Med 1 EOR - Neuro Flashcards
autosomal dominant neurodegenerative d/o. Mutation chromosome 4. Neurotoxicity + cerebral, putamen + caudate nucleus atrophy. = behavioral change –> chorea –> dementia
huntingtons syndrome
CT/MRI of huntingtons shows what?
CT/MRI = cerebral + caudate nucleus atrophy.
prognosis + mgmt of huntingtons
fatal 15-20 yrs after presentation. Chorea mgmt: antidopaminergics (typical + atypical antipyschotics. Tetrabenzine, Benzos.
idiopathic dopamine (inhibitor) depletion → failure to inhibit Ach in basal ganglia. MC onset 45-65yo.
parkinsons
4 cardinal S+S of parkinsonism?
resting tremor (pill rolling)- better with intention
cogwheel rigidity
fixed facial expression
bradykinesia: shuffling gait
MRI: Cytoplasmic inclusions (lewy bodies), loss of pigment cells seen in substantia nigra.
parkinsons
3 txt options for parkinsons: what is the go-to? best for avoiding ADRs of the first line drug? for tremor predoninance?
- *levodopa/carbidopa (sinemet): most effective - “wearing off of bradykinesia” w/ longterm use
- *Dopamine agonists: bromocriptine, pramipexole, ropinirole. Used in young pts to delay use of levodopa (ADRs)
- Anticholinergics: trihexyphenidyl, benztropine - for <70yo w. Tremor predominance.
MC kids from rheumatic fever (group A strep) = antibodies against N-actyel-beta-glucosamine - involve basal ganglia + cortical structures.
syndeham chorea (post-infectious chorea)
txt options for syndenham chorea
chronic ABX for Group A strep - PCN G. severe symptoms =D2 blocker, carbamazepine, or valproic acid
pathologically enlarged ventricular size with normal opening pressures on lumbar puncture
normal pressure hydrocephalus
causes of normal pressure hydrocephalus (primary and secondary)
Causes: idiopathic (maybe congenital that shows symptoms later in life, cerebrovasc dz, decr CSF abs etc.
Secondary: MC intraventricular or subarachnoid hemorrhage
triad: 1. Dementia 2. gait disturbance 3. Urinary incontinence. Dont need all 3 but gait must be primary - “glued foot” - small steps + wide base.
normal pressure hydrocephalus
Dx of normal pressure hydrocephalus
Dx of exclusion then high-volume LP (30-50mL) + document gait before and after procedure.
MRI/CT = enlarged ventricles
txt for normal pressure hydrocephalus
reversible w/ VP shunt (lateral ventricle to abdomen)
necrosis of BOTH upper and lower motor neurons → progressive motor degeneration.
S+S: muscle weakness, loss of ability to initiate + control movements.
Upper: spastic, stiff, hyperreflexive
Lower: progressive bilat fasiculations, muscle atrophy, hyporeflexia, muscle weakness.
amyotrophic lateral sclerosis (ALS) - lou gherigs disease
prognosis + txt options for ALS?
riluzole (glutamate blocker): reduces progression up to 6mo. Fatal 3-5yrs after onset.
spasticity/hyperreflexive, varying degrees of motor deficits. Often associated w/ intellectual/learning disabilities.
cerebral palsy (brain injury during perinatal or prenatal period)
autoimmune peripheral nerve d/o (against Ach - nicotinic- postsynaptic receptor). MC young women. HLA-DR3. 75% have thymic abnormality (hyperplasia or thymoma).
myasthenia gravis
S+S of myasthenia gravis
progressive weakness w/ repeated muscle use + recovery after rest
Ocular weakness: diplopia, ptosis
generalized weakness, bulbar, respiratory!
MG crisis = flaccid paralysis + resp failure
Dx of MG ?
+ Ach receptor Antibodies
what is the Edrophonium (tensilon) test?
rapid response to short-acting IV edrophonium in limb MG
how do you distinguish cholinergic crisis from myasthenic crisis?
if flaccid paralysis improves w/ tensilon test = myasthenic crisis, worse = cholinergic crisis.
what is lambert-eaton syndrome and how do you distinguish it from MG?
Lambert eaton: MC assoc w/ small cell lung CA - antibodies against presynaptic voltage gated Ca+ channels prevents Ach release.
Unlike MG - weakness IMPROVES w/ repeated use.
what is guillan-barre? (what causes it and what is the patho?)
