IM-Neuro Flashcards
Unilateral Medial longitudinal fascicles (MLF) can occur with lacunar stroke in the pontine artery distribution however, bilateral lesions usually happen in
Multiple sclerosis
Internuclear opthalmonplegia
Afferent pupillary defect
“wash out” color vision
Eye pain with movement
Monocular vision loss with central scotoma
Optic neuritis
Fever >40C (104F), confusion, muscle rigidity, autonomic instability. Dx? Cause? Tx?
- Neuroleptic malignant syndrome
- Idiosyncratic drug reaction to dopamine antagonist medications (common is 1st generation antipsychotic, haloperidol)
- Stop the causative agent, dantrolene
Tetrad of Neuroleptic malignant syndrome (NMS)
- Mental status change
- rigidity
- fever
- autonomic dysregulation
The 4 common areas of the brain that Hypertensive intracranial hemorrhages occurs
Basal ganglia
Thalamus
pons
cerebellum
Paresthesis, neuropathic pain Symmetric, ascending weakness Decreased/asending deep-tendon reflexes autonomic dysfunction respiratory compromise Dx? Cause? Tx (2)?
- Guillain-Barre Syndrome
- Preceding GI (Campylobacter) or respiratory infection (HHV, mycoplasma and H. Influenzae)
- IVIG or Plasmapheresis
Diagnostic for Guillain Barre syndrome (2)
- CSF: Increased protein, Normal leukocytes
- EMG and nerve conduction
The most common symptom of Brain tumor is a dull headache associated with >/= 1 of the 3
- N/V
- FND
- Symptoms worsening during the night or with portions that raise ICP (bending, coughing)
Pt with high-grade carotid stenosis (70-99%) should be considered for
Endarterectomy to reduce future stroke risk
Rapidly progressive dementia
myoclonus
sharp, triphasic, synchronous discharges
Dx? Cause?
Creutzfeldt-Jakob disease
A spongiform encephalopathy caused by Prion
Classic triad of
- Fever
- Focal/severe back pain
- Neurologic findings
Spinal epidural abscess
How to diagnose Spinal epidural abscess (3)
- Increased ESR
- Blood and aspirate cultures
- MRI of the spine
Tx for Spinal epidural abscess
- Broad-spectrum antibiotics (Vancomycin + Ceftriaxone)
- Aspiration and surgical decompressions
The most common causative organism for Spinal epidural abscess
Staphylococcus Aureus
Ddx of demential subtypes (6)
- Alzheimer disease
- Vascular dementia
- Frontotemporal dementia (Picks disease)
- Demential with Lewy bodies
- Normal pressure hydrocephalus (NPH)
- Prion disease
- early, insidious short-term memory loss
- Language deficits and spatial disorientation
- Later personality changes
Alzheimer disease
- Stepwise decline
- early executive dysfunction
- Cerebral infarction and/or deep white matter changes on neuroimaging
Vascular dementia
- Early personality changes
- Apathy, disinhibition and compulsive behavior
- Frontotemporal atrophy on neuroimaging
Frontotemporal dementia (Picks disease)
- Visual hallucinations
- Spontaneous parkinsonism
- Fluctuating cognition
Dementia with Lewy bodies
- Ataxia early in disease
- Urinary incontinence
- dilated ventricles on neuroimaging
Normal pressure hydrocephalus (NPH)
- Behavioral changes
- Rapid progression
- Myoclonus &/or seizures
Prion disease
- Parkinsonism
- Autonomic dysfunction
- Widespread neurological signs (Cerebellar, pyramidal or LMN)
Multiple system atrophy (Shy-Drager syndrome)
Postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnormal salivation or lacrimation, impotence, gastroparesis…) are called
Autonomic dysfunction
Pt with parkinsonism experiences orthostatic hypotension, impotence, incontinence or other autonomic symptoms
multiple system atrophy (Shy-Drager syndrome)
CSF WBC count? Glucose? Protein?
Normal=
WBC count= 0-5
Glucose= 40-70
Protein= <40
CSF WBC count? Glucose? Protein?
Bacterial meningitis
WBC count= >1,000
Glucose= <40
Protein= >250
CSF WBC count? Glucose? Protein?
TB meningitis
WBC count=100-500
Glucose= <45
Protein= 100-500
CSF WBC count? Glucose? Protein?
Viral meningitis
WBC = 10-500
Glucose=40-70(normal)
Protein= <150
CSF WBC count? Glucose? Protein?
Guillain-Barre
WBC= 0-5 (normal) Glucose= 40-50 (normal) Protein= 45-1,000
Common chemotherapy drugs causing sensory neuropathy that spears in a stocking-glove pattern ( 3 classes)
- Platinum-based (Cisplatin)
- Taxanes (paclitaxel)
- Vinca alkaloids (Vincristine)
What function is affected in Diabetic neuropathy (3)
- Feeling of imbalance (due to nerves that control proprioception involvement)
- Numbness and tingling
- Motor symptoms (late manifestation- involved LMN)
How do you treat ischemic stroke on a young IV drug user patient how is running a fever? What is the cause?
