Neuro 2 Flashcards
1
Q
Criteria for epilepsy diagnosis
A
- two or more unprovoked seizures occur
- one seizure occurs in a person whose risk of occurrence is at least 60%
- one or more seizures occur in context of known epilepsy syndrome
2
Q
Top five RF for seizure disorder?
A
head trauma, stroke, infectious disorders, toxic-metabolic disorders, drug and alcohol withdrawal
3
Q
Primary neurologic disorders related to seizures:
A
benign febrile convulsions of childhood, idiopathic/cryptogenic seizures, cerebral dysgenesis, symptomatic epilepsy
4
Q
Treatment of eclampsia
A
magnesium sulfate
5
Q
What is porphyria?
A
disorder of heme synthesis, produces neuropathies and seizures
6
Q
Treatment of porphyria
A
gabapentin, pregabalin, levetiracetam
7
Q
Drug toxicity and drug withdrawal typically results in what type of seizure?
A
generalized tonic-clonic
8
Q
Unusual drug that causes seizures?
A
isonazid
9
Q
When does EtOH withdrawal occur?
A
within 48 hours of cessation and resolves within 12 hours
10
Q
When does sedative withdrawal occur?
A
within 2-4 days, but can be delayed to 1 week
11
Q
At what age do benign febrile convulsions occur?
A
6 months to 5 years
12
Q
When do benign febrile convulsions occur?
A
first day of a febrile illness (temp >100.4)
13
Q
How long do seizures of benign febrile convulsions occur?
A
10-15 minutes and lack focal features
14
Q
Treatment for benign febrile convulsions?
A
usually self-limited; can treat with diazepam or buccal midazolam; for recurrences–intermittent oral diazepam at onset of febrile illness
15
Q
Idiopathic seizures account for x of all new -onset seizures
A
2/3
16
Q
Seizures within x week after non-penetrating injury are not predictive of a chronic seizure disorder
A
first week
17
Q
seizures are more commonly seen with hemorrhagic or ischemic stroke?
A
hemorrhagic
18
Q
Non-epileptic seizures are generally what type?
A
general tonic-clonic with warning
19
Q
What differentiates non-epileptic seizures?
A
No LOC, no postictal confusion, EEG does not show organized seizure activity
20
Q
If a seizure/spell event occurs with flaccid unresponsiveness what is likely?
A
hypoperfusion
21
Q
If flaccid unresponsiveness due to hypoperfusion is prolonged it can lead to brief stiffening or jerking, called:
A
convulsive syncope
22
Q
Post-ictal state follows what type of seizure?
A
generalized tonic-clonic
23
Q
A prolonged postictal state follows what type of seizure?
A
status epilepticus
24
Q
Tongue biting is indicative of what type of seizure?
A
gernalized tonic-clonic
25
Three essential elements of seizure diagnosis?
clinical presentation; specific triggers or provoking event; detailed description of event
26
Herpes simplex encephalitis EEG
hi volt 3/sec TL
27
CJD EEG
burst suppression
28
hepatic encephalopathy EEG
bilateral synchronous triphasic waves
29
Four key principles of seizure management
1) establish the diagnosis of epilepsy before starting drug therapy
2) choose the right drug for seizure type
3) treat the seizures rather than the serum drug level
4) evaluate one drug at a time
30
Two MOI of anticonvulsants
- potentiating inhibitory GABA synaptic transmission
| - inhibiting excitatory (glutamatergic) transmissions
31
Nearly all seizure meds can have the SE of?
blood dyscrasias and hepatic toxicity
32
SE of Lamotrigine
SJS in first 8 weeks
33
Phenytoin treats:
PGS
34
Valproic acid treats:
PGSMA
35
Levetiracetam treats:
PGM
36
Lamotrigine treats:
PGSA
37
A seizure can be considered refractory after treatment for?