ACQUIRED inflam demyelinating polyradiculopathy of peripheral nerves. = slow nerve impulse = symmetric paresthesias and weakness. MC campylobacter jejuni, also respiratory of GI infections.
S+S of guillan barre?
ASCENDING bilateral weakness + paresthesias. Decreased DTRs. +/- bulbar muscles (swallowing difficulty) and resp. Muscles.
Autonomic dysfxn: tachy, BP control, breathing difficulties
CSF for guillan barre shows what?
high protein and normal WBC
Txt for Guillan barre? prognosis?
plasmapheresis (removes harmful circulating autoantibodies). OR IVIG (suppresses harmful inflammation/autoantibodies + induces remyelination.
prognosis: 60% full recovery in one year
what risks are increased with a depressed skull fx and what do you do for this?
increased risk infection, seizure, death. Txt: seizure prophylaxis, abx (5-7days cover for bacterial meningitis), tetanus prophylaxis.
autoimmune, inflammatory demyelinating dz of CNS. idiopathic. Assoc w/ axon degeneration of white matter of brain, optic nerve + spinal cord. MC women 20-40yo.
multiple sclerosis
3 types of MS
Relapsing-remitting: MC (episodic exacerbations)
Progressive decline
Secondary progressive: relapsing-remitting that becomes progressive
5 major S+S of MS
- sensory deficits (pain, fatigue, trigeminal neuralgia
- Optic neuritis (retrobulbar) - unilateral eye pain w/ eye movement, vision loss
- motor : upper motor neuron - spasticity, + babinski
- Spinal cord: bladder, bowel, sexual dysfxn
- Charcots neuro triad: nystagmus, staccato speech, intentional tremor.
Dx of MS: primary and confirmatory
clinical - @ least 2 episodes. MRI w/ gadolinium to confirm = white matter plaques hyperdensities. LP: incr IgG (oligoclonal bands).
Txt for MS exacerbations
Acute exacerbations: IV steroids (high dose) 1st line. +/- plasmapharesis
epidural vs subdural hematoma on CT
epidural: biconvex shape.
subdural: crescent shape, DOES cross suture lines
with what severity do you do an urgent evac or craniotomy for subdural hematoma? (parameters for clot thickness, midline shift, ICP)
.s+s of brain herniation or ICP (i.e. fixed dilated or asymmetric pupils), neuro deterioration since time of injury, clot thickness >10mm or >5mm midline shift. Or ICP >20mmHg.
AV malformations and cerebral aneursyms are usually asymp till rupture, then what are the S+S ?
severe HA +/- seizure, focal neuro deficits, vision loss
Neurotic plaques, overproduction or decreased clearance of extracellular deposits of amyloid beta peptides.
alzheimers dz
what is “sundowning”?
worse mental status in evening hours of those w/ dementia
txt options for alzheimers
cholinesterase inhibitor (donepezil, galantamine, rivastigmine). Vitamin E. moderate-severe= memantine (cholinesterase inhibitor) +/- symptomatic txt.
MG and alzheimers are both txted with what medication class?
cholinesterase inhibitors (i.e. rivastigmine)
what txt should be considered for all pts with delerium
thiamine
drug-induced movement disorders: what is the most common kind and drugs that cause it?
MC drug-induced parkinsonism - from any med that interferes w/ dopamine transmission (1st and 2nd gen antipsychotics.
inheritance of essential tremor
autosomal dominant
tremor: MC upper extremities and head (usually spares legs), also voice. Worse w/ emotional stress + intentional movement. Short relief w/ alcohol.
essential tremor
txt options for trigeminal neuralgia
antiepileptics (carbamazepine or oxcarbazepine) (others - gabapentin, lamotrigine, baclofen. Or iv lidocaine ) Sx if refractory.
MC and most aggressive of all primary CNS tumors in adults.
glioblastoma - either primary or secondary (stage IV astrocytoma from stage II or III)
what is cushing’s reflex?
in severe cases of cerebral mass effect - triad: irregular respirations, HTN, bradycardia.
CT/MRI and histology of glioblastoma
CT/MRI = nonhomogenous mass w/ hypodense center + variable ring of enhancement surrounded by edema. May cross corpus callosum (butterfly glioma). Histology = necrotizing tissue, areas of hemorrhage, pseudopalisading (tumor cells line areas of necrosis)
prognosis of glioblastoma
Poor prognosis (often <1yr survival)
where are astrocytomas usually found?
kids: supratentorial, adults - infratentorial
4 grades of astrocytoma
Pilocytic- grade I: juvenile: localized, “most benign”. MC young pts.
