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PANCE review > Neuro > Flashcards

Neuro Flashcards

1
Q

What makes up the brainstem (top to bottom)?

A

midbrain, pons, medulla

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2
Q

Myelination is done by what type of cells?

A

Schwann cells in PNS

Oligodendrocytes in CNS

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3
Q

_______ is communication between brain and thoracic and abdominal viscera.

A

Vagus nerve (CN X)

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4
Q

Describe pathway of corticospinal tract.

A

R motor cortex -> cross at medullary pyramids -> anterior horn -> L side muscle

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5
Q

Symptoms of Lower motor neuron lesion

A 
weakness/paralysis
flaccidity
diminished reflexes
fasciculations (twitches)
muscle atrophy
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6
Q

Symptoms of Upper motor neuron lesion

A

weakness/paralysis
spasticity
increased reflexes
Babinski’s sign

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7
Q

What is an abnormal Babinski?

A

stroke bottom of adult foot and big toe goes up

*normal during infancy

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8
Q

clonus

A

repetitive, rhythmic contraction of muscle when it is stretched (commonly ankle)

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9
Q

What are two sensory pathways and what signals do they transmit?

A

Posterior columns: proprioception, discrimination, vibration

Spinothalamic: pain and temp

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10
Q

Where does each sensory pathway decussate?

A

Posterior columns: medulla

Spinothalamic: immediately in spinal cord

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11
Q

Trace pathway of proprioception, vibration, and discrimination sensation from left side to body to brain.

A

L body -> posterior spinal cord -> posterior column -> cross at medulla -> medial lemniscus -> R thalamus

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12
Q

If pain/temp sensation loss on left side of body, then where is possible lesion?

A

right spinal cord or right thalamus

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13
Q

What pathology destroys an entire half of the spinal cord?

A

Brown-Sequard Syndrome

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14
Q

C6 dermatome

A

thumb

lateral arm

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15
Q

C7 dermatome

A

digits 2 and 3

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16
Q

C8 dermatome

A

digits 4 and 5

medial arm

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17
Q

Dermatome that runs back of calf to lateral foot

A

S1

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18
Q

Dermatome that runs down posterior arm and hand

A

C7

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19
Q

Dermatome that runs down shin to top of foot

A

L5

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20
Q

Which cranial nerves exit from each division of brainstem?

A

2-4 midbrain
5-8 pons
9-12 medulla

  • Olfactory and vision pathway don’t go to brainstem
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21
Q

Effects of optic nerve lesion

A

blindness in one eye, other eye unaffected

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22
Q

Effects of left optic tract lesion

A

blindness in right hemisphere of each eye

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23
Q

Which cranial nerves innervate the extraocular muscles?

A

CN III, IV, VI

IV: superior oblique
VI: lateral rectus
III: all the rest (IO, SR, IR, MR)

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24
Q

Effects of complete CN III lesion

A

ipsilateral eye is “down and out”
dilated pupil
ptosis (drooping eyelid)

