General Neurology Flashcards
Lateral Medullary Syndrome/Wallenberg
Vessel: PICA or vertebral Ipsilateral ataxia Ipsilateral dysphagia Ipsilateral face/contralateral body dec pain/temp Ipsilateral Horner's Vertigo/nystagmus Hiccups
Findings in lateral medullary syndrome
Vitals - ?AF, BP maybe up
CN - Horner’s (ptosis, miosis, anhydrosis), face pain/temp, dec corneal reflex, dec gag reflex, nystagmus (fast AWAY from lesion), hoarse voice
Motor - normal strength/reflexes
Sensory - contralateral pain/temp
Coordination - ipsilateral dysmetria and dysdiachokinesia
Gait - ataxic
Other - hiccups
Medial Medullary Syndrome
Vessel = anterior spinal artery
Ipsilateral tongue weakness
Contralateral arm/leg weakness
Contralateral body vibration/proprioception
Midbrain lesion/Weber’s
Vessel = PCA Ipsilateral CN3 palsy (ptosis, mydriasis, diplopia) Eye down and out Contralateral hemiplegia (face, arm, leg)
ACA
Contralateral leg weak and numb
Contralateral grasp reflex
Left MCA stroke - superior branch
- Broca’s aphasia (expressive, non fluent)
- R weakness face and arm > leg
- Gaze deviation to the left
Left MCA stroke - inferior branch
Wernicke’s aphasia - receptive/fluent
R cortical sensory loss
Right pie in the sky visual loss
Left MCA - main branch M1
- Global aphasia
- Right weakness face and arm >leg
- Right cortical sensory loss
- Right pie in the sky
R MCA superior branch
Left weakness face and arm >leg
Gaze deviation to Right
R MCA inferior branch
Left cortical sensory loss
Left hemineglect
Left pie in the sky
R MCA main branch
Inferior and superior mix
PCA stroke
Contralateral homonymous hemianopia
Pure motor stroke
Localizations: posterior limb internal capsule, corona radiata, midbrain cerebral peduncle, pons
Artery: ant choroidal, small MCA/PCA branch, basilar
Symptoms
- Contralateral face, arm and leg weak
Pure sensory stroke
Localization: thalamus
Artery: thalamoperforators from PCA/MCA
Sx
Contralateral face, arm, leg sensory symptoms
Outpatient Management of TIA/non disabling stroke
- Presenting after 24 hours
- CT head or MRI head (ideally CTA/MRA arch to vertex)
- BW: INR/PTT, glucose, lipid, A1c
- ECG
- Holter 24 hr plus - if think cardioembolic = 2 weeks
- TTE if mechanism unknown
- Start single antiplatelet
- If already on anti platelet could switch to another
Acute Stroke in ER Management
- Symptoms <24 hour
- Eval for TPA or EVT
- ABC, NIHSS, Evaluate/treat seizures
Sx <4.5 hour = CT head ?tpa
Sx <6 hour = CT, CTA arch to vertex ?EVT
Sx 6-24 hr = CT, CTA, CTP if eligible for late window EVT
TPA for Acute Stroke
Inclusion - Ischemic stroke, DISABLING deficit (NIHSS6+, aphasia, hemianopia, visual/sensory extinction, weak against gravity), >18 yo - Time from last known well <4.5 hr Exclusion - Any source of active hemorrhage - Hemorrhage on bring imaging - DOAC use
EVT for Acute Stroke
- Can be in addition to TPA or for those not eligible
Inclusion - > 18 yo, disabling sx, func independent, life expectancy >3 m
- <6 hr from last known well
- CT head small-mod ischemic core
- CTA occlusion in anterior circulation of proximal large vessel (not in posterior circulation, consider basilar)
Acute Stroke BP Management
- TPA = <180/105 x 24 hr
- TPA and EVT = <180/105 x 24 hr
- No TPA <220/120
- EVT only - no targets
Acute Stroke Antiplatelets immediate
ASA 160 mg (sometimes DAPT)
IF not on anti platelet, no TPA and no bleed on CT
IF TPA - wait 24 hr before starting ASA (no DAPT)
High risk TIA/Minor stroke antiplatelets
- If non cardioembolic
- Plavix and ASA 21-30 d then mono therapy
- Minimal loading dose Plavix 300-600 and 160 ASA
