MKSAP Neuro Flashcards
What AEDs increase risk of osteoporosis? Name 4. When should screening start?
Phenytoin, Phenobarbital, Carbamazepine, Valproic acid
Should undergo DEXA scan after 5 years of therapy
What disease is associated w/ exercise intolerance associated w/ myalgia, mild weakness, and myoglobinuria? How can these patients protect against exercise intolerance?
McArdle disease - glycogen storage disease V
They can protect against exercise intolerance by eating carbohydrate-rich diet
What is the medical research council muscle scale and when is it used?
Scale that evaluates muscle strength of each extremity x 3 movements; maximum score is 60, if <48 = ICU related weakness is diagnosed
What AEDs are preferred in pregnancy?
Levetiracetam and Lamotrigine (needs dose increase of 50%)
What 3 AChe inhibitors are used in mild-moderate Alzheimer’s? What are the contraindications to their use? Name 5.
- Donepezil, Rivastigmine, Galantamine
- Sick sinus syndrome, LBBB, uncontrolled asthma, angle-closure glaucoma, ulcer disease; caution with seizures if using donepezil
When do you do carotid endarterectomy?
> 80% stenosis in patients who have not had a stroke
>70% stenosis in females who have had a stroke; >50% in males who have had a stroke
What diagnostic test can be performed in patients w/ mild cognitive impairment to diagnose Alzheimers? What proteins are found?
- LP
2. Decreased amyloid-beta-42 peptide, and increased tau protein & p-tau levels
What monitoring is needed while on fingolimod?
Cardiac (bradycardia w/ first dose), eye exam (macular edema), liver enzymes, CBC (lymphopenia), yearly skin exam (basal cell carcinoma)
What disease presents w/ numbness, distal extremity weakness, unsteady gait, areflexia, and atrophy of distal extremity muscles and foreleg muscles?
Charcot-Marie-Tooth disease
What is St. John’s wort used for? What are some side effects? Name 5.
Depression
GI symptoms, dizziness, confusion, dry mouth, photosensitivity, sedation, urinary frequency, anorgasmia, drug interactions
What medication can improve functional recovery in severe TBI?
Amantadine
What presents as subacute severe pain -> resolution of pain -> progressive weakness and atrophy involving the shoulder girdle and upper extremity muscles?
Idiopathic brachial plexopathy/Neuralgic amyotrophy/Parsonage-Turner syndrome
It is often triggered by infection or surgery
How does reversible cerebral vasoconstriction syndrome clinically present? What are triggers? Name 5. How does it look on imaging? What is the treatment?
- Thunderclap headache
- May be triggered by exertion, valsava maneuvers, emotion, or showering/bathing; also vasoactive drugs (sympathomimetic agents, triptans, cocaine, cannabis), anti-depressants, pregnancy, head/neck surgery or trauma
- Mutlifocal constriction of intracranial vessels on MRA or CT angiography
- Calcium channel blockers (verapamil or nimodipine)
What are the two first line treatments for MS, and which is preferred in liver disease? What are the side effects? What is the FDA approved therapy for primary progressive MS, and what are the side effects? What is the FDA approved therapy for secondary progressive MS, and what are the side effects?
- Interferon beta (avoid in psychiatric disease and liver disease; can cause flu like sx, transaminitis) and glatiramer acetate (can cause injection site reactions, lipoatrophy)
- Ocrelizumab - can cause infections and infusion reactions; increases risk for PML and cancer
- Mitoxantrone - can cause cardiac toxicity and AML; also infection, nausea, oral sores, alopecia, menstrual irregularities, blue discoloration of urine
How does cavernous sinus thrombosis present? What is the most common cause?
Acute onset headache, proptosis, periorbital edema, painful ophthalmoplegia
Most commonly caused by contiguous spread of infection
How does carotid artery dissection present? Vertebral artery dissection?
- Orbital pain, partial Horner syndrome, ipsilateral signs of cerebral or retinal ischemia
- Occipital and neck pain; dysarthria, dysphagia, ataxia, and hemifield visual loss
What type of CNS tumor is a dural-based tumor w/ a smooth rounded shape with a “tail” tracking along the dura outside the brain parenchyma? What is the treatment?
Meningioma
Surgery if symptomatic, observation if small and asymptomatic; no chemotherapy
What is needed for staging of primary CNS lymphoma? What is the treatment?
Whole body PET or CT, bone marrow biopsy, and testicular U/S
IV methotrexate + rituximab; no surgery
How does the paraneoplastic syndrome associated with anti-GAD present? Name 4 findings. What cancers is it associated with?
Stiff person syndrome, type 1 DM, ataxia, brainstem encephalitis, parkinsonism, ophthalmoplegia
Thymoma, breast cancer
What conditions are associated with intracranial HTN? Name 5. What are the treatment options for idiopathic intracranial HTN? What are the potential side effects of these?
- Hypervitaminosis A, tetracyclines, retinoic acid, kidney failure, hypoparathyroidism, addison disease, use of estrogen and progesterone, pregnancy, steroid use or withdrawal
- Acetazolamide (preferred), Topiramate
- Paresthesia, kidney stones, taste perversion; weight loss in topiramate
How does intracranial hypotension present? What is the treatment?
- Orthostatic headache, thunderclap or subacute; may be associated w/ tinnitus, diplopia, neck pain, nausea, photophobia, and phonophobia
- Autologous epidural blood patch - blood is injected into epidural space
What cause of headache presents as diffuse non-nodular pachymeningeal enhancement on brain MRI?
Intracranial hypotension
Can also see cerebellar tonsillar descent, subdural fluid collections, decreased ventricular size, and engorgement of pituitary gland
What is the preferred treatment for trigeminal neuralgia and what are 3 main side effects? What are 3 alternative medications for treatment?
