Lectures Flashcards
MC location of hypertensive intraparenchymal hemorrhage
Basal ganglia
(a) L’Hermitte’s sign
(b) Uhthoff’s sign
(a) L’Hermitte’s sign = electric shock sensation brought on by neck flexion
- not specific to MS, associated w/ cervical spine pathology
(b) Uhthoff’s sign = MS symptoms worse in the heat
- sometimes even use a hot bath to bring on MS symptoms
First step to prevent rebleeding in subarachnoid hemorrhage
Before even doing CTA to locate and surgically clip or endovascularly coil the aneurysm- get SBP under 130!! Nicardipine (cardine) drip
Nicardipine = dihydropyridine CCB
What neuroimaging finding correlates the best w/ clinical disability
Old MS lesions correlate most closely w/ clinical disability
-black holes are e/o irreversible axonal damage
Name the type of seizure
(a) No aura or post-ictal state, unresponsive staring for 10-20 seconds
(b) sudden isolated jerks
(c) starts w/ stiffening, then jerks
(d) focal findings w/ no alteration in awareness
(e) staring w/ automatisms and post-ictal state
Type of seizures
(a) Absence seizures (generalized)
(b) Myoclonic (generalized)
(c) Tonic-clonic (generalized)
(d) Simple partial seizure (partial)
(e) Complex partial seizure (partial) = most common type of seizure
75 yo right-handed M p/w expressive speech difficulty x5 yrs
- anxious and tearful, frequently pauses to search for words, difficulty following demands
- draws sloppy clock lacking in details
- 3/3 recall at 5 mins
(a) Localize the lesion
(b) Dx
(c) Imaging besides basic CT/MRI
(d) Recommended tx
(a) Broca’s area (expressive aphasia) in right-handed male localizes to left frontal lobe
(b) FTD = frontotemporal dementia
- 4th MC type of irreversible dementia
(c) Can do functional imaging- shows decreased glucose uptake in frontal and temporal lobes
(d) First line tx for FTD = acetylcholinestrase inhibitor
- stabilizes course of disease
- then treat the mood symptoms and anxiety separately
Diagnostic criteria of MS
Dx criteria: at least 2 attacks separated in time (at least 30 days apart) and location (in at least 2 of the 4 main locations)
OR one episode + MRI evidence of disease
Nerve conduction study
(a) Describe set up
(b) Function
Nerve conduction study
(a) Stimulating electrodes placed on the skin over a nerve, recoding electrode placed over a different part of the nerve (sensory) or over the muscle it innervates (motor)
(b) To distinguish myelin vs. axon problem
- see if nerve conducts slowly (demyelination) or w/ low amplitude (axonal)
Pt p/w incoherent speech and right-sided weakness
(a) Describe the symptoms
(b) Localize the lesion
(b) Name 3 things on the differential
(a) Symptoms = expressive aphasia and right hemiparesis
(b) Localizes to the left MCA (cortical) territory
(c) Ddx: Left MCA stroke, left frontotemporal hemorrhage, seizure
Should MS pts get pregnancy?
