NEURO Flashcards
what is facial palsy?
Hemifacial weakness/paralysis of muscles innervated by CN VII due to swelling of the cranial nerve
What is the typical presentation of a patient with bell pasly?
acute onset of unilateral facial weakness/paralysis. Both the upper and lower parts of the face are affected (differentiate quickly from stroke
What treatment options are available for bells palsy?
most cases resolve in 1 month.
A short course of steroid therapy (prednisone) and acyclovir, if necessary
what are common etiologys of bells palsy?
causes usually uncertain,
- viral (herpes)
-URI may precede acute event
What is the MC type of aneurysm?
Saccular (berry) MC cause of SAH ; aneurysm that occurs at arterial bifurcations and branches of large arteries at the base of the brain (circle of Willis)
Describe cerebral aneurysm that is “fusiform”
Dilation of the entire circumference of the vessel
Describe cerebral aneurysm that is “mycotic”
typically caused
what are signs and symptoms associated cerebral aneruysm?
sudden onset unusually severe worst headache of life, n/v, seizure, altered state consciousness; increased bp, fever 102F
what risk factors are associated with Cerebral Anerusym
smoking, hypertension, hypercholesterolemia, heavy alcohol use; associated with polycystic kidney and coarctation of the aorta
What LP findings are consistent with ruptured cerebral anerusym
LP has elevated opening pressure, bloody fluid (xanthochromia, RBC)
What is imaging is gold standard for cerebral anerusym ?
cerebral angiography (Digital subtraction angiography )
What LP findings are consistent with cerebral anerusym rupture?
Xanthochromia refers to the yellowish discoloration of cerebrospinal fluid (CSF) due to the presence of bilirubin, a breakdown product of hemoglobin.
-bloody fluid, RBC’s
What is the treatment of chocie for ruptured cerebral aneurysm
surgical clipping, endovascular coiling within first 24 hours; restore respiration
types of annerusyms
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a 69-year-old woman who is brought into the emergency department by ambulance after her husband noticed that she began slurring her speech and had developed facial asymmetry during dinner approximately 30 minutes ago. Her past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. She is noted to have a distinct right facial paralysis. Non-contrast head CT is performed, which is negative for blood, what is the most likely etiology?
cerebral vascular accident, most likely ischemic
A patient presents with sudden monocular blindness that resolves within minutes. Which artery is most likely affected?
A) Middle cerebral artery
B) Anterior cerebral artery
C)Carotid/Ophthalmic artery
D) Posterior cerebral artery
C) Carotid/Ophthalmic artery
Which of the following symptoms is most characteristic of a middle cerebral artery (MCA) stroke?
A) Leg paresis and urinary incontinence
B) Homonymous hemianopsia without motor involvement C) Aphasia and gaze preference
D) Vertigo and drop attacks
C) Aphasia and gaze preference
A patient has leg weakness, hemiplegia, and urinary incontinence. Which cerebral artery is likely involved?
A) MCA
B) ACA
C) PCA
D) Basilar
B) ACA
Which artery is most likely involved in a stroke causing coma, cranial nerve palsies, and apnea?
A) Carotid
B) MCA
C) Basilar
D) PCA
C) Basilar
A patient presents with homonymous hemianopsia and no motor deficits. The stroke most likely occurred in which artery territory?
B) PCA
A patient presents with homonymous hemianopsia and no motor deficits. The stroke most likely occurred in which artery territory?
B) PCA
What is the diagnostic test of choice for cerebral vascular accident
CT without contrast to diagnose if its ischemic or hemorrhagic
what is the treatment of choice for occlusive/ ischemic stroke?
IV tPA if within 3-4.5 hours of symptom onset
what is the most significant and treatable risk factor for stroke?
hypertension
endarterectomy is indicated for carotid artery occlusion of ___%
70
headache that is Unilateral, excruciating, sharp, searing, or piercing pain (often at night), lacrimation, and nasal congestion
is pathologic of what neurological etiology?
Cluster Headache
What is the treatment of choice for cluster headaches?
oxygen 100% at 6–12 L/min for 15 minutes via a nonrebreathing mask provides relief within 15 minutes, and Imitrex
Give in combination injectable sumatriptan (if possible)
What glasgow coma scale indicates a COMA?