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25
Cranial nerves involved in pupillary light reflex
oculomotor (CN III) - allows eyes to constrict with light optic (CN II) - allows consensual response if CN III intact
26
Signs of Horner's Syndrome
ptosis miosis (constricted pupil) anhidrosis (loss of sweating) * loss of sympathetic pathway to face and eyes
27
_____ is only cranial nerve to project contralaterally.
CN VI
28
What are functions of cranial nerves that innervate the face (sensory and motor)?
CN V sensory: 3 branches - ophthalmic, maxillary, mandibular CN VII motor: chewing muscles * both involved in corneal reflex
29
Bell's Palsy vs Cerebral stroke
Bell's Palsy: CN VII lesion, paralysis of entire ipsilateral face Stroke: UMN lesion, facial droop on contralateral side but forehead unaffected
30
Lesion affecting CN VIII that causes unilateral hearing deficit?
acoustic neuroma (or vestibular schwannoma)
31
What is the vestibulo-ocular reflex?
vision steady while head rotates side to side "doll's eye" test in coma patient to determine if brainstem intact
32
What nerve may be damaged if absent gag reflex?
CN IX (glossopharyngeal)
33
If when patient says "ahhh" uvula deviates to the left, then where is the lesion?
Right side of CN X (vagal)
34
How is CN XI tested?
test strength of shoulder shrug and head rotation (trapezius and SCM muscles)
35
How is CN XII tested?
"stick out your tongue" tongue will deviate toward lesion side
36
Effects of cerebellar lesion
"Errors of rate, range, force, and direction" IPSILATERAL ataxia, intention tremor, nystagmus, vertigo
37
Effects of basal ganglia lesion
CONTRALATERAL chorea, resting tremor, akinesia, rigidity
38
Pathophysiology of Parkinson's
shortage of dopamine due to degeneration of substantia nigra (midbrain) motor regions of cerebral cortex inhibited
39
Hallmark signs of Parkinson's
bradykinesia resting tremor lead-pipe or cogwheel rigidity shuffling, hunched-over gait
40
Main treatment of Parkinson's
L-Dopa
41
Side effects of anti-Parkinson meds
Hallucinations, Schizophrenia (too much dopamine)
42
dementia vs delirium
delirium is an acute change in mental status dementia is progressive decline in cognitive function
43
CT/MRI results of Parkinson's
NORMAL; used to r/o other causes
44
Lewy Bodies may be seen on an autopsy of the brain in...
Parkinson’s disease Dementia with Lewy bodies Alzheimer’s disease
45
Risk factors of cerebral aneurysm
``` Smoking ETOH HTN Obesity PCOS Marfan syndrome ```
46
A ruptured cerebral aneurysm ( | Berry aneurysm) is common cause of ___________.
subarachnoid hemorrhage
47
How to manage a cerebral aneurysm?
Known aneurysms monitored: BP control Cholesterol control F/U imaging
48
Location of cerebral vs epidural vs subdural vs subarachnoid hemorrhages
cerebral - within parenchyma or ventricle epidural - btwn dura and skull subdural - btwn dura and arachnoid mater subarachnoid - btwn arachnoid and pia mater
49
Which brain bleed most often caused by trauma?
epidural
50
Severe headache “The Worst Headache of my life!” lasting hours to day =
subarachnoid hemorrhage
51
Gold standard for inter-hemorrhage bleeding dx
Non-contrast head CT
52
How are subdural and epidural hemorrhages differentiated?
crescent shape bleed on CT = subdural biconcave/rounded bleed = epidural
53
Inter-hemorrhage bleeding treatment
``` Reduce ICP (steroids, Mannitol) Control BP Pain killers Anti-seizure meds Surgery: Craniotomy, surgical clipping, endovascular coiling ```
54
Risk factors of stroke/TIA
``` Increasing age African American, American Indian, Hispanics HTN Smoking Diabetes Oral contraception ETOH Afib Heart valve issues Endocarditis ```
55
2 types of stroke? Which more common?
Ischemic (85%) | Hemorrhagic
56
define dysarthria
motor speech disorder due to neurological injury
57
define apraxia
altered voluntary movements
58
Signs of increased intracranial pressure?
``` Vomit w/o nausea Headache Papilledema Seizures Behavior changes Cushing's response (HTN, bradycardia) ```
59
"FAST" exam to identify location and severity of stroke
Face: facial droop Arms: unilateral weakness Speech: slurred Time: seek immediate medical attention
60
What PE exam is used to assess stroke risk?
Look for bruit with U/S Doppler of carotids
61
How to treat ischemic stroke?
Aspirin immediately tPA within 4.5 hours Angioplasty and stents
62
How to treat hemorrhagic stroke?