Diffuse - grade II: invade surrounding tissues but grow slow
Anaplastic- grade III: rare but aggressive
Glioblastoma multiforme- grade IV: MC primary CNS tumor in adults
which astrocytoma grades are enhancing (defined, vascularity) vs nonenhancing on CT/MRI
Grade I-II nonenhancing, grade II-IV enhancing
S+S of schwannoma (acoustic neuroma CN VIII)
unilateral sensorineural hearing loss is an acoustic neuroma until proven otherwise. also tinnitus, HA, facial numbness, vertigo
weber test: normal, conductive loss , sensorineural loss
normal: both ears the same
conductive: lateralize to affected ear
sensorineural: lateralize to normal ear
txt for acoustic neuroma
Sx or focused radiation
MC bacteria causes of brain abscesses
MC staph aureus + strep viridans
dx of brain abscess
MRI (diffusion weighted -DWI) = hyperintense. + CT-guided aspiration → gram stain and histology. Cultures of blood + CSF
txt of brain abscess (from oral/ear/sinus, from hematogenous spread)
ABx + drainage
Empiric from oral/ear/sinus: metronidazole + ceftriaxone or ceftotaxime
Empiric from hematogenous spread: vancomycin + ceftazidime, cefepime or meropenem.
1 cause of disability in US.
stroke
anterior, middle and posterio cerebral arteries: from what vessel do they derive? stroke in each will cause what body part deficit?
Anterior cerebral artery (carotid): Leg control
Middle cerebral artery (carotid): Arm control
Posterior cerebral artery(from vertebral artery): visual issues
what is the upper motor neuron lesion “posture” seen commonly long after CVA?
flexed arm + weak leg on ipsilateral side
txt steps for ischemic CVA (if time for TPA or if not)
ABCs, fibrinolysis! (TPA in 4.5 hrs) lower ICP if herniating (mannitol, hyperventilation -shrinks blood vessels in brain, ventriculostomy/craniotomy)
Time over TPA: Head of bed 30 degrees +NPO (so they dont passively regurg stomach contents → PNA), ASA, BP control (but gradual b/c some tissue needs that perfusion!!), no hypotonic fluids (only NS! b/c itll make brain swell)
S+S posterior circulation stroke
prodromal symptoms, crossed findings (one side of face and opposite side of body weakness), 5 Ds (diplopia, dizzy, dysarthria, dysphagia, dysmetria aka ataxia)
anterior circulation stroke symptoms: dominant vs nondominant side?
Non-dominant side (usually right): behavior, learning process, short term memory. Apraxia (loss of ability to execute purposeful movement). Anasognosia (unable to realize own condition), dysarthria (unable to articulate words) Dominant side (usually left): speech language. Aphasia (remembering words, speaking, writing), agraphia, decreased math comprehension.
TIA symptoms in from internal carotid artery vs vertebro basilar?
internal carotid artery (anterior)= amarosis fugax + weakness in contralateral hand. verterbro basilar (posterior): brainstem/cerebellar symptoms (gait, dizziness, vertigo).
carotid endarterectomy if internal or common carotid have > ___% stenosis
70%
meds after TIA
ASA + dipyridamole or clopiradgrel
intracerebral hemorrhage stroke txt
ABCDEs → ICU. reverse anti-coags, decr BP,
lower ICP mgmt (if herniating) - mannitol, hyperventilation. Sx: ventriculostomy, cranatiomy.
seizure prevention.
txt for HA: cluster? for all types?
what route of administration is best?
Cluster: O2 (higher conc is better) or intranasal lidocaine
All types: dopamine antagonists (droperidol, prochlorperazine, metoclopramide, chlorpromazine), triptans (when given at EARLY symptoms), NSAIDs (ASA, ibuprofen) , opiods (morphine)
Txt: faster is better. IV>IM>PO
HA/migraine prophylaxis options
BBs/CCBs, SSRIs/ TCAs, topiramate/gabapentin
2 types of partial/focal seizure
Simple: maintained consciousness.
Complex/temporal lobe: impaired consciousness. Starts focally. Auras- sensory/autonomic/motor sx that pt is aware of. Automatism: lip-smacking, manual picking, patting, coordinated motor movement.
5 types of generalized seizure (abscence, tonic-clonic, myoclonus, atonic, status epilepticus)
Absence: staring, no post-ictal . MC kids
Tonic-clonic (grand mal): LOC → rigidity, resp arrest → clonic phase (repetative, rhythmic jerking) → postictal (flaccid coma/sleep). + auras as prewarnings.
