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Neuro Flashcards

1
Q

MS

-autoimmune inflammatory condition involving 3 pathophysiological hallmarks:

A

MS

  • degeneration of CNS myelin
  • sclerosis / plaque formation
  • axonal loss
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2
Q

MS

Name 4 predisposing risk factors

A

MS

  • northern latitude
  • smoking
  • vit D deficiency
  • viruses (EBV, measles, HSV)

(also more common in females but men have more severe course)

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3
Q

Pathophysiology of MS

immune mediated destruction of _____ which causes disruption in _____ and death of ________

A

destruction of myelin

disruption of nerve conduction

death of neurons/axons

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4
Q

MS

Name 4 common triggers of MS relapses

A
  • trauma
  • emotional stress
  • pregnancy
  • heat
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5
Q

MS

Name the 4 subtypes of MS
-which one is most common?

A
  1. Remitting-relapsing: initial onset of symptoms, with remission and exacerbations (85-90% of cases)
  2. Primary-progressive: steady decline from onset (10-15% of cases), no relapse/remission
  3. Secondary-progressive: initially remitting/relapsing with steady decline in function (65% of pts with RRMS after 15-20 years)
  4. Progressive-relapsing: progressive from onset with superimposed relapses
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6
Q

MS

Name the common early symptoms of MS

A
  • paresthesia of face, trunk, limbs
  • weakness
  • visual disturbance (diplopia, blurred vision)
  • urinary symptoms (incontinence)
  • fatigue (90%)
  • impaired gait
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7
Q

MS

Name some common cognitive changes with MS

A
  • DEPRESSION* (50%)
  • apathy
  • emotional lability
  • problems with memory, attention, concentration
  • poor judgement and planning
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8
Q

MS

What are 3 systems to assess during physical exam?

A
  • complete neuro
  • eye
  • MSK
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9
Q

Multiple Sclerosis

Imaging of choice?

Lab:

  • 90% will have _________ bands on electrophoresis
  • 2/3 will have persistently elevated _______

What vitamin deficiency has similar symptoms?

A

MRI

90%: oligoclonal IgG bands

2/3: persistently elevated IgG

-B12 deficiency

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10
Q

MS first line medication: _______

Drug class?
Route?
Effect on vaccines?
Common side effects?
Important to monitor for?
A

INTERFERON

  • immunomodulator
  • weekly injectable (avonex IM, rebif sc)
  • will lessen immune response to live vaccines
  • flu-like (fever, chills, myalgia), injection site reaction

Monitor for depression!

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11
Q

MS first line po medication for RRMS ______

Drug class?
Route?
Effect on vaccines?
Common side effects?

A

Tecfidera (dimethyl fumarate)

  • antineoplastic immunomodulator
  • po
  • NO live vaccines
  • side effects: flushing, GI, drop in lymphocytes
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12
Q

MS Patient education topics:

A
  • smoking cessation
  • heat sensitivity
  • vision: rest eyes periodically
  • activity, exercise and rest
  • fluid restriction and pelvic floor exercises: for bladder symptoms
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13
Q

Impact of pregnancy and breastfeeding on multiple sclerosis?

A
  • pregnancy and breastfeeding are PROTECTIVE (may stabilize or remit in pregnancy)
  • 20-40% will have relapse postpartum

-should stop immunomodulators 2-3 months before conception

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14
Q

What is the most common cause of vertigo?

A

BPPV

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15
Q

What is the triad of symptoms in Menieres?

A
  • tinnitus
  • hearing loss
  • vertigo
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16
Q

What is the vestibular neuritis often preceded by?

A

-viral infection

vertigo is often sudden and severe

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17
Q

Vertigo

What are some common medications that can cause vertigo?

