Neuro Flashcards
New unexplained migraine in female > or = 40 years old =
think patent foemen ovale
Migraine prophylaxis
- Beta blockers (best)
- CCB
- TCA
- AED
Migraine abortives
-Ergotamine tartrate/caffeine
(avoid in pregnancy and cardiovasc dz)
-Sumatriptan
(contra = coronary/peripheral vascular dz)
When are imaging studies indicated for concussion?
-loss of consciousness
-evidence of skull fracture
-focal neuro deficits
-cervical spine injury
(CT of brain WITHOUT contrast = tx of choice)
Tx of concussion
Complete cognitive and physical rest
About post concussive headache
- appears w/in a day or so
- may worsen over time
- disequilibrium, poor concentration, impaired memory, increased irritability, emotional lability (may last for months)
- Tx: simple analgesics, amitriptyline, propranolol, ergot derivatives
Jacksonian March
Starts as a tremble in one limb and moves to other parts of body
About Absence Seizures
-misses words in conversation
-brief impairment (<20sec)
impaired consciousness = blank stare
-starts in childhood
(Petit mal)
About Tonic-Clonic Seizures
Tonic is <1min
- rigid, falls to the ground
- *respiration is arrested
Clonic ~2-3min
- lips or tongue bitten, urinary or fecal incontinence
- flaccid coma, then consciousness, then sleep
- sluggish postictal for min-hrs
How does status epilepticus cause harm?
-permanent brain damage secondary to hyperthermia, circulatory collapse, or excitotoxic neuronal damage
Tx of SE
- ABCs
- manage hyperthermia
- break seizure w/ lorazepam or diazepam
- give phenytoin to prevent further seizures
Valproic Acid SE
Teratogenic
blood monitoring
Phenobarbital SE
blood monitoring
effects cognition
Lamotrigine SE
skin rash
Topirimate SE
weight loss
affects cognition
Oxcarbazepine SE
hyponatremia
Most common type of stroke
85% = ischemic
15% = hemorrhagic
(A.A. have higher mortality than other ethnicities)
Ischemic Stroke-Thrombic
50-60% are thrombic
- occurs during sleep, present upon awakening
- *occur over time**
- more progressive, worsens over several hours
- often have TIA prodrome
Ischemic Stroke-Embolic
10-20% are embolic -cardiac or atherothrombic -occurs at anytime, progresses rapidly **suden** RF: afib, dilated cardiomyopathy, MI in previous 4-6wks
Anterior circulation =
Carotid Arteries
Posterior circulation =
Vertebral arteries
Basilar arteries
Carotid Artery occlusion =
contralateral body weakness
- visual loss: amaurosis fugax (lamp shade over eye); gaze deviation toward infarcted hemisphere
- numbness or parasthesias
- lethargy, stupor
Anterior Cerebral Artery Occlusion
- contralateral paralysis leg > arm
- contralateral sensory loss leg > arm
- apraxic gait
- absent spontaneity, lack of initiative
- lack of concern that something is wrong
Middle Cerebral Artery Occlusion
-contralateral motor and sensory loss
-cortical function loss:
Dominant hemisphere = aphasia, agarphia, aclaculia, alexia
Nondominant = neglect, apraxia, confusion
-gaze deviation toward infarcted hemisphere
-contralateral hemiplegia Arm > Leg
Homonymous Hemianopsia
tPA indications
- w/in 4.5hrs of symptom onset
- 18years of age
- not pregnant
- significant neuro deficit, repeated exam
- no improvement on repeated exam, no seizure activity at onset, no recent arterial puncture or LP
Contraindications to thrombolytics
- BP >185/110
- recent surgery
- recent hemorrhage
- admin of anticoagulants
- arterial puncture at non-compressible site
- internal bleeding
- Hx ICH or suspicion of SAH
- platelets <100,000
- head trauma, period stroke, cranial surgery
Tx of TIAs
- long term modification of risk factors
- surgery for focal carotid stenosis (70-98%)
About Hemorrhagic Strokes
- 15% of all strokes
- 10% = ICH RF: HTN
- 5% = SAH = aneurysm rupture RF: smoking
Subdural Hematomas
Concave lesions on brain CT
-bleed btwn dura and arachnoid membranes
-presentation = headache or confusion
Tx: supportive care, monitor w/ CT, surgery in severe
Epidural Hematomas
Convex lesions on brain CT