- Ideally within 12 hours as soon as brain imaging done
Antiplatelets severe intracranial atherosclerosis
TIA/stroke in last 30 days PLUS
70-99% stenosis in major intracranial vessel
Consider DAPT x 3 mos then single
Stroke while on antiplatelets
On ASA –> Plavix
On Plavix –> ASA/dipyridamole
Stroke and Carotid Stenosis
TIA/non disabling + ipsilateral 50-99%
- Get CTA
- Stroke expert ASAP
TIA/non disabling + ipsilateral 70-99%
- CEA either within 48 hr or 2 weeks
- CEA > CAS if >70 yo
Symptoms <50%
- Max medical management
Asymptomatic/remote >6 m + 60-99%
- If life expectancy >5 yr = evaluate by stroke expert
- Maybe CEA/CAS
- Max medical
Stroke and AF Med choice
- DOAC >warfarin
- Bridge with anti platelet (not heparin)
- Mechanical valve OR mod-sev MS = warfarin only
Stroke and AF Timing
TIA <1 d
Mild/small <8 - 3 days
Mod 8-15 - 6 days
Severe/large 16+ - 12 days
Delay if: hemorrhagic transformation, mod-large infarct, high NIHSS, uncontrolled HTN, coagulopathy
Early if: mechanical heart valve, intracardiac thrombus, hypercoagluable
Stroke Secondary Prevention
BP - Past stroke/TIA BP<140/90 Lipids - Check level, start statin, LDL<2/50% drop DM - Test, A1c 7% or less Diet - High fruit/veg, low fat dairy/fibre, plant protein - Na <2 g/day - Exercise mod 4-7 d/week - Stop smoking, alcohol F<10, M<15 - Weight BMI 18.5-25
Stroke PFO
If stroke due to PFO, closure with anti platelet recommended if:
- 18-60 yo
- Stroke non lacunar
- Specialist thinks PFO most likely cause
Post stroke depression
- 1st year highest risk
- screen patients
- if more than mild tx CBT, IPT, SSRI (tx min 6-12 mos)
Patient comes in with major stroke >24 hr after symptoms started
Single anti platelet only
Dissection causing stroke
- If EXTRAcranial carotid or vertebral dissection = anti platelet or anticoagulant
- Heparin or warfarin - can choose either
- Usually x3-6 mos (repeat CTA to see if resolved)
- No evidence for DOACs, duration
- No evidence for anticoagulation with INTRAcranial dissection
Symptomatic extra cranial dissection
IV heparin –> LMWH/warfarin x 3-6 mos
Repeat CTA to see if resolved
Can use anti platelet instead
Asymptomatic extra cranial dissection
Antiplatelet
Any extra cranial dissection and floating thrombus on CTA
Heparin
Then warfarin 3-6 mos
Repeat CTA for resolution
Intracranial dissection
Antiplatelet
Embolic stroke undetermined source
No good evidence for riva or dabi and inc bleed compared to ASA
Stroke in <55 yo
Risk factors still HTN, DLD, smoking
Most commonly - cardioembolic and dissection
Intracranial Hemorrhage Investigation
CTA - rule out underlying lesion, better than MRA for vascular lesion
ICH BP Management
- Assess q15 min x 24 hr
- SBP <140-160 for first 24 hr
- Prefer 140 if <6 hr ago, on anticoagulant, signs of expansion, presenting SBP <220
Long term target <130/80
ICH on anticoagulant
- Reverse anti Xa with PCC
- Reverse dabi with idaracizumab
- LMWH within 12 hr - protamine
- IV UFH - protamine
- TXA may reduce volume
ICH Neurosurgery
Always call for assessment
EVD if dec LOC and hydrocephalus
No surgery if stable and no signs herniation
ICH Work up
Consider MRI to look for mass/AVM/AVF/amyloid
ICH DVTp
IPC then LMWH 48 h after hematoma stable
ICH Seizure
If in first 24 hours no need for AED longterm
ICH Steroids
HARMFUL, don’t use
Rest tremor
Idiopathic PD
Other parkinsonism
Action tremors
Postural
- Enhanced physiologic
- Essential
- Dystonic
Kinetic/intention
- Cerebellar disease
- Li
PD tremor
Low frequency Asymmetrical At rest Respond to levodopa Minimal impairment micrographia
Essential tremor
