Neuro Flashcards
Normal pressure hydrocephalus (NPH) pathophys
CSF accumulation causing enlarged ventricle size with little to no increase in intracranial pressure.
Causes of NPH
Idiopathic
HTN
Decreased CSF absorption
Secondary: intracventricular hemorrhage, subarachnoid hemorrhage, trauma, meningitis, infalmmatory disease, cancer, Paget’s disease of skull base, achondroplasia (dwarf)
NPH clinical presentation
Glue-footed gait is first sign
Urinary incontinence
Falling
NPH physical exam
Brisk DRTs
Grasp reflex
Mental status deficits and critcal thinking decreased
Slower in timed tasks
Performs poorly on tests of devided attention
Difficulty with fluency tests and poor learning
NPH diagnosis
Ventriculomegaly without verebral atrophy on MRI
Stretching/thinning of corpus callosum
Lumbar puncture remove 50 mL of CSF and document pt gait before and after lumbar. Normal to high opening pressure
NPH treatment
Shunt from lateral ventricle to peritoneum or atrium
Idiopathic intracranial hypertension symptoms
Headache, papilledema, vision loss
Elevated intracreanial pressure with normal CSF composition
Idiopathic intracranial hypertension risk factors
Females of childbearing age
Overweight
Obesity
Idiopathic intracranial HTN diagnosis
Modified Dandy Criteria
Papilloedema
Normal neurologic exam
Normal neuroimgaing
Normal CSF constituents
Elevated lumbar puncture presssure >25cm CSF
Neuroimaging findings suggestive of raised inrracranial pressure
Empty sella
Flattening of posterior aspect of the globe and tortuous optic nerve
Transverse venous stenosis
Headache in idiopathic intracranial HTN
Worse in morning or with valsalva maneuver
Worsen with posture change
Retrobulbar pain
Pain with eye movement
Idiopathic intracranial HTN physical exam
Papilledema
Loss of visual field and acuity
Sixth nerve palsy
Idiopathic intracranial physical exam diagnosis
Lumbar puncture with elevated opening pressure.
Above 20-25cm H2O
Normal cell counts
MRI with venography to rule out central venous thrombosis
Opening pressure normal value
6-25cm H20
18cm H2O is average
Idiopathic intracranial HTN treatment
CARBONIC ANHYDRASE INHIBITORS (ACETAZOLAMIDE)
Can add furosemide if symptoms don’t subside
Optic nerve sheath fenestration or CSF shunting
Discontinue whatever might have caused it
Weight loss
Low Na diet
Brain tumor headache
Worse in the morning bc CSF can’t drain downward like it should when you stand up
Brain tumor physical exam to check
Speech
Sight
Strength
Sensation
Stability
Fundoscopic exam to look for papiledema from increased intracranial pressure
Upper motor neuron syndrome
After acute injury
Tendon jerks, spasms
Babinski sign
Brain tumor imaging
MRI is preferred
Brain tumor treatment
Surgery, radiotherapy, chemotherapy
Glucocorticoids help with edema improving neurologic funciton (dexmethasone)
Astrocytomas
Derived from gliomas (most common type of malignant primary brain tumor
Pilocytic astrocytoma
Grade 1 astrocytoma.
One of the most common tumors in. children
In cerebellum and optic nerves at brainstem.
Well demarcated
Giant cells usually found in ventricular wall of pts with tuberous sclerosis
Grade 2 astrocytoma
Often in young adults with seizures
Very invasive
Most often it will become malignant astrocytoma decreasing pt survival time to 5-10 years
Grade 3 astrocytomas
Typically in 30-50 yo pts
Surgery following chemo and radiation is best
Temozolmide usually used for chemo
Grade 4 astrocytoma (Glioblastoma)
Most common high grade astrocytoma.
Present in pts 50s-60s
Ring enhancing masses with centralized necrosis and surrounding edema.