< 9
Glasgow Coma Scale (GCS)
MOTOR RESPONSE
VERBAL RESPONSE
EYE OPENING
What is complex regional pain syndrome?
Idiopathic pain syndrome disproportionate to injury with continuing pain that is disproportionate to any inciting even
characteristics include
-Following trauma, injury
-Non dermatomal limb pain
Extremity pain and at least 1 other sensory, motor, vasomotor, edema, sudomotor symptom
What is the Budapest Criteria ?
Criteria used for complex regional pain syndrome or clinical diagnosis of continuing pain disproportionate to inciting event
How is Complex regional Pain syndrome diagnosed? CRPS isn’t SMART — but we use S.M.A.R.T. to diagnose it.”
CRPS isn’t SMART — but we use S.M.A.R.T. to diagnose it.”
1 sx in 3 of 4 categories:
S = Sensory symptoms (Pain worse than expected, touch/temp sensitivity) =hyperalgesia and/or allodynia
M = Motor or movement problems (Stiffness, weakness, tremors)
A = Autonomic signs (Color, temp, or sweating changes)
R = Rule out other diagnoses
T = Trophic changes (Hair, nail, or skin changes)
What is the treatment recommended for stage 1 complex regional pain syndrome
Neurontin, Elavil, and bisphosphonates
What is the treatment recommended for stage 2 complex regional pain syndrome
Neurontin, Elavil, Bisphosphonates Add steroids
What is the treatment of choice for stage 3 Complex regional pay syndrome ?
Include pain management specialist ⇒ regional nerve block / spinal cord stimulators
What are the main symptoms of concussion?
confusion, memory loss, and loss of consciousness, followed by a headache, dizziness, and nausea or vomiting
True or False the term “concussion” is often used in medical literature as a synonym for mild traumatic brain injury
true
What is the pecarn decision tool?
The prediction rule for children aged 2 years and older
(normal mental status,
no loss of consciousness,
no vomiting, non-severe injury mechanism,
no signs of basilar skull fracture, and no severe headache) do not need imaging
What is delirium?
an acute cognitive dysfunction secondary to some underlying medical condition and is usually reversible
- acute and rapid deterioration in mental status
what is the most common type of delirium in patients ?
VIsual hallucinations
what is the the most common presentation of altered mental status in the inpatient setting
Delirium
19-year-old man presents with delirium, dilated pupils, tachycardia, urinary retention, and hyperthermia. Which of the following classes of drugs is suspected to be the offending agent the patient ingested?
Anticholinergic drugs
What is neurocognitve disorder?
also known as dementia, it is the long term impariment of cognition or memory disease process that usually represents marked deterioration from a previous level of function
Insidious onset, progressive
What is the most common type of neurocognitative disease ?
Alzheimer’s disease
describe the pathophysiology of alzehimers disease
Loss of brain cells, beta-amyloid plaques, and neurofibrillary tangles
What is the treatment of choice for alzeimers disease?
anticholinesterase drugs (Tacrine, Donepezil)
What defictits associated with Frontotemporal lobar degeneration
Language difficulties, personality changes, and behavioral disturbances
What is the diagnoses of choice for encephalitis ?
Lumbar puncture and MRI
PCR for viruses
What is the treatment of choice for encephalitis?
Treat supportively + Acyclovir until HSV and Zoster are ruled out. Empiric antibiotics are often given until bacterial meningitis is excluded
What key symptom would make you suspect encephalitis over a diagnosis of meningitis?
Altered mental status is a key differentiator
name the first line treatment recommended for essential tremor
Propranolol (first line)
Primidone, alprazolam, small amounts of alcohol, gabapentin, topiramate, or nimodipine
Which of the following statements describes essential tremor?
A. a coarse, resting pill-rolling tremor
B. an action tremor that typically worsens with movement and posture maintance
C. typically treated with levodopa in combo with cardiopa
D. uncommon in members of the same family
E. usually presents as a unilateral tremor
B. an action tremor that typically worsens with movement and posture maintance
What is Giant cell Arteritis?
an inflammatory disease affecting the large blood vessels of the scalp, neck, and arms
usually idiopathic +/- autoimmune
What are signs and symptoms associated with Giant cell Arteritis
Headache, jaw claudication with chewing
Acute vision disturbances – amaurosis fugax (temporary monocular blindness) secondary to anterior ischemic optic neuritis
Thickened temporal artery causing scalp pain
>100
How is Giant cell arteritis diagnosed?
