NCC Boards Flashcards
Narrowest part of CSF system?
Aqueduct of Sylvius
Cerebral Aqueduct (same thing)
Where are a line and ICP measured/calibrated?
Interventricular foramen of Monro
What creates and absorbs CSF?
Creates: choroid
Absorbs: arachnoids
Goal ICP to improve outcomes and what ICP worse outcomes?
Goal: <20 mmHg
Worse: >20
Brain trauma foundation treatment threshold for ICP?
> 22
Goal osmolar gap for ICP?
<20
CPP equation and goal?
MAP - ICP
Goal 50-70 mmHg
Mannitol dose for elevated ICP?
1 mg/kg
P1
Pressure through choroid plexus into ventricles
P2
Arterial pulse through parenchyma
P3
Closure of aortic valve (dicrotic notch)
P2 > P1
Reduced brain compliance
Impending herniation
Lundberg A Waves
Pathologic
Increased ICP for 5-10 minutes
“Plateau waves”
Reduced compliance
May indicated impending herniation
ICP can rise as high as 50-100 mmHg
Lundberg B Waves
Increase in ICP 0.5 - 2 x/min
Usually don’t exceed 30 mmHg
Indicator of poor compliance
Normal, ventilated, asleep
Steroid dose for brain mets (usually found at grey-white junction)
10 mg IV decadron then 4 mg IV q6h for acute event
what mimics tetanus?
Strychnine poisoning - check thin-layer chromatography on gastric aspirate and urine sample
Orthopnea definition and dx
SOB laying flat
Heart failure
Cheyne-Stokes definition and dx
Cyclic breathing pattern with apnea -> gradual increase in respiratory frequency and tidal volume -> gradual decline -> apnea
Heart Failure
Hyperpnea definition and dx
Increased depth and rate of breathing linked to increased oxygen demand or metabolic activity and ABG will be normal (versus hyperventilation doesn’t have increased oxygen demand or metabolic activity and will have decreased CO2).
Agonal breathing definition and dx
Irregular, gasping or labored breathing
Anoxic brain injury
Kussmaul respirations definition and dx
Deep, rapid and difficult breathing
Metabolic acidosis, uremia, toxic ingestions (etoh and salicylates)
Apneuristic breathing definition and dx
Prolonged, gasping inhalations then extremely short and inadequate exhalations
Upper pons injury (CVA, trauma) - signifies severe injury and poor outcome, temporary induction can happen with ketamine
Biot respiration definition and dx
Deep breaths interspersed with apnea -> increasing irregularity -> ataxic breathing
Damage to pons (CVA, trauma, uncal herniation), occ opiate intoxication
ALS
Upper and lower motor neuron, pyramidal Betz cells in motor cortex, anterior horn cells of spinal cord (retrograde axonal loss) and lower cranial motor nuclei of brainstem, gliosis replaces lost neurons, bunina bodies, sx: hand weakness, shoulder girdle weakness and foot drop; frontotemporal dementia, pseudobulbar palsy, autonomic symptoms, spectrum
Central neurogenic hyperventilation definition and dx
Persistent hyperventilation
Head trauma, brain hypoxia, or inadequate cerebral perfusion due to midbrain or upper pons
Lower motor neuro findings
Muscle atrophy and fasciculations, weakness
Central neurogenic hypoventilation definition and dx
Persistent hypoventilation
Medullary respiratory centers don’t respond appropriately to stimuli (head trauma, cerebral hypoxia and narcotic suppression)
Ondine’s curse
Hypoventilation due to impaired autonomic ventilation control while maintaining normal voluntarily breathing (forget to breathe while asleep, but ok when awake)
Congenital central hypoventilation syndrome, brainstem tumors or infarcts, and surgical manipulation of 2nd cervical vertebrae for intractable pain
Upper motor neuro findings
Hyperreflexia, poor dexterity, incoordination and spasticity, bulbar: dysarthria and dysphagia
Pick’s Disease
Frontotemporal dementia
Pseudobulbar palsy
Inappropriate periods of crying, laughing, or yawning from involvement of the frontopontine motor neurons
H/O OLT with multiple ring enhancing lesions, crescent-shaped with red staining nuclei organism and treatment
Toxoplasma Tachyzoites
Tx: pyrimethamine and sulfadiazine + corticosteroids for mass effect, leucovorin to reduce hematologic side effects of treatment, 6 weeks
Treatment of cryptococcal meningitis
Flucytosine and amphoteracin
Treatment of cytomegalovirus encephalitis
Antivirals
Immunocompromised HIV patient with ataxic gait, dysdiadochokinesia and dysmetria, MRI T2 hyperintense noncontrast enhancing lesion in right cerebellar peduncle and subcortical regions etiology and treatment.