Surgery: clipping, coiling, hemicraniectomy Meds: Mannitol, corticosteroids
63
Contraindications to tPA use in strokes
``` Suspected intracranial bleed Recent surgery Recent head trauma Active bleeding Intracranial neoplasm HTN > 185/110 ```
64
How is TIA different than full stroke?
- No brain tissue death | - Symptoms typically resolve in an hour
65
Define amaurosis fugax
temporary loss of vision (possible TIA or carotid stenosis)
66
DDX of altered mental status
``` High ICP Dehydration (or insulin overdose) Hypoglycemia Uremia Hyper/hypothermia Meningitis Stroke/TIA Concussion/brain injury Meds/Drugs ```
67
Work up of altered mental status
- Neuro exam: AAOx3, LOC, GCS - Pulse ox - Serum glucose - CBC - CMP (liver, kidney fxtn) - Tox screen - Head CT or MRI
68
Glasgow Coma Scale
Eye movement 1-4 Verbal response 1-5 Motor response 1-6 "less than 8 intubate" 13-15 = concussion 3 = dead
69
How to treat altered mental status from hypoglycemia?
IV Dextrose
70
Mother brings in 12 month old son because he is not showing signs of delayed development - poor muscle tone, has not started walking or talking, and has not been feeding well. He was born premature and at low birth weight. What is likely dx?
Cerebral Palsy
71
Cerebral Palsy treatment
SYMPTOMATIC ``` Benzos (Diazepam) muscle spasms IM Botulinum toxin injection – muscles with spasticity Antiepileptic meds – minimize seizures PT/OT Special ed and learning strategies Behavior therapy and counseling ```
72
What is the #1 risk factor for a child having CP?
prematurity
73
Causes of dementia
``` Alzheimer's (75%) Brain injury Lewy Body dementia Hypothyroidism Vit B12 deficiency Lyme Disease Neurosyphilis ```
74
Labs to run to determine cause of dementia
``` Vit B12 Folic acid TSH CRP CBC Electrolytes Renal function Liver function ```
75
Possible medical treatment of dementia
Acetylcholinesterase inhibitor (Donepezil) Antipsychotics (Risperdal) SSRIs
76
What meds can cause delirium?
anticholinergics | opioids
77
A patient presents with very poor attention. Is this likely dementia or delirium?
delirium
78
Pathology with rapid bilateral ascending paralysis =
Guillain-Barre Syndrome
79
Signs of autonomic fiber deficit
Orthostatic hypotension Changes in heart's rate and rhythm Fluctuating BP Dry eyes and mouth
80
Lumbar puncture results of Guillain-Barre syndrome
elevated proteins | no increase in WBC
81
Pathophysiology of Gullain-Barre syndrome
rapid demyelination of peripheral nerves * MS is demyelination of CNS
82
Gullain-Barre treatment
Immediate IVIG or plasmapheresis | ventilator support
83
Pathophysiology of Multiple Sclerosis
Loss of myelin in CNS (PNS is normal) Possibly autoimmune, infection, genetics???
84
Hallmark signs of multiple sclerosis
Uthoff's phenomena = worsening of sx in the heat L'Hermitte sign = electrical sensations down spine with patient flexes neck Optic neuritis Bladder dysfunction
85
Clinical course of MS
relapsing-remitting; series of normal periods with intermittent flares
86
How to treat acute MS attacks?
``` HD corticosteroids (prednisone, IV Solu-Medrol) Plasma exchange (IVIG) ```
87
How to slow progression of MS?
``` Beta interferons Monoclonal antibodies (-umab) Vitamin D ```
88
Pathophysiology of Myasthenia Gravis
Autoimmune disorder where ACh receptors are blocked by antibodies
89
Patient comes in c/o increased weakness causing ptosis, diplopia, and SOB. The sx's seem to improve with rest. There are NO sensory deficits. What must be considered?
Myasthenia Gravis
90
How to differentiate Myasthenia Gravis and Guillain-Barre Syndrome?
Check reflexes and sensation ``` MG = normal GBS = areflexia, loss of proprioception ```
91
Dx testing for Myasthenia Gravis
Blood: ACh receptor antibodies EMG: muscles fatigue with repetitive stimulation CXR/CT/MRI: tumor or thymoma?
92
How is Lambert-Eaton Syndrome different than Myasthenia Gravis?
Lambert-Eaton autoimmunity against influx of calcium (ACh receptors in MG) Repetitive stimulation on EMG will improve symptoms (EMG causes fatigue in MG)
93
Medical therapy for Myasthenia Gravis
Long acting anti-cholinesterase meds Immunosuppressive drugs Removal of thymus if thymoma
94
Clinical definition of epilepsy
recurrent seizures; 2 or more unprovoked seizures
95
2 broad categories of seizures and how they are different?
Generalized - involve entire brain | Partial - involve small region of brain
96
