Neuro Flashcards
Bell’s Palsy
Peripheral mononeuropathy
- facial palsy: LMN type facial weakness
- Bell’s palsy: idiopathic facial nerve involvement outside CNS w/out evidence of aural or more widespread neuro involvement
Et: pregnant women, elderly
- a/w HSV-1, Lyme
Sxs:
- acute unilateral facial weakness, develops over hours
- may be an impairment of taste, lacrimation, hyperacusis
Ddx: Ramsay Hunt syndrome: viral otitis external + CN 7 palsy (VZV in geniculate ganglion)
Dx:
- exam reveals no abn beyond territory of facial Nerve
- EP, MRI may be needed
Eyebrows will move UP if it were an UMN lesion**
Mgmt:
- supportive: artificial tears; most recover w/out treatment but take wks/mo
- mild/mod: pred taper
- mod/sev: pred taper + valacyclovir
Cluster headache
Repetitive HA for wks/mo with f/u periods of remission
MC at night
Sxs:
- severe, paroxysmal, unilateral, orbital/supraorbital HA
- pain begins around eye or temples
- a/w: ipsilateral ptosis, photophobia, lacimation, miosis, rhinorrhea
Mgmt:
- high flow face mask O2 100% *
- sumatriptan
- neuro OP referral
Prophylaxis: verapamil, lithium, pred bridge
Migraine
MC women, in the morning
Triggers: menses, dehydration, stress, sleep deprivation
Sxs:
- gradual onset
- NV, photophobia, photophobia
- aura last 1hr
- relieved by cool, dark room, sleep
Premonitory: fatigue, dec concentration, photophobia, photophobia, blurred vision, neck stiffness
Aura: visual disturbance, numb/tingling, weakness, speech disturbance
Cutaneous allodynia
Dx:
Without Aura:
- 4-72hr; normal neuro exam
- at least 2: unilateral, pulsating, mod/sev, aggravation by routine physical activity
- at least 1: N, V, photophobia, photophobia
With Aura:
- recurrent attacks of reversible focal neuro sx (last 5-60min)
- HA begins during aura or follows w/in 60min
Mgmt:
- quiet, dark room
- IVF if poor PO intake or vomiting
ABORTIVE: sumatriptan, naproxen 500mg, IV reglan or chlorpromazine for NV
- or prochlorperazine, ondansetron
Prophylaxis:
- *amitriptyline
- other: topiramate or divalproex (wt loss, birth defects), propranolol
Tension headache
Infrequent <1d/mo
Frequent 1-14d/mo
Chronic >15d/mo
Sxs:
- bilateral, constant, dull, non-throbbing, band-like pressure
- pericranial muscle tenderness (head, neck, shoulders)
- hours to days
- nausea and photophobia may be present, milder than migraine
Dx: 2 or more:
- bilateral head/neck pain
- steady pressure/tightening and non-throbbing pain
- mild-mod pain
- not aggravated by normal physical activity
Mgmt:
- nonpharm: heat, ice, massage, rest, biofeedback
pharm: - mild/mod: ibuprofen, naproxen, APAP
- mod/sev: ketorolac
caffeine + analgesics = more effective than analgesics alone
Essential tremor
Tremor w/movement
- rhythmic involuntary back/forth oscillation
- ETOH decreases tremor (risk for alcoholism)
Dx:
- bilateral arm tremor w/2+ amplitude in at least 1 arm and at least 1 in other arm
OR
- predominant cranial-cervical tremor with 2+ amplitude and 1+ amplitude in at least 1 arm
Mgmt: propranolol**
- second line: primidone, benzos, barbiturates
Parkinson disease general
Resting Tremor:
- unilateral, can spread contralaterally
- “pill rolling”
- dec w/purposeful action
Bradykinesia: MC symptom
- generalized slowness of mvmt
- weakness, incoordination, Dec ability to initiate voluntary movement
- begins distally
- dragging/shuffling steps
Rigidity:
- Inc resistance to passive mvmt of joint
- usually begins same side as tremor
- cogwheel rigidity* - jerky resistance and relaxation (stop and go)
- lead pipe rigidity* - tonic restriction that is not smooth throughout ROM
Postural instability:
- impairment of centrally-mediated postural reflexes: imbalance, falls
- major cause of disability, occurs late in disease
- pull test* - pull pt by shoulders = fall or take multiple steps backwards
Other sxs:
- hypomimia, speech impairment, dysphagia
- blurred vision, impaired vestibuloccular reflex, impaired upward gaze and convergence
- micrographia, dystonia, myoclonus
- shuffling gait
- cognitive dysfunction/dementia, mood disorders
- orthostatic hypotension
Parkinson disease Mgmt
First line
- Levodopa + carbidopa +/- entapacone
- levodopa: DA prodrug
- carbidopa: prevents degradation of levodopa so it crosses BBB
- entapacone: prolongs action of levodopa
lack of response to Levodopa >1000mg/d = wrong diagnosis, not PD
- Dopamine AG: pramipexole, ropinirole, rotigotine
Second line - use when levodopa has become less effective
- MOA-B: selegiline, rasagiline
- NMDA AAG: amantadine (AE: livedo reticularis)
- Anticholinergic: trihexyphenidyl, benztropine
