MTB 3 - Neurology Flashcards
Why can a TIA cause a loss of vision in one eye (amaurosis fugax)?
the 1st branch of the internal carotid artery is the ophthalmic artery
What percent of strokes are ischemic?
80%
Sxs of anterior cerebral artery stroke:
LE > UE weakness Personality changes or psych disturbances Urinary incontinence
Sxs of middle cerebral artery stroke:
UE > LE weakness Aphasia (Left-side) Apraxia/neglect (Right side) Eye deviation *toward* the lesion Contralateral homonymous hemianopsia with macular sparing
Sxs of posterior cerebral artery stroke:
Prosopagnosia
Sxs of vertebrobasilar artery stroke:
Vertigo n/v Vertical nystagmus Dysarthria and dystonia Sensory changes in face and scalp Bilateral findings
Sxs of posterior inferior cerebellar artery stroke (PICA)
Ipsilateral face Contralateral body Vertigo + Horner’s
Sxs of lacunar infarcts:
*Must be absence of cortical deficits* Ataxia Parkinsonian signs Sensory deficits Hemiparesis (mostly the face) Possible bulbar signs
How long does a noncontrast CT take to become 95% sensitive for ischemic stroke?
3-5 days
How long does MRI take to become 99% sensitive for nonhemorrhagic stroke?
Within 24 hours
List 8 absolute contraindications to tPA:
Hx of hemorrhagic stroke Presence of intracranial mass Active bleeding or surgery within 6 weeks Presence of bleeding disorder CPR within 3 weeks that was traumatic (compressions) Suspicion of aortic dissection Stroke within 1 year Head trauma or brain surgery in last 6 months
What med should you add for all ischemic stroke patients?
Statin
What tests are indicated for a stroke patient after you have done your CT and given thrombolytics or aspirin?
Echo - looks for clots or vegetations Carotid duplex - Look for stenosis >70% (endarterectomy) EKG - Warfarin if A-fib Holter monitor if the EKG is normal
What additional tests should you do on pts
ESR VDRL or RPR ANA, double-standed DNA Protein C and S Factor V Leiden mutation Antiphospholipid syndrome
What should you get the BP down to in ischemic stroke prior to CT? How do you achieve it?
185/110 10mg labetalol
Give the tx for status epilepticus:
Lorazepam…wait 10-20 minutes. If still there give –> Fosphenytoin …wait 10-20 minutes. If still there give –> Phenobarbital …wait 10-20 minutes. If still there give –> general anesthesia (Propofol, thiopental, or midazolam)
What tests do you do on a pt having a seizure?
Na, Ca, Mg, glucose, O2, creatinine Head CT urgently Urine toxicology Liver and renal fxn
When to do an EEG (electroencephalogram)?
Only if your initial workup doesn’t reveal the etiology - including CT and MRI of the head
When will you treat after the first seizure?
Strong family hx of seizures Abnormal EEG Status epilepticus Non-correctable precipitating cause (brain tumor)
Tx of mild parkinson’s in a pt
Anticholinergics (Benztropine or hydroxyzine)
Tx of mild parkinson’s in a pt >60
Amantadine (b/c anticholinergics in an elderly pt carry a lot of side-effects)
First line treatment for parkinson’s in a pt with severe sxs (inability to perform ADLs)
Levodopa/carbidopa Dopamine agonists (ropinirole, pramipexole)
When is essential tremor present? What’s the tx?
At rest and with intention Propranolol
Most common sx in MS
Optic neuritis
Other common sxs in MS:
Atonic bladder Fatigue Hyperreflexia Spasticity Depression
Best initial test for MS? Most accurate?
MRI for both
When to get a CT scan for MS?
Never
What to do for MS if MRI is nondiagnostic?
LP showing oligoclonal bands
Best initial therapy for MS?
Steroids for acute exacerbations
Name some disease-modifying therapies in MS:
B-interferon Glatiramer Natalizumab
What is a serious side-effect of Natalizumab?
PML
What to order in all patients with memory loss?
Head CT B12 T4/TSH RPR or VDRL
Tx of alzheimers?
Anticholinesterases (Donepazil, Rivastigmine, galantamine)
Tx of frontotemporal dementia?
Same as alzheimers (less efficacy though)
What causes CJD?
Prions
How does CJD present?
Rapidly progressive dementia Myoclonus Pt is younger than in alzheimers
Best initial test for CJD?
LP which shows 14-3-3 protein (if present it spares the need for a brain biopsy)
Most accurate diagnostic test for CJD?
Brain biopsy
Describe Lewy Body dementia:
Parkinson’s w/ dementia Vivid, detailed hallucinations caused by alpha synuclein defect
Triad of NPH: - a/w Alzheimers
Urinary incontinence Dementia Wide-based gait/ataxia
How to diagnose NPH?
