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Rosh Review > Nervous System Disorders > Flashcards

Nervous System Disorders Flashcards

1
Q

Pathophysiology of isoniazid toxicity

A

Overdose causes pyridoxine (vit B6) and GABA deficiency

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2
Q

Clinical scenario of isoniazid toxicity

A

Seizures usually start 30-120 minutes after severe isoniazid ingestion
Less severe ingestions present as AMS

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3
Q

Tx for isoniazid toxicity

A

Pyridoxine and benzos (seizures), though pyridoxine only thing that will stop seizures

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4
Q

What are the adverse effects of isoniazid ingestion?

A

Hepatotoxicity and peripheral neuropathy

Altered mental status, status epilepticus

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5
Q

What are Brudzinski’s and Kernig’s signs?

A

Brudzinski - Flexing neck causes hips and knees to flex
Kernig - Resistance and pain with knee extension while hip is flexed at 90 degrees

Brudzinski’s - bend the brain; Kernig’s - extend the knees

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6
Q

Cause of normal-pressure hydrocephalus

A

Most often a build up of CSF due to decreased absorption

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7
Q

Don’t forget to perform this type of exam when working up Bell’s Palsy

A

Ear exam - otitis media, malignant otitis, mastoiditis can all affect CN VII and look for vesicles that could represent Ramsay Hunt syndrome (Zoster)

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8
Q

Isoniazid is a known cause of what systemic autoimmune disorder?

A

Systemic lupus erythematosus

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9
Q

Tx for dystonic reaction

A

Diphenhydramine or benztropine

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10
Q

Cause of extrapyramidal symptoms

A

Blockade of dopamine receptor leads to a relative acetylcholine excess - hence anticholinergics as tx

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11
Q

Types of extrapyramidal symptoms and time of onset

A
  1. Acute dystonia (spasm of tongue, neck, face, and back); hours to days
  2. Akathisia (compulsive, repetitive motions, agitation); hours to days
  3. Parkinsonism (tremor, shuffling gait, drooling, stooped posture, instability); 5-30 days
  4. Tardive dyskinesia (lip smacking, worm-like tongue movements, “fly-catching”); months to years
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12
Q

What is dyschromatopsia?

A

Change in color perception. Can be a symptom of MS

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13
Q

What will LP show in MS?

A

50% of cases will show pleocytosis with increased number of lymphocytes.
85-95% of cases will show oligoclonal bands of IgG

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14
Q

Treatment for MS

A
  • Acute attacks: glucocorticoids
  • Plasma exchange
  • Disease-modifying therapy
  • Possibly hematopoietic stem cell transplantation
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15
Q

Hallmark of encephalitis

A

Abnormal brain function

  • AMS
  • Psychiatric symptoms
  • Emotional lability
  • Ataxia
  • Seizures
  • Lethargy/Coma
  • Sometimes focal neuro changes
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16
Q

Most common viral cause of encephalitis

A

Enterovirus

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17
Q

Anti-N-methyl-D-aspirate receptor autoimmune encephalitis can be the presenting symptom of what tumor?

A

Ovarian teratoma

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18
Q

Clinical manifestations of optic neuritis

A
  • Sudden loss of monocular partial or complete vision
  • Pain with movement of affected eye
  • Optic disk pallor may be seen
  • Afferent pupillary defect
  • Uhthoff phenomenon - transient worsening of vision with increased body temp
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19
Q

Etiologies of optic neuritis

A
  • MS (most common)
  • Infection (lyme, herpes, syphilis)
  • Autoimmune (lupus, neurosarcoidosis)
  • Methanol poisoning
  • B12 deficiency
  • Diabetes
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20
Q

Tx for optic neuritis

A

Corticosteroids (IV)

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21
Q

Most common complication with VP shunts

A

Obstruction - proximal are more common in the first year after placement and 2/2 catheter migration, clot or choroid plexus within the tubing, or tissue debris.
Distal more common 2+ years after placement and include pseudocyst formation in abdomen and disconnection or kinking of the tubing

Infection is second most common

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22
Q

Describe slit ventricle syndrome

A

Q165329

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23
Q

Where is the most common location for a shunt fracture to occur?

