Neuro Flashcards
What is the risk of stroke in the first 3 months following a transient ischemic attack?
10-15%,with most events occurring in the first 2 days
Most common site for hypertensive hemorrhage is
PUTAMEN
Gold standard for evaluating the precise anatomy of the AVM
Conventional X-ray angiography
Largest lesion of avm is located at
POSTERIOR HALF OF HEMISPHERE
(Wedge shaped lesion extending to the ventricles),
Angiograpgic features of AVM that predicts higher bleeding risks
Smaller lesionS
Deep vein drainage
Vein outflow stenosis
Intranidal aneurysm
Results from multiple small vessel infarcts within the subcortical white matter likely from chronic hypertension and may lead to subcortical dementia syndrome
Leukoaraiosis
Aka periventricular white matter disease
The most common cause of viral meningitis
ENTEROVIRUS
What is the recommended chemrophylaxis for individuals exposed to meningococcal meningitis?
RIFAMPIN 600mg q12 for
2 days
What is the antibiotic of choice for meningococcal meningitis for susceptible strains?
PENICILLIN G
What is the antibiotic of choice for meningococcal meningitis with CSF ISOLATES N. Meningitidis that is resistant to penicillin and ampicillin ?
CEFOTAXIME
OR
CEFTRIAXONE
What is the ALTERNATIVE chemrophylaxis for individuals exposed to meningococcal meningitis?
Azithromycin
Ceftriaxone
Px with HIV and meningitis symptoms and CSF abnormalities.
India ink staining of CSF: (+)FUNGI
Diagnosis?
WHAT IS THE TREATMENT?
Diagnosis: CRYPTOCOCCAL MENINGITIS
TX
Amphotericin B + FLUCYTOSINE X al least 2 weeks
Followed by FLUCONAZOLE X at least 8weeks
a patient suspected of HERPES SIMPLEX VIRUS encephalitis but with CSF PCR analysis that is negative. What is the next course of action?
Continue Acyclovir and REPEAT LUMBAR PUNCTURE
What is the standard criterion for treatment success in syphilitic meningitis?
NORMAL CSF count within 12 months and
decrease in VDRL titer by TWO dilutions or
REVERT to NON REACTIVE within 2 years of complete therapy
What condition presents with recurrent meningoencephalitis with uveitis, retinal detachment, alopecia, lightening or eyebrows and lashes, cataracts and glaucoma
VHK
VOGT KOYANAGI HARADA SYNDROME
What virus causes tropical spastic paraparesis
Human T cell lymphocytic virus 1
What is the management for status epilepticus
Anticonvulsant: Give IV BENZODIAZEPINE
(Lorazepam, midazolam,clonazepam)
followed by antiepileptic drugs: Levetiracetam 20mg/kg
(Phenytoin, valproate acid)
Most common syndrome associated with focal seizures with impairment of consciousness and has distinctive clinical, EEG and pathological feature
Mesial temporal lobe epilepsy syndrome
Highly selective loss of specific cell populations within hippocampus in most cases
Mesial temporal lobe epilepsy syndrome
Most common seizure type resulting from metabolic derangement
Generalized tonic clinic seizure
First line antiepileptic drug for focal seizure that acts in the modulation of the release of synaptic vesicles
levetiracetam
When cerebral blood flow remains poor for a longer duration leading to infarction in the border zones between the major cerebral artery distributions with WIDESPREAD BRAIN NECROSIS
Global hypoxia Ischemia
Resulting cognitive sequele to Global hypoxia Ischemia
HIE
HYPOXIC ISCHEMIC ENCEPHALOPATHY
Magnitude of flow reduction is a a function of collateral blood flow:
Bloodflow of zero
Brain tissue death within 4-10mins
Magnitude of flow reduction is a a function of collateral blood flow:
Bloodflow of <16-18ml/100g tissue/min
INFARCTION WITHIN AN HOUR
Magnitude of flow reduction is a a function of collateral blood flow:
Bloodflow of <20ml/100g tissue/min
Ischemia without infarction
Medical support in stroke: maintain glucose of
60-180mg/dL using an insulin infusion
Peak of cerebral edema
2nd to 3rd day and can last for 10days
Management of cerebral edema
- Water restriction, IV mannitol
- Avoid hypovolemia
- Hemicraniectomy
What is the prophylactic surgery for prevention of brainstem compression
SUBOCCIPITAL DECOMPRESSION OF LARGE CEREBELLAR INFARCTS
The only antiplatelet agent proven safe and effective for the acute treatment of ischemic stroke
Aspirin