Progressive Multifocal Leukoencephalopathy from papovavirus (BK, JC, SV40 strains)
Tx: reverse immunocompromised state
Conduction aphasia localization
Information can’t travel from Wernicke’s area to Broca’s area
Posterior aspect of left superior temporal gyrus, left supramarginal gyrus and underlying white matter (including arcuate fasciculus)
Brocas aphasia localization
Broca’s area
Left inferior frontal gyrus
Inability to name unique entities (ex: famous people) location
Left temporal pole
Transcortical motor aphasia localization
Left cingulum bundle
Neck pain, headaches and TIA symptoms name and etiology
Horner syndrome
Right ICA dissection > vertebral artery dissection
Causes of bacterial meningitis by age: 17-59 and >60
Neisseria meningitis
Strep pneumo
4th ventricle lesion with hydrocephalus, increased cell density in papillary fronds without nuclear pleomorphism and necrosis lesion
Choroid plexus papilloma
Meningioma: imaging, commonality, pathology, mutation, path and treatment
Homogenous enhancing, dural based
Infra or supratentorial, can be bifrontal, can be all over
MC primary tumor in adult, women > men,
Arachnoid cells, can be in NF2, Cowden and Gorlin syndrome
22q12
“whorl” of meningothelial cells, “psammoma bodies”
Tx: surgery > radiation (atypical, anaplastic, recurrent, surgically inaccessible), VEGF inhibitors
Glioma: imaging location, pathology, characteristics that portend better prognosis, treatment
Infra or supratentorial, can be bifrontal, can be mutliple
Astrocytes and/or oligodendrocytes, higher grade (GBM): atypia, hypercellular, increased mitotic rate/vascularity/necrosis
IDH-mutant type (vs. IDH-wildtype), MGMT promotion methylation, younger, lower grade = better prognosis than
Tx: surgery, radiation, temozolomide
CNS Lymphoma: imaging, epidemiology, symptoms, other tests, treatment
Wide imaging, diffusion weighted imaging, patchy on post contrast MRI
Increases with age, immunocompromised and immunocompetent
Neurocognitive/neuropsychiatric symptoms possible
Biopsy (large B cell = 90%), LP, optho slit lamp, PET scan, testicular US, bone marrow bx, steroids can obscure diagnosis (lymphotoxic)
Treatment: methotrexate, chemo + autologous stem-cell transplant
Metastatic brain tumors: location, prevalence, MC tumors, location, treatment, better prognosis, risk of recurrence after surgery
Isolation or with multiple lesions
10x’s more common than primary
MC: breast, lung and melanoma (can be any)
Grey-white junction
Treatment: surgery (dominant symptomatic lesion, up to 3 lesions), radiation (whole brain if multiple lesions), steroids (edema), chemo (CNS penetration: methotrexate, thiotepa, cytarabine, temozolamide, vinorelbine, capecitabine, carboplatin, topotecan), immunotherapy, AED (non-enzyme inducing: levetiracetam, lacosamide, zonisamide)
Better: younger, good functional status, solitary lesion
50-60% risk of local recurrence post-resection
Spinal cord tumors: intradural-extramedullary, intradural-intramedullary and extradural types
Intradural-extramedullary: meningioma, nerve sheath tumor
Intradural-intramedullary: ependymoma, astrocytoma
Extradural: metastasis, chordoma, ewing sarcoma/osteosarcoma, lymphoma
Benign spinal cord tumors
Meningiomas, nerve sheath tumors (schwannoma, neurofibroma, ganglioneuroma)
Malignant spinal cord tumors
Gliomas
Benign spinal column tumors
Hemangioma, osteoid osteoma, osteoblastoma
Malignant spinal column tumors
Chordoma, chondrosarcoma, Ewings sarcoma, lymphoma, metastasis (MC in adults), plasma cell neoplasms
Management of spinal cord tumors
Are there neurologic deficits for surgery?
Is the tumor sensitive to radiation or chemo?
Radiosensitive mets: lymphoma, myeloma, small cell lung cancer, germ cell, prostate and breast;
Radioresistant mets: melanoma, RCC, NSCLC, GI cancer, sarcoma;
Carcinomatous Meningitis
Imaging (Dural enhancement, enhancement of meninges, enhancement around brain stem) or LP
CN or radicular nerve deficits
CSF poor sensitivity (3 taps required), MRI brain + c/t/l spine: linear enhancing deposits in cerebellar folia, cortical sulci or cranial nerves; nodular enhancement of the cauda equina or coating of the spinal cord
Whole brain XRT or craniospinal XRT, systemic chemo with CNS penetration (EGFR TK inhibitors), intrathecal chemo (methotrexate, thitepa, cyterabine), palliative shunt placement (if obstructive hydrocephalus)
Paraneoplastic syndromes: ab location, panel location, number of techniques to dx, treatment
Antibodies to cell surface or synaptic antigen or intracellular antigens
Serum and CSF antibody panel - check panel before starting treatment (can be false neg or pos)
Confirm ab positivity with two separate assay techniques
Serial testing not useful
Negative ab test does not exclude a paraneoplastic neurologic disorder
Identify and treat any underlying cancer
Methylprednisolone 1 gm daily x 5 days then taper
IVIG or PLEX > Rituximab and/or cyclophosphamide
Acute complications of radiation therapy: timing, symptoms, treatment, mechanism and prognosis
Days to weeks: AMS, fatigue, worsening preexisting neurologic deficits
Tx: steroids
Potential mechanisms: cerebral edema, neuroinflammation, vascular toxicity, transient blood-brain barrier disruption
Prognosis: sx generally resolve with steroids
Early-delayed complications of radiation therapy: timing, symptoms, mechanism
Weeks to 6 months: cognitive symptoms, fatigue, headache, nausea and lethargy
Mechanism: transient demyelination
Late-delayed complications of radiation therapy:
Months to years: cognitive decline, possible focal findings
Imaging and path: leukoencephalopathy, tissue necrosis (can mimic tumor recurrence), brain volume loss, secondary tumors, vasculopathy (can cause ischemia or hemorrhage)
Mechanism: direct cytotoxic effects on various neural cells and their progenitors, chronic inflammation and neurovascular injury
Treatment: neurostimulants, shunt
HSV encephalitis population and treatment
Think about in patients with cancer undergoing whole brain radiation
Tx: acyclovir
Complications of chemotherapy: CNS
Acute (reversible) encephalopathy, subacute encephalopathy, chronic encephalopathy, reversible posterior (leuko)encephalopathy syndrome (PRES), multifocal leukoencephalopathy, thrombotic microangiopathy, cerebral infarcts, cortical blindness, optic neuropathy, visual disturbances, psedotumor cerebri, cerebral venous thrombosis, cerebellar dysfunction, seizures, aseptic meningitis
Complications of chemotherapy: PNS
Platinum compounds: cisplatin, oxaloplatin
Vinca alkaloids: vincristine, vinblastine, vindesine
Taxanes: paclitaxel, docetaxel
Bortezomib
Thalidomide
Suramin
CAR-T (tisagenlecleucel, axicabtagene, ciloleucel and brexucabtagene autoleucel) for leukemia and lymphoma CNS effects
Cytokine release syndrome and neurotoxicity
Immune effector cell-mediated neurotoxicity syndrome, ICANS
3-10 days after administration
Encephalopathy, behavior changes, headaches, tremor, seizures, coma
Cerebral edema
Steroids and supportive care
Tocilizumab: improves cytokine release syndrome but won’t impact neurotoxicity
Which patients with cancer and neurologic symptoms should get steroids?
