Neuro Flashcards
most common cause of dementia
Alzheimer dz
Definitive diagnosis Alzheimer’s disease
brain biopsy
screening for Alzheimer disease
Mini-Mental Status Examination or the Montreal Cognitive Assessment
meds to treat sx in Alzheimers disease
cholinesterase inhibitors, such as donepezil, galantamine, and rivastigmine
most common form of facial paralysis
bell palsy
what cranial nerve is affected in bell palsy
seventh cranial nerve (facial nerve)
bell palsy is believed to be caused by
herpes simplex virus activation that leads to nerve inflammation, demyelination, and palsy
sx bell palsy
sudden onset of unilateral facial paralysis
PE bell palsy
drooping at the affected corner of the mouth, drawing of the mouth to the unaffected side, inability to close the eye, eyebrow sagging, hyperacusis, decreased tearing, loss of taste on anterior two-thirds of the tongue, and disappearance of nasolabial fold
forehead sparing –> stroke
tx bell palsy
prednisone 60–80 mg/day for 1 week. Ideally, treatment should be initiated within the first 3 days of symptom onset
how do you differentiate delirium and dementia
delirium - evidence the disturbance is caused by a medical condition, substance overdose or withdrawal, or medication side effect
HALLMARK IS INATTENTION
meds associated w delirium
sedatives, anticholinergics, opioids, benzodiazepines, and antihistamines
is delirium reversible
yes usually
assessment for delirium
confusion assessment method
dementia
one or more progressive, age-related deficits in cognition and memory that cause difficulty in daily activities and are not the result of delirium or another treatable medical condition
largest risk factors for the development of dementia
advanced age and cerebrovascular disease
history for dementia
A detailed history should be elicited from both the patient and close relatives regarding the patient’s former functioning, decline in function, velocity of decline, and limitations in daily functioning as the next step. Close relatives should be questioned separately from the patient for more honest answers
tx classes for dementia
cholinesterase inhibitors (Donepazil and Rivastigmine) and N-methyl-D-aspartate receptor antagonists (Memantine)
MC stroke/cerebrovascular accident
ischemic
RF stroke
hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, atherosclerosis, valvular disease, hypercoagulable disorders, and vasculitis. Cigarette smoking and cocaine
common sx stroke
facial droop, slurred speech, and contralateral limb weakness
dizziness, vision loss (homonymous hemianopia), and difficulty walking
most sensitive test for stroke
MRI
what imaging is performed first mainly in ER for someone w stroke
non contrast CT of the head
tx stroke
intravenous thrombolytic therapy with alteplase (recombinant tissue-type plasminogen activator) within 3-4.5 hours of sx onset
high-dose statin therapy and antiplatelet therapy, such as aspirin, should be started within 48 hours, as soon as oral medications can be safely started
tx for pts w stroke with large artery occlusions within proximal anterior circulation
intra-arterial mechanical thrombectomy
most common movement disorder
essential tremor
sx essential tremor
high-frequency postural or action tremor (6–12 Hz) that preferentially affects the upper extremities. The tremor is typically present bilaterally and is slightly asymmetric. Tremors can occur in multiple areas, such as the head, voice, tongue, face, and occasionally the lower limbs
what is essential tremor exacerbated by
anxiety, excitement, or adrenergic stimulation
worsens w age
what is essential tremor relieved by
relieved by small amounts of alcohol
PE essential tremor
tremor is activated by voluntary movement or when the arms are held in a fixed posture, and it is exacerbated during goal-directed activities, such as using eating utensils or finger-to-nose testing
dx essential tremor
bilateral upper limb action tremor without other motor abnormalities, at least 3 years in duration, with or without tremor in other locations, and absence of other neurological signs
any patient under age 40 with an unexplained tremor or other involuntary movements should be evaluated for
Wilson dz
Tx essential tremor
First-line treatment is with propranolol. Primidone can also be used if the patient does not respond to propranolol or is unable to tolerate it
in what population are cluster HA more common
men
sx cluster HA
severe, unilateral orbital, supraorbital, or temporal pain, and restlessness or agitation. Autonomic symptoms occur ipsilateral to the pain and can include ptosis, miosis, anhidrosis, conjunctival injection, nasal congestion, rhinorrhea, and lacrimation
how long can attacks last for cluster HA
15 and 180 minutes and occur up to eight times per day
how many attacks to be diagnosed w cluster HA
at least 5
what should pts undergo during initial evaluation of cluster HA
MRI with and without contrast
tx cluster HA
100% oxygen at 10–12 L/min for 15–20 minutes. Subcutaneous sumatriptan, intranasal sumatriptan, or intranasal zolmitriptan are also effective
where should intranasal sumatriptan be sprayed
contralateral side
preferred agent for long term prevention of cluster HA
verapamil
cluster HA are associated w
depression and decreased quality of life.