Higher frequency Symmetrical Action/posture Fam hx common Good response to alcohol, no to levodopa Significant impairment Writing messy
Enhanced physiologic tremor
High frequency Small amplitude Symmetrical Postural Enhanced by caffeine, anxiety, stress, TSH, drugs, withdrawal
Dystonic tremor
Dystonia patients when they fight their posture Head and hands Asymmetrical Irregular Postural, not at rest
Cerebellar tremor
Intention or postural
Can also have ataxia, dysdiachokinesia
Young –> think MS, Wilson’s
Stroke -> sudden onset, older, asymmetric
Psychogenic tremor
Rest/posture/intention mix Irregular Variable freq and amplitude Distractible Entrainable
Parkinsonism Symptoms
- Tremor - rest, low amp, thumb
- Rigidity
- Akinesia/bradykinesia - slow, fatigue and decrement
- Postural - hesitant gait (short shuffling, reduce arm swing), freezing
Parkinsonism DDx
- Idiopathic PD
- Park plus - LBD, PSP, MSA, CBD
- Vascular - stroke
- Drug induced - antipsychotics, metoclopramide
- Genetic - Wilson’s
- Toxins - manganese
Idiopathic PD Dx
- Parkinsonism - akinesia + one of rigidity or tremor
- Two supportive
- Absence absolute exclusion
- No red flags
IPD Absolute Exclusion
- Cerebellar abnormal - MSA
- Downward vertical gaze palsy/slow vertical saccades - PSP
- Dx FTD
- Exclusive lower extremity Parkinsonism x 3 yrs - vascular
- Tx dopamine receptor blocker - drug induced
- No response to L dopa
- Cortical sensory loss, apraxia, aphasia (CBD)
- Normal functional neuroimaging of dopaminergic system
- Alternative dx documented
IPD Supportive Criteria
- Response to L dopa
- L dopa induced dyskinesia
- Rest tremor of limb
- Documented olfactory loss/cardiac sympathetic denervation on MIBG scintigraphy
Red flags IPD
- Rapid gait impairment - wheelchair within 5 years onset
- No progression of motor sx
- Early bulbar dysfunction
- Stridor
- Sev autonomic failure in first 5 yrs
- Recurrent falls within 3 years onset
- Anterocollis
- Absence common non motor sx despite 5 yrs disease
- Pyramidal signs
- Bilateral symmetric
Typical PD Disease Course
Preceding - Anosmia - REM sleep behaviour disorder - Constipation Early - Asymmetric tremor, bradykinesia and rigidity Late - Postural instability/falls - Dementia - Visual hallucinations - Autonomic
Levodopa/Carbidopa
- PD motor sx
- Convert to dopamine in CNS
SFx - N/V, ortho HOTN, sedation, confusion, hallucinations
- Dyskinesia
- Dopa dysregulation (Addiction)
Pramipexole
PD Motor sx - Dopamine agonist SFx - Ortho HOTN - Sleep attacks - Halluncations - ICD - gamble, sex, shop, eat - Leg swelling
Trihexyphenidyl
Tremor ANTIcholinergic SFx - Dry eyes, blurry vision, dry mouth, constipation, retention - Memory issues
Selegiline
PD motor sx
MAOi inh
- HTN crisis tyramine foods
- Serotonin syndrome
Entacapone
Prolong L dopa
COMT inhibitor
Orange urine
Amantadine
Dyskinesias
- Anticholinergic
- Insomnia
- Levido reticularis
- CI if seizures
Domperidone
Ortho HOTN
Dopamine agonist in gut
QT prolong
PD Guidelines
- no CT/MRI routine
- Ldopa most effective
- Regular exercise program
- deep brain stimulation
- Botulinum for drooling
- Ortho HOTN - midodrone, fludrocortisone, domperidone
- REM SBD before dx
Drug induced parkinsonism
- Symmetric Parkinsonism
- Tremor postural
- Weeks/mos of onset of drug
Think metoclopramide, antipsychotic
Vascular parkinsonism
Risk factors, multiple small strokes
- Symmetric
- Lower body parkinsonism
- Falls, pyramidal
- Dementia, incontinence
- Tremor not common
- Poor response to Ldopa
MSA
- Symmetrical parkinsonism
- No tremor
- Early falls, ataxia
- Dysautonomia - ortho, ED, incontinent
- Pyramidal signs
- Stridor