Tx: supportive care, monitor w/ CT, surgery in severe
Essential Tremor
-cause unknown or may be autosomal dominant
=intention tremor
Tx of essential tremor
- propranolol
- primidone
- alprazolam
- topirimate
- gabapentin
- or surgery (thalamotomy, deep brain stimulator)
Parkinson’s Dz
-tremor at rest
-rigidity
-bardykinesia
-progressive postural instablity
(dementia and depression are very common)
First line tx of parkinsons
Dopaminergics
-Levodopa w/ carbidopa
Second line tx of parkinsons
Anticholinergics
-benztropine
-Amantadine
(helpful in early, mild parkinsonism; reduces dyskinesias due to chronic levodopa therapy)
Other Meds for tx of parkinsons
COMT inhibitors (stop break down of levodopa)
-entacapone
-tolcapone
Dopamine agonists (activate dopamine receptors in basal ganglia)
-bromocriptine
-pergolide
MAOB Inhibitors (inhibits breakdown of domain in the brain)
-selegiline
About Huntington’s Dz
- Autosomal dominant
- 100% penetrance
- Chromosome 4
- insidiously after 30y/o
- suicide is very common (psychosis then suicide, then chorea)
CT/MRI in Huntington’s Dz
Cerebral atrophy
Myasthenia Gravis
Autoimmune disorder
- PURE MOTOR SYNDROME
- blockage of transmission at Ach receptors
- young females > males @ 20-40y/o
- worsens in evenings
- especially in extra ocular, pharyngeal, facial
How to test for Myasthenia Gravis
-Ach receptor antibody assays for elevated levels
Tx of Myasthenia Gravis
- Anticholinesterase therapy (pyridostigmine bromide; neostigmine)
- Steroids
- Thymectomy (b/c 10% have thymoma cancer)
Guillian Barre Syndrome
- destruction of myelin and or axon by ganglioside antibodies
- ascending paralysis
- distal to central
- *associated w/ campylobacter jejuni**
- viral URI
- diarrhea illness (campylobacter)
- surgery
- immunization
- malignancies (lyphoma, leukemia)
Guillian Barre Syndrome workup
LP -albuminocytologic dissociation -increased protein >45 -pleocytosis, WBC normal Electrophysiology -marked slowing of conduction
Guillian Barre Tx
Symptomatic, immunosuppressive, supportive tx
MS
- inflammatory process
- Multifocal demyelination of the white matter of the brain and spinal cord
- relapsing-remitting pattern w/ chronic progressive course
Presentation of MS
- blurred, double vision in a single eye
- ataxia
- babinski sign
- new neuro symptoms in a young person key pres
MS on MR/CT
MRI = Dawson's fingers CT = plaques
MS CSF
- increased IgG levels
- increased lymphocytes
- oligoclonal bands
- myelin basic protein may be elevated
- glucose is usually normal
Tx of MS
- Corticosteroids for acute attacks
- to reduce freq and relapses = Interferon, IV gamma globulins
- regular exercise
RF for Alzheimer’s Dz
Advancing age, family history, head trauma
also possibly: HTN, hyperlipidemia, smoking, DM
Diagnosis of AD
- functional impairment
- MRI to evaluate for vascular dz
- brain biopsy = gold standard (post-mortem = neurfibrillary tangles, beta-amyloid plaques)
Tx of AD
Acetylcholinesterase inhibitors (donepezil, rivastigmine, glantamine) NMDA antagonist (memantine)
Bell Palsy
U/L paralysis or weakness of facial muscles supplied by CN 7w/o evidence of neuro dz or apparent cause
U/L total or partial paralysis of facial muscles
Bell Palsy can be associated w/
- reactivation of HSV or Varicella Zoster
- Viral infection
- Lyme Dz
- Cancer
- DM
- Pregnancy
- Other
Tx of Bell Palsy
- most resolve spontaneously
- oral prednisone w/ acyclovir
Diabetic Peripheral Neuropathy
Occurs secondary to vascular insufficiency, nerve infarct; associated w/ hyperglycemia
- stocking and glove distribution
- rule out other causes of polyneuropathy
Other causes of polyneuropathy
- uremia
- ETOH and nutritional deficits
- connective tissue deficits
- vasculitis
- vitamin b12 deficiency
- hypothyroidism
- amyloidosis
Tx of diabetic neuropathy
- tight control of serum glucose
- TCA (amitriptyline, nortriptyline)
- AED (carbamazepine, gabapentin)
- Aggressive Mgmnt (lidocaine patch, tramadol)
