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Lectures Flashcards

1
Q

MC location of hypertensive intraparenchymal hemorrhage

A

Basal ganglia

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2
Q

(a) L’Hermitte’s sign

(b) Uhthoff’s sign

A

(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

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3
Q

First step to prevent rebleeding in subarachnoid hemorrhage

A

Before even doing CTA to locate and surgically clip or endovascularly coil the aneurysm- get SBP under 130!! Nicardipine (cardine) drip

Nicardipine = dihydropyridine CCB

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4
Q

What neuroimaging finding correlates the best w/ clinical disability

A

Old MS lesions correlate most closely w/ clinical disability

-black holes are e/o irreversible axonal damage

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5
Q

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

A

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

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6
Q

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

(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

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7
Q

Diagnostic criteria of MS

A

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

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8
Q

Nerve conduction study

(a) Describe set up
(b) Function

A

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)

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9
Q

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

(a) Symptoms = expressive aphasia and right hemiparesis
(b) Localizes to the left MCA (cortical) territory
(c) Ddx: Left MCA stroke, left frontotemporal hemorrhage, seizure

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10
Q

Should MS pts get pregnancy?

A

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
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11
Q

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

(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)

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12
Q

If suspecting stroke, how to control BP

A

Stroke- 80% are ischemic, so need to allow for HTN to try to preserve penumbra (maintain flow)

= permissive HTN (MAPs of 110-140)

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13
Q

LP findings for bacterial vs. viral meningitis

A

Bacteria- neutrophilic predominance

Viral- lymphocytic predominance
-gross blood indicative of HSV encephalitis

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14
Q

Pt presents 1 hr after symptom onset w/ left MCA stroke

(a) Immediate action
(b) Long term plan

A

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

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15
Q

Lesions typical to MS that aren’t the 4 main

A

4 main: periventricular, juxtacortical, infratentorial (posterior fossa), spinal

Other common: corpus callosum, optic nerve

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16
Q

MC cause of

(a) nontraumatic ICH in the elderly
(b) ICH in children

A

(a) Amyloid Angiopathy
- bleeds in multiple hemispheres

(b) ICH in children = AVM

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17
Q

(a) MC inherited stroke d/o?

(b) 2 main features

A

(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

18
Q

Differentiate risk of twin having MS if the one twin has it

(a) Monozygotic
(b) Dizygotic

A

(a) 30% risk
(b) 5% risk
- so hereditary component, but doesn’t explain it all

19
Q

Mechanism of tonsilar herniation

A

Protrusion of cerebellar tonsils thru the foramen magnum, causing compression of the lower brainstem and upper cervical spinal cord

20
Q

Use of LP in the diagnosis of MS

A

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

21
Q

Tx for PML in HIV+ pt

A

HAART to reduce viral load

But very poor recovery and prognosis

22
Q

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

(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

23
Q

(a) Prognosis of MS

(b) Good prognostic factors

A

(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

24
Q

34 yo M p/w HA and fever to 103.4, mild lethargy and confusion
-no focal findings

(a) Describe symptoms
(b) Ddx

A

(a) Encephalopathy

(b) Viral vs. bacterial meningitis

25
Q

(a) MS presenting factors

(b) What neurologic signs would make you think against a dx of MS?

A

(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

26
Q

Contraindications to tPA

A
  • 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
27
Q

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

(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)

28
Q

Ddx for brain nodule

A

4 T’s and A (for good measure)

Ts:
tumor (primary)
tumor (secondary = mets)
toxo
Tb

and abscess

29
Q

First line tx for MS attack

A

High-dose glucocorticoids

Typical course: 5 days of IV methylprednisolone at 1g/day

30
Q

Electromyogram

(a) Describe set up
(b) Function

A

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

31
Q

Neuromyelitis Optica = Devic’s Disease

(a) Main features
(b) Tx

A

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

32
Q

Top 4 (in order) causes of irreversible dementia

A

1- Alzheimer’s
2- Vascular
3- Lewy Body
4- Frototemporal

33
Q

Most common surgical procedure done for epilepsy

A

After 2 AEDs- most successful if it can be localized on MRI

MC procedure = anterior temporal lobectomy

34
Q

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

(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

35
Q

Differentiate pressure vs. rate support for vent settings

A

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

36
Q

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

(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

37
Q

Multiple sclerosis

(a) Mechanism
(b) Age of onset
(c) 2 associated conditions
(d) Behavioral RF

A

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

38
Q

Cause of upward herniation

A

Increased pressure in the posterior fossa, causing midbrain to be pushed thru the tentorial notch

39
Q

Describe Cheyne-Strokes respirations

A

Oscillation in ventilation btwn apnea (temporary stop in breathing) and hyperapnea

40
Q

Empiric tx for meningitis

A

Abx:

  • ceftriaxone
  • vanc
  • ampicillin if immunocompromised or old to cover for listeria

and acyclovir

Neuro Shelf (12 decks)

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