- Distal myoclonus
- No response to levodopa (orofacial dyskinesia)
PSP
- Symmetric parkinsonism
- Axial rigid
- No tremor
- Early falls
- Verticular supranuclear gaze paresis
- Hyperfrontalis
- Sev dysarthria
- Mild dementia
- Poor response LD
CBD
Very asymmetric parkinsonism Dystonia Myoclonus Apraxia Aphasia Cortical sensory loss Alien limb No response to LD
LBD
- Symmetric parkinsonism
- Tremor
- Early dementia
- Fluctuating attention
- Visual hallucinations
- Hypersensitive to antipsychotics
- some response to LD
- REM SBD
CRAO
Vasculopathy
Sudden complete PAINLESS unilateral vision loss
Cherry red spot
Papilledema
Bilateral disc edema
think intracranial HTN
Acute optic neuritis
Young F
Unilateral eye pain
Vision loss
Pale disc = prior optic neuritis
Glaucoma
Older Poor peripheral vision No pain Eye pressure elevated Large cup to disc ratio Pale disc
Diabetic Retinopathy
Cotton wool spots Microaneurysms Hard exudates Neovascularization Flame hemorrhages
Hypertensive Retinopathy
Cotton wool spots Hard exudates Flame hemorrhages AV nicking Copper Wiring Disc Edema
Infective endocarditis eye
Roth Spot
Approach to Diplopia nerves involved
- CN6 = LR
- CN4 = SO
- CN3 = the rest, eyelid, constrict
- Sympathetics = dilation
Cavernous Sinus contains
CN 3,4, V1, V2, 6 and sympathetics
Monocular diplopia
Psych or Ophtho
Binocular diplopia
Neurology problem
Horizontal images
CN 6 palsy
Vertical images
CN 4 palsy
Oblique images
CN 3 palsy
Diplopia worse near
CN 3/4
Diplopia worse far
CN 6
Diplopia worse looking L/R
CN 6
Diplopia worse looking up/down
CN 3/4
CN3 Palsy vs Horner’s
Ptosis - Both Pupil - Horner = miosis - CN3 = mydriasis Anisocoria - Horner worse in dark - CN3 worse in light Diplopia - CN3 down and out Rule Out - Horner - carotid dissection in neck - CN3 PCOMM aneurysm
Binocular Diplopia
- EOM - thyroid
- NMJ - MG
- Cavernous sinus
- Brainstem internuclear - stroke, MS INO
CN3 Palsy ischemic vs compressive
- Both have ptosis and down and out
- Ischemic pupil spared, comp mydriasis
- Ischemic no pain, comp pain
- Ischemic in DM/DM/HTN
- Comp in aneurysm
CTA for CN3
- Complete CN3 and pupil spared = no CTA
- Partial CN3 and pupil spared = CTA
- Pupil involved = CTA
Horner’s syndrome
- Ptosis
- Miosis
- Anhidrosis
Ddx - First order neuron - stroke, demyelinating, tumour - MRI brain
- Second order - T1 radic, pan coast tumor - MRI C spine/CT chest
- 3rd order - carotid dissection/aneurysm - CTA neck/brain
CN6 Palsy
- Binocular diplopia, horizontal images, worse far, worse looking to same side as palsy
Inv - CT/CTA if cavernous sinus
- MRI brain with GAD - tumor, inflame, infection
- MRI brain with MRV/CTV (for VST) then LP (IIH)
Complete Cord Syndrome
- Bilateral sensation below
- Bilateral weakness (LMN at level, UMN below)
- Bowel and bladder problems
- Above C3=respiration
- Above T6=auto dysreflexia
- If sudden injury may initially be flaccid and absent reflexes
Etiology
- Trauma
- Large disc
- Hemorrhage
- Abscess
- Transverse myelitis
Central Cord
- Suspended sensory loss pain/temp
- No weakness
- No loss vib/prop
Etiology
- Syringomyelia (fluid filled cyst in spinal cord)
- Intramedullary tumor
Anterior Cord Syndrome
- Bilateral loss pain and temp
- Bilateral weak
- Bowel and bladder
- Normal prop/vib
Etiology
- Spinal cord infarction (ant spinal artery)
- Disc herniation
Posterior Cord Syndrome
- Bilateral loss prop/vib
- +/- weakness
- Pain/temp fine
Etiology
- Syphilis - tabes dorsalis
- B12 - subacute combined degeneration
B12 Def - SCD
- Anemia, atrophic glossitis
- Dementia
- Normal pupils, dec visual acuity