ALL unless CNS lymphoma is on the differential
Data on phenytoin in SAH for seizure prophylaxis
Links between phenytoin and poor neurologic outcome
No change in rates of seizures, increased complications
What reduces neurologic symptoms associated with vasospasm and improves neurologic outcome after aneurysmal SAH? What is it’s effect on incidence of vasospasm?
Nimodipine (less stroke and poor neurologic outcome)
No decrease in incidence
Which part of triple H therapy increases cerebral blood flow after SAH?
Euvolemic hypertension
Elevated mean velocities versus global elevation with normal Lindegaard ratio meaning
Elevation in mean velocities can be a sign of cerebral vasospasm, however, if a global elevation with a normal Lindegaard ratio is more likely due to cerebral hyperperfusion
EEG findings with cerebral vasospasm after SAH
Decrease in alpha-delta variability
Periodic discharges = worse overall outcome
Acute severe headache, normal neurologic exam
Parimesencephalic SAH (PMSAH)
10% of all SAH
Hemorrhage anterior to midbrain or pons, no extension around brainstem, into supracellar cistern or proximal Sylvian fissure
DSA unlikely to show aneurysm
Good outcome, few complications
Confusion, seizures, hypertension
Posterior reversible encephalopathy syndrome
Hypotension, hyponatremia, increased urine sodium, increased urine output, and low cvp treatment
Cerebral Salt Wasting
Fluid bolus (1st line)
Can use fludricortisone and salt tabs
Normal to hypertensive, hyponatremia, low urine output, increased urine sodium treatment
Free water restriction (1st line)
Salt tabs
Can use tolvaptam (vasopressor receptor antagonists)
How does magnesium inhibit smooth muscle contractions?
Binds to voltage-dependent calcium channels to inhibit smooth muscle contraction
May also inhibit glutamate release
Milrinone mechanisms
Phosphodiesterase III inhibitor
Vasodilation and inotropic properties
Weak data shows some improvement in vasospasm
Intraventricular nimodipine
Reduced delayed cerebral ischemia
Rescue therapy
Hypothermia in delayed cerebral ischemia
Limited data
Decreases cerebral blood flow
Improves outcomes in high grade SAH (limited data)
Diagnosis
Vertebral artery aneurysm
Diagnosis
Anterior spinal artery aneurysm
Diagnosis
Posterior Inferior Cerebellar Artery Aneurysm (PICA)
Contralateral loss of pain and temp body, ipsilateral loss of pain and temp face, ipsilateral horners, ataxia, hearing loss and facial droop stroke - vessel?
AICA stroke
Lateral pons
Contralateral loss of pain and temp body, ipsilateral loss of pain and temp face, ipsilateral horners, ataxia, dysphagia, hoarseness, decreased gag stroke - vessel?
PICA stroke
Lateral medulla
Contralateral motor deficit, tongue deviation stroke - vessel?
Anterior spinal artery
Medial Medulla
Vertigo, nausea, vomiting, ipsilateral facial numbness, horners syndrome, dysphagia and ataxia stroke vessel
Lateral medullary or Wallenberg syndrome, superior cerebellar artery syndrome
Inferior posterior cerebellar hemisphere, inferior vermis, lateral medulla
PICA
Ipsilateral limb ataxia, vertigo, nystagmus, dsyarthria stroke vessel
Superior cerebellar artery syndrome
Dorsolateral upper brainstem and cerebellar and superior cerebellar peduncle
SCA
Ipsilateral ataxia, hearing loss, Horner’s syndrome, contralateral decreased temp and pinprick stroke vessel
Lateral pontine syndrome
Ipsilateral labrynth, lateral potine tegmentum
AICA
Somnolence, convergent nystagmus, skew deviation, vertical gaze paralysis, some components of proximal basilar/PCA stroke vessel
Top of the basilar syndrome
Midbrain, thalamus and mesial temporal lobes and occipital lobes
Top of basilar artery
Ipsilateral loss of facial sensation, ipsilateral ataxia stroke vessels
Lateral mid-pontine syndrome: Lateral and medial pontine perforators from mid-basilar artery
Ipsilateral ataxia, contralateral weakness, “wrong way” gaze deviation (pons ponders paresis)
Medial mid-pontine syndrome: Lateral and medial pontine perforators from mid-basilar artery
Quadriplegia, horizontal gaze paralysis, bifacial paralysis
May have preservation of vertical eye movements
Locked-in syndrome - bilateral lower pons from proximal basilar artery
Contralateral arm and leg weakness, ipsilateral tongue paralysis
Medial medullary or Dejerine syndrome
Medulla and cervical spinal cord
VA
Arteries for these three
PICA / AICA / SCA
Posterior cerebral vascular territories
Clinical features by vascular territory
Imaging features by vascular territory
EEG Findings in DCI in SAH
Earliest sign: loss of fast frequency (ex: alpha)
Alpha-delta ratio and alpha variability predict onset of vasospasm (up to 3 days before vasospasm)
Alpha/delta ratio: ischemia tends to reduce alpha frequencies and increase delta frequencies - Reductions in alpha/delta ratio suggest vasospasm, especially if reduction occurs focally in one hemisphere.
Relative alpha variability: Measurement of the normal fluctuation in alpha-activity over time. Decreased relative alpha variability may be a reflection of delayed cerebral ischemia.
