Deja - Internal - Neurology Flashcards
What is RIND?
Neurologic deficits that lasts >24h and <3wks.
2 greatest risk factors for a stroke?
- HTN
2. Smoking
2 MC etiologies for ischemia:
- Thrombotic etiology 2o to atherosclerosis.
2. Embolic etiology which is usually either cardiac in origin or from carotid arteries.
MC etiology of a CVA:
Ischemia.
Infarct in the deep gray matter associated with HTN and atherosclerosis:
Lacunar infarct.
MC source of emboli that leads to stroke:
Carotid atheroma.
Thalamus, internal capsule, and cerebral white matter deficit causing FLEXION of the upper extremities:
Decorticate posturing.
Upper brainstem deficit causing EXTENSION of the upper extremities:
Decerebrate rigidity.
Occlusion of MCA supplying the DOMINANT hemisphere:
- Contralateral hemiparesis.
- Hemisensory deficit.
- Aphasia.
- Homonymous hemianopsia.
Occlusion of MCA supplying the nondominant hemisphere:
- Contralateral hemiparesis.
- Hemisensory deficit.
- Homonymous hemianopsia.
- Confusion.
- Apraxia.
- Body neglect on contralateral side.
Occlusion of ACA:
- Broca aphasia.
- Contralateral weakness of lower extremity.
- Incontinence.
Occlusion of PCA:
- Homonymous hemianopsia with MACULAR SPARING.
- CN III palsy.
- Aphasia + Alexia if DOMINANT hemisphere is affected.
Occlusion of PICA:
- Vertigo.
- Ataxia.
- Contralateral pain and temperature disturbance.
- Dysphagia.
- Dysarthria.
- Ipsilateral Horner syndrome.
Occlusion of AICA:
- Deafness.
- Tinnitus.
- Ipsilateral facial weakness.
- Gaze palsy.
Occlusion of ophthalmic artery:
Amaurosis fugax (transient monocular blindness).
1st study to order if you suspect a stroke in a patient?
CT of head WITHOUT contrast to rule out active bleeding.
What other studies can be done to further assess the stroke patient?
- MRI to evaluate for subacute infarction.
- Carotid Doppler US to rule out carotid artery stenosis.
- Echocardiogram to rule out embolic sources.
TIA treatment:
Start with aspirin. If fail, give plavix (clopidogrel).
When would you consider a carotid endarterectomy?
If the patient had carotid artery stenosis >70%.
Cardioembolic stroke treatment:
Anticoagulation with heparin or Coumadin.
Treatment that improves outcome in a patient who present with an EMBOLIC stroke with symptoms beginning <3hr ago?
tPA.
Single most useful test to evaluate seizures?
EEG.
What tests should be done on a patient suspected to have had a seizure?
- Complete neurologic examination.
- Check for incontinence, tongue lacerations, other injuries to the body to distinguish from syncope.
- Lab: CBC, electrolytes, Ca, glucose, O2, LFTs, BUN, Cr, RPR, ESR, Urine tox screen.
- MRI/CT can also be done to rule out a mass.
Factors that increase the risk of having a seizure?
- History of having a seizure in the past.
- CNS tumor.
- CNS infection.
- Trauma.
- Stroke.
- High fever in children.
- Drugs.
Todd paralysis:
Postictal state in which there are focal neurological deficits that lasts 24-48hs.
Usually associated with focal seizures.
2 types of generalized seizures:
- Tonic-clonic seizures.
2. Absence seizures.
Phenytoin - Side effects:
- Agranulocytosis.
- Gingival hyperplasia.
- Hirsutism.
Valproic acid - Side effects:
- Hepatotoxic.
- Thrombocytopenia.
- Neutropenia.
Carbamazepine - Side effect:
Aplastic anemia.
What test is used to diagnose meningitis?
Lumbar puncture with CSF analysis including Gram stain, cultures.
How is a brain tumor diagnosed?
CT with contrast/MRI with gadolinium localizes the lesion and a biopsy is used to get the histologic class of the tumor.
What is the MC mesodermal tumor?
Meningioma.
How are most brain tumors treated?
- Surgical excision and radiation.
2. Medulloblastomas also require chemotherapy and schwannomas are treated with surgery alone.
Who is at higher risk for developing MS?
- Those with a family history of MS.
- Those who lived up until puberty in northern latitudes or temperate climates.
- Females. (2:1)
What is the typical course of MS?
Multiple progressive neurologic alterations that wax and wane and cannot be explained by a single lesion.
