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Clinical Medicine > Neuro 2 > Flashcards

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
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2
Q

Top five RF for seizure disorder?

A

head trauma, stroke, infectious disorders, toxic-metabolic disorders, drug and alcohol withdrawal

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3
Q

Primary neurologic disorders related to seizures:

A

benign febrile convulsions of childhood, idiopathic/cryptogenic seizures, cerebral dysgenesis, symptomatic epilepsy

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4
Q

Treatment of eclampsia

A

magnesium sulfate

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5
Q

What is porphyria?

A

disorder of heme synthesis, produces neuropathies and seizures

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6
Q

Treatment of porphyria

A

gabapentin, pregabalin, levetiracetam

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7
Q

Drug toxicity and drug withdrawal typically results in what type of seizure?

A

generalized tonic-clonic

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8
Q

Unusual drug that causes seizures?

A

isonazid

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9
Q

When does EtOH withdrawal occur?

A

within 48 hours of cessation and resolves within 12 hours

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10
Q

When does sedative withdrawal occur?

A

within 2-4 days, but can be delayed to 1 week

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11
Q

At what age do benign febrile convulsions occur?

A

6 months to 5 years

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12
Q

When do benign febrile convulsions occur?

A

first day of a febrile illness (temp >100.4)

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13
Q

How long do seizures of benign febrile convulsions occur?

A

10-15 minutes and lack focal features

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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

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15
Q

Idiopathic seizures account for x of all new -onset seizures

A

2/3

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16
Q

Seizures within x week after non-penetrating injury are not predictive of a chronic seizure disorder

A

first week

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17
Q

seizures are more commonly seen with hemorrhagic or ischemic stroke?

A

hemorrhagic

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18
Q

Non-epileptic seizures are generally what type?

A

general tonic-clonic with warning

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19
Q

What differentiates non-epileptic seizures?

A

No LOC, no postictal confusion, EEG does not show organized seizure activity

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20
Q

If a seizure/spell event occurs with flaccid unresponsiveness what is likely?

A

hypoperfusion

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21
Q

If flaccid unresponsiveness due to hypoperfusion is prolonged it can lead to brief stiffening or jerking, called:

A

convulsive syncope

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22
Q

Post-ictal state follows what type of seizure?

A

generalized tonic-clonic

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23
Q

A prolonged postictal state follows what type of seizure?

A

status epilepticus

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24
Q

Tongue biting is indicative of what type of seizure?

A

gernalized tonic-clonic

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25
Q

Three essential elements of seizure diagnosis?

A

clinical presentation; specific triggers or provoking event; detailed description of event

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26
Q

Herpes simplex encephalitis EEG

A

hi volt 3/sec TL

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27
Q

CJD EEG

A

burst suppression

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28
Q

hepatic encephalopathy EEG

A

bilateral synchronous triphasic waves

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29
Q

Four key principles of seizure management

A

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

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30
Q

Two MOI of anticonvulsants

A
  • potentiating inhibitory GABA synaptic transmission

- inhibiting excitatory (glutamatergic) transmissions

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31
Q

Nearly all seizure meds can have the SE of?

A

blood dyscrasias and hepatic toxicity

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32
Q

SE of Lamotrigine

A

SJS in first 8 weeks

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33
Q

Phenytoin treats:

A

PGS

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34
Q

Valproic acid treats:

A

PGSMA

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35
Q

Levetiracetam treats:

A

PGM

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36
Q

Lamotrigine treats:

A

PGSA

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37
Q

A seizure can be considered refractory after treatment for?

A

2 years

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38
Q

Epilepsy itself is associated with what birth defects?

A

still birth, microcephaly, seizure disorders

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39
Q

what two seizure drugs are associated with neural tube defects?

A

valproic acid and carbamazepine

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40
Q

What’s the safest anticonvulsant in pregnancy?

A

Lamotrigine

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41
Q

All women on anticonvulsant drugs of child bearing age are given?

A

1 mg/day of folate

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42
Q

What types of seizures are at little risk to a fetus?