(2) Worsening focal slowing or late-appearing epileptiform abnormalities (e.g., epileptiform discharges, periodic/rhythmic activity) may predict delayed cerebral ischemia
Management of delayed cerebral ischemia
Treat hypovolemia and hypomagnesemia
MAP therapy (85) - levo or neo may be needed - brain lacks alpha-1 receptors
Lower opening pressure of EVD
IR for intra-arterial vasodilator and/or angioplasty
Intrathecal nicardipine for refractory vasospasm, systemic milrinone (MILRISPASM - improved functional outomes, Montreal Neurologic Hospital protocol)
CRASH trial
High-dose methylprednisolone over 48-hours within 8 hours of TBI
Higher mortality at 2 weeks and 6 months
CLEAR III Trial
Intraventricular TPA safe in IVH but no clinical benefit
Goal PbtO2 in TBI (with goal ICP and CPP)
> 25 mmHg with ICP < 22 mm Hg and CPP 60 - 70 mm Hg
IMPACT versus CRASH Head Injury Prognostic Models
Risk factors for post traumatic seizures
GCS 10 or lower initially
Immediate seizures
Post traumatic amnesia lasting longer than 30 minutes
Linear or depressed skull fracture
Penetrating head injury
Subdural, epidural or intracerebral hematoma
Cortical contusion
Age 65 or younger
Chronic alcoholism
Data on hypothermia in TBI
Not recommended for adults with diffuse injury
Peds without improvement in function, worse mortality
Burr hole with drain placement in chronic subdural: effect on recurrence and 6 month mortality?
Decreased risk of recurrence
Decreased 6-month mortality
Presence of sacral sparing (versus no sacral sparing) on initial evaluation in SCI?
More likely to make motor recovery with complete motor injury but sensory preservation on initial exam versus no sacral sparing
Who should get a CT venogram in skull based fractures to evaluate for sinus thrombosis?
Fractures extending into transverse, sigmoid or jugular bulb petrous temporal bone (over fractures extending into superior saggital sinus)
Retained fragments in this location increase the risk of seizures after penetrating trauma.
Eloquent cortex
Rare life-threatening side effect of valproic acid?
Pancreatitis
Alcohol withdrawal seizures characteristics and timing
Seizure seizure of flurry of generalized tonic-clonic seizures within first 6-48 hours
Diagnosis: delirium, agitation, tachycardia, hypertension, fever, 2-4 days after admission in alcoholic
Delirium tremens
What is more effective in eclamptic seizures: magnesium, diazepam or phenytoin?
Magnesium
Management of recurrent seizure in eclmepsia after 1st seizure treated with magnesium?
Benzodiazepine
IV midazolam: loading, repeat dose, half-life, side effects/prolonged use
Loading: 0.2 mg/kg
Repeat: 0.2 - 0.4 mg/kg q5 mins until seizure stops
1/2 life: 1.5 - 3.5 hrs
Prolonged use: tachyphylaxis, prolonged half-life
Side effects: sedation, respiratory depression, hypotension
IV Propofol: loading, repeat, contraindications, side effects, labs to monitor
Loading: 1 mg/kg
Repeat: 1-2 mg/kg bolus q5 mins until seizure stops
Contraindications: allergy to soybean oil, egg lecithin or glycerol, caution in combo with carbonic anhydrase inhibitors (ex: zonisamide and topiramate - risk refractory acidosis)
Side effects: sedation, large lipid load, occasional pancreatitis, dose-dependent hypotension, Propofol infusion syndrome (metabolic acidosis, rhabdo, ciculatory collapse -> death)
Monitor: CPK, triglycerides, amylase/lipase, blood gas, lactic acid
IV Pentobarbital: loading, repeat, max bolus rate, half life, side effects, serum level target
Loading: 5 mg/kg
Repeat: 5 mg/kg until seizure stops
Max bolus rate: 20 - 50 mg/min
IV Dose: 1 mg/kg/hr (usual maintenance range: 0.5 - 10 mg/kg/hr)
Half life: 15-60 hrs
Side effects: prolonged coma (days after meds stopped), hypotension, myocardial depression, immune suppression, ileus, allergies (including Steven-Johnsons)
Target levels: ?
Diagnosis and treatment: peripheral edema, blistering, pain and discoloration of extremity after IV phenytoin
Purple glove syndrome
Treatment: may need excision
Young woman with mental disorder and new seizures and worsening hallucinations and dyskinesia EEG findings and diagnosis
Extreme delta brush (background delta slowing with overriding fast beta activity)
NMDA encephalitis
Confusion, agitation and tonic-clonic seizures EEG findings and diagnosis
Temporal lateralized periodic discharges
HSV encephalitis
Memory and behavior changes, coordination difficult, visual disturbances, rapid progression EEG findings and diagnosis
Generalized periodic discharges
Creutzfeldt-Jakob disease
Treatment agent for cryptococcal neoformans meningitis that causes aplastic anemia? What is it’s mechanism?
Flucytosine (bone marrow suppression, pancytopenia, aplastic anemia, agranulocytosis), can also cause UC and bowel perforation
Inhibits RNA and DNA synthesis
Dual treatment agents for cryptococcal neoformans meningitis and their increased toxicities?
Flucytosine and Amphotericin B
Hepatic, renal and hematologic toxicities
What brain lesion has a CT finding of inner hypodense center and outer hyperdense rim? What is the first antibiotic regimen of choice?
Brain abscess
IV ceftriaxone (3rd generation cephalosporin) and flagyl
EEG findings for Grade I - IV of anoxic encephalopathy
I: Alpha
II: Theta
III: Slow delta
IV: low-amplitude delta
Anatomic site for CVA causing deviation of angle of mouth to left and left-sided weakness
Genu of internal capsule has motor fibers and corticobulbar fibers
Basal ganglionic bleeds can compress this area and lead to these symptoms
What does infarct of the facial nucleus cause?
Crossed hemiplegia
What does involvement of the facial nerve at the stylomastoid foramen or terminal branches lead to?
Lower motor pattern of facial nerve palsy without any motor weakness
NMS toxicity meds and treatment
Dopamine-receptor antagonist or rapid withdrawal of dopaminergic meds
Dantrolene, dopamine agonists, benzodiazepines
Fractures where cause purple tympanic membrane discoloration?