Cerebral palsy
Disorder of posture +/- movement d/t Nonprogressive* disorder of the developing brain
Sxs:
- spastic diplegia
- MC population in healthy premature infants
- lower extremity
- normal intellectual and hand function - spastic hemiplegia
- one side of body
- seen w/intracranial hemorrhage or stroke
- CNS malformation - spastic quadriplegia
- entire body
- hypoxic-ischemic encephalopathy
- CNS malformation - dyskinetic (more basal ganglia involvement)
- dystonic; athetoid
- higher tendency of normal intellect but may have trouble speaking
- kernicterus is common cause - ataxic - generalized low tone
Mgmt:
- PT, speech, OT
- baclofen - reduce muscle spasm, drooling
- botox - spasticity
Multiple sclerosis
Young adult w/at least 2 episodes of CNS dysfunction w/partial resolution
- Numbness, pins/needles pain, tightness, coldness, swelling of limbs
- Impaired vibration and joint position sense
Lhermitte’s sign: electric shock sensation down spine into limbs
Trigeminal neuralgia
Optic neuritis: unilateral eye pain, central scotoma visual loss, Marcus Gunn pupil
Other: UE paraplegia, LE spasticity, increased DTR, intention tremor
Dx:
- MRI: spinal/cerebral plaques
- CSF analysis: oligoclonal bands
- Visual evoked potentials
Mgmt:
- acute: plasmapheresis + steroids
- chronic: immunomodulating interferons
Myasthenia gravis
Et:
- d/t abs against AchR (B/T cell mediated)
- infants may get transient syndrome from affected mom; also at risk for congenital arthrogyrposis (contractures from lack of mvt in utero)
Sxs:
- weakness: ptosis, EOMs, resp muscles, bulbar muscles (dysarthria/dysphagia), proximal > distal extremity
- ocular sxs (CN involvement): bilateral, asymmetric
PE:
- ptosis, EOM drift
- nasal speech
- proximal muscle weakness
- normal sensation/DTRs
Sxs improve w/rest and cold!!
Dx:
- ice pack test
- Tensilon (edrophonium test): short-acting cholinesterase inhibition = more ACh available = improvement w/in a minute but dissipates <5 min
- serum: AchR abs, anti-MUSK abs, autoimmune testing
- chest CT: r/o thymoma
- PFTs, EMG
- Slow repetitive nerve stimulation: CMAP dec overtime
Mgmt:
Pyridostigmine (cholinesterase inhibitor)
- inc Ach at receptor; lasts 3-6hr
- SE: diarrhea, NV, diaphoresis
Corticosteroids (r/o lymphoma, malignancy)
Steroid sparing: AZA (r/o bone marrow suppression)
MG Crisis: respiratory failure requiring mechanical ventilation
- IVIG, plasmapheresis
- secure airway
- d/c anticholinesterase meds; avoid steroids
Thymoma or refractory Tx: thymectomy
Infants: respiratory, nutrition support; will recover once they clear the abs (not actually making them themselves)
Alzheimer’s general
- *MC cause of dementia
- *Progressive disease: memory loss, personality changes, global cognitive dysfunction, functional impairment
- personality changes may precede cognitive impairments
- median survival after dx = 4.5; death d/t pneumonia (aspiration) or CVD
Genetics: APOE4
MC in women
6th leading cause of death
50% of people meeting criteria don’t have diagnosis in medical record
Sporadic: MC, thought to result from a failure in amyloid beta (AB) clearance mechanisms
Familial: mutations in genes encoding amyloid precursor protein; caused by increased production or aggregation of AB
Alzheimer’s Sxs
Early:
- short-term memory loss prominent*
- disoriented to time and place
- aphasia, anomia, acalculia
- employment/home mgmt difficulties
- apraxias, visuospatial disorientation - easily lost
- gait disorders: difficulty walking = short, slow, shuffling steps, flexed posture, wide base
Late:
- loss of social skills
- psychotic sxs: psychosis w/paranoia, hallucinations
- rigidity, bradykinesia
- mutism, incontinence, bedridden = terminal
Alzheimer’s Dx/Tx
Cognitive assessment, neuropsych eval
Routine labs
MRI* = cortical atrophy, enlarged ventricles
Screening not currently recommended
Global pathology:
- progressive degenerative disorder
- abnormal cleavage of amyloid precursor protein (APP)
- abnormal accumulation of amyloid beta protein deposited in plaques
Histopath
- neurofibrillary tangles: tau protein, ubiquitin
- neuritic (amyloid) plaques
Neuropsych
- cholinergic deficiency
- cascade leads to neuronal cell death - dec production of Ach
Mgmt:
- r/out other causes: pain, infection, constipation, incontinence, dehydration, medication
- nonpharm: environmental change, dec stimulation
- meds: start low and Inc slow; consider ADs
- Cholinesterase Inhibitors**
- NMDA AAG: memantine**
- stop meds if not helping, reassess in 3-6mo
Prevention: long-term regular exercise