A 
anticonvulsants
antidepressants
antipsychotics
anxiolytics/sedations
anti-HTN
nitrates
diuretics
insulin/hypoglycemic agents
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18
Q

Define the difference between central and peripheral vertigo

A

Peripheral: dysfunction in inner ear/vestibular nerve

Central: from brainstem/cerebellar ischemia
eg MS, seizures, migraines, neoplasm

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19
Q

Common symptoms accompanying:

  • CENTRAL VERTIGO
  • PERIPHERAL VERTIGO
A

Central: diplopia, dysphagia, dysarthria, abN motor/sensory exam, paresthesia

Peripheral: vertigo usually severe, no associated brainstem symptoms. May have triad of Menieres

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20
Q

Central vertigo on physical exam will have deficits in:

A

-cerebellar function

finger to nose, rapid alternating movement, gait

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21
Q

Vertigo

Name 3 systems to assess during physical exam

A
  • ENT (to r/o otitis media)
  • CVS (carotid bruit)
  • Neuro (duh)
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22
Q

Nystagmus with Dix-Hallpike maneuver is _____ with central vertigo and ______ with peripheral vertigo

A

central: delayed nystagmus
peripheral: immediate nystagmus

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23
Q

Bloodwork for vertigo workup

A

CBC
TSH
Lytes
Syphilis screen

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24
Q

Contraindications for Epley’s maneuver

A
  • neck fracture/instability
  • head injury
  • unstable carotid disease
  • recent retinal detachment
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25
Q

What are three classes of medications to suppress vestibular symptoms of vertigo?

A
  • antihistamines (eg meclizine, gravol, Benadryl)
  • Benzos
  • antiemetics (eg ondansetron, metoclopramide, prochlorperazine)
  • these medications are not routinely recommended or used but can be considered for severe acute vertigo
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26
Q

Trigeminal neuralgia

Hallmark features (key descriptors)

A

recurrent severe paroxysmal episodes of electric shock pain along CN V distribution

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27
Q

Trigeminal neuralgia

Risk factors:

  • possible link to ____ and ____
  • most commonly associated with ______
A

Risk factors:
-possible link to HTN and migraines

-most common association with MS

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28
Q

Trigeminal neuralgia

Describe characteristics of the pain

  • description
  • timing
  • location
  • triggers
  • associated symptoms
A

Description: electric shocks, severe, stabbing

Timing: Lasts seconds to 2 min, can occur 0-50x/day, does not typically wake people at night
Common to have continuous dull pain between attacks

Location: over CN V distribution (often V2 or V3)
Unilateral, can be bilat over time (esp with MS), rare to be simultaneous

Triggers: light touch along CN V, chewing, brushing teeth, smiling, shaving, cold air, talking

Associated symptoms: tearing, conjunctival injection, rhinorrhea

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29
Q

Trigeminal neuralgia

Diagnostics?

A

Based on clinical hx

  • neuro, ENT, dental/TMJ exam
  • MRI to r/o brain lesion as cause of compression
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30
Q

Trigeminal neuralgia

First line treatment medication: _______

  • precautions
  • contraindications
  • monitoring
  • common side effects
A

First line Rx: carbemazepine (Tegretol)

Precaution: CYP inducer, test for HLA-B*15:02 in Asians (risk of SJS/TEN)

Contraindications: many drug interactions

Monitoring: serum levels

Side effects: GI (n/v/d), hyponatremia, skin (rash, pruritis), drowsiness, blurred/double vision

**need gradual taper

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31
Q

Meningitis

Risk factors/Predisposing conditions

  • what age?
  • sequelae of what diseases?
  • comorbid with what conditions?
A

Meningitis Risk factors:
-age: (<4, adolescents, university students living in dorms)

  • sequela of Lyme disease, dental infection, OM, bacterial sinusitis, Hib, varicella, STI
  • penetrating head wound, spinal trauma
  • sickle cell, asplenia, Hodgkin’s, Ab deficiencies
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32
Q

Organisms most commonly responsible for bacterial meningitis in:

  • neonates
  • kids and teens:
  • adults:

Transmission?

A
  • Neonates: GBS, E. coli, listeria monocytogenes
  • 2 to 18: N. meningitidis (nasopharynx entry), S. pneumoniae, Hib
  • Adults 19-59: S. pneumoniae, N. meningitidis, Hib
  • Adults 60+: S. pneumoniae, L. monocytogenes, N. meningitidis

DROPLET transmission

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33
Q

What are some causes of aseptic meningitis?

A
  • virus
  • fungus
  • non-infectious (eg blood in subarachnoid space)
34
Q

What are the 3 hallmark symptoms (triad) of bacterial meningitis?