Myoclonus: NO LOC. sudden, brief, sporadic invol. Twitch
Atonic: “drop attacks” - sudden loss of postural tone
Status epilepticus: repeat, generalized w/out recovery >30min
EEG
______= bilateral symmetric 3Hz spike or normal.
_____ = generalized high-amplitude rapid spiking.
absence = bilateral symmetric 3Hz spike or normal. Grand mal = generalized high-amplitude rapid spiking.
txt for abscence seizure vs grand mal
Absence: ethosuximide
Grand mal: valproic acid, phenytoin (blocks Na+ channels in CNS), carbamazepine, lamotrigine
txt for status epilepticus
lorazepam/diazepam (benzos to increase GABA) → phenytoin → phenobarbital (barbituate - increase GABA axn)
what labs can help differentiate pseudoseizure from real?
*prolactin levels increase with seizures - helps differentiate from pseudoseizure
4 manifestations of tertiary syphilis
- Gumma: granulomas on skin + body tissues (bones)
- Neurosyphilis: HA, meningitis, dementia, vision/hearing loss, incontinence.
“Tabes Dorsalis” (demyelination of posterior columns → ataxia, areflexia, burning, pain weakness) - Argyl-robertson pupil: small, irregular pupil that constricts normally to hear accommodation but not to light.
- Cardiovascular: aortitis, aortic regurg, aortin aneurysms.
screening vs confirmatory test for syphilis
screening - RPR or VDRL. Confirmatory: treponemal tests (FTA-ABS) -
bacterial meningitis: what is most likely organism for each after group? txt for each? (<1mo, 1mo-18,, 18-50, >50)
<1mo : (MC- GBS, also Listeria monocytogenes) - txt: ampicillin +cefotaxime or aminoglycoside).
1mo-18yo: MC Neisseria meningitis (w/ petichial rash!), also S pneumo - txt: ceftriaxone + vancomycin
18-50yo: MC S pneumo, also neisseria meningitis (w/ petichial rash!) - txt: ceftriaxone + vancomycin
>50yo: S pneumo, Listeria monocytogenes - txt: ampicillin +ceftriaxone + vancomycin
kernigs vs bruzinski signs
+ kernigs: unable to straighten knee w/ hip flexion. + brudsinski: neck flexion = knee/hip flexion
CSF meningitis: bacterial vs viral vs fungal (WBCs, protein, glucose, appearance)
Bacterial: WBCs 100-100,000 and >80% neutrophils, high protein, DECREASED glucose. + gram stain. TURBID
Viral: WBCs 10-300, lymphocytes. Normalish protein, NORMAL GLUCOSE. CLEAR
Fungal: WBCs 10-200 lymphocytes. DECREASED glucose.
when do you start abx for suspected meningitis?
empiric before LP! (based on most common organism for age)
add-on medication for meningitis for S pneumo or H flu
dexamethasone
txt for viral meningitis
supportive
MC cause of encephalitis?
HSV 1
what symptoms indicate encephalitis over meningitis ?
abnormal cerebral fxn (irritable, lethargy, behavior changes, seizure)
Dx encephalitis: CSF, MRI (what lobe is MC involved)
CSF = same as viral meningitis (lymphocytosis, normal glucose) . imaging = temporal lobe MC involved.
txt for encephalitis
supportive, control cerebral edema. HSV or no known cause - valacyclovir +/- immunoglobulin if immunocompromised. Worse prognosis than meningitis
what do each of the 4 lobes of the cerebral cortex control?
Frontal lobe: planning + consequences (prefrontal), primary motor (frontal)
Parietal lobe: body sensation, somatosensory
Temporal lobe: hearing, complex visual images
Occipital lobe: vision
what does the basal ganglia control?
voluntary motor movement, coordination, cognition, emotion
what do the three parts of the brainstem control? (midrain, pons, medulla oblongata)
Midbrain: relays audio/visual info, eye movement
Pons: relay station between cerebrum + medulla (motor/sensory), regulates breathing
Medulla oblongata: vital body fxns (HR, breathing, autonomic fxns)
txt for bells palsy
acyclovir or valcyclovir
those CLOSELY exposed to meningitis should be given what drugs?
cipro, rifampin, or ceftriaxone
why is ceftriaxone not given to those < 2months old for meningitis? (while its given for all other ages)
it can cause kernicterus (from increased bilirubin) = mental retardation