Basilar skull fx - petrous ridge of temporal bone
What lab checks for CSF leak?
beta transferrin
Pathology of HSV encephalitis
CSF: lymphocytes, high protein, inc RBCs, normal glucose
perivascular cuffs of lymphocytes with “owl’s eye” intranuclear inclusions, foamy macrophages and areas of hemorrhages
Treatment of HSV encephalitis (dose and duration)
IV acyclovir: 10 mg/kg body weight q8 hrs for 14-21 days
Versus acyclovir, what does valganciclovir treat?
Cytomegalovirus
Diagnosis: progressive memory impairment over 6 months, reduced blinking, rigidity, arm tremors, decreased arm swinging with walking, dementia, liver firmness, palpable splenic tip, MRI with globus pallidus and putamen atrophy?
Wilsons disease
Mutation that causes Wilson’s disease and treatment
ATP7B - copper incorporation into ceruloplasmin
Pencillamine
What is a patient at risk for with immune reconstitution syndrome?
TB meningitis after starting antiretrovirals for HIV with history of TB exposure
Diagnosis of CSF:
Pressure 5-20
Normal appearance
0.18 - 0.45 g/L protein
2.5 - 3.5 mmol/L glucose
Normal gram stain
Glucose - CSF to serum: 0.6
WCC <3
Normal CSF
Diagnosis of CSF:
Pressure >30
Turbid appearance
> 1 g/L protein
> 2.2 mmol/L glucose
Gram stain positive
Glucose - CSF to serum: < 0.4
WCC >500
90% PMN
Bacterial meningitis
Diagnosis of CSF:
Pressure: normal or mild increase (5-20 or min above)
Clear appearance
< 1 g/L protein
2.5 - 3.5 (normal) mmol/L glucose
Gram stain Normal
Glucose - CSF to serum: >0.6
WCC <1000
Monocytes
10% have >90% PMN
30% have >50% PMN
Viral meningitis
Diagnosis of CSF:
Pressure: normal or mild increase (5-20 or min above)
Clear or fibrin web appearance
0.1 - 0.5 g/L protein
1.6-2.5 mmol/L glucose
Gram stain normal
Glucose - CSF to serum: < 0.4
WCC 100 - 500
Monocytes
Fungal meningitis
Diagnosis: CSF slightly increased raised pressure, pleocytosis 25-500 with lymphocytic predominance, decreased glucose (20-40), increased protein, no growth on culture in patient with history of HIV who just started antiretrovirals?
TB meningitis
Diagnosis: hydrophobia or aerophobia (spasm from stimulus), agitation, changes in mentation, autonomic dysfunction, increased DTR, nuchal rigidity, + Babinski sign, tachypnea, tachycardia, fever -> hyperactivity
Rabies from rhabdovirus (peripheral nervous system to central to encephalomyelitis then back to peripheral nerves)
50-70% of meningitis after skull fracture are due to what organism?
Strep pneumoniae
Does prophylactic antibiotics after CSF rhinorrhea decrease the risk of meningitis?
No
Location of CVA causing dysphagia, dysarthria, nystagmus, right-sided horners syndrome, ipsilateral ataxia and loss of gag reflex with contralateral loss of pain and temperature
Posterior inferior cerebellar causing right-sided lateral medullary syndrome - Wallenberg syndrome
9th and 10th cranial nerves, sympathetic and spinocerebellar tract affects
Crossed signs
What causes sudden lower extremity weakness, sensory deficit, episodic hypertension, profuse sweating, CSF with pleocytosis and elevated IgG, with MRI with local cord swellling?
Transverse Myelitis
Idiopathic (60%), other causes: viral infection (Herpes), immune system disorders (neuromyelitis optica) and demyelinating diseases (MS)
MC thoracic region
What kind of paraplegia is copper deficiency and adrenoleukodytrophy associated with?
Spastic paraplegia
What is albuminocytologic dissociation is characteristic of what disorder? What is it?
Guillain-Barre Syndrome
CSF has elevated protein and normal cell count
What guarantees poor functional outcome or death if a patient is not cooled after cardiac arrest?
- Absent pupillary or corneal reflexes on day 3 (but not before)
- Bilateral extensor posturing or absent motor responses on day 3 (but not before)
- Myoclonus status epilepticus within 24 hours
- Serum NSE >33 on days 1-3
- Somatosensory evoked potentials (SSEPs) showing bilaterally absent negative responses 20 ms after stimulation (N20) on days 1-3
Day 1: No brainstem reflexes = :(
Day 1: Myoclonus status epilepticus = :(
Day 1-3: Serum NSE > 33 = :(
Day 3: Absent pupil or corneal reflexes; extensor or absent motor response = :(
Day 1-3: SSEP absent N20 responses = :(
When patients have hypothermia after cardiac arrest, what can NOT be used to provide prognostication?
- Motor examination
- Serum NSE
- Early myoclonus
- Corneal reflexes
- Myoclonus status
When patients have hypothermia after cardiac arrest, what CAN still be used to provide prognostication?
SSEPs once rewarmed
Possibly bilaterally absent N20 on SSEPs, unreactive EEG or combination of early myoclonus and absent pupillary or corneal reflexes
4 aspects of CAM-ICU
- Acute onset and fluctuating course
- Inattention
- Disorganized thinking
- Altered level of consciousness
What can cause neuropsychiatric symptoms in the absence of focal motor deficits?
Acute infarct of the caudate nucleus
An ischemic stroke where can cause receptive aphasia (fluent aphasia) and be misinterpreted as “confusion”?
Dominant left temporal lobe
An ischemic stroke where can present with only altered mental status?
Thalamic lesion (even unilateral)
What should be ordered with MRI if infection or neoplasm is on the differential?
Gadolinium
Visual disturbances, seizures, headaches, altered mentation diagnosis and treatment?