Head CT LP showing normal pressure MOA: no increase in SA space volume, expansion of ventricles compresses fibers of corona radiate and causes the triad of symptoms
Tx of NPH?
Shunt
Sxs of Huntington’s?
Look for family hx since it’s inherited Dementia Psychiatric disturbance w/personality change Chorea/movement disorder
How to diagnose Huntington’s?
Genetic testing Autosomal dominant
Tx of Huntington’s?
Tetrabenazine for movement disorder Antipsychotics for symptom control
When should you get a CT or MRI for headaches?
Sudden and/or severe Onset after age 40 Focal neurological findings
When do you give migraine prophylaxis? What do you give for it?
Propranolol if >4 headaches per month CCB, TCA, SSRI also work All these will take several weeks to take effect
How do triptans work to abort migraines?
Constrict vessels -This is why they’re dangerous in HTN, pregnancy, and CAD (causing cardiac ischemia)
How do cluster HAs present?
Unilateral Redness and tearing of eye Rhinorrea Men > women by 10 to 1 *No aura*
Tx of Cluster headaches:
Abortive: 100% O2 or triptans Prophylaxis: CCB (Verapamil)
Presentation of Temporal arteritis:
Tenderness over temporal area Jaw claudication
Tx of temporal arteritis?
Steroids BEFORE biopsy to prevent vision loss
Dx of temporal arteritis?
ESR Temporal artery biopsy
Presentation of pseudotumor cerebri:
Young obese woman HA Diplopia 6th nerve palsy Visual field loss Transiently obscure vision Pulsatile tinnitus
All pts with vertigo will have ___
Nystagmus
All pts with vertigo should have a ____
MRI of the internal auditory canal
List 6 diseases that cause vertigo:
BPV Vestibular neuritis Labyrinthitis Meniere’s Acoustic neuroma Perilymph fistula
Which of the 6 disease that cause vertigo also cause hearing loss/tinnitus?
Labyrinthitis Meniere’s Acoustic neuroma Perilymph fistula
How does BPV present?
Vertigo alone with position changes Tx: Epley maneuver. Meclizine has modest efficacy
What is vestibular neuritis, how does it present, and what is the tx?
Inflammation of only the vestibular portion of CN VIII. No hearing loss/tinnitus (cause only vestibular part is affected) Tx: Meclizine
What is labyrithitis, how does it present, and what is the tx?
Inflammation of cochlea Vertigo, hearing loss and tinnitus Acute and self-limited Can treat with meclizine and steroids
How does meniere’s disease present?
Vertigo, hearing loss, tinnitus (just like labyrinthitis) Ear fullness *Chronic and remitting episodes* Tx: Salt restriction and diuretics
Acoustic neuromas (Vestibular schwannoma) can be related to what?
Neurofibromatosis - type 2: BL benign primary intracranial tumor of the myelin-forming cells of the vestibulococholear nerve (CN8)
How does an acoustic neuroma present?
Ataxia Hearing loss, tinnitus, vertigo
Dx and tx of acoustic neuroma?
MRI of auditory canal Surgical resection
What is a perilymph fistula?
Rupture of tympanic membrane from either trauma/barotrauma that leads to a perilymph fistula. Tx is fixing the hole surgically
How does Wernicke-Korsakoff syndrome present?
Hx of alcoholism Confusion/confabulation Ataxia Memory loss Gaze palsy/ophthalmoplegia Nystagmus
Tx of wernicke-korsakoff syndrome?
Thiamine, then glucose
Most accurate test for bacterial meningitis?
Culture
Pt has bacterial meningitis. What is the organism if the Gram stain shows: Gram-positive diplococci? Gram-negative diplococci? Gram-negative coccobacillary organisms? Gram-positive bacilli?
Gram-positive diplococci = Pneumococcus Gram-negative diplococci = Neisseria Gram-negative coccobacillary organisms = Haemophilus Gram-positive bacilli = Listeria
What CSF glucose level is consistent with bacterial meningitis?
When it’s
In whom does cryptococcus infect?
HIV-patients with
Best initial test for cryptococcus? Most accurate?
Initial: India Ink Accurate: Cryptococcal antigen
Best initial therapy for cryptococcus?
Amphotericin and 5-flucytosine - Add fluconazole if CD4 doesn’t rise
Tx of Lyme?
IV ceftriaxone or penicillin
Describe Rocky Mountain Spotted Fever. What is the tx?
Starts on wrists -Fever, HA and malaise *precede* the rash Tx: Doxycycline
How does TB meningitis present?
Like bacterial, but much slower. If sxs come on over hours, it’s not TB
Tx of TB meningitis?
RIPE + Steroids
Unique CSF finding in TB meningitis?
Very high protein level
How does Neisseria meningits present? What should you always do to patients with Neisseria meningitis?