Signs and symptoms of MS:
- Limb weakness.
- Paresthesias.
- Optic neuritis.
- Nystagmus.
- Scanning speech.
- Intranuclear ophthalmoplegia.
- Vertigo.
- Diplopia.
Lhermitte sign:
Shock-like sensation down the spine when patient flexes their neck.
Also known as the “barber chair phenomenon”.
What can be seen on MRI on a patient with MS?
MRI shows multiple, asymmetric, periventricular plaques with multiple areas of demyelination.
What does the CSF show in an MS patient?
Oligoclonal bands - Elevated IgG.
MS treatment:
Steroids during acute episodes and IFN-β to prolong remission.
What is the underlying pathology in ALS?
Slow progressive loss of upper and lower motor neurons in CNS.
What are the clinical signs and symptoms of ALS?
- Asymmetric, progressive muscle weakness initially with fasciculations which present clinically as difficulty swallowing.
- Upper + Lower motor neuron signs on physical exam.
- NO bowel or bladder involvement.
How is ALS diagnosed?
Clinically –> Combination of UPPER + LOWER motor symptoms in 3 or more extremities.
An EMG will show widespread denervation and fibrillation potentials in at least 3 limbs.
What is the main treatment for ALS?
Supportive care.
What do ALS patients ultimately die from?
Respiratory failure.
What is Guillain-Barre?
Autoimmune, demyelinating disorder affecting the peripheral nerves (particularly motor fibers).
Bacterial infection associated with Guillain-Barre?
C.jejuni
What often precedes Guillain-Barre?
Bacterial infection causing diarrhea, specifically with Campylobacter, viral infection, or vaccination.
Clinically, how does Guillain-Barre present?
SYMMETRIC ASCENDING PARALYSIS.
Eventually progress to paralysis of the diaphragm, leading to respiratory failure.
What tests would you do to diagnose Guillain-Barre syndrome?
Lumbar puncture and EMG.
What would you see in the CSF after a lumbar puncture in Guillain-Barre?
Incr. Protein; Normal cell count –> Known as albuminocytologic dissociation.
What interventions should be undertaken in a patient with Guillain-Barre syndrome?
Monitor respiratory function very closely and intubate if needed.
–> Plasmapheresis and IVIG.
Prognosis of Guillain-Barre?
Good.
MC type of headache:
Tension headache.
Signs and symptoms of a tension headache?
Bilateral, band-like, dull, most intense at neck/occiput, worsened with stress.
What psychiatric disorder is it most commonly associated with headache?
Depression.
What is the MC age group with tension headache?
Between 20-50.
Headache with rhinorrhoea, unilateral, stabbing, retro-orbital, ipsilateral lacrimation, ptosis, and nasal congestion.
Cluster headache.
Headache with photophobia, nausea, aura, and being unilateral?
Migraine.
Common triggers for migraines:
- Menstruation.
- Stress.
- Foods.
- Alcohol.
Risks of temporal arteritis - Associated with?
Polumyalgia rheumatica.
How is it diagnosed?
Must do a temporal artery biopsy.
Elevated ESR is just a screening test.
MCC of SAH?
Trauma.
MC underlying cause of a spontaneous SAH?
Aneurysm rupture.
MC heritable disorder associated with SAH?
AD PKD.
How is an SAH diagnosed?
- CT shows subarachnoid blood (dark).
- LP shows bloody CSF with xanthocromia.
- Cerebral angiography to find berry aneurysms.
Symptom of berry aneurysm rupture?
CN III palsy.
MC location for a berry aneurysm?
Anterior communicating artery (30%), followed by posterior communicating artery. Then MCA.
Sequence of events in an epidural hematoma?
Patient has a lucid interval lasting from minutes to hrs followed by a loss of consciousness and hemiparesis.
What can cause a “blown” pupil in a patient with an epidural hematoma?
Uncal herniation.
What is seen on CT in a patient with an epidural hematoma?
Convex (lens shaped) hyperdensity that does NOT cross the midline.
What vessels are involved in a subdural hemorrhage?
Bridging veins.
In what population are subdural hematomas most common?
Elderly + Alcoholics.
Course of events in a subdural hematoma?
Patient can have symptoms similar to dementia since mental status changes and hemiparesis can present subacutely.
What is seen on CT in a patient with a subdural hematoma?
Crescent-shaped, concave hyperdensity that may cross the midline.
What does RIND stand for?
Reversible ischemic neurologic deficit.