Chemo lasts 6-12 months
Median survival rate is 14-18 months
VEGF (bevacizumab) also being used
Oligodendroglioma
Perinuclear clearing and reticular pattern of blood growth (fried egg)
Surgery then radiation and chemotherapy
Ependymomas
RUmors from ependymal cells on ventricular surface
Adults usually have them on filum terminale of spinal cord
Meduloblastomas
Most common malignant brain tumor of childhood
Highly cellular tumors with abundance of dark stainging
75% live long term after treatment
Meningiomas
Most common primary brain tumor
Arise from dura mater and made of meningothelial cells
Dural tail often seen (light bulb appearance)
More common in females
Schwannomas
Generally benign
Acoustic neuromas (vestibular schwannomas) most common
Related to NF2 gene
hearing loss, dizziness, tinnitus.
MRI
Where do tumors metastatic to brain develop
Most develop at gray-white matter junction
What cancer has the highest odds of metastasizing to brian
Melanoma
Most common organ source of brain metastases
Lung and breast carcinomas
What layers of meninges most commonly infected
Leptomeninges (arachnoid and pia mater)
What layer of meninges is most effected by inflammation
Pachymeninges (dura mater)
What type of infection is most common cause of meningitis
Viral
Meningitis early symptoms
Fever
Headache
Stiff neck
No apetite
N/V
Muscle aches
Cryptococcal meningitis pathogen
Cryptococcus gattii
Fungal (yeast)
Found in pigeon droppings
Crosses BBB
Has antiphagocytic capsule
Cryptococcal meningitis presentation
Mostly just in immunocompromised (AIDS)
Present with symptoms of pneumonia
Musculum contagiosum skin lesions
What virus group is most common cause of meningitis
Enteroviruses
Also can be caused by herpes, and arboviruses
Aseptic meningitis
Viral meningitis
Enteroviruses examples
Poliovirus
Rhinovirus
Coxsackie A&B
Echovirus
Viral meningitis symptom
Headache
Neck stiffness
N/V
Malaise
Rash
NO AMS
Viral (aseptic)Meningitis physical exam
Nuchal rigidity
Positive brudzinski (neck flexion produces knee and/or hip flexion)
Positive Kernig sign (Inability to straighten knee with hip flexion)
Viral meningitis diagnostics
Rule out bacterial
Lumbar puncture best test
Viral meningitis lab findings
Lymphocytosis (>5 usually 25-2000)
Normal or low glucose
High protein (>50)
SLightly elevate opening pressure (70-180)
NEGATIVE GRAM STAIN
Viral meningitis treatment
Fever control with antipyretics
Hydration
Anti-emetics
Acyclovir if caused by herpes, epstein barr, varicella zoster
Purulent meningitis
Bacterial meningitis
Usually history of otitis or sinusitis
Bacterial meningitis pathology
Usually hematogenous spread to brain
Adjacent spread (from sinus, skull, orbits)
Acute bacterial infections (nasopharyngial conlonization to blood stream to meninges causing inflammation)
Could come from lyme disease
Strep pneumoniae bacterial meningitis
Most common cause in adults and children >3yo
Neisseria meningitides bacterial meningitis
Most common in oder children (10-19yo)
Second most common in adults
RASH
Group B strep (Strep agalactiae) bacterial meningitis
Most common cuase in neonates <1month from vaginal flora and infants <3months
Listeria monocytogenes bacterial meningitis
Increased incidence in neonates, >50yo, and immunocompromised
Strep pneumonia meningitis risk factors
Alcohol
URTI
DM
Skull fracture
Pneumococcal pneumonia
Listeria monocytogenes meningitis risk factors
Immunocompromised
Age <1month and >60yo
Pregnant
Ingesting contaminated food
Bacterial meningitis clinical findings
AMS
Headache
Neck stiffness
N/V
Fever
Bacterial meningitis late symptoms
Increased intracranial pressure
Papilledema
Poor pupil reactivity
Cushing’s reflex (bradycardia, HTN, irregular respirations)
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