Neuro Flashcards
a patient in a MVA is alert then suddenly becomes vegetative; CT shows minute punctate hemorrhages with blurring of grey-white border; what is the diagnosis?
diffuse axonal injury (key clues: deceleration injury, sudden rapid decline, sx out of proportion to CT findings, grey-white border damage in the area where densities are different)
steps of working up a solitary pulm nodule
chest x-ray, compare to previous, if stable do nothing, if new do chest CT, if benign do serial CT’s, if suspicious do PET or biopsy, if definite malignancy surgery
a patient with previous whiplash injury develops decreased pain and temp sensation in upper extremities along with weakness; what is the diagnosis
syringomyelia (CSF expansion of the central canal leads to compression of spinothalamic crossing fibers and possibly cervical and thoracic portions of corticospinal tracts)
what are four main pathognomonic symptoms of fetal alcohol syndrome
- small palpebral fissures
- smooth philthrum
- thin upper lip
- microcephaly
how do you differentiate between cauda equina syndrome and conus medularis syndrome
cauda equina syndrome involves UNILATERAL radicular pain, saddle hypoesthesia, asymmetric muscle weakness, hyporeflexia due to peripheral neuropathy
conus medularis involves BACK PAIN w/o significant radicular pain, perianal hypoesthesia and symmetric muscle weakness and hyperreflexia (more of an UMN b/c it is part of spinal cord)
what is the most common pediatric brain tumor
astrocytoma (note: they can be infratentorial or supratentorial)
what differentiates a complex partial seizure with lip smacking from an absence seizure with lip smacking
in absence there is no post-ictal state; also, hyperventilation during EEG can reproduce an absence seizure pattern (3Hz spike and wave pattern)
what’s the difference between a typical vs. atypical absence seizure
atypical absence seizure lasts longer and has slower spike and wave pattern (
what is Lennox Gastaut syndrome
childhood seizures of multiple types, impaired cognition, slow spike and wave EEG activity
a patient on metoclopramide for gastroparesis develops muscle pain and contraction; why is this and what do you do for it
dystonic reaction; metoclopramide is a dopamine antagonist and like the antipsychotics can cause extrapyramidal symptoms like parkinsonisms, dystonic rxns and rarely NMS; tx=benztropine or diphenhydramine
in what condition do you see albumino-cytologic dissociation
Guillain-Barre
what CSF findings are characteristic of Multiple Sclerosis
oligoclonal bands (IgG relative increase compared to other classes); however a CSF IgG index can have false positives
port-wine stain, leptomeningeal angiomas, glaucoma, seizures, mental retardation are all a part of what syndrome
Sturge-Weber
what are the symptoms of tuberous sclerosis
HAMARTOMA: hamartomas, adenoma sebaceum, mitral regurg, ash-leaf spots, rhabdomyoma, (tuberous sclerosis), autosomal dOminant, mental retardation, renal Angiomyolipoma, seizures
you diagnose a patient with likely Guillain Barre; what should you do next for management?
serial spirometry to assess FEV and FVC to determine if intubation is needed (peak flow is a less accurate alternative)
how does hyperventilation help decrease intracranial pressure
increased paCO2 promotes vasodilation and increased cerebral blood flow; lowering the CO2 in the blood promotes vasoconstriction to lower cerebral blood flow and thereby lower intracranial pressure
what is the most important risk factor for stroke
hypertension (not smoking)
sporadic upper motor and lower motor neuropathies with no sensory deficits is characteristic of what disease
Amyotropic Lateral Sclerosis
what drugs are used to treat Alzheimers
cholinesterase inhibitors (donepezil, galantamine, rivastigmine) and the NMDA-R antagonist memantine
what is the treatment for a solitary brain met vs. multiple brain mets
for a single brain met: surgical resection, then follow with stereotactic radiosurgery or whole brain radiation therapy
multiple mets: whole brain radiation therapy or supportive therapy
what is Todd’s paralysis
post-ictal paralysis
how do you differentiate between the two causes of ring enhancing lesions in an AIDS patient
toxoplasmosis usually shows multiple lesions (toxo serologies are not confirmatory as they are positive in many people) whereas CNS lymphoma would be a single lesion (check for CSF EBV DNA to confirm dx)
if you see EBV DNA in the CSF of a patient you should be thinking what condition
CNS lymphoma
an exclusively breastfed baby develops bilateral bulbar palsies followed by descending flaccid paralysis; what is the diagnosis and how do you treat it
botulism (via ingestion of dust-borne spores)
tx=human-derived botulism immune globulin
how can you differentiate between botulism and Werdnig-Hoffman (spinal muscular atrophy)?