2 years
38
Epilepsy itself is associated with what birth defects?
still birth, microcephaly, seizure disorders
39
what two seizure drugs are associated with neural tube defects?
valproic acid and carbamazepine
40
What's the safest anticonvulsant in pregnancy?
Lamotrigine
41
All women on anticonvulsant drugs of child bearing age are given?
1 mg/day of folate
42
What types of seizures are at little risk to a fetus?
partial and absence seizures
43
Which drug needs to be monitored closely due to levels needing to be doubled or tripled during pregnancy?
Lamotrigine
44
When should you consider withdrawing a patient's seizure meds?
After 2-5 years of being seizure free
45
When removing a seizure med how long should you taper?
6 weeks minimum
46
Which form of seizure (broadly) has aura?
focal
47
Describe a simple partial seizure:
movements of single muscle group in face, limb, or elsewhere
48
In a simple partial seizure, if it spreads to involve neighboring regions of cortex it's called?
Jacksonian march
49
Autonomic symptoms of a simple partial seizure?
pallor, flushing, sweating, piloerection, pupil dilation, vomiting, hypersalivation
50
Psychiatric symptoms of a simple partial seizure?
memory distortions, thought or cognitive deficits, affective disturbances, hallucinations or illusions
51
Is there LOC with simple partial seizure?
No
52
Is there postictal state with simple partial seizure?
yes
53
How long does postictal state last with simple partial seizures?
30 minutes to 36 hours
54
Complex partial seizure usually occurs in which lobe?
temporal lobe or medial frontal lobe
55
Is there LOC with complex partial seizure?
yes
56
Is there aura with complex partial seizure?
Yes (epigastric sensations, fear, deja vus, olfactory hallucinations)
57
Which form of aura is most common in complex partial seizures?
epigastric sensations
58
How long do seizures last in a complex partial seizure?
1-3 minuts
59
What does the EEG show in complex partial seizure?
shows focal TL spikes or appear normal
60
Partial seizures with secondary generalization look like what other type of seizure?
generalized tonic-clonic seizure
61
Partial seizures with secondary generalization are more likely in adults or children?
adults
62
Describe pathology of generalized seizures
depolarization during tonic phase, followed by rhythmic depolarization and repolarization during clonic phase
63
Do tonic clonic seizures have LOC?
yes
64
Do tonic clonic seizures have aura?
usually no
65
Sequence of a tonic clonic seizure?
tonic phase, clonic phase, recovery
66
What happens in the tonic phase of a tonic clonic seizure?
LOC, tonic contraction of limbs for 10-30 seconds; contraction or respiratory and masticatory muscles; patient falls to ground
67
What happens in the clonic phase of a tonic clonic seizure?
alternating muscle contractions and relaxation that is symmetric for 30-60 seconds; muscles then become flaccid; breathing returns; mouth may have frothing saliva; urinary incontinence
68
What happens in the recovery phase of a tonic clonic seizure?
confusion and HA; full orientation 10-30 minutes; PE normal, may have + Babinski sign; pupils alway sreact to light
69
Does tonic clonic seizures have a post-ictal state?
yes, usually a few minutes
70
Whats the big SE of valproic acid?
liver damage in children under ten
71
Is there LOC in absence?
yes, 5-10 seconds
72
Describe absence?
abrupt but brief LOC without loss of postural tone; may have subtle motor manifestations, eye blinking, staring, slight head turning; fully oriented after it stops
73
Three types of absence?
typical; atypical; with myoclonus
74
Describe a typical absence seizure?
abrupt cessation of activities, motionless, blank stare and loss of awareness lasting about 10 seconds; attack ends suddenly and resumes normal activities immediately
75
Describe an atypical absence seizure?
longer duration than typical, often accompanied by myoclonic, tonic, atonic, and autonomic features as well as automatisms
76
Describe an absence seizure with myoclonus:
absence with myoclonic components
77
When do absence seizures begin?