A

partial and absence seizures

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43
Q

Which drug needs to be monitored closely due to levels needing to be doubled or tripled during pregnancy?

A

Lamotrigine

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44
Q

When should you consider withdrawing a patient’s seizure meds?

A

After 2-5 years of being seizure free

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45
Q

When removing a seizure med how long should you taper?

A

6 weeks minimum

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46
Q

Which form of seizure (broadly) has aura?

A

focal

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47
Q

Describe a simple partial seizure:

A

movements of single muscle group in face, limb, or elsewhere

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48
Q

In a simple partial seizure, if it spreads to involve neighboring regions of cortex it’s called?

A

Jacksonian march

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49
Q

Autonomic symptoms of a simple partial seizure?

A

pallor, flushing, sweating, piloerection, pupil dilation, vomiting, hypersalivation

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50
Q

Psychiatric symptoms of a simple partial seizure?

A

memory distortions, thought or cognitive deficits, affective disturbances, hallucinations or illusions

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51
Q

Is there LOC with simple partial seizure?

A

No

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52
Q

Is there postictal state with simple partial seizure?

A

yes

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53
Q

How long does postictal state last with simple partial seizures?

A

30 minutes to 36 hours

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54
Q

Complex partial seizure usually occurs in which lobe?

A

temporal lobe or medial frontal lobe

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55
Q

Is there LOC with complex partial seizure?

A

yes

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56
Q

Is there aura with complex partial seizure?

A

Yes (epigastric sensations, fear, deja vus, olfactory hallucinations)

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57
Q

Which form of aura is most common in complex partial seizures?

A

epigastric sensations

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58
Q

How long do seizures last in a complex partial seizure?

A

1-3 minuts

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59
Q

What does the EEG show in complex partial seizure?

A

shows focal TL spikes or appear normal

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60
Q

Partial seizures with secondary generalization look like what other type of seizure?

A

generalized tonic-clonic seizure

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61
Q

Partial seizures with secondary generalization are more likely in adults or children?

A

adults

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62
Q

Describe pathology of generalized seizures

A

depolarization during tonic phase, followed by rhythmic depolarization and repolarization during clonic phase

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63
Q

Do tonic clonic seizures have LOC?

A

yes

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64
Q

Do tonic clonic seizures have aura?

A

usually no

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65
Q

Sequence of a tonic clonic seizure?

A

tonic phase, clonic phase, recovery

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66
Q

What happens in the tonic phase of a tonic clonic seizure?

A

LOC, tonic contraction of limbs for 10-30 seconds; contraction or respiratory and masticatory muscles; patient falls to ground

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67
Q

What happens in the clonic phase of a tonic clonic seizure?

A

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

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68
Q

What happens in the recovery phase of a tonic clonic seizure?

A

confusion and HA; full orientation 10-30 minutes; PE normal, may have + Babinski sign; pupils alway sreact to light

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69
Q

Does tonic clonic seizures have a post-ictal state?

A

yes, usually a few minutes

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70
Q

Whats the big SE of valproic acid?

A

liver damage in children under ten

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71
Q

Is there LOC in absence?

A

yes, 5-10 seconds

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72
Q

Describe absence?

A

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

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73
Q

Three types of absence?

A

typical; atypical; with myoclonus

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74
Q

Describe a typical absence seizure?

A

abrupt cessation of activities, motionless, blank stare and loss of awareness lasting about 10 seconds; attack ends suddenly and resumes normal activities immediately

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75
Q

Describe an atypical absence seizure?

A

longer duration than typical, often accompanied by myoclonic, tonic, atonic, and autonomic features as well as automatisms

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76
Q

Describe an absence seizure with myoclonus:

A

absence with myoclonic components

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77
Q

When do absence seizures begin?

A

Always begin in childhood and rarely persist into adolescence or adulthood

78
Q

Describe a tonic seizure?

A

sustained increase in muscle contraction lasting a few seconds to minutes; drop attacks; respiratory arrest and cyanosis; LOC

79
Q

Describe a clonic seizure?

