Neuro Flashcards
primary vs secondary HA
primary HAs are recurrent and benign. Secondary is new onset and life threatening
What HA is frequency and bilateral and most common HA
tension HA
What HA is unilateral, aura, recurrent, associated with periods.
migraine
You are thinking migraine, but you find focal neurological findings, what must be ruled out?
stroke
patient can’t stay still, male patient, horrible pain, tearing, sweating, ptosis and miosis, all symptoms are unilateral, what type of HA
Cluster
thunder clamp HA
subarachnoid
tx for HA
dopamine agonist (
route to giving medications for HA
IV is faster than IM, IM is faster than oral
treat for HA
O2(higher concentration the better) or intranasal lidocaine
HA preventions
Antidepressants, anticonvulsants, Antihypertensives
Ischemic stroke is what color on CT
black
hemorrhagic stroke is what color on CT
white
What type of stroke is known for headache?
hemorrhagic
sudden onset of L arm, what artery
right side middle cerebral artery
sudden onset of L leg, what artery
right side anterior cerebral artery
treatment for hemorrhagic stroke
ABC, lower BP, reverse anticoagulopathy, Lower ICP.
how do you lower ICP with hemorrhagic stroke
mannitol, hyperventilation, burr hole
ischemic stroke management
ABC, Fibrinolysis (break up clots), Lower ICP
general stroke management (ischemic)
head of bed at 30 degrees, NPO, bed rails up, ASA, (allow BP to be a little high in ischemic stroke), no hypotonic fluids, control fever, control blood sugar, stop from getting blood clots.
what are the five Ds of a posterior stroke?
Dizziness (vertigo)
- Diplopia
- Dysarthria
- Dysphagia
- Dysmetria
one side of the face and the opposite side of the body if affects. where is the stroke?
posterior circulation / vertebral/basilar system
A patient presents with the ability to produce fluent speech, though the words and sentence structures do not make sense. In which of the following areas of the brain is the defect occurring?
Wernicke’s aphasia (’Receptive aphasia’) occurs when the area of the brain that organizes speech is affected. The patient retains the ability to produce speech, but is unable to organize it into comprehensive language.
patient presents with loss of the left visual field in each eye. What is the most likely location for the lesion
Lesions in the right optic tract will cause a left homonymous hemianopsia.
most common cause of subarachnoid hemorrhage
aneurysm due to HTN
worse/different headache of life, presented with syncope
subarachnoid hemorrhage
get a sentinel headache (initial) than get better
subarachnoid hemorrhage
how do you dx subarachnoid hemorrhage
CT (if negative use LP there will be blood) if either is positive =surgery
what level of spine is LP done
L2 (b/c cord ends)
xanthochromia
bright red blood cells in CF, positive for subarachnoid hemorrhage
tx of subarachnoid hemorrhage
control: pain, bp, reverse blood thinners, control seizures. Bleed blocks CF drainage can cause hydrocephalus
best study to see damage of TIA
advanced imagining
tx for TIA
aspirin, carotid endarterectomy (>70% blockage), anticoagulant
patient has TIA, look at what PE finding
carotid bruit and a fib on ECHO
what is Bell’s Palsy? what nerve
unilateral facial palsy without other symptoms, CN VII.
what causes Guillian Barre
immunizations (flu vaccine) GI illness (camptobacyter)
cannot wrinkle forehead is this bell’s palsy or stroke
bell’s palsy (cannot close eye, wrinke forehead, ear pain before palsy, lacrimation)
tx of bell’s
acyclovir and steroids
DM neuropathy
is symmetrical weakness in lower legs
symmetric bilateral lower extremity weakness that is ascending 2-4 weeks after benign illness, then progressive, symmetric, distal to proximal lower extremity weakness over 2 weeks
Guillian Barre
worse complication of Guillian Barre
diagram weakness and Autonomic: cardiac, urinary retention
LP on Guillian Barre will show
elevated protein
tx for Guillian Barre
plasmapheresis and IV immunoglobin
myasthia gravis hallmark
improves with rest and ptosis gets worse throughout the day, worry about diaghramic weakness
dx of myasthia gravis
edrophonium test
you suspect myasthenia gravis, what must be ruled out and how
thymona on chest xray
anti acetylcholine receptor test antibodies
is positive in 90% of myasthenia gravis patient
tx of myasthia gravis
cholinesterase inhibitors (pyridostigmine), corticosteroids, immunosuppressive agents, IVIG, plasmapheresis
what is Lambert-Eaton?