Always begin in childhood and rarely persist into adolescence or adulthood
78
Describe a tonic seizure?
sustained increase in muscle contraction lasting a few seconds to minutes; drop attacks; respiratory arrest and cyanosis; LOC
79
Describe a clonic seizure?
prolonged regularly repetitive contractions involving the same muscle group at a rate of 2-3 cycles per second; LOC
80
Describe a myoclonic seizure?
sudden, brief, shock-like, involuntary, single, or multiple contractions of muscle groups of various locations
81
What type of myoclonic seizures are most common?
juvenile myoclonic epilepsy
82
Two types of myoclonic seizure?
myoclonic atonic; myoclonic tonic
83
Describe atonic seizure?
sudden loss or diminution of muscle tone lasting 1-2 seconds, involving head, trunk, jaw, or limb musculature; loss of postural tone, leading to a fall or drop attack
84
Atonic seizures are most commonly seen in?
lennox-gastuat syndrome
85
How long does status epilepticus last?
5-30 minutes without ceasing OR seizures recur so frequently that full consciousness is not restored between episodes
86
What's the word for excessive lymphocytes, indicating leukocytosis found in 15% of status epilepticus patients?
Postictal pleoyctosis
87
Drug therapy for status epilepticus control?
diazepam or lorazepam/midazolam initially; then phenytoin, repeat, phenobarbital. If ineffective use propofol.
88
Special health issues that may result from status epilepticus?
hyperthermia, lactic acidosis, leukocytosis
89
Describe confused?
disoriented; impaired thinking and responses
90
Describe delirious?
disoriented; restlessness, hallucinations, delusions
91
Describe drowsy or somnolent?
Can be aroused by minimal stimulus, but poor attention and easily falls back to sleep
92
Describe lethargic?
severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep
93
Describe obtunded?
like lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states
94
Describe stuporous?
sleep like state (not unconscious); little/no spontaneous activity. Only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to unresponsive state
95
Name the levels of consciousness:
conscious, confused, delirious, drowsy or somnolent, lethargic, obtunded, stuporous, comatose
96
The ladder of consciousness:
normal state --> vegetative state --> general anesthetic --> coma --> brain death
97
Coma results from?
lesions that affect the RAS or both hemispheres
98
Three things tested in Glasgow coma scale?
eye opening; best motor response; best verbal response
99
Scores for glasgow coma scale go from?
3-15
100
Is a high or low glasgow coma scale good?
high
101
coma glasgow scale?
3-8
102
a sudden coma is likely due to?
vasculary, especially brainstem stroke or SAH
103
rapid progression stroke is likely due to?
intracerebral
104
longer progression stroke is likely due to?
tumor, abscess, or chronic SDH
105
if stroke is preceded by confusion or agitation it's likely due to?
metabolic or infectious cause
106
When does hypothermia occur in coma?
caused by ethanol or sedative drug intoxication, hypoglycemia, Wrnicke encephalopathy, hepatic encephalopathy, and myxedema
107
Coma with hyperthermia occurs when?
heat stroke, status epilepticus, malignant hyperthermia (related to inhalational anesthetics, anticholinergic drug intoxication, pontine hemorrhage, and certain hypothalamic lesions)
108
What type of eye condition strongly suggest subarachnoid hemorrhage?
subhyaloid hemorrhages (superficial retina)
109
Three signs of basilar skull fracture?
raccoon eyes, battle sign (swelling overlying mastoid bone), hemotympanum
110
How can CSF rhinorrhea and otorrhea be distinguished from nasal mucous?
beta-2 transferrin is unique to CSF
111
What size are the pupils in an opioid OD?