Most common site of infarction via cardioembolism
Intracranial internal carotid artery ICA
MCA middle cerebral artery
PCA posterior cerebral artery
Most common cause of cardioembolic stroke
NONVALVULAR OF NONRHEUMATIC AF
Annual average is 5%
Most common source of artery to artery embolus
CAROTID BIFURCATION
Most frequent site in the carotid for artery to artery embolism stroke
Common carotid bifurcation
Proximal internal carotid artery PICA
Location of infarction in a patient who
Presents with PURE MOTOR HEMIPARESIS ONLY
Posterior limb of internal capsule
Or
PONS
Location of infarction in a patient who
Presents with PURE SENSORY ONLY
Ventral THALAMUS
Location of infarction in a patient who
Presents with ATAXIC HEMIPARESIS ONLY
VENTRAL PONS
OR
INTERNAL CAPSULE
Location of infarction in a patient who
Presents with DYSARTHRIA AND CLUMSY HANDS OR ARMS ONLY
Ventral pons
Genu of internal capsule
Cause of stroke that affects cervical arteries mainly in women, presence of multiple rings or segmental narrowing alternating with dilation in carotid or vertebral arteries.
FIBROMUSCULAR DYSPLASIA
Most significant risk factor in stroke and TIA
Hypertension
BP goal <140-150/90
(Recommendation of vascular neuro <130/80)
Elderly: lower SPP
DRUGS: ACEI AND THIAZIDES DIURETIC
What DM drug lowers risk of recurrent stroke, MI and vascular death
PIOGLITAZONE
Anticoagulation goal INR in chronic NONVALVULAR AF that prevents cerebral embolism and is safe
INR 2-3
For primary prevention or for patients who have experienced stroke or TIA, what drugs reduces the risk by about 67%
Vitamin k antagonist (warfarin,dicumarol)
Oral thrombin inhibitor that is non-inferior to VKA in preventing second stroke or systemic embolization
DABIGATRAN
Higher dose of dabigatran that makes it superior to VKA
150mg/d
Lower dose of dabigatran that makes it have lower rate of major bleeding compared to VKA
110mg/d
Oral Factor Xa inhibitor that is non-inferior and EVEN SUPERIOR to VKA, with LOWER RISK of bleeding
APIXABAN
Oral anti-Xa anticoagulants that are non inferior to VKA
Rivaroxaban and ENDOXABAN
anticoagulant therapy for untreated rheumatic heart disease
Long term warfarin (untreated RHD)
3 month anticoagulation course in Acute MI REDUCES risk of embolism in:
Acute myocardial infarction with:
Anterior q wave infarction Substantial LV dysfunction CHF MURAL THROMBOSIS AF
Most serious complication of prosthetic heart valve implantation
STROKE sec to thromboembolism
True or false
AVOID ANTITHROMBOTIC AGENTS FOT INFECTIVE ENDOCARDITIS
True
May cause pericardial hemorrhage
What is the recommended antithrombotics for non bacterial thrombotic endocarditis
Full dose unfractionated HEPARIN or SC LMWH
MCA forms collateral formation via
LEPTOMENINGEAL VESSELS
Parts supplied by the lenticulostriate arteries from the proximal MCA
Outer Globus pallidus
Posterior limb of internal capsule
Adjacent corona radiata
Caudate nucleus
Manifestation of MCA syndrome
Contralateral hemiplegia Hemianesthesia Homonymous hemianopia Ipsilateral preferential gaze (1-2 days) Dysarthria due to facial weakness
Manifestation of MCA syndrome with dominant hemisphere involved
GLOBAL APHASIA
Manifestation of MCA syndrome with non-dominant hemisphere involved
ANOSOGNOSIA
CONSTRUCTIONAL APRAXIA
NEGLECT
Anti-epileptic drug that modulates release of synaptic vesicles
Levetiracetam
Brivaracetam
Antiepileptic drug that inhibits T type ca channels in the thalamus neurons
ETHOSUXIMIDE
VALPROIC ACID
HLA allele that caries high risk for developing serious skin reaction from carbamazepine, phenytoin, oxcabazepine and lamotrigine
HLA B 1502
HLA Allele that is associated with carbamazepine induced hypersensitivity reaction in patients of European or Japanese ancestry
HLA A 31:01
Patient profile with the greatest chance of remaining seizure free after drug withdrawal
- Complete medical control of seizures for 1-5 years
- Single seizure type, with generalized seizures having a better prognosis than focal seizures
- Normal neuro examination including intelligence
- No family history of epilepsy
- Normal EEG
After reasonable attempt to withdraw antiepileptic drugs after 2 years, most recurrences occurs when?