A

Just above the clavicle

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24
Q

Peripheral vs. Central vertigo

A

Q312352 table

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25
Q

Clinical presentation of botulism

A

Descending, symmetric, flaccid paralysis (upper>lower)

  • first cranial nerve dysfunction with diplopia, dysphonia, dysphagia, and dysarthria; vertigo also common; decreased salivation -> painful tongue and sore throat
  • weakness in upper and lower extremities and muscles of respiration -> tachypnea and respiratory failure
  • DTRs may be decreased
  • Normal sensory exam
Nonspecific flu-like illness
Postural hypotension
Parasympathetic blockade
- decreased salivation
- GI ileus
- Urinary retention
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26
Q

Clinical presentation of botulism (infants)

A
  • Constipation
  • Weak suck, feeble cry, poor gag reflex, pooled secretions
  • Generalized weakness, hypotonia, loss of head control
  • “Floppy baby”
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27
Q

Causes of botulism

A
  • Infant: ingestion of honey or corn syrup contaminated with spores
  • Food-borne - inadequately preserved or undercooked foods; home canning; ingestion of preformed toxin
  • Wound: iatrogenic or inadvertent from cosmetic or therapeutic injection
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28
Q

Management of botulism

A
  • Contact CDC
  • Supportive care
  • Respiratory monitoring
  • Equine serum heptavalent botulism antitoxin (>1 year old)
  • Human-derived botulism immune globulin (<1 year old)
  • Abx (for wounds)
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29
Q

What is the role of dexamethasone in a child presenting with a high-risk for H. Flu meningitis?

A

Has been shown to decrease hearing loss associated with H. Flu meningitis in children

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30
Q

Exclusion criteria for tPA

A
  • Significant head trauma or prior stroke in previous 3 months
  • Sx suggest SAH
  • Arterial puncture at noncompressible site in previous 7 days
  • History of prior ICH
  • Intracranial neoplasm, AVM, or aneurysm
  • Recent intracranial or intraspinal surgery
  • SBP >185 or DBP >110
  • Active internal bleeding
  • Acute bleeding diathesis
  • Plt <100,000
  • Heparin received within 48 hrs resulting in abnormally elevated aPTT
  • Current use of anticoagulant with INR >1.7 or PT > 15 sec
  • Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated aPTT, INR, or factor Xa assay
  • Glucose <50
  • CT shows multilobar infarction
  • Suspected/confirmed endocarditis

Relative exclusion criteria

  • pregnancy
  • Sz at onset with postictal residual neuro impairments
  • Major surgery or serious trauma within previous 14 days
  • Recent GI or urinary tract hemorrhage (within previous 21 days)
  • Recent MI (within previous 3 months)
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31
Q

What is the rate of intracranial hemorrhage in patients given tPA for acute myocardial infarction?

A

Less than 1%

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32
Q

Presentation of carotid artery dissection

A
  • Severe neck, facial, or retroorbital pain
  • Unilateral headache
  • Pulsatile tinnitus
  • Partial Horner (ptosis, miosis)
  • Contralateral hemiparesis
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33
Q

Tx for carotid artery dissection

A

If signs of acute ischemic stroke -> thrombolytic therapy

If no evidence of acute ischemic stroke -> anticoagulation or antiplatelet medication

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34
Q

Remember to start what oral therapy if diagnose SAH

A

Nimodipine 60mg q4 hrs, ideally given within 4 days of aneurysmal rupture

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35
Q

When is TXA indicated to prevent earlier re-bleeding in patients with aneurysmal SAH?

A

For short period of time when surgical clipping or endovascular coiling of the aneurysm will be delayed and there are no contraindications to its use

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36
Q

What clinical feature can differentiate a patient with cluster headache from another primary headache syndrome?

A

Restlessness or pacing behavior

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37
Q

Which medication is recommended as initial preventive therapy for patients with chronic cluster headaches?

A

Verapamil

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38
Q

INR Reversal rules

A
  1. INR above therapeutic range but <5; no significant bleeding
    - Lower dose or omit dose, monitor more frequently, and resume at lower dose when INR is therapeutic
    - If only minimally above therapeutic range, no dose reduction may be required
  2. INR >5, but <10; no significant bleeding
    - Omit next 1-2 doses, monitor more frequently and resume at lower dose when INR is therapeutic
    - Alternatively, omit dose and give vitamin K (=5 mg PO), particularly if at increased risk of bleeding
    - If more rapid reversal required due to surgery requirement, vitamin K (2-4 mg PO) can be given with exception that a reduction of INR occur in 24 hours
    - If INR still high, additional vitamin K (1-2mg PO)
  3. INR >/=10; no significant bleeding
    - Hold warfarin and give vitamin K (2.5-5 mg PO) with expectation INR will be reduced substantially in 24-48 hours
    - Resume therapy at lower dose when INR is therapeutic
  4. Serious bleeding at any elevation of INR
    - Hold warfarin; give vitamin K (10mg by slow IV infusion), supplemented with four-factor PCC
    - Vitamin K can be repeated every 12 hours if necessary
  5. Life threatening bleeding
    - Hold warfarin; give FFP, PCC, or recombinant factor VIIa, supplemented with vitamin K (10mg by slow IV infusion)
    - Repeat if necessary, depending on INR
39
Q

What factors are replaced with 3-factor PCC?