Adolesecent w/petechial rash and high neutrophils on CSF Place them in *respiratory isolation* *Prophylaxis for close contacts* with rifampin, cipro, or ceftriaxone
How does listeria meningitis present? Tx?
Elderly and neonatal and HIV patients Pts with no spleen Pts on steroids Immunocompromised *Add ampicillin to therapy!*
Fever + confusion = ___
encephalitis
Almost all encephalitis in the US is caused by ___
Herpes
How to diagnose encephalitis?
Head CT first PCR of CSF 2nd (most accurate)
Best tx for herpes encephalitis?
Acyclovir Foscarnet if resistant to acyclovir
How does acyclovir work?
Inhibits tyrosine kinase
How does a brain abscess present?
Fever, HA, focal neuro deficits CT shows a *contrast-enhancing* ring
How to manage an abscess in an HIV-negative pt?
Brain biopsy
How to manage an abscess in an HIV patient?
Treat for toxoplasmosis: *Pyrimethamine and sulfadiazine for 2 weeks and repeat CT*
What is PML?
Progressive Multifocal Leukoencephalopathy -In HIV pts -No ring enhancement -Tx is just to raise CD4 with HIV drugs
Presentation of neurocysticercosis:
Pt from Mexico with a seizure
What does head CT show in neurocysticercosis?
Multiple 1 cm cystic lesions Over time they will calcify
Tx of neurocysticercosis?
Albendazole if not yet calcified Anti-epileptic drugs if calcified
Who should receive stress ulcer prophylaxis? What do they get?
Give PPIs to pts with: -Head trauma -Burns -Endotracheal intubation with mechanical ventilation
Sxs of subarachnoid hemorrhage?
Thunderclap Stiff neck Photophobia LOC in 50% of pts Focal neuro deficits
How to diagnose a SAH?
Head CT If inconclusive, do LP
How to know if an increased WBC count in the CSF is from infection or just from blood?
Ratio of WBC:RBCs *1:500 is normal* *>1:500 signals infection*
Tx of SAH?
- Angiography to determine site of bleeding 2. Embolize bleeding site (superior to clipping) 3. Nimodipine to prevent stroke from vasospasm
What’s the pathophysiology, causes, sxs, dx, and tx of syringomyelia?
Pathophys: Defective fluid cavity in the center of the cord Causes: Trauma, tumors, congenital problem Sxs: Capelike loss of pain/temp sensation and down UEs Dx: MRI Tx: Surgically
Can cord compression from metastatic tumors cause pain and tenderness in the spine?
Yes
How does a spinal epidural abscess present?
Back pain + tenderness + fever
Tx of spinal epidural abscess?
Oxacillin/nafcillin
When is pain the worst with spinal stenosis?
LE pain when walking downhill
Dx and tx of spinal stenosis?
Dx: MRI Tx: Surgical decompression
Describe Brown-Seguard syndrome:
Loss of: -Ipsilateral motor fxn -Contralateral pain and temperature sense
Most urgent step in management of cord compression?
Steroids to relieve pressure on the cord
When is the diagnosis of cord compression clear?
Back pain + tenderness + hyperreflexia of the legs
Signs of ALS:
UMN: Hyperrflexia, Weakness, Spasticity LMN: Muscle wasting, fasciculations
Tx of ALS and how does it work?
Riluzole Blocks accumulation of glutamate
Radial nerve palsy results in ____
Wrist drop
Peroneal nerve palsy results in ____
Foot drop Loss of foot eversion
What can cause peroneal nerve palsy?
High boots pressing at the back of the knee
Sxs of Bell’s Palsy:
Hemifacial paralysis Loss of taste on anterior 2/3rd of tongue (CN VII) Hyperacusis d/t loss of stapedius control (the shock absorber)
Tx of Bell’s?
Steroids
What is reflex sympathetic dystrophy also known as?
Chronic regional pain syndrome
In whom does reflex sympathetic dystrophy (Chronic regional pain syndrome) effect?
Pts with previous injury to the extremity
Sxs of Chronic regional pain syndrome:
Extreme pain of burning quality upon light touch
Tx of chronic regional pain syndrome?
NSAIDs Gabapentin Occasionally nerve block
Tx of RLS?
Pramipexole or ropinirole (dopamine agonists)
Best initial test for myasthenia?
Anti-acetylcholine receptor antibodies
Best initial tx of myasthenia?
Pyridostigmine or neostigmine
What to do for myasthenic pts if initial meds don’t work?
Thymectomy (if pt is
What to do if thymectomy doesn’t work for myasthenic pts?
Prednisone
Sxs of myasthenia?
Weakness in muscles of mastication (can’t finish meals) Blurry vision Diplopia Ptosis
What can be used for myasthenia in order to keep patients off of long-term steroids?
Azathioprine and cyclosporine
How do cyclosporine and azathioprine work?
Inhibit the immune system by altering T-cells so they can’t function as well