Which seizures are Generalized?
``` Grand mal Absence Clonic Myoclonic Tonic Atonic ```
97
Which seizures are Partial seizures?
Simple Complex Partial with secondary generalization
98
simple vs complex partial seizure
simple - conscious | complex - impaired awareness; can't recall event, often with aura
99
Characteristics of grand mal seizure
unconscious ictal cry at onset convulsions of tonic and atonic postictal phase after
100
Seizure of only a brief loss of consciousness without loss of postural tone =
absence (petit mal)
101
Most common epidemiology of absence seizures
children with epilepsy
102
What is an atonic seizure?
sudden loss of postural tone with brief LOC | eg. head drop
103
Peak incidence of febrile seizures
18-24 months old
104
Febrile seizures management
Reassure parent | Tylenol
105
Jacksonian March
seizure that spreads from distal limb to larger region
106
How to determine which type of seizure a patient has?
EEG (electroencephalogram) - generalized: spikes and slow waves - simple partial: focal rhythmic discharges - complex partial: intricate spikes with slow waves
107
Why do lumbar puncture for seizure?
to diagnose possible CNS infection
108
A life-threatening neurologic disorder defined as 5 minutes or more of a continuous seizure activity or several clinical seizures without return to baseline in between
Status epilepticus
109
Medications for status epilepticus
Benzos 1st line - Lorazepam | Anticonvulsants - Phenytoin
110
Cardiac and non-cardiac causes of syncope
Cardiac: Arrhythmias, heart valves d/o, HTN, aortic dissection, cardiomyopathy Non-cardiac: Postural hypotension, dehydration, high altitude, TIA, migraine, situational syncope (blood drawing, micturition, defecation, swallowing, coughing)
111
Pathophysiology of syncope
global cerebral hypoperfusion
112
Symptoms of syncope
``` Pale, cold skin Partial or complete LOC Lightheaded Nausea Blurred vision ```
113
Tilt table test
to elicit orthostatic syncope secondary to autonomic dysfunction
114
Syncope treatment
``` Position patient on ground, with legs slightly elevated or leaning forward with head between knees x 10-15 mi IV access Oxygen administration Advanced airway techniques Glucose administration Pharmacologic circulatory support Defibrillation or temporary pacing ```
115
Epidemiology of Tourette disorder
2-15 yo
116
Symptoms of Tourette disorder
``` Motor tics (blinking, tongue, jerking, etc.) Vocal tics (yelling, swearing, throat clearing) ```
117
How to rule out other conditions that may be causing tics in Tourette?
``` EEG – if tics and seizure activity exists MRI – brain abnormalities TSH levels - hypothyroidism Urine drug screen Serum Copper – Wilson’s disease ```
118
Treatment of Tourette disorder?
Deep brain stimulation Behavioral therapy Dopamine antagonists (fluphenazine, pimozide) * Haloperidol is historically the drug of choice
119
Definitive way to differentiate syncope from seizure?
EEG to pick up abnormal firing patterns in brain
120
Main excitatory and inhibitory neurotransmitters in the brain
glutamate excitatory | GABA inhibitory
121
Why is CT done before a lumbar puncture?
CT to look for signs of increased ICP (e.g. ventricular dilation) LP with increased ICP can cause negative pressure in spinal canal and possible herniation
122
How is equilibrium of CSF level in brain maintained?
choroid plexus produces it, while arachnoid granulations reabsorb it into the venous system
123
_______ is caused by increased CSF in the brain.
hydrocephalus
124
What is Cushing's response?
HTN, bradycardia, and irregular respirations in response to increased ICP and/or hydrocephalus
125
What is pseudotumor cerebri? How is it treated?
signs of elevated ICP, but brain appears normal on CT Tx: Acetazolamide (decreases CSF production), LP shunt to decrease ICP
126
Meningeal signs
Nuchal rigidity Brudzinski's sign: involuntary flexing of hip and knees when neck flexed Kernig's sign: flexing hip 90 degrees then extending knee causes pain
127
Layers of head from skull to brain
bone, epidural space, dura mater, subdural space, arachnoid membrane, subarachnoid space, pia mater, brain parenchyma
128
Most common offending organisms of meningitis in neonates, children, and adults?
Neonates: GB strep, E. coli, Listeria | Children/Adults: H flu, strep pneumo, N. meningitidis
129
Viruses that cause meningitis
Herpes simplex CMV HIV
130
Treatment of epidural bleed