Temporal artery biopsy
What is the treatment of choice for Giant Cell Arteritis?
high dose prednisone – do urgently to prevent blindness (Do not wait for biopsy results)
Ascending paralysis beginning in distal limbs: leg weakness ⇒ total paralysis of all four limbs, facial muscles, eyes, loss of reflexes
Guillain Barre Syndrome
What post infectious causes are most commonly associated with guillianin - Barre syndome
Post-infectious cause: campylobacter jejuni = MC, CMV, Epstein-Barr, HIV
How is the diagnoses of Guillain Barre syndrome made, and how do you treate ?
based on lumbar puncture ⇒ elevated CSF protein with normal CSF WBC
plasma exchange (remove circulating antibodies) and IVIG
Describe the typical presentation of a patient with huntington disease
Dementia, mutism, dysphagia
Chorea ⇒ nonrepeating, complex, involuntary rhythmic movements that may appear purposeful
What MRI findings are consistent with huntingtons disease?
cerebral atrophy and atrophy of the caudate nucleus
What is the classic triad of huntingtons disease
Progressive dementia, chorea, and autosomal dominant inheritance
A 45-year-old patient with a confirmed diagnosis of Huntington’s disease presents with chorea and psychiatric symptoms. Which of the following is the most appropriate treatment approach for managing the chorea associated with Huntington’s disease?
Tetrabenazine is a vesicular monoamine transporter 2 (VMAT2) inhibitor and is commonly used to treat chorea associated with Huntington’s disease. It works by depleting presynaptic stores of monoamines such as dopamine, thereby reducing the involuntary movements characteristic of chorea.
What is the most maligant type of brain intracranial tumor?
Astrocytoma= grade 4= gliobastoma
a 34-year-old man who is brought by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights. His temperature is 103.1° F, blood pressure is 134/82 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient’s neck and the patient’s legs.
Meningtis
What is the classic triad of a patient with meningitis?
headache, fever, and a stiff neck (nuchal rigidity)
Unlike encephalitis, ______ has no mental status changes
Meningitis
name this sign described as knee extension causing pain in neck?
Kernig (“Kernig” starts with a “K”, like “knee”)
Describe the Brudzinski sign
Flexion of the hips during attempted passive flexion of the neck
Describe bacterial etiologies of meningitis
Neonate: E. coli (gram-negative rods) and S. agalactiae (Group B Streptococcus)
Most people: S. pneumoniae (gram-positive diplococci), N. meningitidis (gram-negative diplococci)
Immunocompromised: Cryptococcus neoformans (Diagnosis: India ink stain)
What are the most common viral etiology for meningitis
enteroviruses,
viruses such as herpes simplex virus, HIV, mumps, West Nile virus, and others also can cause viral meningitis
Describe CSF findings on lumbar puncture that would be consistent with bacterial meningitis ?
↑ Protein ↓ Glucose (bacteria love to eat glucose)
Describe CSF findings on lumbar puncture that would be consistent with Viral meningitis ?
No specific characteristics but may have lymphocytes
A headache of varying intensity, often unilateral, and accompanied by nausea and sensitivity to light and sound.
Migraine
What medications are used prophylacitcally for migrane headache?(4)
Atenolol, propranolol, verapamil or TCAs
What medications are used as abortive medications for migrane headaches?
Triptans (do not use in ischemic heart disease), ergotamine (do not use in pregnant women)
What is Multiple Sclerosis ?
A disease in which the immune system eats away at the protective covering of nerves (myelin sheath)
What is Lhermittes’s sign?
electrical shock sensation in limb/ torso brough on by flexion of neck
= commonly associated with multiple sclerosis
What are the most common problems associated with multiple sclerosis ?(4)
Sensory loss, optic neuritis, weakness, parethesias
What are the four different types of MS ?