Other symptoms in

  • neonates
  • children and adults
A
  • nuchal rigidity
  • fever
  • altered LOC

BABIES: high pitched cry, inconsolable, bulging fontanelles, poor feeding, vomiting (vomiting, seizures)

KIDS/ADULTS: sudden onset severe constant headache worse with movement, CNS (vomiting, seizures)
Rash depends on organism –> can be macular, maculopapular, petechia, palpable purpura

35
Q

Assessment for meningitis:

-specific history (besides OLDCARTS) to ask:

A
  • current/recent hx of OM, URI, sinus infection
  • chickenpox exposure
  • recent dental treatment
  • immunizations
  • spinal or cranial surgeries
  • substance use
  • neonates: prenatal history
36
Q

Assessment for meningitis

Physical exam:

  • systems to focus on:
  • special tests:
A
  • full head to toe exam
  • systems of focus: neuro, derm (petechial/ecchymotic rash), ENT (dental disease)

Brudzinski’s (supine, passive neck flexion causes hip flexion)
Kernig’s (supine, pain with extension of flexed knee and hip)

37
Q

CSF findings will show high _____ and -____ and low ______ with bacterial meningitis

A

high WBC
high protein
low glucose

38
Q

What are some associated complications with bacterial meningitis?

A

brain damage, hearing loss, learning disability, amputations

39
Q

Before prescribing Carbemazepine, need to test for ________ in _______ (pt demographic) due to increased risk of ___________

A
  • HLA-B*15:02
  • Asian patients
  • SJS or TEN (toxic epidermal necrolysis)
40
Q

Define restless legs syndrome

More common in (sex)

A

-uncomfortable urge to move legs especially at night

2x more common in women

41
Q

Restless legs syndrome

Name some risk factors

including. ….
- chronic diseases?
- medications? 4 class of meds

A
  • pregnancy (third trimester)
  • ESRD (25-50% esp with hemodialysis)
  • venous insufficiency/varicose veins
  • chronic disease: diabetes, anemia, Parkinson’s, MS
  • Medications: antiemetics (metoclopramide), antipsychotics, antidepressants (SSRI, SNRI, TCA), antihistamines
42
Q

What is the hypothesized pathophysiology of restless legs?

  • neurotransmitter involved?
  • low _____ in brain?

What are some triggers?

A
  • basal ganglia dopamine dysfunction
  • low ferritin

Triggers:

  • ETOH
  • sleep deprivation
  • caffeine
  • long care trips/sitting for long periods
43
Q

URGES mnemonic for restless leg syndrome diagnosis

A 
Urge to move the limbs
Rest or inactivity: worsens symptoms
Getting up and moving: relief of symptoms
Evenings: symptoms get worse
Secondary causes must be excluded
44
Q

What is first line treatment for moderate to severe RLS?

Generic:
Trade:
Classification
Duration of treatment:
Adverse side effects:
Precautions:
Monitoring:
A

Generic: Pramipexole
Trade: Mirapex
Classification: Dopamine Agonist
Therapeutic Indication:
MOA: unknown, stimulates dopamine receptors
Duration (interval) of treatment:short term use as long term can worsen symptoms within a few months
take until symptoms resolve

Adverse S/E:
1) Hypotension
2) Dyskinesia
3) Rebound symptoms
Precautions: Avoid abrupt stopping, CNS depressant
Monitoring: renal clearance, BP (orthostatic hypotension)

45
Q

RLS

best to make medications at what time?

How to long stay on treatment?

A

1 to 2 hours before bedtime

dopaminergic agents: best to limit to short term use
*long term use can worsen symptoms

46
Q

What are some triggers that can lower seizure threshold?

A
  • sleep deprivation, fatigue
  • emotional or physical stress
  • hypoglycemia
  • hyperventilation
  • medication withdrawal (benzodiazepines, alcohol)
  • hormonal changes (women before or during menses)

Environmental stimuli: blinking lights, fuzzy TV, loud noises, music, odour, being startled

47
Q

Seizures occur when there is an imbalance between excitatory and inhibitory neurotransmitters

Main excitatory neurotransmitter in CNS?
Main inhibitory neurotransmitter in CNS?

A

Glutamate: excitatory neurotransmitter
GABA: inhibitory neurotransmitter

48
Q

What is the pathophysiological difference between generalized and focal seizures?

