syndrome (small cell lung cancer)