A

prolonged regularly repetitive contractions involving the same muscle group at a rate of 2-3 cycles per second; LOC

80
Q

Describe a myoclonic seizure?

A

sudden, brief, shock-like, involuntary, single, or multiple contractions of muscle groups of various locations

81
Q

What type of myoclonic seizures are most common?

A

juvenile myoclonic epilepsy

82
Q

Two types of myoclonic seizure?

A

myoclonic atonic; myoclonic tonic

83
Q

Describe atonic seizure?

A

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
Q

Atonic seizures are most commonly seen in?

A

lennox-gastuat syndrome

85
Q

How long does status epilepticus last?

A

5-30 minutes without ceasing OR seizures recur so frequently that full consciousness is not restored between episodes

86
Q

What’s the word for excessive lymphocytes, indicating leukocytosis found in 15% of status epilepticus patients?

A

Postictal pleoyctosis

87
Q

Drug therapy for status epilepticus control?

A

diazepam or lorazepam/midazolam initially; then phenytoin, repeat, phenobarbital. If ineffective use propofol.

88
Q

Special health issues that may result from status epilepticus?

A

hyperthermia, lactic acidosis, leukocytosis

89
Q

Describe confused?

A

disoriented; impaired thinking and responses

90
Q

Describe delirious?

A

disoriented; restlessness, hallucinations, delusions

91
Q

Describe drowsy or somnolent?

A

Can be aroused by minimal stimulus, but poor attention and easily falls back to sleep

92
Q

Describe lethargic?

A

severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep

93
Q

Describe obtunded?

A

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
Q

Describe stuporous?

A

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
Q

Name the levels of consciousness:

A

conscious, confused, delirious, drowsy or somnolent, lethargic, obtunded, stuporous, comatose

96
Q

The ladder of consciousness:

A

normal state –> vegetative state –> general anesthetic –> coma –> brain death

97
Q

Coma results from?

A

lesions that affect the RAS or both hemispheres

98
Q

Three things tested in Glasgow coma scale?

A

eye opening; best motor response; best verbal response

99
Q

Scores for glasgow coma scale go from?

A

3-15

100
Q

Is a high or low glasgow coma scale good?

A

high

101
Q

coma glasgow scale?

A

3-8

102
Q

a sudden coma is likely due to?

A

vasculary, especially brainstem stroke or SAH

103
Q

rapid progression stroke is likely due to?

A

intracerebral

104
Q

longer progression stroke is likely due to?

A

tumor, abscess, or chronic SDH

105
Q

if stroke is preceded by confusion or agitation it’s likely due to?

A

metabolic or infectious cause

106
Q

When does hypothermia occur in coma?

A

caused by ethanol or sedative drug intoxication, hypoglycemia, Wrnicke encephalopathy, hepatic encephalopathy, and myxedema

107
Q

Coma with hyperthermia occurs when?

A

heat stroke, status epilepticus, malignant hyperthermia (related to inhalational anesthetics, anticholinergic drug intoxication, pontine hemorrhage, and certain hypothalamic lesions)

108
Q

What type of eye condition strongly suggest subarachnoid hemorrhage?

A

subhyaloid hemorrhages (superficial retina)

109
Q

Three signs of basilar skull fracture?

A

raccoon eyes, battle sign (swelling overlying mastoid bone), hemotympanum

110
Q

How can CSF rhinorrhea and otorrhea be distinguished from nasal mucous?

A

beta-2 transferrin is unique to CSF

111
Q

What size are the pupils in an opioid OD?

A

1-1.5 mm

112
Q

Normal: 3-4 mm, equal, brisk and symmetric

A

metabolic or toxic cause

113
Q

Thalamic: 2 mm reactive, early compression

A

mass lesions or swelling; interruption of descending sympathetic pathways

114
Q

Fixed, dilated: >7 mm

A

usually compression of CN III and sympathetic nerve fibers; anticholinergic or sympathomimetic drug intoxication

115
Q

Fixed, midsize: 5 mm

A

brainstem damage at the midbrain level, which interrupts both sympathetic, pupillodilator and parasympathetic, pupilloconstrictor nerve fibers

116
Q

Pinpoint: 1-1.5 mm

A

focal pons lesion, or cerebellar (OCR absent); thalamic hemorrhage; opioid OD (OCR intact), organophosphate poisoning, miotic eye drops, neurosyphilis (Argyll Robertson pupils)

117
Q

Anisocoria can indicate what type of lesion?

