MTB 3 Flashcards
What percentage of carotid stenosis do we operate on? Don’t we operate on?
Greater than 70%
We don’t operate on 50%
Risk factors that must be controlled in carotid stenosis?
DM HbA1C must be < 7%
HTN
LDL < 100
Stop tobacco smoking
Dx for HA upon bending over to tie laces (Positional)?
Colloid cyst of 3rd ventricle
Migraine HA Presentation
Visual disturbance Photophobia Aura Related to menses, emotions, food N/V
Cluster HA Presentation
Frequent
Short duration
High intensity
Men more than Women
What is tx for Cluster HA?
100% Oxygen
Ergots
Sumatriptan
What is pseudotumor cerebri ass’d with?
Chronic lung dz
Addisons
Tetracycline
HA ass’d with Vit A toxicity?
Pseudotumor cerebri
HA w papilledema and diplopia? Why diplopia?
Pseudotumor cerebri
CN 6
HA presents with tearing, red eye w rhinnorhea?
Cluster HA
- current, in “clusters” over time
HA ass’d with Horner syndrome? Ipsi or Contra?
Cluster HA
Ipsilateral
What must be assessed for with HA and red eye?
Glaucoma
Retroorbital HA that starts suddenly, peaks rapidly, lasts about 2 hours?
Cluster HA
HA with scalp tenderness, ass’d with polymyalgia rheumatica?
Temporal Arteritis
Pt with 1st time convulsion + > 35 yoa, what must we rule out?
Brain tumor
HA that is Bilateral?
Tension HA
HA in young men, ass’d with alcohol?
Cluster
Are Cluster HA’s uni or bilateral?
Unilateral
Tx for Migraine HA?
Triptans
Ergotamine
Testing for Pseudotumor cerebri?
CT or MRI to R/O intracranial mass lesion
LP: Increased Pressure (otherwise Normal)
Most accurate test for Giant cell arteritis?
Bx
Migraine PPX tx?
TCAs (Amitriptyline) Beta blockers CCBs - Verapamil SSRIs Botulinum Valproic Acid Topiramate
Tx for tension HA?
NSAIDs
Tx for Pseudotumor cerebri?
Weight loss
Acetazolamide
Pseudotumor cerebri Tx if medical does not work?
Ventriculoperitoneal shunt
Effective tx in cluster HA but not migraines?
100% Oxygen
Prednisone
Lithium
PPX for Cluster HA?
CCBs
Preventive tx not necessary
Trigeminal Neuralgia Tx?
CN V Carbamezapine Phenytoin Baclofen Gabapentin Lamotrigine
Who gets a Zoster vaccine?
All persons > 60 yoa to prevent shingles
Electrolyte disturbances that cause seizures?
Hypo or Hypernatremia Hypoglycemia Hypocalcemia Hypomagnesemia Hypoxia
Causes of seizures
VITAMINS Vascular Infxn Traum AI Metabolic Idiopathic Neoplasm pSychiatric
Definition of status epilepticus
Recurrent or continuous seizure that lasts 5-30 minutes
Best initial tx of status epilepticus
Mangement if ineffective
Benzo - Lorazepam or diazepam IV
If persists -> Phenytoin or Fosphenytoin
Still persists -> Phenobarb
Still -> NM Blocking agent: Succinylcholine, Vecuronium, Pancuronium to allow for intubation
General anesthesia - Midazolam or Propofol
Which has fewer AE’s: Phenytoin or Fosphenytoin?
Fosphenytoin
Long term AE’s for Phenytoin?
IV - HyptoTN, AV block Vertigo Ataxia Gingival Hyperplasia Hirsutism Rash LA
What is a partial seizure?
Focal to one part of body
I.e. Just leg or just arm
What is a simple v complex seizure?
Simple - in tact consciousness
Complex - LOC
Describe a tonic clonic seizure
Grand mal
Generalized
Varying phases of muscular rigidity (tonic) then jerking of muscles (clonic)
What is the first line tx for a Partial seizure?
Carbamazepine
Phenytoin
What is a partial w secondary generalization?
Tonic clonic manifestation - diffuse muscle aches
Increased CPK
Tongue biting
Loss of bladder control
What is a complex seizure?
Presentation?
LOC w automatisms
Chewing, picking hand movements, lip smacking
Absence (Petit mal) seizure EEG pattern?