A

Generalized: originate within and engage both hemispheres

Focal: originate in one hemisphere –> can spread

49
Q

Name 4 types of generalized seizures

A

tonic clonic
absence (petit mal)
atonic
myotonic

50
Q

What are the difference in features between absence and focal onset impaired awareness seizures?

A

Absence (“petit mal”): brief loss of consciousness with minimal/no loss of muscle tone
● Lasts seconds 5-10 seconds
● Often mistaken for “daydreaming” (cannot be interrupted)
● Can be accompanied by lip-smacking, eyelid twitching
● No preceding aura or postictal confusion
● Clusters, can frequently have >20/day
● Onset in childhood

Focal Onset Impaired Awareness Seizures
(Complex Partial Seizures): seizure activity with impaired loss of consciousness
● Lasts 1-2 min
● Sudden onset of blank “daydreaming” stare that cannot be interrupted
● Often accompanied by automatism (eg lip-smacking, chewing, fumbling, rubbing hands)
● Can have brief postictal confusion

51
Q

Describe features of focal onset aware seizures (simple partial seizures):

A

Focal Onset Aware Seizures (Simple Partial Seizures): seizure activity without loss of consciousness. Commonly known as “auras”
● Brief (<1 min)
Common descriptors:
● Rising abdominal sensation (roller coaster)
● Anxiety, fear, joy, “déjà vu”
● Numbness, tingling
● Flashing lights, unusual smells

52
Q

History questions to ask during assessment of seizure disorder:

A

History is key! From patient and a witness if possible

Assess for:

  • description of symptoms (often the first symptom is the most helpful clue - video is helpful)
  • past medical hx of childhood seizures, head trauma, infection, systemic disorders (malignancies, fluid/electrolyte imbalance eg hypoglycemia), neurological disease, stroke
  • family hx of seizures
  • provoked or unprovoked? (use of drugs and alcohol, sleep deprivation)

In patients with known epilepsy on antiepileptic medications:

  • adherence to medications (most common cause of breakthrough seizure)
  • medication interactions
  • concurrent use of alcohol or substances, illness (fever, vomiting)
53
Q

How is status epilepticus defined?

Seizures lasting ______ with no ___________

A

Repeated seizures lasting >5-10 min with no intervening periods of normal neurologic function

54
Q

What is the most common cause of seizures in people with epilepsy?

A

missed anti-epileptic medication

55
Q

Alcohol use > _____ drinks/day increases seizure risk

A

3 drinks/day

56
Q

Anti-epileptic drugs are usually started after the _____ seizure

A

second

57
Q

What should be included in routine follow up of seizures?

Also what 3 areas of preventative screening?

A
  • medication compliance
  • -mental health/suicide risk (increase risk with some AEDs)
  • CBC, LFTs, Cr, [drug]
  • annual drug levels if on stable dose and no seizures

screening for:

  • contraception/plan for pregnancy
  • bone density (osteopenia and osteoporosis with long term AED use)
  • dental care
58
Q

Stevens Johnson Syndrome and Toxic Epidermal Necrolysis can happen ____ months after initiation of AEDs

A

four months!

carbamazepine/oxcarbezepine
phenytoin
lamotrigine

59
Q

Seizures

Pregnancy considerations with AEDs

  • folic acid supplement of _____/day if wanting to conceive:
  • impact of AEDS on oral contraception
A

Folic acid: 4 mg/day

Oral contraception less effective (esp if on enzyme-inducing AEDs eg phenytoin, carbamazepine, topiramate)

60
Q

Focal impaired awareness seizures (complex partial) often begin in _____ lobe

A

temporal lobe

61
Q

Dizziness is often separated into 3 categories:

-define each

A

Presyncope: lightheaded, “nearly fainting” from decreased cardiac output or blood flow to brain

Vertigo: illusion of movement “spinning” “whirling”
-central vs peripheral

Disequilibrium: instability with walking

62
Q

Name common causes of disequilibrium

A 
• peripheral neuropathy
	• musculoskeletal disorder interfering with gait
	• vestibular disorder 
	• cerebellar disorder
and/or cervical spondylosis
63
Q

Name common causes of presyncope

A

Presyncope
• cardiac dysrhythmias
• coronary heart disease
congestive heart failure

64
Q

Name common causes of non-specific dizziness

A 
Nonspecific dizziness
	• psychiatric disorders (anxiety, depression, panic disorder) 
	• Hyperventilation 
	• Head trauma / whiplash
Hypoglycemia
65
Q

What 2 categories of medications have a high chance of causing dizziness?