PRES
Treatment: treat hypertension, tx seizures or coma
Stop immunosuppressants if trigger
Mental deterioration, dementia, involuntary myoclonic jerks, anxiety, depression, OCD, psychosis, speech impairment, gait instability, lack of coordination diagnosis and treatment?
Creutzfeldt-Jakob Disease
Cause: prion
Treatment: none
Confusion, seizures, speech difficulties, memory impairment, psychiatric manifestations with high atni-TPO or anti-M antibodies diagnosis and treatment?
SREAT (Steroid-responsive encephalopathy associated with autoimmune thyroiditis)
Treatment: steroids (like all steroid responsive encephalopathies), IvIg and Plasmapheresis
MRI: non enhancing MRI with increased intensity of T2 and fast fluid-attenuated inversion recovery (FLAIR) imaging in the white matter as well as dural enhancement
What’s wrong with the “ICP” tracing?
P2 higher than P1 is a sign of problems with intracranial compliance and risk of elevated ICPs
MRI findings in acute ischemic stroke
Hyperacute (24 hrs) and Acute (24 hours to 1 week)
1. DWI - focal area of restricted diffusion (high signal)
2. ADC - focal area of low intensity
Subacute and chronic
Hyperintense DWI - T2 shine through
ADC - moves from hypointense to hyperintense
Adderall reacts with MAOIs (phenelzine), serotonergic meds (venlafaxine and amitryptiline, opiates, dextromethorphan, buspiron, lituium, LSD) and CyP2D6 inhibitors (bupropion, fluoxetine, paroxetine, terbinafine, methadone, levomepromazine, citalopram, quinidine) how?
MAOI: hypertensive crisis
Serotonergic meds: serotonin syndrome
CyP2D6 inhibitors: serotonin syndrome
Diagnosis and treatment: seizures, behavioral changes with fevers in patient with HIV (CT hypodense with surrounding edema, MRI iso-hypointense on T1 and hypo to hyperintense on T2)
Cerebral toxoplasmosis
Treatment: sulfadizine (1000-1500 mg QID) + pyrimethamine (200 mg loading then 50-75 mg daily) + leucovorin (10-25 mg daily)
Alternative to sulfadiazine = clindamycin (600 mg IV or oral QID) + pyrimethamine (200 mg loading then 50-75 mg QID) + PO leucovorin
Alternative: atovaquone (1500 mg PO BID) + pyrimethamine (200 mg loaind then 50-75 mg daily) + leucovorin (10-25 mg daily)
Drugs or other etiologies that can cause acute ophthalmoplegia, areflexia and ataxia with preceeding bacterial or viral illness? Can involve cranial nerves causing facial oculomotor or bulbar weakness that can extend to limbs, distal hyporeflexia, focal paresis, loss of light and vibratory sense in distal extremities with autonomic dysfunction? What is the diagnosis and treatment?
Heroine, suramin, streptokinase, isotretinoin, TNF-alpha antagonists (ex: adalimumab), autoimmune diseases (ex: RA)
Miller-Fisher Syndrome (variant of GBS)
Treatment: IvIg, plasmapheresis
Corticosteroids are not effective
What tau level is diagnostic of CJD?
1150 pg/mL
Source of ischemic stroke in patients with hereditary hemorrhagic telangiectasia with bubble study positive after 3 cardiac cycles? What if less than 3 cycles?
At least 3 cycles: DVT through pulmonary AV malformation
Before 3 cycles: DVT through PFO
Where does dexmedetomidine bind?
Alpha-2 receptors
What drug do the following conditions and drugs make people more resistant to?
- CP, burn injuries, hemiplegia, peripheral nerve injuries, chronic infections of botulism and tetanus
- Anticonvulsants: valproic acid and carbamazepine, anticholinesterase inhibitors: neostigmine and pyridostigmine
Nondepolarizing neuromuscular blockers (ex: rocuronium, pancuronium, vecuronium, atricurium)
Complication after LP causing cauda equina syndrome? Treatment?
Epidural hematoma
Surgical decompression within 48 hours
Corticospinal tract injury causes what?
Spastic paresis below injury
Spinothalamic tract injury causes what?
Loss of temp and pain contralaterally
Interruption of a sympathetic pathway in Brown-Sequard syndrome can cause what? (Ex: posterior stab wound to neck with hemitransection of cord)
Horners syndrome (ptosis, miosis and anhydrosis)
Which arteries supply the nucleus responsible for vestibuloocular reflex (doll’s eyes)?
Anterior inferior cerebellar artery and posterior inferior cerebellar artery supply the vestibular nucleus in brainstem
Vestibulo-ocular reflex: moving head to left -> otoliths in semicircular canal of ear -> L vestibular N to vestibular nucleus -> activate contralateral nerve of eye: oculomotor, abducent and trochlear)
What positioning do you put patients with pneumocephalus in?
30 degree Fowler position
Which antibiotic can lead to neuromuscular blockade with impaired ventilation, acute respiratory failure, seizures, coma and death especially when administered with concomitant neuromuscular blocking agents? Treatment?
Gentamycin
Treatment: calcium
Treatment of rhinoorbital cerebral mucormyocosis
Amphotericin B and surgical debridement (and reverse immunosuppressed state)
What causes man in a barrel syndrome?
Watershed infarcts of zones between anterior and middle cerebral artery distributions
Cause of internuclear ophthalmoplegia?
Lesion in the medial longitudinal fasciculus (CN III and VI)
Cause of ipsilateral fixed and dilated pupil?
Edinger-Westphal nucleus lesion(parasympathetic efferent of the eye)
Cause of down and out gaze, ptosis and absent light reflex?
CN III lesion
Cause of palsy of the superior oblique muscle of the eye
Trochlear nerve lesion
What is the frequency of the breach rhythm?