A

II, IX, and X

40
Q

Hunt and Hess classification of SAH

A

Grade I - mild headache, normal mental status, no nerve deficits (70% survival)
Grade II - severe headache, normal mental status, may have CN deficit (60%)
Grade III - somnolent, confused, may have CN or mild motor nerve deficit (50%)
Grade IV - stupor, mod-severe motor deficit, may have intermittent reflex posturing (20%)
Grade V - coma, reflex posturing or flaccid (10%)

41
Q

When is vasospasm most common after a SAH?

A

2-21 days

42
Q

Most common cause of SAH

A

Ruptured aneurysm

43
Q

Cushing’s triad

A

HTN
Bradycardia
Irregular and shallow respirations

44
Q

What time after onset of symptoms does xanthrochromia generally start following a SAH?

A

12 hours

45
Q

Tx for cryptococcal meningitis

A

Amphotericin B and flucytosine followed by fluconazole suppression until adequate immune reconstitution (if this does not occur, then indefinitely)

46
Q

Tx for neonatal seizures

A

Phenobarbital

47
Q

What worrisome maternal hx should you consider in a neonate with seizures?

A

Maternal drug use -> withdrawal seizures

48
Q

What should raise concern for encephalitis from just meningitis?

A

Behavioral/Personality changes and neurologic deficits

49
Q

Which mosquito-transmitted viruses commonly cause encephalitis in the US?

A

Eastern and Western Equine
West Nile
St. Louis
Lacrosse

50
Q

The radial nerve arises from what nerve roots?

A

C5-T1

50
Q

Tx for radial nerve palsy

A

Wrist splint with 60 degrees of dorsiflexion to prevent atrophy and contractures

About 90% of radial nerve mononeuropathies that occur because of sleep, coma, or anesthesia will recover within 6-8 weeks

51
Q

Ulnar nerve neuropathy symptoms

A

Decreased finger adduction/thumb grasp, 4th/5th digit paresthesias

52
Q

Sciatic neuropathy symptoms

A

Decreased knee flexion

Foot drop

53
Q

Common peroneal neuropathy symptoms

A

Foot drop

54
Q

Lateral femoral cutaneous neuropathy symptoms

A

Upper thigh dysesthesia/numbness

55
Q

Clinical presentation of transverse myelitis

A
  • Transverse level of sensory impairment
  • Paraplegia
  • Sphincter disturbance
56
Q

Etiologies of Transverse Myelitis

A
  • Acquired CNS autoimmune disorders - MS, neuromyelitis optica, acute disseminated encephalomyelitis
  • Infectious: West Nile, Herpes, HIV, HTLV-1, Zika, Lyme, Mycoplasma, Syphilis
  • Systemic Inflammatory Autoimmune Disorders: Ankylosing spondylitis, Behcet disease, scleroderma, Sjogren, Lupus
  • Other: neurosarcoidosis, paraneoplastic syndromes
57
Q

Dx of transverse myelitis

A

MRI will show swelling of cord and is generally performed to exclude compressive lesion

LP shows lymphocytosis and elevated protein

58
Q

Tx of transverse myelitis

A

IV glucocorticoids

Plasma exchange

59
Q

Which segment of the spine is most commonly involved in transverse myelitis?

A

Thoracic - cervical spine rarely affected

60
Q

Anterior cord syndrome is most commonly caused by what type of injury?

A

Flexion injury

61
Q

Blockade of which receptor helps reduce the incidence of extrapyramidal effects?

A

Muscarinic acetylcholine receptors

62
Q

Ulnar nerve functions

A
  • Innervation of forearm muscles
  • Intrinsic muscles of hand
  • Sensation to little finger and ulnar half of ring finger
63
Q

Median nerve function

A
  • Muscles of wrist flexion and finger flexion

- Sensation over volar surface of hand from thumb to radial half of ring finger

64
Q

Radial nerve function

A
  • Muscles of wrist extension
  • Muscles of finger and thumb extension
  • Sensation of dorsal aspect of hand from thumb to radial half of ring finger (except tips of index, middle and radial half of ring finger)
65
Q

What is the innervation of the biceps muscle?

A

Musculocutaneous nerve (C5 and C6)

66
Q

Motor hand function testing

A

Median: OK sign
Ulnar: Scissors motion or spreading fingers
Radial: thumbs up; wrist/finger extension

67
Q

What nerve root plays the most significant role in motor function of diaphragm?