uncommon disorder of neuromuscular junction
transmission with the primary clinical manifestation of PROXIMAL muscle weakness. defective release of acetylcholine
what cancer is Lambert-Eaton associated with
small cell
proximal muscle power increases with sustained contraction as day goes on
Lambert-Eaton
Dx of Lambert-Eaton
Dx: electrophysiologic studies
tx of lambert eaton
Tx: plasmapheresis, immunosuppressive therapy, tumor treatment
pregnancy ladies get what type of meningitis
listeria
Neonates get meningitis from
Group B Strep., E. coli, Listeria
2 months to 6 years get what type of meningitis
2 months to 6 years: Strep pneumonia, H. flu Type B, Neisseria
meningitidis
greater than 6 including adults get what type of meningitis
Greater than 6 years: Strep pneumonia, Neisseria meningitidis
Brudzinski’s sign:
flexion of knees with flexion of the head
Kernig’s sign:
head flexion when the knees are flexed and then the leg is extended
○ Mnemonic: K = Knees
dx meningitides, must get what before LP
get CT scan
findings in LP with bacteria meningitis
low sugar
tx of meningitis for age Less than 8 wks age
Ampicillin + Cefotaxime (or Aminoglycoside)
antibiotic used for listeria
Ampicillin
Greater than 3 mo (and adults) tx for meningitis
Ceftriaxone + Vancomycin
treatment Immunocompromise/Chronic EtOH/>50 yrs with meningitis
Ampicillin + Ceftriaxone + Vancomycin
Head trauma/VP shunt/CNS surgery: tx for meningitis
Vancomycin + Ceftazadime
decreases deafness related to H. flu
Dexamethasone
admit bacteria or viral meningitis
bacteria
treat close contact if patient is treated with meningitis with?
Ciprofloxacin, Rifampin, Ceftriaxone
Waterhouse-Friderichsen syndrome
complication of adrenal failure due to meningitis
prevention of meningitis
Haemophilus influenzae type b (Hib)
Pneumococcal conjugate vaccine (PCV7)
Pneumonococcal polysaccharide vaccine (PPSV)
Meningococcal conjugate vaccine (MCV4)
encephalitis is…….
viral or bacterial
Infection of brain parenchyma causing destruction of neurons, Usually caused by viruses
○ HSV1, HSV2, Varicella, Equine, West Nile, HIV, Measles, Rabies
dx encephalitis
CT head, Lumbar puncture: Viral and bacterial cultures, antigen tests, MRI: classic temporal lobe pattern
Brain Biopsy
tx of encephalitis
Antiviral medications: e.g., acyclovir, foscarnet
Empiric antibiotics for bacterial meningitis
● Antiepileptics
● Steroids: e.g., dexamethasone
● Supportive care (these are sick people!)
do encephalitis need to be admitted
YES, ICU
bacterial LP
glucose low, elevated pressure and high protein
viral LP
Lymphocytes (everything else is normal)
TB LP
high protein
encephalitis LP
normal pressure, normal glucose and protein
ring enhanced lesion with focal neurologic finding
brain abscess
things that cause brain abscess
Usually bacterial, can be fungal
● Direct spread: Sinus infection, ear infection
● Emboli: Endocarditis, cyanotic congenital heart disease
● Treatment: long term antibiotics and surgical drainage
parkinsons is the loss of
dopaminergic neurons
treatment of parkinson’s
Levodopa (supplement dopamine) plus carbidopa (stops breakdown of levodopa) ○ Side effects: dyskinesias ● MAO-B inhibitors: well tolerate Anticholinergics deep brain stimulator
Myasthenia Gravis associated with
associated with thymus tumor → thymoma
signs and symptoms of MG
Proximal weakness – repeated movements (brushing hair)
● Fatigue
● Ptosis, Diplopia
● Dropping head
dx of MG
“Tensilon test” (edrophonium), stops breakdown of Ach, pt will have increased strength
other physical and lab test that help dx MG
Fatigability test: continued upward gaze leads to ptosis, relieved with rest
● “Ice pack test” ptosis should improve with cold
● Antibodies to Ach receptors
● “Tensilon test” (edrophonium), stops breakdown of Ach
what disorder is similar to MG but no weakness and patient has lung cancer
Lambert Eaton
treatment of MG
Acetylcholinesterase inhibitors: neostigmine, pyridostigmine
● Immunosuppressants: prednisone, azothioprine
● IgG plasmapharesis
● Thymectomy → can improve even without thymoma
huntington’s disease is genetic auto dominant or recessive
dominant 50% of offspring get it!