6-11 Hz mixed with waves of higher and lower frequencies, including beta, mu or theta activity
Can be high amplitude spiky or sharply contoured activity similar to epileptiform activity, pure breach rhythms do not have an after-going slow wave and doesn’t spread to rest of brain
Sleep recordings can differentiate between breach rhythm and epileptiform activity (breach can affect both sleep and wake sleep rhythms)
Causes of hyperdensities in dentate nucleus of cerebellum
INH
Flagyl
Metabolic disorders: maple syrup urine disease, canavan’s disease, glutaric-aciduria-type-1
Transfuse for eptifibatide bleeding?
DDAVP
Cryo
What happens when merrem and valproic acid are taken together?
Decreased valproic serum concentrations
what can be used to temporize an aneurysm in SAH until it can be clipped?
TXA or amicar
Limit risk of rebleeding
What medication for intubation causes fatal side effects in the neuro ICU?
Succinylcholine - fatal hyperkalemia in patients with neuromuscular disorders, prolonged immobilization or issues with spinal cord
Short acting, depolarizing paralytic
Fever, thrombocytopenia, microangiopathic hemolytic anemia (shistocytes), neurologic symptoms and renal insufficiency diagnosis and treatment
TTP
Plasma exchange until platelet count normalizes
Refractory cases: rituximab
Dysautonomia with CSF with albuminocytologic dissocation diagnosis and treatment?
Guillain Barre Syndrome
Plasma exchange, IvIg
Diagnosis of neurologic changes with Horner’s syndrome during CEA
Carotid dissection
What reflex can you skip during the brain death exam and still declare the patient brain dead?
Oculocephalic reflex IF oculovestibular reflex is absent
Treatment of nonthyroidal illness?
Continue current care
Treatment of sinking flap syndrome
Clamp VP shunt
Trendelenburg position
Hydration
Stop hyperosmolar therapy
Need to raise ICP to counteract external atmospheric pressure and herniation
Treatment of CAR T-cell therapy neurotoxicity
High-dose glucocorticoids (dexamethasone)
Can add acetazolamide to reduce elevated ICP (or other methods to reduce ICP) and control cerebral edema
Signs of recovery despite post anoxic myoclonus on EEG?
EEG reactivity
Time-locked midline-maximal spines over a continuous background
Thunderclap headaches with or without other symptoms with segmental constriction of cerebral arteries? Diagnosis and time to resolution? What can they have? Treatment?
Reversible Cerebral Vasoconstriction syndrome (aka: postpartum angiopathy, migrainous vasospasm, drug-induced crebral vasculopathy or benign angiopaty of the central nervous system)
Resolves in 3 months
Associations: Unruptured aneurysms and convexity/sulcal SAH
Treatment: calcium channel blockers (resolves)
Mirgrains with aura, relapsing TIAs and ischemic strokes with subcortical infarcts, psychiatric symptoms, gradual cognitive impairment to severe dementia with leukoencephalopathy diagnosis? Most common cause of what? Gene involved?
Cerebral Autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
MC cause of stroke in adults younger than 65
NOTCH3 gene on chromosome 19
Ischemic strokes and hemorrhagic strokes, seizures, headaches and cognitive impairment diagnosis and vessels involved and treatment?
Moyamoya disease (disease = bilateral, syndrome = can be unilateral)
Terminal portion of ICA and associated abnormal vascular network at base of the brain
Treatment: ASA (prevent stroke but no evidence this helps), surgical revascularization
How does ketamine raise BP?
Antagonist of NMDA receptor (avoid in patients that have uncontrolled hypertension)
Drowsiness, encephalopathy, ocular changes, and renal failure with severe anion-gap metabolic acidosis diagnosis and etiology of toxicity? Antidote and treatment if evidence of end organ damage?
Methanol toxicity
Methanol metabolized into formaldehyde to formic acid and formate causes elevated anion gap with neurologic, renal and ocular toxicity
Fomepizol (works for ethylene glycol also)
End-organ damage = add HD
What is contraindicated in TTP?
Platelet transfusion - increases risk of arterial thrombosis and mortality
TTP versus ITP
Cause
ITP is an autoimmune disorder that occurs when the body produces antibodies that destroy platelets. TTP is caused by a deficiency in the enzyme ADAMTS13, which controls blood clotting.
Treatment
Corticosteroids and rituximab can be used to treat both ITP and TTP, but plasma exchange therapy (PEX) is the first-line treatment for TTP, while corticosteroids are the first-line treatment for ITP.
Size cut off for observing post-catheter femoral pseudoaneurysms intervention? 1st line treatment? Treatment if complicated?
> 3 cm or growing on serial imaging (q1-2 weeks)
Treatment: US guided thrombin injection
Treatment if complicated (hemodynamic instability, expanding hematoma, neurovascular deficit, localized cellulitis or severe pain): open surgical repair
What does amantadine do in TBI?
Improves rates of recovery in vegetative or minimally conscious states
The 2012 study “Placebo-controlled trial of amantadine for severe traumatic brain injury” concluded that amantadine increases the rate of recovery after severe TBI in patients in a vegetative or minimally conscious state. The 2018 Guidelines on Disorders of Consciousness recommend amantadine 100-200 mg bid started 4-16 weeks post-injury. Some early observational studies showed improvement in Disability Rating Scale in patients treated with amantadine, but significant improvement in final functional outcome has yet to be confirmed in a randomized controlled trial.
Rescue ICP and DECRA takehome
Rescue ICP and DECRA demonstrated that early surgical intervention did not improve outcomes or mortality, though ICP was controlled. The better approach was to use the medical management of ICP for as long as possible (randomized to early (less than 72 hours) versus late (greater than 72 hours)). Once ICP’s became refractory to conservative medical management, a large frontotemporal decompressive craniectomy was recommended both for ICP control and improvement of outcomes.
Level IIA–to improve mortality and overall outcomes
1. NEW–Secondary DC performed for late refractory ICP elevation is recommended to improve mortality and favorable outcomes.
2. NEW–Secondary DC performed for early refractory ICP elevation is not recommended to improve mortality and favorable outcomes†.
