Clinical questions - Neurology Flashcards
Wernicke’s encephalopathy presentation, tx
ataxia, encephalopathy, oculomotor dysfunction
Tx: IV thiamine
Glucose (D5 or D50) before thiamine theoretically damages mammillary bodies worsening wernicke’s
Subarachnoid hemorrhage - presentation, work up, treatment
Severe headache, +/- LOC without trauma
W/U: CT head w/o con - if negative LP to look for blood in CSF
Tx: ICU admit BP control CCB - amlodipine to prevent vasospasm Surgical clipping or embolization to prevent re-bleeding - necessary to prevent death
Myasthenia graves crisis - presentation, treatment
Ptosis and difficulty swallowing - edrophonium with temporary resolution of ptosis
Difficulty breathing which can quickly deteriorate to respiratory failure requiring mechanical ventilation
Cause: auto-Ab to cholinergic receptors at the NMJ
Tx:
Less severe but symptomatic - cholinesterase-i : pyridostigmine
Severe (i.e. resp failure): plasmapheresis or IVIG
Chronic immunosuppression with prednisone, azathioprine
Brain tumor that is rare, slow growing, often found in frontal lobe in adults
Oligodentroglioma
Brain tumor that is benign, MC childhood supratentorial tumor
Craniopharyngioma - risk bitemporal hemianopsia
mc malignant primary brain tumor in adults, rapidly progressive
glioblastoma
Brain tumor that is most commonly secretes prolactin, may cause bitemporal hemianopsia
Pitutary adenoma - prolactinoma
highly malignant cerebellar tumor in children
medulloblastoma
common primary brain tumor, typically benign
meningioma
Absence (petite mal) seizure presentation and treatment
occasional periods of impaired consciousness lasting 30-45 seconds
Tx: ethosuximide
Initial dementia work up
TSH, B12
MRI brain to r/o normal pressure hydrocephalus or tumor
Lumbar spinal stenosis presentation, dx, treatment
gradually worsening pain walking downhill but improves walking uphill or leaning over a shopping cart
PE: DTRs decreased/absent in ankles/knees
Negative straight leg test
Dx: MRI L spine
Tx:
Mild: PT, NSAIDs
Severe: Sx decompression
West Nile Encephalitis presentation, dx, tx
presentation: headache, confusion (more common in older pts), weakness, myalgia, fever, malaise, with exposure to mosquitos - acute febrile illness in summer months
PE: maculopapular rash
CSF: elevated protein, normal glucose, moderate lymphocytes (looks viral)
Tx: supportive - fluids, rest
Upper motor neuron signs
Hyperreflexia weakness decreased control Spastic paralysis \+ Babinski
Lower motor neuron signs
flaccid paralysis
areflexia or hyporeflexia
Upper or lower neuron sign associated with: stroke
UMN
Upper or lower neuron sign associated with: Bell’s palsy
LMN
Upper or lower neuron sign associated with: spasticity
UMN
Upper or lower neuron sign associated with: TIA
UMN
Upper or lower neuron sign associated with: Guillain-Barre’ syndrome
LMN
Upper or lower neuron sign associated with: caudal equine sn
LMN
Multiple sclerosis presentation, work up, tx
s/s of CNS lesions separated by time and space
- optic neuritis
- sensory deficits
- Lhermitte sign (electrical pain down spine/arms when tilt head down
- motor weakness
- bowel/bladder problems
- gait/balance problems
- generalized fatigue
w/u: MRI brain/spinal cord with several plaques of demyelination in various stages of healing
Tx:
Acute: prednisone or methylprednisolone
Chronic: b-interferon, iterimere
Parkinson disease - pathophys, presentation, treatment
Loss of dopaminergic neurons in the substantia nigra
Presentation: tremor, difficulty walking, shuffling gait with difficulty taking first step, frequent falls
PE: limited facial expression, resting tremor, increased muscle tone, cogwheel rigidity in extremities
No obvious cerebellar deficits
initial tx: Levodopa/carbidopa
- Levodopa taken up in the CNS and converted to dopamine
- Carbidopa inhibits breakdown of levodopa in circulation
Advanced disease: deep brain stimulation
- subthalamic nucleus
- decrease inhibition of movement
- wont slow dz progression, tx symptoms and motor fluctuations
Radial nerve palsy - presentation, tx
“Saturday night palsy” - wrist drop, inability to extend fingers, decreased sensation
Self limited, no treatment
Resolves on its own in 2-3 months
Brown-sequard syndrome
Hemisection of spinal cord, typically penetrating wound to back
Neuro exam: loss of proprioception and vibration sense and paralysis on ipsilateral side, pain and temp loss on contralateral side
Diagnosis of brain death and clinical scenarios that can mimic brain death
Diagnosis of brain death: Assess brain blood flow -cerebral angiography gold standard - inaccurate in severe hypotension -Transcranial doppler EEG
Mimics: Locked In Sn Neuromuscular paralysis Drug intoxications Guillain-Barre' Sn Hypothermia
Restless leg syndrome - work up and treatment
Discomfort in legs at night relieved by movement
Always check iron studies and replete if needed
Intermittent:
- Levodopa
- Benzos
Persistent:
Dopamine agonists: pramipexole, ropinirole
Gabapentin/pregabalin
Cryococcus neoformans Meningitis in HIV
Headache and fever
LP: elevated opening pressure, CSF low glucose, mildly elevated protein, small number of lymphocytes, NO RBC
Confirm dx with india ink stain, if positive, still confirm with cryptococcal Ag in serum or CSF
Tx:
Amphotericin B + flucytosine x2 weeks
THEN PO fluconazole for 8 weeks
LP/CSF findings for bacterial, viral, fungal meningitis
Bacterial:
High opening pressure
Low glucose
Neutrophil predominant
Viral:
Normal opening pressure
Normal glucose and protein
Lymphocytic predominant
Fungal: high opening pressure low glucose mildly elevated protein small number of lymphocytes
Anterior spinal artery syndrome
Anterior spinal artery supplies the everything except the posterior columns of the spinal cord which is supplied by the posterior spinal artery.