Migraines occur due to
occurs due to primary neuronal dysfunction, which results in cortical spreading depression, activation of the trigeminovascular system, and increased neuronal sensitivity
who is more commonly affected by migraines
women
4 distinct phases of migraine
prodrome, aura, headache, and postdrome
migraine prodrome
occurs 24–48 hours prior to the onset of headache and can include an increase in yawning, food cravings, neck stiffness, or changes in mood (euphoria, depression, and irritability).
Approximately one-fourth of patients with migraine will experience the aura phase (classic migraine), and those who do not experience the aura are diagnosed with common migraine
migraine aura sx
visual (bright lines, scintillating scotoma), auditory (tinnitus, hearing loss), language (aphasia, paraphasia, dysarthria), somatosensory (burning, paresthesia, numbness), or motor (jerking, repetitive movements, paralysis)
sx migraine
often unilateral and is described as throbbing or pulsatile. Severity increases over hours. Phonophobia, photophobia, and osmophobia are common. Additionally, nausea is frequent and may be accompanied by vomiting
duration of migraine
4 hours to several days
triggers for migraine
stress, menstruation, barometric pressure changes, dehydration, fasting, and wine
tx migraines
naproxen or acetaminophen (first line)
triptans
Migraine prophylaxis should be considered in
patients with more than four headaches per month or more than seven days per month with a headache
migraine prophylaxis
eta-blockers, such as metoprolol or propranolol, and anticonvulsants, such as topiramate or valproate. Other therapies often employed are antidepressants, including tricyclic antidepressants (amitriptyline), and selective serotonin and norepinephrine reuptake inhibitors (venlafaxine)
most common headache
Tension-type headache
sx tension type HA
mild to moderate, nonthrobbing headache that is bilateral, with pain in the frontal and occipital regions
PE tension type HA
typically vague and include tenderness of pericranial myofascial tissues and increased myofascial trigger points. Patients do not present with nausea or vomiting but may have photophobia or phonophobia. Patients may also report increased stress or mental tension as well as migraine precipitating or aggravating tension-type headaches in patients who have both.
precipitating factors tension type HA
fatigue, loud noise, glare, and stress
dx tension type HA
at least 15 episodes of headache per month lasting 30 minutes to 7 days over 3 months, no nausea or vomiting, either photophobia or phonophobia but not both, and at least two of the following symptoms: bilateral location, pressing or tightening quality, mild to moderate intensity, and not aggravated by routine physical activity
tx tension type HA
nonsteroidal anti-inflammatory drugs and aspirin. Acetaminophen is also an option. Triptans are typically not an effective treatment
prophylaxis tension type HA
Amitriptyline is the recommended first-line treatment to prevent tension-type headache
sx onset Parkinson dz
occurring between 45 and 65 years of age
Parkinson dz is due to
Degeneration of the basal ganglia in the substantia nigra results in dopamine depletion and leads to an imbalance of dopamine and acetylcholine.
sx parkinson dz
resting or pill-rolling tremor, cogwheel or lead pipe rigidity, bradykinesia, postural instability, masked facies or infrequent blinking, cognitive changes, sleep disorders, shuffling gait, and loss of autonomic arm swing during ambulation. Dysdiadochokinesia is a loss of the ability to perform rapid alternating movements and may be present in patients with Parkinson disease
what supports dx of Parkinson disease
Unilateral symptoms at onset support the diagnosis of Parkinson disease, as does improvement of the symptoms after high-dose levodopa therapy
tx parkinson dz
Dopamine agonists (e.g., pramipexole, ropinirole, bromocriptine) should be used in patients < 65 years of age to delay the use of levodopa, which is associated with more adverse effects (e.g., nausea, vomiting, hypotension, dyskinesias). Levodopa with carbidopa is considered the mainstay of treatment for patients > 65 years of age.
levodopa is associated w
on-off phenomenon, in which transient, abrupt fluctuations in motor symptoms occur in response to falling plasma levels of levodopa
What sign seen in Parkinson disease is characterized by a sustained blink response to repetitive tapping over the bridge of the nose?