A

antidepressants

anticholinergics

66
Q

What are the most helpful physical exam findings during assessment of dizziness?

A
  • positional change in symptoms
  • orthostatic BP and HR
  • gait
  • nystagmus
67
Q

All vertigo (central and peripheral) is worse with ________ and generally accompanied by ____ and ______

A

worse with movement of head

  • accompanied by:
  • nystagmus
  • postural instability (hard to stay upright)
68
Q

Ear symptoms (tinnitus, hearing loss) is suggestive of _______ vertigo

A

peripheral

69
Q

Name 3 risk factors for carpal tunnel syndrome

A
  • hobby/work with repetitive wrist/hand movements or use of vibrating tools
  • pregnancy
  • aging

Conditions that cause edema/inflammation:

  • cysts, lesions, masses
  • RA, DM, thyroid/endocrine disease
  • burn trauma/structural change
  • mechanical overuse
  • infectious diseases (TB, leprosy)
  • genetics (small carpel tunnel space, anatomical anomalies)
70
Q

Carpal tunnel syndrome:

involves the _____ nerve which contains these spinal nerves:
and innervates _______

A

median nerve

-spinal nerve
C6-8, T1

-innervates forearm, wrist, hand

71
Q

What are some signs and symptoms of carpal tunnel?

A
  • pain (wrist, referred to elbow and /or shoulder)
  • tingling, numbness and/or burning (paresthesia) in first 3 radial fingers (D1-3)
  • sensation can radiate up to wrists into forearms
  • weak grip, dropping objects
  • worse at night
72
Q

Describe physical assessment for carpal tunnel

A

Exam:

  • hand: palmar deformity, wasting in hand muscles, bony deformity
  • neuro-MSK assessment of hand
  • 2 point discrimination: to hand, forearm, upper arm

Special tests:

  • Tinel’s
  • Phalen’s x 60 sec (positive = palmar numbness/tingling/pain to D1-4)
  • manual compression (positive = paresthesia within 30 sec)
73
Q

What are some non-pharm treatment options for carpal tunnel?

A
  • avoid triggering activities
  • stretching
  • Frequent rest breaks to rest arms and wrists
  • Wrist splints in neutral position overnight for one month
  • Ergonomic adaptation
  • Carpal tunnel release for severe symptoms
74
Q

What is the first line pharm treatment for carpal tunnel?

A

Ibuprofen or naproxen (NSAIDs)

75
Q

Bells Palsy

What is it caused by?

A

etiology unknown

-most likely reactivation of HSV causing inflammation and compression of CN VII (facial nerve)

76
Q

Risk factors for Bells Palsy?

A
  • diabetes
  • pregnancy (third trimester, immed PP)
  • HTN
  • hypothyroidism
  • recent infection
77
Q

Bell’s Palsy:

Signs and symptoms:

upper or lower motor neuron?

A

rapid acute onset

unilateral facial weakness
-unable to close one eye
-eye lid sagging
-mouth drooping
may have retro-auricular pain
-may have drooling, decreased tearing, altered taste, sound sensitivity

LOWER motor neuron
(sparing of forehead suggests upper motor neuron)

78
Q

Physical exam for Bell’s Palsy:

-pertinent positive and negative findings?

A

Facial symmetry: drooping mouth, unable to close eye, forehead sparing?

Ears: r/o OM, Ramsay Hunt (herpetic lesions in canal or behind ears)

Neuro: CN - able to close eyes completely? raise eyebrows?

79
Q

Bell’s Palsy

Pharm management?

Non-pharm?

A

Prednisone 60-80 mg daily x 1 week for all patients

Valacyclovir only in severe cases (in conjunction with steroid)

EYE PROTECTION

  • eye lubricant
  • taping eye shut
  • patch at night but only after taping eye shut first
  • sunglasses
80
Q

Bell’s Palsy

When to refer?

A
  • abnormal neuro exam
  • bilateral palsy
  • slow progression at 3-4 weeks
  • no improvement at 3-4 months

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