1-1.5 mm
112
Normal: 3-4 mm, equal, brisk and symmetric
metabolic or toxic cause
113
Thalamic: 2 mm reactive, early compression
mass lesions or swelling; interruption of descending sympathetic pathways
114
Fixed, dilated: >7 mm
usually compression of CN III and sympathetic nerve fibers; anticholinergic or sympathomimetic drug intoxication
115
Fixed, midsize: 5 mm
brainstem damage at the midbrain level, which interrupts both sympathetic, pupillodilator and parasympathetic, pupilloconstrictor nerve fibers
116
Pinpoint: 1-1.5 mm
focal pons lesion, or cerebellar (OCR absent); thalamic hemorrhage; opioid OD (OCR intact), organophosphate poisoning, miotic eye drops, neurosyphilis (Argyll Robertson pupils)
117
Anisocoria can indicate what type of lesion?
midbrain, CN, or eye lesion
118
Anisocoria of what difference is significant?
>1 mm
119
Disconjugate deviation of eyes indicate?
structural brain stem lesion
120
Conjugate lateral deviation of eyes indicates?
ipsilateral poutine infarction OR contralateral frontal hemispheric infarction
121
Unilateral dilated, fixed pupil without consensual responses indicate?
supratentorial mass lesion, impending brain herniation, posterior communicating aneurysm
122
OCV in conscious patients?
nystagmus directed away from stimulus
123
OCV in comatose with intact brainstem?
Deviation of eyes toward stimulus; may see conjugate horizontal movements
124
Deviation of eyes toward stimulus; may see conjugate horizontal movements rules out?
brainstem lesion
125
Deviation of eyes toward stimulus; may see conjugate horizontal movements suggests?
metabolic or bilateral hemisphere lesion causes
126
OCV absent response seen in?
sedative drug intoxication, lesion in cerebellum or brainstem, peripheral vestibular disease
127
OCV downward deviation suggests?
drug intoxication
128
What OCV is seen in lesion of CN III?
ipsilateral eye abducts normally, but no adduction of contralateral eye
129
Decorticate:
elbow flex, shoulder adduction, leg ext/IR
130
Decorticate seen in?
thalamus or large hemispheric mass/effect compressing thalamus from above
131
Decerebrate:
elbow extension, shoulder/forearm IR, leg extension
132
Decerebrate seen in?
midbrain dysfunction, more severe damage usually
133
Benzodiazepine antagonist?
Flumazenil
134
Considered permanent vegetative state if x if non-traumatic
>3 months
135
Considered permanent vegetative state if x if traumatic?
>1 year
136
What four things can a coma lead to?
locked-in syndrome; vegetative state; chronic coma; brain death
137
Vegetative state can lead to what three things?
minimally conscious state to evolving independence; permanent vegetative state
138
Causes of locked-in syndrome?
pontine infarction, hemorrhage, central pontine myelinolysis, tumor, or encephalitis
139
How can you distinguish a vegetative state from a coma?
exhibit spontaneous eye opening and sleep-wake cycles
140
Vegetative state: absence of--
awareness of self or environment; purposeful or voluntary behavioral response to all stimuli; language comprehension or expression
141
Vegetative state: presence of:
intermittent wakefulness manifested by the presence of sleep-wake cycles; autonomic functions; cranial nerve and spinal reflexes
142
Vegetative state EEG
diffuse slow-wave activity; if severe, isoelectric EEG
143
Three conditions of diagnosis of brain death
preconditions showing irreversibility; signs showing complete cessation of all clinical brain functions; confirmatory tests
144
preconditions showing irreversibility for brain death
presence of a structural brain lesion sufficient to produce all clinical signs; absence of reversible significant toxic or metabolic encephalopathy; sequential repeated testing or one test followed by a confirmatory blood flow test
145
signs showing complete cessation of all clinical brain functions
coma; apnea; brainstem areflexia
146
What's the most common disabling neurological disorder?
Stroke
147
Stroke is a syndrome characterized by these four key features:
sudden onset; focal involvement of the CNS; lack of rapid resolution; vascular cause
148
How long does a stroke have to occur to distinguish it from a TIA?