Myerson sign
dx epilepsy
patient has at least two unprovoked seizures that occur more than 24 hours apart. Seizures are classified as either focal or generalized, referring to the area of onset of electrical activity in the brain.
Automatisms
common with focal seizures and may include lip smacking, fidgeting with the hands, and chewing. Generalized seizures can be classified as tonic-clonic, absence, myoclonic, and atonic.
Tonic-clonic seizures
abrupt loss of consciousness followed by stiffening of the arms and legs and jerking or twitching of the muscles. Tongue-biting and incontinence are common
Absence seizures
more common during childhood and are characterized as frequent brief episodes of sudden staring with impaired consciousness
Myoclonic seizures
sudden brief muscle contractions affecting a group of muscles, usually the arms, with preserved consciousness
Atonic seizures/drop attacks
result in a sudden loss of control of muscles, particularly in the legs
Seizures can be triggered by
flashing lights, hyperventilation, and strong emotions
what should be performed in all adults w first onset of seizure
Magnetic resonance imaging of the brain with contrast
what can be helpful in diagnosing epilepsy, determining seizure type, and evaluating for interictal activity
Electroencephalogram
tx seizure
Following a first-time seizure, patients may not be started on antiepileptic therapy if their neuroimaging and neurological examination are normal
generalized epilepsy: valproate, lamotrigine, and levetiracetam are appropriate first-line options
absence seizures: ethosuximide
focal seizure disorders: lamotrigine, oxcarbazepine, and phenytoin
what can worsen some types of generalized seizures
Carbamazepine and phenytoin
What is the term used to describe periodic paralysis following a seizure?
Todd paralysis
Simple partial seizures
focal seizures in which there is no impairment of consciousness
Complex partial seizures
type of focal seizure in which consciousness is impaired. They are associated with a postictal state, in which confusion or memory loss is present after the seizure subsides.
EEG characteristic of an absence seizure
brief 3 Hz spike-and-wave
EEG complex partial seizure
sharp spikes and slow waves
Status epilepticus tx
medical emergency.
The airway should be protected, and intravenous dextrose administered if hypoglycemia is present. Intravenous lorazepam, intravenous diazepam, or intramuscular midazolam should be given first line, followed by intravenous phenytoin or fosphenytoin
Syncope
transient, self-limited loss of consciousness due to inadequate cerebral blood flow
main causes of syncope
reflex syncope, orthostatic syncope, cardiac dysrhythmias, and structural cardiopulmonary disease
Benign paroxysmal positional vertigo is most common in
women > 60
benign paroxysmal positional vertigo is caused by
loose calcium crystals known as otoconia from the utricle that end up in the posterior semicircular canal.
sx benign paroxysmal positional vertigo
Episodes of vertigo last < 1 minute and are provoked by sudden changes in head position. Hearing loss and neurologic changes are absent.
what is diagnostic for benign positional paroxysmal vertigo
Vertigo beginning within 30 seconds and resolving within 30 seconds of performing the Dix-Hallpike maneuver is diagnostic
tx benign positional paroxysmal vertigo
Epley maneuver is a particle repositioning maneuver
transient ischemic attack
acute episode of neurologic compromise, which could include slurred speech, vision deficit, or extremity weakness, that resolves on its own without causing tissue damage. Most transient ischemic attacks resolve within 24 hours
To identify patients at increased risk for stroke after a transient ischemic attack, the ABCD2 system of risk stratification can be employed
A stands for age. Patients over 60 years are awarded 1 point. B stands for blood pressure. Patients with systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg receive 1 point. C stands for clinical features. Patients with unilateral weakness during the ischemic episode are awarded 2 points, and patients with speech deficits receive 1 point. D stands for duration. If the transient ischemic attack lasted for ≥ 60 minutes, the patient receives 2 points. Symptom duration of 10 to 59 minutes is awarded 1 point. D also stands for diabetes, so patients with diabetes are awarded 1 point. A total score of 6 to 7 indicates a high 2-day risk of stroke. A score of 2 to 5 indicates a moderate 2-day risk of stroke, and a score of 0 or 1 is indicative of low risk.
Patients at moderate to high risk of stroke should receive
both aspirin and clopidogrel daily while awaiting results of imaging