First 3 months
Marked increase in seizure frequency around the time of menses
CATAMENIAL EPILEPSY
Pregnant women should take how many mg of folate
1-4mg/day
What is the most common primary headache syndrome
Tension type headache
Prophylaxis or Preventive treatment for headache
TOPIRAMATE
PROPANOLOL
AMITRIPTYLINE
VALPROATE
What is the mechanism of action of sumatriptan
5HT 1B/1D RECEPTOR AGONIST
What is the only proven treatment for CHRONIC tension type headache
AMITRIPTYLINE
Drugs that can be used to treat acute tension type headache
Acetaminophen
Aspirin
NSAIDS
True or false
TRIPTANS can only be effective in MIXED TTH with +MIGRAINE
True
Best treatment option for cluster headache
100% oxygen at 10-12L for 15-20mins
What is the treatment of choice for a Unilateral, severe short lasting episodes of headache, with very frequency attacks (5-40x per day) , has a rapid course and a marked autonomic features ipsilateral to the pain
Diagnosis: PAROXYSMAL HEMACRANIA
TOC: Indomethacin
Presents with EXCRUCIATING PAROXYSMS of lancinating pain involving her right cheek and jaw. (Lancinating : it give u fever or flu sa kasaki)
Speaking, chewing or brushing her teeth can trigger an attack. After pain occurs there is a period of time where she can speak, eat or brush without pain hence paroxysm.
TRIGEMINAL NEURALGIA
What is the most important risk factor for Alzheimer’s disease
Age > 70 years and a POSITIVE family history
Risk factors for Alzheimer’s disease:
Diabetes
History of head trauma with concussion
Women who carries a single APO E4 allele
There widespread neurotic PLAQUES, neurofibrillary tangles [NFTs] and AB accumulation in blood vessels wall In the Cortex And Leptomeninges
Alzheimer’s disease
Medication for Alzheimer’s that is no longer used due to hepatoxicity
TACRINE
Medications used for Alzheimer’s
DONEZEPIL
RIVASTIGMINE
Galantamine
Memantine
Most common source of brain metastases
Lung and breath CA
What malignancy has the greatest propensity to metastasize to the brain
MELANOMA (same embryonic source)
malignancies that will cause hemorrhagic metastases to the brain 🧠
Renal cell ca
Choriocarcinoma
Melanoma
Papillary thyroid carcinoma
Which brain malignancy is characterized by Codeletion of 1p/19q and usually have IDH mutation
Oligodendroglioma
What virus plays an important role in the pathogenesis of primary CNS lymphoma
Epstein Barr virus
In a patient who presents with facial paralysis of wrinkle his forehand or close his eye) , (+)pain behind ear may precede the paralysis for a day or two, (+)decrease taste (+)hyperacusis
Bell’s palsy - MCC of facial paralysis
Normal NE except for facial nerve
Best treatment for Bell’s palsy
Prednisone 60-80mg daily during the first 5 days then tapered over the next 5days
True or false
Antiviral agents (acyclovir or valacyclovir) combination with glucocorticoid maybe marginally better than prednisone alone in severe Bell’s palsy
True
What is the most favorable prognostic sign in Bell’s palsy
Presence of Incomplete paralysis in the first week
In Bell’s palsy, evidence of denervation after 10days on EMG indicates
AXONAL degeneration
In a patient recurrent episodes of vertigo lasting for 30 minutes associated with TINNITUS and a feeling of fullness in his right ear. + Decreased hearing in the right ear.