Well dat’s not for you to decide shithead…but the facts:
- pregnancy is a relatively protected state in MS (attacks less common)
- but post-partum state is a period of increased attack activity
24 yo M w/ h/o seizures on dilantin BIB friend after two seizures at work, in the ER he has two additional seizures
(a) Dx
(b) Most likely etiology
(c) Tx
- tx if refractory
(a) Status epilepticus = multiple seizures w/o return to baseline/multiple seizures in 15 minutes
(b) MC = missed dose of AEDs
- EtOH withdrawal/intoxication
- hypoglycemia
(c) Tx = ativan ASAP
- if doesn’t stop: add a second AED (keppra or valproate)
- if still doesn’t stop: consider intubation and sedation (versed drip)
If suspecting stroke, how to control BP
Stroke- 80% are ischemic, so need to allow for HTN to try to preserve penumbra (maintain flow)
= permissive HTN (MAPs of 110-140)
LP findings for bacterial vs. viral meningitis
Bacteria- neutrophilic predominance
Viral- lymphocytic predominance
-gross blood indicative of HSV encephalitis
Pt presents 1 hr after symptom onset w/ left MCA stroke
(a) Immediate action
(b) Long term plan
1 hr s/p MCA stroke
(a) tPA (push 10% then infuse the rest over 1 hr) and intervention for clot retrieval
- tPA alone won’t get it out or dissolve such a large clot
(b) After tPA/clot retrieval, target low BP (sBP under 140) to avoid hemorrhage in the setting of reperfusion
Lesions typical to MS that aren’t the 4 main
4 main: periventricular, juxtacortical, infratentorial (posterior fossa), spinal
Other common: corpus callosum, optic nerve
MC cause of
(a) nontraumatic ICH in the elderly
(b) ICH in children
(a) Amyloid Angiopathy
- bleeds in multiple hemispheres
(b) ICH in children = AVM
(a) MC inherited stroke d/o?
(b) 2 main features
(a) MC inherited stroke d/o = CADASIL = Cerebral autosomal dominant arteriopathy w/ subcortical infarcts and leukoencephalopathy
(b) Migraines and lacunar strokes
- 85% p/w TIA or stroke at age 40-50
Differentiate risk of twin having MS if the one twin has it
(a) Monozygotic
(b) Dizygotic
(a) 30% risk
(b) 5% risk
- so hereditary component, but doesn’t explain it all
Mechanism of tonsilar herniation
Protrusion of cerebellar tonsils thru the foramen magnum, causing compression of the lower brainstem and upper cervical spinal cord
Use of LP in the diagnosis of MS
Not everyone needs an LP to diagnose MS, but can be helpful in equivocal cases
95% of MS pts will have oligoclonal bands in the CSF (and not in the serum) which are evident of CNS inflammation
Tx for PML in HIV+ pt
HAART to reduce viral load
But very poor recovery and prognosis
54 yo M p/w vertigo, unsteady gait, HA, nausea, BP 230/110
PMH: HTN, AFib on dabigatran
(a) Where do his symptoms localize?
(b) Acute mgmt
(a) Posterior cerebellum
(b) Acute mgmt =
1. prevent expansion of the bleed by getting his BP down!!! Start nicardipine drip
2. reverse his anticoagulation: FFP, vitamin K, Kcentra
3. Manage ICP: go get the clot
(a) Prognosis of MS
(b) Good prognostic factors
(a) MS prognosis- very variable
- but usually not lethal, about 1/3 develop disability causing them to be unable to live independently
(b) Good prognostic factors: female, young age of onset
- sensory symptoms at onset
- fewer lesions present on MRI at onest
34 yo M p/w HA and fever to 103.4, mild lethargy and confusion
-no focal findings
(a) Describe symptoms
(b) Ddx
(a) Encephalopathy
(b) Viral vs. bacterial meningitis
(a) MS presenting factors
(b) What neurologic signs would make you think against a dx of MS?