- Carbamazepine - hyponatremia, agranulocytosis, dizziness
2. Oxcarbazepine, Baclofen, Gabapentin, Lamotrigine
What are the contraindications for triptans?
Uncontrolled HTN, vascular disease (coronary, cerebral, or peripheral), or migraine w/ hemiplegic or brainstem auras
What two medications lack vasoconstrictor properties for migraine so may be used for acute migraine in patients w/ vascular disease, migraine w/ aura, and uncontrolled HTN?
Lasmiditan - highly selective 5-HT receptor agonist
Ubrogepant - calcitonin gene related peptide antagonist
What are 3 treatment options for status migrainosus?
Several days of steroids
IV dopamine antagonist + IV benadryl, IV ketorolac, and hydration
IV DHE + anti-emetics
What are the 5 meds that can be used in migraine prophylaxis? What are 4 second line agents?
- Propanolol, timolol, metoprolol, valproic acid, topiramate
- Atenolol, amitriptyline, venlafaxine, NSAIDs
What are erenumab, fremanezumab, galcanezumab, and eptinezumab used for?
Monoclonal antibodies used in migraine prophylaxis
How do cluster headaches present? What is the treatment?
- Cluster headache lasts 15 min to 3 hours, recurs 1-8 times daily over a span of weeks to months; months to years of remission; nocturnal attacks, may be precipitated by alcohol ingestion
- Oxygen, subcutaneous sumatriptan; Verapamil as long term prevention
How does short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) present?
Headache lasting 1 second to 10 minutes, may recur more than 100 times daily; typically no periods of remission
Treat w/ lamotrigine but mostly refractory to medical management
How does chronic paroxysmal hemicrania present? What is the treatment?
Headache lasting 2-30 minutes, can recur up to 40 times daily; typically no periods of remission
Indomethacin
What is the management for cough headache? What is the management for primary stabbing/ice pick headaches?
- Indomethacin; Brain MRI since up to half of patients can have a Chiari malformation
- Indomethacin
What are the indications for surgery/drainage in acute vs. chronic subdural hematomas? What is the indication for urgent evacuation of an epidural hematoma? At what size should a cerebellar hemorrhage be evacuated?
- Acute - hematoma thickness >10 mm, GCS <9, pupil asymmetry/fixation
- Chronic - hematoma thickness >10 mm, midline shift >5 mm, significant neurological compromise
- GCS <9, anisocoria, hematoma >30 mL in volume
- > 3 cm
What are the differences between absence seizure and focal seizure w/ altered awareness?
Absence seizure does not have aura, lasts <15 seconds, stops abruptly, no post-ictal state, can have multiple daily, and usually precipitated by hyperventilation
Focal seizure can have an aura, lasts >30 s, gradually terminates, has post-ical lethargy, can occur once weekly or monthly, not likely to be precipitated by hyperventilation
How can temporal lobe seizures present?
Rising feeling in stomach, deja vu, fear -> staring, arrest of speech or behavior, automatisms, altered smell/taste/hearing
What is the most common cause of medication-resistant adult-onset focal epilepsy?
Mesial temporal sclerosis w/ hippocampal atrophy
How does juvenile myoclonic epilepsy present?
Myoclonic seizures - may report dropping items from their hands; most have GTCS, 30% have absence seizures
Triggered by sleep deprivation, stress, and alcohol use
What are the 3 first line AEDs for focal seizures? 3 first line agents for generalized seizures?
- Lamotrigine, Levetiracetam, Oxcarbazepine
2. Lamotrigine, Levetiracetam, Valproate
What are some side effects of phenobarbital? Name 4.
Sedation, hepatotoxicity, rash, pancytopenia, osteoporosis
What are some side effects of phenytoin? Name 8.
Sedation, ataxia, tremor, diplopia, bradycardia, hypotension, rash, gingival hyperplasia, cerebellar atrophy, peripheral neuropathy, osteoporosis, pancytopenia, hepatotoxicity
What are some side effects of valproic acid? Name 6.
Sedation, ataxia, tremor, diplopia, weight gain, PCOS, reversible parkinsonism w/ dementia, pancytopenia, osteoporosis, hepatotoxicity, pancreatitis
What are some side effects of carbamazepine and oxcarbazepine? Name 5.
Sedation, tremor, diplopia, dizziness, hyponatremia, rash, pancytopenia, osteoporosis, hepatotoxicity
What are some side effects of lamotrigine? Name 4.
Sedation, ataxia, tremor, diplopia, headache, dizziness, rash
- Rapid titration associated with SJS, TEN, and DRESS
- Preferred in patients w/ depression or psychosis
- Can worsen myoclonus
What are some side effects of topiramate and zonisamide? Name 6.
Sedation, ataxia, tremor, diplopia, poor concentration, word finding difficulty, paresthesias, weight loss, anhidrosis, nephrolithiasis, acute angle glaucoma*, psychosis, cleft lip/palate in fetus
What are some side effects of levetiracetam? Name 3.
Sedation, irritability, psychosis, depression, thrombocytopenia (rare)
What are some side effects of lacosamide? Name 4.
Sedation, ataxia, tremor, diplopia, PR prolongation/AV block, atrial fibrillation
Which AED should be avoided in elderly patients? Patients with hepatic insufficiency? Patients w/ acidosis and nephrolithiasis (2)? What AEDs need to be dose reduced in CKD (3)?
- Valproic acid
- Valproic acid
- Topiramate, Zonisamide
- Gabapentin, Pregabalin, Levetiracetam
Aneurysms of what size in the posterior & anterior circulation can be managed conservatively?
<7 mm in posterior, <12 mm in anterior