spinal muscular atrophy does not affect the pupils and the motor weakness is more pronounced in the lower extremities than upper
what medications predispose to pseudotumor cerebri
tetracyclines and isotrentinoin (hypervitaminosis A)
what is Shy-Drager syndrome
Shy-Drager syndrome also known as multiple system atrophy involves Parkinsonism, autonomic dysfunction (orthostatic hypotension, incontinence, gastroparesis, etc.) and widespread neurologic deficits
what is the first line therapy for pseudotumor cerebri
acetazolamide (inhibits choroid plexus carbonic anhydrase)
how do you differentiate between a basal ganglia hemorrhage and thalamus hemorrhage
both have contralateral loss of motor and sensation
basal ganglia involves gaze away from the hemiparesis (toward the hemorrhage) whereas thalamic hemorrhage involves gaze away from the hemorrhage and is associated with nonreactive miotic pupils
what drug is used to prevent cerebral vasospasm
nimodipine
besides monitoring with spirometry, how do you treat Guillain Barre Syndrome
IVIG or plasmapheresis (glucocorticoids are not effective)
what laboratory result confirms diagnosis of Guillain Barre Syndrome
CSF analysis showing albuminocytologic dissociation (high protein with normal WBC)
a child with an ear infection has headaches and vomiting at night and in the morning; what is your greatest concern (dx?) and what is the next step of workup?
brain abscess (as a complication of otitis media) get a CT with contrast (will show ring-enhancing lesion) or brain MRI
how do you differentiate anterior cord syndrome from central cord syndrome
anterior cord usually occurs after a burst fracture and involves bilateral loss of motor and pain/temp sensation below the lesion
central cord usually follows a cervical injury and involves bilateral motor weakness and pain/temp sensation in a cape distribution
cephalohematoma vs. caput succedaneum
cephalohematoma=subperiosteal hemorrhage, slow forming, no scalp discoloration, limited to one cranial bone
caput succedaneum=scalp bruise from birth trauma (presenting part) that can cross suture lines
what is the treatment for a simple febrile seizure
reassurance;
for a complicated seizure (longer than 15 min or multiple episodes) consider imaging
key distinction between normal aging and dementia
dementia=impaired daily function
what does aura tell you about the type of seizure
that it is likely partial (since the aura comes from a discrete focus)
what does very high creatine kinase tell you about the type of seizure
likely generalized (either primarily or secondarily to a partial)
what are the most common side effects of levodopa/carbidopa
hallucinations, confusion, dizziness
intraventricular hemorrhage from germinal matrix is most commonly due to what predisposing factors
prematurity and low birth weight
name a drug that is used to treat resting tremor in young patients with Parkinson’s
trihexyphenidyl
headaches that are worse at night or worsen with leaning forward, valsalva or cough are concerning for what condition
intracranial hypertension
prochlorperazine, chlorpromazine and metoclopramide all have what mechanism of action
D2 receptor antagonists (antiemetics)
what should you provide for abortive therapy for migraine?
prophylaxis?