A

C4

68
Q

What is the significance of sacral sparing in a spinal injury?

A

It shows potential for recovery and is more common with incomplete cord syndromes

69
Q

Key differences between conus medullaris syndrome and cauda equina syndrome

A

Conus medullaris - sudden and bilateral, radicular pain less severe, less marked hyperreflexic distal paresis of lower limbs, fasciculation, early urinary and fecal incontinence, localized numbness to perianal area

Cauda equina - more marked asymmetric areflexic paraplegia, atrophy more common, gradual and unilateral, localized numbness at saddle area, sphincter dysfunction tends to present late

70
Q

What vertebral level is responsible for the sensation of the big toe?

A

L5

71
Q

Clinical distinction between encephalitis and meningitis

A

Presence of neurologic abnormality in encephalitis - new psych sx, cognitive deficits (aphasia, amnesia, acute confusional state), seizures, movement disorders

72
Q

Which anatomical regions of the brain does infectious encephalitis have a predilection for?

A

Gray matter of temporal lobes and inferior frontal lobe

73
Q

Describe caloric testing

A

Requires an intact TM not fully obscured by blood or cerumen
Intact brain stem function, caloric testing elicits nystagmus with both a fast and slow component

Fast beating portion of nystagmus moves toward opposite or same ear depending on temperature of water
COWS - cold opposite; warm same

In comatose patient, cold water will produce tonic deviation of eye toward ear instilled with cold water

74
Q

What is the most common cause of pupil-sparing third cranial nerve palsies?

A

Vascular complications of diabetes with infarction of the nerve

75
Q

Risk factors for spinal epidural abscess

A
  • IVDU/endocarditis
  • Chronic renal failure
  • Diabetes
  • Immunosuppression
  • Recent back surgery, epidural puncture
76
Q

What lab test is most likely to be abnormal in patients with spinal epidural abscess?

A

ESR is often elevated despite a frequently normal WBC count

77
Q

Most common cause of death in Parkinson disease

A

Respiratory failure

78
Q

Four characteristic complaints of Posterior Reversible Encephalopathy Syndrome

A
  • Headache
  • AMS
  • Visual Disturbance
  • Seizures

Symptoms evolve fairly rapidly over hours to days

79
Q

What will neuroimaging show for PRES?

A

Bilateral vasogenic edema

White matter edema in bilateral posterior cerebral hemispheres

80
Q

Which antihypertensive agents are recommended in the tx of PRES?

A

Labetalol or Nicardipine

81
Q

Most appropriate order of medications in suspected meningitis

A
  1. Dexamethasone
  2. Empiric antibiotics
  3. Head CT
  4. LP
82
Q

What is the most reliable physical exam finding in patients with meningitis?

A

Jolt accentuation - baseline headache increases when the patient turns the head horizontally two or three rotations per second

83
Q

Tx for Temporal (Giant Cell) Arteritis

A 
Prednisone (if no vision loss)
Methylprednisolone IV (if vision loss is present)
84
Q

What systemic disease is frequently associated with temporal arteritis?

A

Polymyalgia rheumatica (30-40% of patients)

85
Q

What causes NPH?

A

Most commonly due to impaired absorption of CSF

86
Q

What symptom of NPH is most responsive to shunting

A

Gait impairment

87
Q

What type of posturing most commonly associated with uncal or cerebellar tonsillar herniation?

A

Decerebrate or extensor posturing

88
Q

What common extrapyramidal sx is irreversible?

A

Tardive dyskinesia develops over months to years of antipsychotic exposure and is usually irreversible

89
Q

What nerve injury may be associated with fibular head fracture? What physical exam findings would be found?

A

Common peroneal nerve

  • splits into deep peroneal nerve -> sensation between first and second toe and motor function to tibialis anterior (dorsiflexion and inversion of ankle) and extensor hallucis longus (extension of great toe)
  • and superficial peroneal nerve -> peroneus longus (aids in ankle eversion but tibialis does most) and sensation to dorsum of foot
90
Q

Most frequent cause of stroke in patients <45 y/o

A

Carotid artery dissection

91
Q

Carotid artery dissection presentation

A
  • Unilateral neck pain
  • Headache around eye or frontal area
  • Abrupt onset
  • Partial ipsilateral Horner syndrome
92
Q

Tx of choice for carotid artery dissection?

A

Anticoagulation (heparin followed by warfarin) if no evidence of acute ischemic stroke

Thrombolytic therapy if evidence of acute ischemic stroke

Rosh Review (22 decks)

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