- Antibiotics
since the cause is bacterial endocarditis with acute cardioemoblic stroke
Secondary causes for Restless leg syndrome (7)
- Iron deficiency anemia
- Uremia (ESRD, CKD)
- Diabetes mellitus
- Multiple Sclerosis
- Parkinson disease
- Pregnancy
- Drugs (antidepressants, Metoclopramide)
How do you use to treat restless leg syndrome (2)
- 1st line-Dopamine agonists (pramipexole)
- alternative- Alpha-2-delta calcium channel ligands (gabapentin enacarbil)
Exertional heat stroke (EHS) is small spectrum as heat exhaustion with a body temp >40c (104) but is characterized in addition by
Central nervous system dysfunction (confusion, irritability and seizures)
How do you manage Exertional heat stroke (4)
- Rapid cooling (ice water immersion)
- Fluid resuscitation
- Electrolyte correction
- Management of end-organ complication
What end-organ complication can happened from Exertional heat stroke? (4)
- Renal failure
- Hepatic Failure
- DIC
- ARDS
- Ipsilateral hemiparesis
- ipsilateral dimminisedh proprioception, vibratory sensation and light touch
- Contralateral diminished pain and temp
Hemisection of the spinal cord - Brown-Sequard syndrome
Pt with hand tremors and increased resistance has eye circus-cornea infection with a dilated and sluggish pupils , what is the diagnosis and the cause?
Acute-closure glaucoma
- Anticholinergic drug (Trihexyphenidyl) used for treatment of parkinson disease
Weakness in Myasthenia gravis can be exacerbated by various factors including
- Medication (amino glycoside, mg, BB, neuromuscular blocking agents)
- Surgery (Thymecotomy)
- Pregnancy
- infections
What beside test can be done for Myasthenia gravis and its mechanism?
Ice pack test to the eyelids
- Cold temp improves muscle strength by inhibiting the breakdown of acetylcholine at the neuromuscular junction
How do you treat pt with car accident who is experiencing pain but also a history of illicit drug on methadone rehab program?
Treat with narcotic (morphine IV) like any one with pain
The two common organisms the cause a single brain abscess, with Brain CT/MRI showing first cerebrates then infection consolidation to a ring-enhancing lesion with central necrosis
- Staph aureus
- Viridians strep
Is it multiple or single lesion on MRI for cerebral toxoplasmosis ring0enhancing lesions?
Multiple ring-enhancing lesions
focal dystonia involving the sternocleidomastoid muscle
Torticollis
Sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures
Dystonia
Depression-related cognitive impairment in elderly pt can appear like
Dementia
Treat them with antidepressant and/or psychotherapy
The strongest association with both ischemic and hemorrhagic stroke? and reason?
- Hypertension
- Elevated shearing force on the intracerebral vascular endothelium, causing atherosclerotic process and promotes thrombi formation
Weakness on the lower extremities, fatigue and muscle cramps on patient that is on Thyrochlorthiazide and metoprolol
electrolyte imbalance (hypokalemia)
EKG changes with hypokalemia (3)
- U waves
- Flat and broad T waves
- PVC beats
Rapidly progressive ascending paralysis
absence of fever and sensory abnormalities
normal CSF examination
Tick-borne paralysis
right-sided weakness and speech difficulty (broca’s lesion), with difficulty writing and repeating (expressive aphasia)
Location of lesion? Artery affected?
- Dominant (left-hemisphere) frontal lobe
- Left MCA
Sparse and confluent speech Preserved comprehension Impaired repetition Right hemiparesis (face and Upper limb) Aphasia syndrome ?
Broca aphasia
Fluent and voluminous but lacks meaning Greatly diminished comprehension Impaired repetition Right superior visual field defect Aphasia syndrome ?
Wernicke aphasia
Fluent with phonemic errors
Preserved comprehension
very poor repetition
Aphasia syndrome ?
Conduction aphasia
Headaches that are worst in the morning are mostly related to
increased ICP
Young woman with frequent morning headache worst with head movement . Dx?