Normal MRI and neurological exam . What should be the procedure done?
Ménière’s disease
Procedure : audiometry
Patient complains of vertigo lasting for 30mins with movement lasting for 3 weeks, with relief when he lies down. NO HEARING LOSS and with normal NE. (-) DIX HALLPIKE MANEUVER
DIAGNOSIS AND TX?
BPPV
TX: CANALITH repositioning procedure
True or false:
A negative DIX HALLPIKE maneuver does not rule out BPPV
True
What is the most common Antibody target for miller fisher syndrome
Anti-Gq1b IgG found in >90%
May have an acute onset that Mimics GBS but symptoms deteriorate after 9 weeks and relapses at least 3x
Chronic inflammatory demyelination polyneuropathy
CIPD
What is the gold standard for the diagnosis of small fiber neuropathy
Skin biopsy
Systemic malignancy that commonly associated with subacute sensory neuropathy due to antibodies and cytotoxic T cells that cross react with the HU proteins of the dorsal root ganglion neurons resulting in immune mediated neuronal destruction
Small cell LUNG cancer
May present with visual symptoms that are generally monocular and are preceded by periorbital pain aggravated by eye movements
Multiple sclerosis
Chronic use of natalizumab for chronic Multiple sclerosis may cause infection by the John Cunningham virus seen on CSF by PCR
Progressive multi focal leukoencephalopathy
Is an oral sphingosine - 1 phosphate inhibitor that reduces the attack rate and improves all measures of disease severity in multiple sclerosis thru the sequestration of lymphocytes in The periphery thus inhibiting their trafficking to the CNS
FINGOLIMOD (oral) -S1P inhibitor 0.5mg PO OD
Disease modifying therapies for relapsing MS
- FINGOLIMOD
- Dimethyl fumarate
- teriflunomide
Disease modifying therapies for relapsing MS which is a Krediet cycle metabolite with anti-inflammatory effects
Inhibits the ubiquitylation and degradation of nuclear factor E2 related factor
Dimethyl fumarate
Disease modifying therapies for relapsing MS which is a dihydro-orotate dehydrogenase inhibitor, exerts anti inflammatory effects by limiting the proliferation of rapidly dividing T and B cells (CYTOSTATIC)
TERIFLUNOMIDE
Variant of MultiPle sclerosis may present acutely as solitary lesion, often mistaken as brain tumor, and follows a fulminant course typically with no remissions
Marburg’s variant
Diagnostic procedure for myasthenia gravis
(+) anti-Achr radioimmunoassay
Acetylcholine
Negative anti-achr radioimmunoassay does not rule out myasthenia gravis and 40% will have positive
Anti-Musk antibodies
A zero positive MG px was admitted at ICU with respiratory failure, severe weakness and dysphasia. What is the best treatment option:
A course Of 5 five plasma exchanges over a 10 days period
Steroid therapy for myasthenia crisis
Start high dose prednisone 60mg/day given in a single dose
Ina patient diagnosed with MG taking “pyridostigmine 180 mg q hours” complains of excessive drooling, diarrhea, slurring Of speech and worsening of weakness. What is the common side effect?
Acetylcholine inhibitor overdose
Patient shows cholinergic symptoms
What is the most common sign/symptom accompanying severe migraine attacks?
Nausea
52/F, presents with a unilateral, throbbing frontal headache of moderate in intensity and aggravated by movement, associated with nausea and vomiting. The headache is being felt repeatedly and lasting for almost the entire day. PE: normal. What is the most likely diagnosis?
Migraine