Generalized, symmetric 3-Hz spike and wave discharge pattern
What is Lennox-Gustant syndrome
Pediatric seizure syndrome
Less than 7 yoa
Mental Retardation
Do we start antiepileptic drugs for a single seizure?
No. Unless:
it is status epilepticus
Fam Hx
Abnormal EEG
When do we discontinue seizure meds? How do we test for this?
When pt has been seizure free for 2 years
Test with sleep deprivation EEG
Intracranial HTN = ICH
Pressure
Causes
IC pressure > 20 mmHg
Trauma, lesion, hydrocephalus, impaired CSF outflow
Sx’s seen in ICH
Sx’s: Diffuse HA, worse in morning, N/V early in day, visual changes, papillaedema, confusion, somnolence, Cushing reflex (HTN + bradycardia)
Cerebral Salt wasting syndrome
Pathophys
Inappropriate secretion of vasopressin, causes H2O retention
- Increased secretion of ANP/BNP causing cerebral salt wasting -> HYPOnatremia
- resolves in 1-2 wks
What is commonly ass’d with ICH?
SIADH
How is presentation of SAH different from meningitis?
SAH
- very sudden in onset
- LOC
Best initial test for SAH
CT w/out contrast
Most accurate test for SAH
LP Puncture - if FN CT CSF: - Xanthochromia - 4-6 hrs to develop - Increased WBCs - Ratio of WBCs/RBCs is normal
What should one suspect if WBC/RBC ratio is increased? (WBC count exceeds normal)
Meningitis
Normal ratio of WBC/RBC in CSF?
One WBC for every 500-1000 RBCs
1:500
“Boot shaped” hemorrhage?
SAH
EKG of SAH
Large or inverted T waves = cerebral T waves
- excessive sympathetic activity
How do we find the site of aneurysm?
Angiography
When do we use contrast in CT/MRI of head?
Detection of mass or lesion - cancer or abscess
NOT with blood
Tx for SAH
- Nimodipine prevents ischemic stroke
- Embolization (coiling)
- Ventriculoperitoneal shunt if hydrocephalus develops
- Seizure ppx - Phenytoin to prevent
Complication w Nimodipine
First 24 hours -> Rebleeding
Days 3-10 -> Vasospasm
Embolization or surgical clipping for SAH?
Embolization
Pt presents with burning pain and paralysis in UE, relative sparing of LE?
Central cord syndrome
- elderly pts secondary to forced hyperextension of their neck
Spinal cord problem ass’d with burst fracture?
Anterior cord syndrome
What is presentation of anterior cord syndrome?
Total loss of motor function below the level of the lesion w loss of pain and temp on both sides below lesion
Test for anterior cord syndrome?
MRI
Loss of all fnc except for posterior column, flaccid paralysis below level of lesion, loss of DTRs at level of lesion, loss of pain and temp?
Anterior Spinal Artery Infarction
What causes subacute combined degeneration of cord?
Presentation
B12 Deficiency
Neurosyphilis
- Affect the posterior column - so position and vibration are lost
How does spinal trauma present?
Acute onset of limb weakness/sensory changes below level of injury
Sphincter fnc impaired
Loss of DTRs followed by hyperreflexia below level of trauma
Tx: glucocorticoids
Pt presents with motor and sensory deficit, change in bowel/bladder dysfunc, after after having an epidural catheter?
Epidural hematoma from a traumatic insertion
What is transverse myelitis?
Inflammation of the spinal cord causes axonal demyelination
How does transverse myelitis present?
Weakness, numbness of limbs
Ass’d with CMV, spinal cord injury
Brown Sequard Syndrome
2 Ipsi, 1 Contra
Unilateral hemisection of SC from injury
Loss of pain/temp on Contra
Motor Fnc + position/vibration - Ipsi
Loss of pain/temp bilaterally upper back and both arms?
Syringomyelia
Capelike distribution
Will also have loss of reflexes and muscle atrophy
What is Syringomyelia ?
Fluid filled dilated central canal
- Tumor or trauma
What is communicating Syringomyelia ass’d with?
Arnold Chiari
Nocturnal HA + morning vomiting?
Intracranial pathology
Most accurate test for Syringomyelia?
MRI
Tx for Syringomyelia?
Surgical removal of tumor