- UMN weakness - brisk knee reflexes, upping toes
- LMN weakness - loss of ankle reflexes
- Loss of vib/prop
- Can have loss of pain/temp/vib/propr distal
- Sensory ataxia
- Positive Romberg
Syphilis tabes dorsalis
- Gummas, LN, aortitis
- Dementia
- Argyll Robertson pupils
- Normal strength
- Loss reflexes
- Loss vib/prop
- Sensory ataxia
- Positive Romberg
Hemi Cord/Brown Sequard
- Ipsilateral weakness
- Ipsilateral loss vib/prop
- Contralat loss pain/temp
Etiology
- Trauma
- Demyelination - MS
Pure Motor Spinal Cord
Asymmetric weakness - UMN only(HTLV) or LMN only (ALS) or both (West Nile/polio)
L5 vs Peroneal Neuropathy
Ankle inversion and hip ABduction strong in peroneal, weak in L5
C7 vs radial neuropathy
Radial lesion
- Strong pronator teres, triceps
- weak BR
C7 Lesion
- Strong BR
- Weak pronator teres, triceps
C8/T1 vs Ulnar
Ulnar
- FPL (flex thumb), APB (abduct thumb), EIP strong
C8/T1
- FPL, APB, EIP weak
White on CT
- Calcium/bone
- Contrast
- Blood - acute, hrs to days
- Melanoma, lymphoma
Blood on CT
Hyperdense - hrs to days
Isodense - 1-2 weeks
Hypodense - 3-4 weeks
Rule out SAH with CT head if
Within 12 hrs from onset and read by neuroradiologist
Otherwise need LP
T2 and FLAIR MRI
Hyperintense = any pathology
Stroke, tumor, blood, demyelination
DWI and ADC
Acute stroke <14 d will be white on DWI and dark on aDC
GRE or SWI
Blood of any age or calcium
T1 with gad
enhancement = tumor, new demyelinating lesion, infection
ALS
Selective loss of pyramidal neurons and motor neurons
Die from respiratory failure
Bulbar - dysphagia, dysarthria, dyspnea, brisk jaw jerk
LMN at level of lesion
UMN below lesion
UMN findings
Spasticity
Hyper reflexia
Upgoing toes
LMN findings
Atrophy
Fasciculations
Weakness
ALS Dx
MRI C spine
NCS/EMG
ALS Tx
Multidisciplinary clinic
Riluzole - inc survival 3 mos
Edaravone - dec functional decline
Sialorrhea - anticholinergic, suction, botox
Spasticity - PT, baclofen, botox
Cramps - tonic water, gabapentin, baclofen
ALS Respiratory Care
- FVC baseline and q 3 months Home NIV - Symptoms - orthopnea - SNIP <40, MIP <40 - Upright FVC <65% - FVC sit/supine <80% symptoms - Daytime PCO2>45 - Abnormal nocturnal oximetry/sleep disordered breathing
Pseudobulbar Palsy
UMN lesion in the corticobulbar pathway (medulla and CS tract) Sx 1. Dysphagia 2. Dysarthria 3. UMN findings 4. Pseudobulbar affect Etiology 1. ALS 2. MSA 3. PSP
Outpatient stroke last 48 hours very high risk features and tx
Features: unilateral weakness, language/speech Tx 1. Send to ED stroke centre 2. Imaging within 24 hours 3. ECG Tx DAPT 2-3 wks
Outpatient stroke 48 hrs-2 weeks high risk
Unilateral weakness, language/speech disturbance
See stroke neurologist within 24 hrs
Tx DAPT 2-3 wks
Outpatient stroke 48 hrs-2 weeks medium risk
No weakness, language/speech change
Stroke expert within 2 weeks
Tx DAPT 2-3 wks
Outpatient stroke >2 weeks
See stroke expert in 1 month
Tx DAPT 2-3 wks
Amaurosis Fugax
Painless Sudden transient blindness Usually embolic from ipsilateral carotid Monocular Last <5-10 mins
Bell’s palsy Tx
- Prednisone
2. +/- acyclovir
Motor grading
0 = paralysis 1 = flicker 2 = can't move against gravity 3 = can move against gravity 4 = move against some resistance 5 = complete strength
LEMS
Anti Ca channel Ab
Associated with small cell carcinoma
Proximal muscle weakness = incremental response
Hyporeflexia or absent
Pontine lesion
Pupils small and fixed
Triptan and ergot CI
CAD
Cauda Equina
Acute
- Weakness/paraparesis
- Reduced DTRs at knees/ankles
- Bilateral sensory loss
- urinary retention +/- fecal incontinence
- LBP to legs (sciatica)
- NO babinski