A

midbrain, CN, or eye lesion

118
Q

Anisocoria of what difference is significant?

A

> 1 mm

119
Q

Disconjugate deviation of eyes indicate?

A

structural brain stem lesion

120
Q

Conjugate lateral deviation of eyes indicates?

A

ipsilateral poutine infarction OR contralateral frontal hemispheric infarction

121
Q

Unilateral dilated, fixed pupil without consensual responses indicate?

A

supratentorial mass lesion, impending brain herniation, posterior communicating aneurysm

122
Q

OCV in conscious patients?

A

nystagmus directed away from stimulus

123
Q

OCV in comatose with intact brainstem?

A

Deviation of eyes toward stimulus; may see conjugate horizontal movements

124
Q

Deviation of eyes toward stimulus; may see conjugate horizontal movements rules out?

A

brainstem lesion

125
Q

Deviation of eyes toward stimulus; may see conjugate horizontal movements suggests?

A

metabolic or bilateral hemisphere lesion causes

126
Q

OCV absent response seen in?

A

sedative drug intoxication, lesion in cerebellum or brainstem, peripheral vestibular disease

127
Q

OCV downward deviation suggests?

A

drug intoxication

128
Q

What OCV is seen in lesion of CN III?

A

ipsilateral eye abducts normally, but no adduction of contralateral eye

129
Q

Decorticate:

A

elbow flex, shoulder adduction, leg ext/IR

130
Q

Decorticate seen in?

A

thalamus or large hemispheric mass/effect compressing thalamus from above

131
Q

Decerebrate:

A

elbow extension, shoulder/forearm IR, leg extension

132
Q

Decerebrate seen in?

A

midbrain dysfunction, more severe damage usually

133
Q

Benzodiazepine antagonist?

A

Flumazenil

134
Q

Considered permanent vegetative state if x if non-traumatic

A

> 3 months

135
Q

Considered permanent vegetative state if x if traumatic?

A

> 1 year

136
Q

What four things can a coma lead to?

A

locked-in syndrome; vegetative state; chronic coma; brain death

137
Q

Vegetative state can lead to what three things?

A

minimally conscious state to evolving independence; permanent vegetative state

138
Q

Causes of locked-in syndrome?

A

pontine infarction, hemorrhage, central pontine myelinolysis, tumor, or encephalitis

139
Q

How can you distinguish a vegetative state from a coma?

A

exhibit spontaneous eye opening and sleep-wake cycles

140
Q

Vegetative state: absence of–

A

awareness of self or environment; purposeful or voluntary behavioral response to all stimuli; language comprehension or expression

141
Q

Vegetative state: presence of:

A

intermittent wakefulness manifested by the presence of sleep-wake cycles; autonomic functions; cranial nerve and spinal reflexes

142
Q

Vegetative state EEG

A

diffuse slow-wave activity; if severe, isoelectric EEG

143
Q

Three conditions of diagnosis of brain death

A

preconditions showing irreversibility; signs showing complete cessation of all clinical brain functions; confirmatory tests

144
Q

preconditions showing irreversibility for brain death

A

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
Q

signs showing complete cessation of all clinical brain functions

A

coma; apnea; brainstem areflexia

146
Q

What’s the most common disabling neurological disorder?

A

Stroke

147
Q

Stroke is a syndrome characterized by these four key features:

A

sudden onset; focal involvement of the CNS; lack of rapid resolution; vascular cause

148
Q

How long does a stroke have to occur to distinguish it from a TIA?