abortive: NSAIDs, triptans (require early administration), antiemetics (metoclopramide, prochlorperazine)
ppx: antiepileptics (gabapentin, topiramate), TCA’s, beta-blockers, CCB’s
what is tolterodine
an anticholinergic
what does a positive arm drop test tell you (passively abduct the arm past 90 degress and ask the patient to adduct)
if the arm drops rapidly= positive => likely rotator cuff tear
Parkinson’s is caused by overactivity of ______ neurons and underactivity of ______ neurons
overactivity of cholinergic neurons
underactivity of dopaminergic neurons
how can you differentiate BPPV from Meniere’s disease
in Meniere’s disease vertiginous episodes are usually preceeded by ear fullness/pain and there is often accompanying hearing los/tinnitus
BPPV has no auditory sx and is brought on by predictable head movements
which two kinds of point mutations in DNA typically cause the most severe disease
nonsense (stop codon) and frameshift
what are the similarities and differences between Marfan’s and Homocystinuria
both: tall, long arms and fingers, joint and skin hyperlaxity
Marfan’s: aortic root dilation, normal intellect
Homocystinuria: mental retardation, fair complexion, HYPERCOAGULABILITY (strokes, MI’s)
how do you treat homocytinuria
B6, folate and B12 to lower homocysteine levels and antiplatelets or anticoagulation to reduce risk of thrombotic events
what treatment should you start in a patient who had a stroke from septic embolus
antibiotics ONLY (no aspirin)
name four major complications of heat stroke
rhabdomyolysis, renal failure, ARDS and coagulopathy
a patient with an insect bite on the face develops severe headaches, bilateral periorbital edema and extraocular muscle movement deficits; what is the dx and tx?
dx: cavernous sinus thrombosis (infectious origin due to valveless veins in the face)
tx: antibiotics, monitor/prevent cerebral herniation
a patient with a past history of opioid abuse is in severe pain due to MVA; what treatment should be given?
IV morphine; patients with addiction history should be given same treatment as other patients in acute pain (adequate treatment of severe acute pain actually decreases risk of relapse)
what do you see on EEG for a patient with Creutzfeld-Jacob
sharp, triphasic wave forms on EEG
forceful abduction and external rotation (blocking a basketball shot) results in inability to internally rotate the arm and sensation loss over the lateral upper arm; what is the likely nerve injury
axillary nerve; anterioinferior dislocation of the humerus in the glenohumeral joint causes axillary nerve damage resulting in deltoid and teres minor weakness as well as loss of sensation over lateral upper arm
a MMSE less than what number is indicative of dementia
less than 24
impaired rapid alternating movements and intention tremor suggests lesion of what CNS structure
cerebellum
medulloblastoma usually develops in what part of the cerebellum?
what specific deficit does this cause?
cerebellar vermis
truncal ataxia
what are the characteristic features of neurofibromatosis 1 vs. neurofibromatosis 2?
NF1: cafe au lait spots, macrocephaly, learning disabilities, neurofibromas
NF2: bilateral accoustic neuromas and cataracts
what is the most important risk factor for cerebral palsy
prematurity
hypertonia, hyperreflexia, clasp-knife spasticity, intellectual disability and equinovarus deformity (toes pointing down and inward) suggests what disease
cerebral palsy
most common intracranial lesion in neurofibromatosis 1
optic glioma
a hyperextension injury in a patient with degenerative spine changes resulting in upper > lower extremity weakness should make you think
central cord syndrome (syringomyelia)
differentiate between L5 radiculopathy and common peroneal neuropathy
both have impaired eversion and dorsiflexion; L5 radiculopathy will also have weak inversion and plantarflexion due to tibial nerve deficit and will also have radiculopathic shooting back pain
most common site of lacunar infarcts
internal capsule
a stroke causing contralateral face arm and leg weakness with no other deficits is likely due to a lesion where?
internal capsule
what happens to pupilary light reflex and deep tendon reflexes in brain death
pupilary light reflex=gone, DTRs=present
brain death=cerebrum and brainstem death, though the spinal cord may still be functioning and therefore DTR’s can be present in a brain dead person
ESR and CK for steroid-induced myopathy vs. polymyalgia rheumatica vs. hypothyroid myopathy
steroid-induced: normal ESR, normal CK
polymyalgia rheumatica: high ESR, nl CK
hypothyroid: nl ESR, high CK
a patient with only motor deficits and with contralateral face, arm and leg hemiparesis should make you think of what territory and blood supply
posterior limb of the internal capsule; anterior choroidal artery
what are the motor and sensory deficits of a femoral nerve injry
motor deficits: thigh flexion, knee extension
sensory deficits: anterior thigh and knee, medial leg
etiology of Friedrich’s ataxia and associated symptoms
autosomal recessive trinucleotide repeat (GAA) leading to dysfunctional frataxin gene and impaired mitochondrial function
sx: staggering ataxic gate, kyphoscoliosis, hypertrophic cardiomyopathy, pes cavus, hammer toes
spinal muscular atrophy, poliomyelitis and ALS all involve which nervous structure
anterior horn of the spinal cord
what are the four types of extramyramidal system side-effects seen with dopamine 2 antagonists and in what order do they occur?