3. A large frontotemporoparietal DC (not less than 12 × 15 cm or 15 cm in diameter) is recommended over a small frontotemporoparietal DC for reduced mortality and improved neurological outcomes in patients with severe TBI.
SMART trial takehome
The SMART trial demonstrated improved outcomes in the general ICU population when treated with a balanced solution compared with NaCl 0.9%.
Locked-in syndrome injury location, cause, characteristics?
The locked-in syndrome is caused by an insult to the ventral pons, most commonly an infarct, hemorrhage, or trauma. The characteristics of the syndrome are quadriplegia and anarthria with preservation of consciousness. Patients retain vertical eye movement and upper eyelid function, facilitating non-verbal communication.
Data on ICP and PbtO2?
More studies are needed to fully evaluate the safety as well as efficacy of treatment-directed protocols based on both ICP and PbtO2 as compared to ICP monitoring and treatment alone.
SUP-ICU and PEPTIC trial takehome
The SUP-ICU Trial is a multi-national, randomized trial comparing pantoprazole vs placebo in critically ill patients in the ICU. The trial concluded that among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo.
The PEPTIC trial investigated the comparative efficacy of pantoprazole versus H2 blockers in mechanically ventilated critically ill patients and did not find a significant difference in any of the outcomes studied.
Data on BP management post-thrombectomy for acute ischemic stroke with large vessel occlusion
Neither AHA/ASA and NCS have any statements or guidelines with definite guidance on the issue of post-thrombectomy blood pressure management. While the optimal BP targets remain uncertain some guidance can be found in emergent thrombectomy trials. In a single-center analysis of 217 patients who underwent thrombectomy, a 10-mmHg increment in maximum SBP during the first 24 hours post-thrombectomy was associated with a lower likelihood of functional independence and a higher likelihood of mortality at 3 months. In the MR CLEAN Trial, higher baseline SBP was associated with a higher risk of symptomatic intracranial hemorrhage, the investigators also found a U-shaped association because both low and high baseline SBP was associated with poor functional outcome. Therefore, in the setting of a successful thrombectomy with TICI 3, it is most reasonable to keep the SBP between 140-160.
Treatment of BP after rtPA
The current 2019 AHA/ASA Acute Ischemic Stroke guideline recommends that BP be <185 mm Hg systolic and <110 mm Hg diastolic before treatment with alteplase and <180/105 mm Hg for the first 24 hours after treatment
Mechanism of clopidogrel
ADP/P2Y12 irreversible inhibitor
Hepatic metabolism to active drug and clearance
Poor metabolizers exist
the Salzburg criteria to diagnose non-convulsive status epilepticus
EEG should demonstrate
(1) more than 25 epileptiform discharges (ED) per 10-second epoch, i.e., >2.5/s
(2) patients with EDs ≤ 2.5/s or rhythmic delta/theta activity (RDT) exceeding 0.5/s
AND at least one of the additional criteria:
(3a) clinical and EEG improvements from antiepileptic drugs (AEDs)
(3b) subtle clinical phenomena
(3c) typical spatiotemporal evolution
Weight loss, cough, lymphadenopathy, joint pain, altered mental status with PRES electrolyte abnormality?
Hypercalcemia (sarcoidosis with PRES)
Diagnosis hyporeninemic hypoaldosertonism with hyperkalemia, metabolic acidosis and acidic urine and cause?
Type 4 RTA can be caused by diabetic nephropathy and medications: heparin and heparin analogs, spironolactone
What antiepileptic can cause pancytopenia rarely?
Levetiracetam
Reversal of warfarin bleeding?
PCC (superior to FFP) and vitamin K
Electrolyte abnormalities in tumor lysis syndrome
HYPOcalcemia
Hyperkalemia, hyperphosphatemia, hyperuricemia
Intervention for this disease?
Moyamoya disease
Endovascular stenting contraindicated - rapid restenosis
Superficial temporal artery bypass to MCA (EC-IC bupass)
PATCH trial
Platelet transfusion in Cerebral Hemorrhage - platelet transfusion inferior to standard care for patients on antiplatelet therapy before ICH
More serious side effects during hospital course
STICH trial
Surgical Trial in Intracerebral Hemorrhage
No benefit in surgical evacuation of ICH, early evacuation worse outcomes
When should cerebellar hemorrhage have intervention?
Neurologic deterioration
Brainstem compression
Hydrocephalus from ventricular obstruction
CLEAR III trial
Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrahge III - RCT, double-blind, placebo-controlled, multiregional trial
IVH + EVD - intraventricular alteplase does not improve functional outcome at the modified Ranking Score (mRS) 3 versus irrigation with saline
Diagnosis and at risk patients for CT with dilated cortical veins, cortical SAH, dense appearing cerebral sinus that becomes an empty delta sign with contrast? What is the treatment?
Cerebral venous thrombosis
Pregnancy
Other risks for venous thrombosis: hematologic, oncologic, autoimmune
Head trauma
Recent intrathecal or spinal procedures
Treatment: anticoagulation (heparin gtt)
Diagnosis, affected nerves and treatment?
Carotid-cavernous fistula causing chemosis (fluid-buildup)
CN III and IV -> opthalmoplegia
Treatment: endovascular occlusion of fistula
CADISS trial
Cervical Artery Dissection in stroke Study
Randomized, end-point blinded study
No different in efficacy of antiplatelet and anticoagulant drugs in preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection
Coumadin contraindicated in pregnancya
Dabigatran reversal
Idrucizumab
Seizure prophylaxis in stoke patients?
No data
Thunderclap headache diagnosis? Other names? Associations? Progression? Complications?
Reversible cerebral vasoconstriction syndrome
Pseudovasculitis
Associated with drugs, pregnancy and other headache types
Self-limited, may be complicated by seizures or cerebral ischemia
Interventions for spinal cord infarction?
Placement of lumbar drain - reduces intrathecal pressure and allows for increased spinal cord perfusion
DO not lower MAP
Use distal bypass during surgery to restore cord perfusion in segments disrupted by grafting