Burr hole drainage
131
Common organisms causing epidural and subdural abscesses
staph aureus | streptococcus
132
Typical cause of encephalitis
VIRAL - HSV, enterovirus, mumps, rabies, mosquito borne (West Nile, St. Louis Encephalitis)
133
Results of CSF exam for a bacterial infection
increased WBCs (neutrophils) increased protein decreased glucose
134
Blood on CSF exam indicates what?
bright red that goes away - trauma of spinal tap yellowish blood (xanthochromia) - subarachnoid hemorrhage
135
Predominance of PMNs on lumbar puncture =
bacterial meningitis
136
Broca's aphasia
deficit in language production (both spoken and written) | preserved comprehension
137
Wernicke's aphasia
deficit in understanding language | "word salad"
138
Effects of middle cerebral artery stroke
face, arm > leg deficits on contralateral side | Broca and Wernicke aphasias if left MCA
139
Effects of anterior cerebral artery stroke
leg > arm deficits on contralateral side | lack of motivation due to frontal lobe ischemia
140
Effects of posterior cerebral artery stroke
vision changes on contralateral side
141
A pure sensory deficit can occur from infarct of _______.
thalamus
142
Ipsilateral CN III palsy Contralateral hemiplegia Location of stroke?
Midbrain (PCA ischemia)
143
Right-sided facial numbness and weakness Loss of right eye abduction Left-sided hemiplegia Location of stroke?
Right pontine (basilar ischemia)
144
Deviation of uvula to right Right-sided muscle weakness and loss of sensation Signs of Horner's syndrome Location of stroke?
Left medullary stroke
145
Right-sided ataxia Location of lesion?
Right cerebellum
146
Compression of what nerves can lead to incontinence and impotence?
S2-S4
147
Which nerves does the patellar reflex test?
L3/L4 (quad muscle)
148
Which nerves does the Achilles reflex test?
S1/S2 (gastrocnemius muscle)
149
Which nerves innervate the bicep?
C5/C6
150
Which nerves innervate the tricep?
C7/C8
151
DDX of weakness alone with no sensory changes
- Motor pathway deficit (pure motor stroke or ALS) - NMJ deficit (Myasthenia Gravis) - Muscle pathology
152
Signs of ALS
insidious, progressive motor weakness mix of UMN and LMN findings NO affect on sensory pathways, eyes, bladder/bowel like MS
153
shingles of CN VII that causes severe facial palsy and vesicular eruption in external auditory canal or pharynx
Ramsay Hunt Syndrome
154
Distal sensory loss and muscle weakness in "unathletic" child may be what inherited disease?
Charcot Marie-Tooth
155
Metabolic deficiency that can cause peripheral neuropathy
B12 deficiency
156
Medications that cause tardive dyskinesia?
dopaminergic antagonists - antipsychotics
157
Stroke with ipsilateral gaze preference =
middle cerebral artery
158
Spontaneous seizure and brain bleed in previously asymptomatic young patient. Likely dx?
AV malformation
159
Headache with "band-like" tightness
Tension HA
160
Preventative treatment of tension headaches
Amitriptyline
161
How are migraines differentiated from other headaches?
unilateral N/V photophobia aura
162
Abortive treatment of tension HA
NSAID, Tylenol, Excedrin | Toradol if in ER
163
Abortive treatment of migraine HA
Mild: NSAID, Tylenol Moderate: Excedrine, Triptans Severe: Toradol, Metoclopramide, Ergotomines, Opioids * must treat before HA starts
164
Possible prophylaxis for migraines
BB, CCB, Amitriptyline, SSRI, antiseizure, diet changes
165
Treatment for cluster headaches
100% oxygen x 15 min
166
What symptoms make you worry that tension HA may be a tumor?
new or different HA in adult N/V worse with exertion signs of increased ICP
167
Descending paralysis + intact sensation and mentation =
Botulism
168
Pathophysiology of Botulism
Clostridium toxins block release of ACh at NMJ
169
When to do CT on head injury?
``` GCS less than 15 Basilar fx signs 2+ vomiting Age over 65 Amnesia over 30 min Dangerous injury Seizures Neuro deficits ```
170
Signs of basilar skull fracture?
Battle sign Raccoon eyes Hemotympanum Otorrhea or rhinorrhea
171
Signs of Alzheimer's Dementia
MEMORY LOSS impaired formation of new memories anosognosia (lack of insight) executive dysfunction
172
Mainstay treatment of Alzheimer's and its MOA
Donezepil - acetyl cholinesterase inhibitor to increase cholinergic function
173
GABA analog used to treat neuropathic pain, seizures, and anxiety
Pregabalin (Lyrica)

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