- acute dystonia
- akathesia
- drug-induced Parkinsonisms (i.e. bradykinesia, resting tremor)
- tardive dyskinesia
contralateral anesthesia (and dysesthesia) with transient contralateral hemiparesis and athetosis is indicative of what condition and what nervous structure
Dejerine-Roussy syndrome (also known as thalamic pain syndrome); VPL of the thalamus
a 60 year old gets bitemporal vision loss: what two categories of tumors should you suspect
pituitary adenoma and craniopharyngioma (bimodal age distribution)
how can you differentiate between aminoglycoside toxicity and Meniere’s
Meniere’s is a chronic condition with episodes of vertigo, tinnitus and low frequency hearing loss
aminiglycosides can cause hearing loss and vestibulopathy, but rarely vertigo (due to bilaterality) and rather tend to cause a positive head thrust with difficulty holding gaze on head turn and horizontal saccades upon return to object
for CN3, where are the parasymp fibers relative to the motor fibers
motor is protected (inner nerve; damaged by ischemia)
parasympathetic is on the outside (damaged by compression)
how does cyanotic heart disease predispose to brain abscess
right to left shunt bypasses the lungs where bacteria are often trapped and phagocytosed
what are the three P’s of McCune Albright syndrome
precocious puberty, pigmentation (cafe au lait spots), and polyostotic fibrous dysplasia
what is the gold standard for diagnosis of muscular dystrophy and what findings do you see
genetic testing (not biopsy!)
deletion of dystrophin gene on chromosome Xp21
what is the inheritence pattern of Duchenne muscular dystrophy
X-linked recessive
a child with hypotonia/weak suck reflex, hyperphagia, obesity, and hypogonadism should make you think of what condition
Prader-Willi (big momma’s boy, small willi)
due to maternal uniparental disomy of chromosome 15q11-q13
what are the symptoms of Angelman syndrome
inappropriate smiling/ laughter, hand flapping, ataxia, seizures, MR
how can you tell Duchenne vs. Becker muscular dystrophy
Duchenne onset is 2-3 years of age while Becker is 5-15 and weakness is milder
an adolescent who develops myotonia (delayed muscle relaxation) and dysphagia likely has what condition?
what is the inheritance pattern?
myotonic dystrophy
autosomal dominant (as opposed to Duchenne and Becker which are X-linked recessive)
lens dislocation in Marfan’s vs. homocysinuria
Marfan’s: upward lens dislocation
homocystinuria: downward lens dislocation
what causes edema in Turner’s syndrome
congenital lymphedema due to abnormal development of lymphatic system
what drug that is used to treat essential tremor can cause acute intermittent porphyria (abdominal Pain, Port wine urine, Polyneuropathy, Psychiatric sx,
primidone (which gets converted to phenobarbitol)
most common pathogen to cause brain abscess due to local extension from sinusitis
viridans strep (staph is more common via hematogenous spread to brain)
pharmacotherapy for restless leg syndrome includes what
dopamine agonists (pramipexole) calcium channel ligands (gabapentin) iron for deficient patients
a child has a seizure at home; in the ED she has evidence of otitis media and neuro exam is normal; she is now alert and cooperative; what should you do next?
oral antibiotics; no further workup needed for febrile seizure
when you give a triptan what other drug for migraine do you have to avoid
ergotamines (triptans and ergotamines both affect serotonin receptors to cause vasoconstriction so risk of vasospasm is high and they have to be given at least 24 hours apart)
first line medical treatment for pseudotumor cerebri
acetazolamide +/- furosemide