Idiopathic intracranial hypertension (pseudotumor cerebri)
The site of hemorrhage for neurological findings:-
- Contralateral hemiparesis & hemisensory loss
- Homonymous hemianopsia
- Gaze palsy
Basal ganglia (putamen)
The site of hemorrhage for neurological findings:-
- Usually NO hemiparesis
- Facial weakness
- Ataxia and nystagmus
- Occipital headache and neck stiffness
Cerebellum
The site of hemorrhage for neurological findings:-
- Contralateral hemiparesis and hemisensory loss
- Nonreactive biotic pupils
- Upgaze palsy
- Eyes deviate Toward hemiparesis
Thalamus
The site of hemorrhage for neurological findings:-
- Contralateral hemiparesis (frontal lobe)
- Contralateral hemisensory loss (parietal lobe)
- Eyes deviate away from hemiparesis
- High incidence of seizures
Cerebral lobe
The site of hemorrhage for neurological findings:-
- Deep coma & total paralysis within mins
- Pinpoint reactive pupils
Pons
Hypertensive hemorrhages involve small penetrating arteries that affect locations
- basal ganglia (putamen)
- Cerebellar nuclei
- Thalamus
- Pons
The 3 things caused by internal capsule affected by putaminal hemorrhage
- Contralateral hemiparesis
- Contralateral Hemianesthesia
- Conjugate gaze deviations toward the side of the lesion
Ignoring the left side of a space ? what part of the brain is involved?
- Hemi-neglect sydnrome
- Right (non-dominant) parietal lobe
Triad of:
Encephalopathy
Ocular dysfunction
Gain ataxia
Wernike encephalopathy
Wernike encephalopathy Tx:
Thaiamine before or with IV fluids with glucose
Triad of:
Gain disturbance
dementia
urinary incontinence
NPH (Normal pressure hydrocephalus)
The only approved medication for ALS and its’ mechanism of action
-Riluzole
Glutamate inhibitor
The best test to rule in or out Vit B 12 deficiency
Methylmalonic acid (MMA)
Damage to descending corticosipinal tracts in spinal cord compression (SCC) S & S (2)
- LE weakness
- Loss of Rectal tone
Damage to Ascending sensory spinothalamic tracts in spinal cord compression (SCC) S & S
- loss of sensation two level below the level of lesion
Damage to Descending automatics in the reticulospinal tract in Spinal cord compression (SCC) S & S (3)
- Urinary retention
- Bladder flaccidity
- Bladder shock
Sudden-onset severe back pain Perianal hypo/anesthesia Symmetric motor weakness Hyperreflexia Early-onset bowel and bladder dysfunction
Conus medullaris syndrome
Usually bilateral, sever radicular pain Saddle hypo/anesthesia Asymmetric motor weakness Hyporeflexia/areflexia Late-onset bowel and bladder dysfunction
Cauda equina syndrome
Proximal muscle weakness
Autonomic dysfunction (Dry mouth…)
Cranial nerve involvement (ptosis…)
Diminished or absent deep-tendon reflexes
Lambert-Eaton syndrome
Fluctuating muscle weakness
Ocular (ptosis, diplopia)
Bulbar (dysphagia, dysarthria)
Facial, neck and limb muscles
Myasthenia garvis
- Symmetrical and more proximal muscle weakness
- Interstitial lung disease, esophageal dysmotitly, raynaud phenomenon
- polyarthritis
- Esophageal dysmotitlity
- Skin findings (Gottron papules, heliotrope rash)
Dermatomyosities (skin findings)
Polymysoties
27, headaches, N/V, Elevated CSF pressure, normal neuroimaging
Pseudotumor cerebri - Benign intracranial hyprtension
Severe headache
bilateral periorbital edema
CN III, IV, V and VI deficiets
Cavernous sinus thrombosis
Situational syncope is triggered by (3)
cough, micturition, defecation
Vasovagal or neurally mediated syncope is triggered by (3) and what are the prodromal symptoms (3)
- Prolonged standing, emotional distress and painful stimuli
- Nausea, warmth, diaphoresis
The most common cause of CN III palsy in adults is ___ and due to ____
Ischemic neuropathy
poorly controlled diabetes mellitus
Small penetrating artery occlusion due to hypertensive arteriolar sclerosis
Lacunar stroke
Which area of the brain is affected by lacunar stroke? (3)
- basal ganglia
- Subcortical white matter (internal capsul, corona radiata)
- Pons
Risk factors for Lacunar stroke (5)
- Hypertension #1
- DM
- Advanced age
- Elevated LDL
- Smoking
Pure motor hemiparesis
Pure sensory stroke
Ataxic hemiparesis
Dysarthria-clumsy hand
-Lacunar stroke
Complication of SAH in 24hrs?
rebleeding
Complication of SAH in 3 days
Vasospasm
Complication of SAH giving hyponatremia
SIADH secretion
Brain tumors found in grey-white matter junctions are
metastatic brain tumors
areflexic weakness in upper extremities and dissociated sensory loss following a “cape” distribution
Syringomyelia
What disease is associated with Syringomyelia
Arnoid Chiari malformation type 1
Monocular painless acute vision loss
Central retinal artery occlusion due to embolized atherosclerotic plaque form ipsilateral carotid artery
- Acute confusion
- Temp >40c
- Tachycardia
- coagulopathic bleeding after heavy work under direct sunlight
Exertional heat stroke
Worsening tremor with finger-to-nose testing, and when arms are stretched. Dx? Tx?