Relapsing-remitting most common (85%) symptoms come and go – episodic flare-ups occurring over days to weeks between periods of neurologic stability
Secondary progressive (relapsing-remitting progresses to steady decline)
Primary progressive (no remission, steady decline from onset)
MRI showing plaques / Dawson fingers (white matter lesions)
and CSF: Elevated IgG, oligoclonal bands
are consistent with the diangoses of
Multiple sclerosis
What medication is used to prevent relapses in multiple sclerosis
interferon betas
Autoimmuine attack of acetycholine receptors at the neuromuscular junction which results in motor problems
Myasthenia gravis
what is the classical clinicla presentation of a patient with myasthenia gravis?
patient with (eye symptoms) ptosis, diplopia and muscle weakness that worsens with use
The simplest, most common diagnostic tool for myasthenia gravis is the
Tensilon test (edrophonium)
Tensilon prevents the breaking down of the chemical acetylcholine, which then helps stimulate the muscles
name the treatment of choice for myasthenia gravis
Acetylcholinesterase inhibitor (pyridostigmine/neostigmine) = first line ⇒ stops breakdown of acetylcholine
Immunosuppressive drugs (prednisone) ⇒ reduce the production of autoantibodies
What is the gold standard test for diagnosisng myasthenia gravis?
single fiber electromyography
What causes Parkinsons Disease?
Degeneration of basal ganglia cells in the substantia nigra leading to loss of dopamine-containing neurons located in the substantia nigra
What is the medication of choice for Parkinsons disease in patients <65
< 65 dopamine agonists: bromocriptine, pramipexole, ropinirole
Describe a focal sezuire with retianed consciousness
No alteration in consciousness. Abnormal movements or sensations
Describe focal seizures with a loss of awareness
type of focal seizure may also be called a focal dyscognitive seizure (previously known as complex partial seizures)
Altered consciousness, automatisms (i.e. Lip-smacking)
a postictal state (confusion and loss of memory), which differentiates them from absence seizures
What type of seizure involves a postictal state (confusion and loss of memory) which differentiates them from absence seizures
Focal seizures with a loss of awareness
What is the treatment/ drugs of choice for focal seziures ?
phenytoin and carbamazepine
What type of seziure occurs when there is widespread seizure activity in the left and right hemispheres of the brain?
Generalized seizure
describe a absence seziure (formerly known as petit mal)
characterized by a brief impairment of consciousness with an abrupt beginning and ending. At times, involuntary movements may occur, but they are uncommon, and the patient has no recollection, and witnessess commonly miss them
think Staring spells, eyelid flutter, no post-ictal phase
what is a tonic clonic or convulsive seizure formerly known as grand mal)?
Seizure which occurs bilaterally symmetric and without focal onset Begins with a sudden loss of consciousness—a fall to the ground
Tonic phase: very stiff and rigid 10-60 seconds.
Clonic phase: generalized convulsions and limb jerking
Postictal phase: a confused state
What is atonic seizure ?
hint: (also known as drop attacks)
A seziure which looks like syncope, a sudden loss of muscle tone
Convulsion associated with an elevated temperature greater than 38°, > 6 mos < 5 years, absence of central nervous system infection or inflammation
Febrile seizure
What is status epilepticus?
a single epileptic seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between them
this term refers to a transient loss of consciousness/postural tone secondary to an acute decrease in cerebral blood flow, it usually characterized by a rapid recovery of consciousness without resuscitation
Syncope
What is the treatment of status epilepticus
Benzodiazepines (lorazepam) are the preferred initial treatment, after which typically phenytoin is given
What pathology is described as a 25-year-old male presents with a headache. He describes the headache as a tightening, band-like quality on both sides of his forehead. It is non-throbbing, but feels like a “tight cap.” He denies phonophobia or photophobia, nausea, or vomiting. On physical exam, you note pericranial muscle tenderness.
Tension Headaches
Describe Transient Ischemic Attack
A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
Blockage in blood flow does not last long enough to cause permanent infarction
Sudden onset of neurologic deficit, lasting minutes to <1 h (15-30 min on average), a reversal of symptoms within 24 h
What is Amaurosis Fugax and how does it relate to the internal carotid artery ?
monocular vision loss - temporary “ lampshade down one eye “ commonly associated with TIA due to internal carotid artery manifestation
How is TIA typically diagnosed?
CT (without contrast), MRI more sensitive, carotid doppler ultrasound to look for stenosis, CT angiography, MR angiography of the neck
What are the treatment guidelines for TIA ?
Hospital admission for new-onset and recurrent TIA unless a confident diagnosis of the cause of the event can be made
Antiplatelet therapy: Aspirin ± dipyridamole OR clopidogrel
Note: If high-risk → warfarin should be used