(a) MS presenting features: MC is sensory findings, next motor (weakness), or visual (optic neuritis)
(b) If pt p/w early cognitive deficits, aphasia, mov’t d/o, seizures- these aren’t typical => look for other etiologies
Contraindications to tPA
- age under 18
- e/o intracerebral hemorrhage or SAH (even if NCHCT normal)
- recent major surgery or GI/internal bleed
- Plt under 100k, INR over 1.7, Noac dose w/in past 48 hrs
- blood glucose not 50-400
84 yo M p/w behavioral difficulties
- pjs to work, unable to handle housework or finances
- says his wife is exaggerating and he is fine
- fluent speech, repetition intact, follows commands, appropriate and happy affect
- poor recall, not oriented to month of year, president is ‘Bush’
- trouble demonstrating how he’d brush his teeth or comb his hair
(a) Dx
(b) Progression of memory findings in this d/o
(a) Alzheimer’s- characteristic pt w/ normal affect and decision making, but stuck at a time in the past
- not oriented
- poor memory
- loss of learned activities = apraxias = temporal lobe deficits
(b) First anterograde (cant form new memories), then eventually retrograde amnesia (won’t recognize children etc)
Ddx for brain nodule
4 T’s and A (for good measure)
Ts: tumor (primary) tumor (secondary = mets) toxo Tb
and abscess
First line tx for MS attack
High-dose glucocorticoids
Typical course: 5 days of IV methylprednisolone at 1g/day
Electromyogram
(a) Describe set up
(b) Function
EMG
(a) Electrode placed directly into a muscle to look at the recruitment pattern of motor unites
(b) Distinguish neuropathy vs. myopathic d/o
- neuropathic shown as low recruitment, high recruitment is an attempt to compensate for myopathic d/o
Neuromyelitis Optica = Devic’s Disease
(a) Main features
(b) Tx
NMO
(a) Optic neuritis and acute myelitis
- simultaneous inflammatory and demyelinating symptoms of the optic nerve and spinal cord
- NMO-IgG seropositivity in 75% (autoimmune)
(b) Tx = IV steroids and plasmaphoresis
- but NOT disease modifying agents used in MS
Top 4 (in order) causes of irreversible dementia
1- Alzheimer’s
2- Vascular
3- Lewy Body
4- Frototemporal
Most common surgical procedure done for epilepsy
After 2 AEDs- most successful if it can be localized on MRI
MC procedure = anterior temporal lobectomy
32 yo F w/ h/o lung cancer p/w back pain and trouble walking x1 day
-trouble urinating, b/l leg weakness, no UE symptoms
(a) Dx
(b) Mgmt
(a) Dx = cord compression
- low cervical spine or below (UE not involved)
(b) Mgmt
- high dose decadron (decrease inflammation)
- place foley
- MRI spine w/ and w/o contrast: contrast shows breakdown of the BBB
- long term: surgical decompression vs. radiation
Differentiate pressure vs. rate support for vent settings
Pressure support- pt does the work of breathing on his/her own
Rate support- vent set at breaths per minute, pt only can breath over the rate or else stays at that rate
61 yo F p/f fall
- progressive cognitive deterioration, personality change, and frequent falls x6 mo
- poor hygiene, poor memory
- frequent high intensity jerks of head, torso, and extremities
- hyperreactive reflexes and b/l positive Babinski’s
(a) Localize the lesion
(b) Dx
(c) Testing to get to dx
- EMG findings
- LP findings
(a) Lesion is very generalized (no localizable findings)- initially makes you think metabolic process, but UMN signs (hyperreflexia and Babinski’s) localizes to CNS
(b) CJD
- fast generalized neurologic decline, characteristic myoclonic jerks
(c) First do imaging: often normal at first
- EMG: characteristic 1Hz generalized spike and wave (1Hz is slow)
- LP: send off specifically for 14-3-3- protein
Multiple sclerosis
(a) Mechanism
(b) Age of onset
(c) 2 associated conditions
(d) Behavioral RF
MS
(a) Autoimmune demyelinating (white matter) disease, auto-antibodies attack the myelin sheath
(b) 20-40
- if under 10 or over 60, think of another dx
(c) Associated w/ EBV and vitamin D deficiency (much lower risk near the equator)
(d) Only one behavioral risk factor = cigarette smoking
Cause of upward herniation
Increased pressure in the posterior fossa, causing midbrain to be pushed thru the tentorial notch
Describe Cheyne-Strokes respirations
Oscillation in ventilation btwn apnea (temporary stop in breathing) and hyperapnea
Empiric tx for meningitis
Abx:
- ceftriaxone
- vanc
- ampicillin if immunocompromised or old to cover for listeria
and acyclovir