Essential tremor
Propranolol
Antibodies against nicotinic receptors on the motor endplate found, NSIM?
CT scan of the chest (thymoma search :)
-Encephalopathy
-Oculomotor dysfunction
-Postural and gait ataxia
Dx? Tx?
Wernicke encephalopathy
IV Thiamine followed by glucose infusion
What are the Oculomotor dysfunction in Wernicke encephalopathy? (2)
Horizontal nystagmus
bilateral abducent palsy
what is one symptom that Wernicke encephalopathy has but not pt with cobalamin (Vit B12) deficiency don’t have
Occulomotor symptoms (are unusual for Vit B12 deficiency )
Uncontrolled HTN Occipital headache neck stiffness N/V Nystagmus Ipsilateral hemiataxia (No hemiparesis or sensory loss) Dx? NSIM>
Spontanous cerebellar hemorrhage
-CT scan of the head w/o contrast and emergent surgical decompression
When do you discontinue Phenytoin in pt with hx of unprovoked seizure
- No seizure for >2 years
- slowly tapered down
Ischemic stroke symptoms within 3-4.5 hours ,Tx?
IV tPA
Ischemic Stroke with no prior antiplatelet therapy, Tx?
Aspirin
Ischemic Stroke with on antiplatelet therapy, Tx?
Add dipyridamole OR clopidogrel (on the top of Asprin)
Ischemic Stroke with a-Fib, Tx?
Long-term anticoagulation (Warfarin, Dabigatran, rivaroxaban (Xarelto) or Apixaban (Eliquis)
Ischemic Stroke with large anterior circulation artery occlusion within 24hrs of symptom onset, Tx (2 step)?
Thrombectomy (regardless if pt received tPA)
then aspirin
Patient with intracranial large-artery atherosclerosis, Tx(2 step)?
- Aspirin + clopidogrel for 90 days
- Then Aspirin
Unilateral motor impairment, where is the lesion?
Posterior limb of internal capsule (lacunar infarct)
Contralateral somatosensory and motor deficit (Face, arm and leg), where is the lesion?
MCA
Contralateral somatosensory & motor deficit predominantly in LE, where is the lesion?
ACA
Alteranate syndromes with contralateral hemiplegia & ipsilateral cranial nerve involvement, possible ataxia, where is the lesion?
Verterbrobasilar symptom lesion (supplying the brain stem)
Conjugate eye deviation toward the side of infarct and homonymous hemianopia, where is the lesion?
MCA
Aphasia (dominant hemispheres)
Hemineglect (nondominant hemisphere) where is the lesion?
MCA
-Sensory ataxia
-Lancinating pains (sharp, stabbing pain. back & lower limbs)
-Neurogenic urinary incontinence
-Miotic and irregular pupils with no constriction to light but normal with accommodation
Dx? Tx?
- Tabes dorsalis
- IV Penicillin
Miotic and irregular pupils with normal constriction with accommodation but not with light, Name? Dx? Cause?
- Argyll Robertson Pupils
- Tabes dorsalis
- Treponema pallidum (Syphillus)
1st line of treatment for Idiopathic intracranial hypertension (2)
Acetazolamide +/- Furosemide
The 4 sellar masses that are benign
Pituitary adenoma
Craniopharyngioma
Meningioma
Pituicytoma (low grade glioma)
The 4 sellar masses that are malignant
Primary - germ cell tumors -chordoma -lymphoma Metastatic (breast, lung)
Presentation in sellar mass (3)
- Visual defects (bitemporal blindness-optic chiasm)
- headache
- Pituitary hormonal deficiencies
1st line of tx for fibromyalgia (2)
aerobic exercise
good sleep hygine
2nd line of tx for fibromyalgia
Tricyclic antidepressants (amitriptyline)
Cancer pain management for mild pain (2)
- Acetaminophen
- NSAIDs
Cancer pain management for moderate pain (3)
- Codeine
- Hydrocodone
- Tramadol
Cancer pain management for severe pain (2)
Strong short-acting opioids
- Morphine
- Hydromorphone
Cancer pain management for severe pain that is not controlled by short-acting opioids only (2)
Add long-acting opioids (calculate total daily dose and convert to long-acting formulation)
- Fentanyl patch
- Oxycodone
The main differences between Parkinson and Lewy bodies on cognitive function & dementia is ?
-Dementia appears early in Lewy body
Late in Parkinson disease
- Bilateral hemiparesis
- diminished bilateral pian and temp sensation
- Intact bilateral proprioception, vibration sensation and light touch
Anterior cord syndrome
Tx for a myasthenic crisis (3) on the top of intubation
- Plasmapheresis
- IVIG
- Corticosteroids