A

24 hours

149
Q

Loss of consciousness occurs in less than x seconds after blood flow to brain has stopped

A

15 seconds

150
Q

Irreparable damage to the brain tissue occurs within x of ischemia

A

5 minutes

151
Q

Clinical symptoms of cerebral ischemia occur when global or regional blood supply falls below? #

A

50 mL per 100 g per minute

152
Q

Global Ischemic Injury

A

occurs in the setting of complete cardiovascular collapse

153
Q

Diffuse hypoxic injury

A

causes include travel to high altitude, severe anemia, pulmoary disease

154
Q

focal ischemia

A

caused by occlusion of vessel

155
Q

Cerebral hemorrhage

A

SAH, ICH

156
Q

Cerebral edema

A

swelling

157
Q

Five types of cerebral ischemia?

A

global ischemic injury, diffuse hypoxic injury, focal ischemia, cerebral hemorrhage, cerebral edema

158
Q

Cerebral edema usually peaks between x and x after onset of ischemic injury?

A

48-72 hours

159
Q

Which is more common hemorrhagic or ischemic strokes?

A

Ischemic

160
Q

Ischemic death of brain tissue occurs when flow is less than? %

A

20% of normal

161
Q

Damage to anterior cerebral artery

A

contralateral leg weakness

162
Q

Middle cerebral artery injury

A

contralateral face and arm weakness greater than leg weakness, sensory loss, visual field cut, aphasia or neglect (depending on side)

163
Q

Posterior cerebral artery injury

A

contralateral visual field cut

164
Q

deep/lacunar injury

A

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
Q

basilar artery injury

A

oculomotor deficits and/or ataxia with crossed sensory/ motor deficits

166
Q

vertebral artery injury

A

lower cranial nerve deficits (vertigo/nystagmus/dysphagia or dysarthria and tongue/ palate deviation) and/or ataxia with crossed sensory deficits

167
Q

Name some anti-coagulants

A

Warfarin, heparin

168
Q

Name some anti-platelets

A

aspirin, clopidogrel

169
Q

Name a thrombolytic

A

rtPA

170
Q

IV administration of rtPA within x hours of onset

A

4.5 hours

171
Q

Treatment of stroke should occur within x minutes of the patient’s arrival

A

60 minutes

172
Q

Indications for rtPA

A

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
Q

Within the first 24 hours of administration of rtPA what shouldn’t be administered?

A

anticoagulants and antiplatelets

174
Q

What should be avoided after rtPA

A

arterial puncture, placement of central venous lines, bladder cath, ng tubes

175
Q

Stroke BP goal

A

<180/105 x 24 hours

176
Q

What orally can occur after stroke?

A

orolingual angioedema

177
Q

How does rtPA work?

A

binds to plasminogen and breaks down fibring strands in the blood clot

178
Q

AE of rtPA?

A

fever, bleeding

179
Q

advantage of rtPA

A

does not cause allergic reactions, does not induce hypotension

180
Q

Other treatments for strokes?

A

intra-arterial thrombolysis; mechanical thrombectomy; carotid endarterectomy; carotid artery stenting; posterior fossa decompression; decompressive craniotomy

181
Q

intra-arterial thrombolysis

A

intra-arterial administration of rtPA; 4.5-6 hours or with history of major surgery

182
Q

Mechanical thrombectomy:

A

within 6 hours; clot retrieval

183
Q

Carotid endarterectomy

A

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
Q

Carotid artery stenting AE

A

associated with an increased periprocedural stroke, but decreased periprocedural MI

185
Q

Posterior fossa decompression for?

A

brainstem compression after cerebellar infarction

186
Q

Decompressive craniectomy to prevent?

A

transtentorial herniation and death in patients younger than 60 years old who deteriorate within 48 hours after large hemispheric strokes

187
Q

Secondary stroke prevention: BP goal

A

<140/85

188
Q

Secondary stroke prevention: diabetes

A

<126

189
Q

secondary stroke prevention: cholesterol

A

<200

190
Q

secondary stroke prevention: LDL

A

<100

191
Q

secondary stroke prevention: INR

A

2-3

Clinical Medicine (13 decks)

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