24 hours
149
Loss of consciousness occurs in less than x seconds after blood flow to brain has stopped
15 seconds
150
Irreparable damage to the brain tissue occurs within x of ischemia
5 minutes
151
Clinical symptoms of cerebral ischemia occur when global or regional blood supply falls below? #
50 mL per 100 g per minute
152
Global Ischemic Injury
occurs in the setting of complete cardiovascular collapse
153
Diffuse hypoxic injury
causes include travel to high altitude, severe anemia, pulmoary disease
154
focal ischemia
caused by occlusion of vessel
155
Cerebral hemorrhage
SAH, ICH
156
Cerebral edema
swelling
157
Five types of cerebral ischemia?
global ischemic injury, diffuse hypoxic injury, focal ischemia, cerebral hemorrhage, cerebral edema
158
Cerebral edema usually peaks between x and x after onset of ischemic injury?
48-72 hours
159
Which is more common hemorrhagic or ischemic strokes?
Ischemic
160
Ischemic death of brain tissue occurs when flow is less than? %
20% of normal
161
Damage to anterior cerebral artery
contralateral leg weakness
162
Middle cerebral artery injury
contralateral face and arm weakness greater than leg weakness, sensory loss, visual field cut, aphasia or neglect (depending on side)
163
Posterior cerebral artery injury
contralateral visual field cut
164
deep/lacunar injury
contralateral motor or sensory deficit without cortical signs (i.e. aphasia/apraxia/neglect/loss of higher cognitive functions), clumsy hand-dysarthria syndrome and ataxic hemiparesis
165
basilar artery injury
oculomotor deficits and/or ataxia with crossed sensory/ motor deficits
166
vertebral artery injury
lower cranial nerve deficits (vertigo/nystagmus/dysphagia or dysarthria and tongue/ palate deviation) and/or ataxia with crossed sensory deficits
167
Name some anti-coagulants
Warfarin, heparin
168
Name some anti-platelets
aspirin, clopidogrel
169
Name a thrombolytic
rtPA
170
IV administration of rtPA within x hours of onset
4.5 hours
171
Treatment of stroke should occur within x minutes of the patient's arrival
60 minutes
172
Indications for rtPA
time of symptom onset <4.5 hours; measurable neurologic deficit; 4-22 on stroke scale; high risk patients often have early CT scan changes showing large area of edema or mass effect
173
Within the first 24 hours of administration of rtPA what shouldn't be administered?
anticoagulants and antiplatelets
174
What should be avoided after rtPA
arterial puncture, placement of central venous lines, bladder cath, ng tubes
175
Stroke BP goal
<180/105 x 24 hours
176
What orally can occur after stroke?
orolingual angioedema
177
How does rtPA work?
binds to plasminogen and breaks down fibring strands in the blood clot
178
AE of rtPA?
fever, bleeding
179
advantage of rtPA
does not cause allergic reactions, does not induce hypotension
180
Other treatments for strokes?
intra-arterial thrombolysis; mechanical thrombectomy; carotid endarterectomy; carotid artery stenting; posterior fossa decompression; decompressive craniotomy
181
intra-arterial thrombolysis
intra-arterial administration of rtPA; 4.5-6 hours or with history of major surgery
182
Mechanical thrombectomy:
within 6 hours; clot retrieval
183
Carotid endarterectomy
surgical removal of thrombus from a stenotic common or internal carotid artery in the neck; indicated for patients with anterior circulation TIAs and high grade extracranial internal carotid artery stenosis
184
Carotid artery stenting AE
associated with an increased periprocedural stroke, but decreased periprocedural MI
185
Posterior fossa decompression for?
brainstem compression after cerebellar infarction
186
Decompressive craniectomy to prevent?
transtentorial herniation and death in patients younger than 60 years old who deteriorate within 48 hours after large hemispheric strokes
187
Secondary stroke prevention: BP goal
<140/85
188
Secondary stroke prevention: diabetes
<126
189
secondary stroke prevention: cholesterol
<200
190
secondary stroke prevention: LDL
<100
191
secondary stroke prevention: INR
2-3