Hx of atherosclerosis, AAA/repair, trauma
loss of pain and temperature and motor function bilaterally below level of the occlusion
Vibration and proprioception intact
Normal pressure hydrocephalus
Dementia, gait abnormality, urinary incontinence
ddx: depression (no urinary or gait sxs), PD or LBD (no tremor or rigidity)
Tx: ventricular shunting
Evaluation of stroke
CT head w/o contrast to r/o hemorrhagic stroke
- acute blood is bright white
- Ischemic stroke is negative first 24-48 hrs - dark on CT
MRI ischemic stroke shows earlier than CT
Guillian-Barre syndrome
Recent history of respiratory infection, GI infection (Camphylobacter)
Demyelination of peripheral nerves with symmetric motor weakness and hyporeflexia that gradually ascends and involves upper extremities
-risk of respiratory failure
Paraesthesia complaints but normal sensory
Autonomic dysfunction: tachycardia, hypotension, urinary retention
Course usually progresses for 2 weeks, plateaus for 2 weeks, then improves over weeks to months
CSF: elevated protein, normal cellular count - albuminocytologic disassociation
Tx:
ICU monitoring
-Intubate if resp failure
-Plasmapheresis or IVIG if rapidly progressing or respiratory failure or bulbar involvement (can’t swallow)
Essential tremor
tremor at rest, worsens with intentional movement
Less pronounced with alcohol use
Tx: b-blocker like propranolol
Acute, self-limited vertigo with hearing loss and tinnitus
Acute labrynthritis
Vertigo is independent of head movement, no hearing loss or tinnitus, may result from viral infection
Vestibular neuritis - tx meclizine
Vertigo + ataxia, hearing loss, and tinnitus. MRI shows tumor near the internal auditory canal
Acoustic neuroma
Vertigo with change of head position, no hearing gloss, tinnitus, or ataxia, positive Dix-Hallpike maneuver
Benign paroxysmal positional vertigo (BPPV)
Chronic vertigo + hearing loss and tinnitus, treat with salt restriction and diuretics
Meniere’s dz
Antithrombotic therapy for acute thrombotic stroke
Initially give ASA 162-325 mg
Plavix or aggrenox (asa + dipyridamole) or asa
No warfarin unless cardiothrombotic (afib)
Indications for carotid endarterectomy
Symptomatic with narrowing 70-99% (recent stroke or TIA)
Symptomatic male with 50-69% stenosis
Asymptomatic 60-99% stenosis with life expectancy of more than 5 years
Medical treatment of carotid artery stenosis
statin
BP control
Lifestyle modifications - quit smoking, wt loss, increase exercise
Spinal cord compression
back pain, urinary incontinence, difficulty walking with BLE weakness, decreased sensation, and hyporeflexia
May have hx of cancer - concern for mets causing theca sac pressure
W/U: MRI/CT spine
First step in treatment: steroids to reduce swelling
Amyotrophic lateral sclerosis (ALS)
Upper and lower motor signs - sensory neurons intact
- muscle weakness begins in hands, progressively worsening
- weakness in legs, worsening of balance
- Slurred speech
PE: muscle atrophy, fasciculations in hands, calves
Decreased strength
Hyperreflexia
+ Babinski
Tx:
Riluzole slows progression
Universally fatal in 3-5 yrs
Bells palsy
facial nerve palsy involves upper and lower face (if upper spared, cortical stroke), often decreased taste sensation on anterior tongue
Difficulty talking, inability to close eye all the way
Associated with HSV, Zoster, Lyme dz, sarcoidosis, DM, tumors
Tx:
High dose steroids +/- acyclovir or valacyclovir
Syringomyelia
Cystic degeneration within spinal cord, usually cervical spine or upper thoracic following an injury like whiplash
-dilated area compresses the anterior white commissure causing decreased pain and temp sensation in a yolk like distribution over neck, shoulders and down both arms
Tx:
Surgical shunt to decompress dilated area
Carpal tunnel syndrome
Entrapment of the medial n. by flexor retinaculum 2/2 inflammation -> tingling and weakness in the first 3 digits of hand, often associated with repetitive work
Tx:
- wrist brace/splint - if can’t avoid repetitive use attributing to it
- Steroid inj
- surgery if fail above
Most common cause of headache
tension headache - posterior head starts
Periorbital pain with lacrimation and/or rhinorrhea
cluster headache +/- congestion ipsilateral side
Obese woman with palpilledema and headache
Idiopathic intracranial hypertension - pseudotumor cerebri
Scintillating scotomas prior to headache
migraine
jaw muscle pain with chewing, headache
temporal arteritis (giant cell arteritis) - quick steroids risk of vision loss
Headache responsive to 100% oxygen supplementation
cluster HA
In a patient with suspected bacterial meningitis, what should be ordered prior the the LP and why
CT head to r/o mass
IF AMS Papilledema Seizure w/in past week Immunocompromised state Focal neurologic symptoms