what is Huntington’s dz
Degeneration and loss of neurons with atrophy in caudate nucleus/putamen
symptoms of huntington’s dz
Psychosis usually predominates
○ Antisocial/poor impulse control
movement disorder and dementia
tx of huntingston’s
Tetrabenzanine: depletes monoamines and antidepressants and antipsychotics
categories of of Glascow coma
motor, verbal, eye opening
highest GC score and lowest
15 and 3
presentation of 2 types of Brainstem hemorrhage
pontine and cerebellar
Pontine: pinpoint pupils
Cerebellar: extensor posturing, lost papillary reflex
Herniation syndromes
two types uncial herniation and central herniation(this is worse)
Uncal herniation: dilated, non-reactive ipsilateral pupil
○ Central herniation: loss of brain stem reflexes, decorticate posturing and irregular respirations
Pseudocoma test
Nystagmus with caloric vestibular testing (freezing cold water in pt’s ear)
Consider ICP protection with
mannitol or hypertonic saline
types of delirium
Hyperactive: withdrawal or intoxication (EtOH, drugs)
● Hypoactive: Hepatic encephalopathy, hypercapnia
● Mixed: Daytime sedation, nocturnal agitation
visual hallucinations, must rule out
acute delirium
medications that can help or exacerbate delirium
Rivastigmine, haldol, ativan, propofol
Vascular dementia dffers from other dementia by…
gait or deep tendon reflex abnormalities
Changes in tau protein → causes neurofibrillary tangles, senile plaques and atrophy is what disorder?
Alzheimer’s Disease
Alzheimer’s Disease risk factors
age, Down’s syndrome, family history, HTN, insulin resistance, obesity
autoimmune antibodies → inflammatory demyelinating polyneuropathy → delayed nerve conduction → symmetric ascending weakness paralysis
Guillian Barre
hallmark of Guillian Barre syndrome
Poor to absent reflexes
Lumbar Puncture shows Elevated protein > 400mg/dL in 90%, ascending weakness and decreased nerve conduction studies or muscle biopsy.
Guillian Barre.
Dx Gold standard is nerve conduction and muscle biospy
treatment of autonomic symptoms of guillian barre
Treat autonomic symptoms ○ Bradycardia → atropine ○ Hypertension → nitroprusside or beta blocker ○ Hypotension → IVF ○ Heart block → temporary pacing
medical treatment of GB (guillian barre)
IVIG or plasma exchange proven to shorten recovery by 50% but Steroids alone do not work
MS is know for migratory and chronic symptoms name some of the migratory symptoms
Sensory loss Cerebellar sx (dysarthria, ataxia, tremor) Heat intolerance Motor spinal cord sx Optic neuritis, Muscle spasticity, Lateral gaze diplopia Bladder dysfunction, constipation
Optic neuritis with MS
painful vision loss, color perception is altered, disc looks normal, usually unilateral, flashes of light (phosphrenes)
retrobulbar pain
dx of MS
McDonald Criteria :Clinical scoring system + MRI + CSF
Lumbar Puncture :Oligoclonal band pattern on electrophoresis
● MRI
○ Atrophy and “black holes” signify axonal death
tx for acute exacerbation of MS
steroids
chronic treatment for MS
Interferon, immunosuppressives
symptom control MS
Symptom control
○ amantadine (fatigue), baclofen (spasticity), Aricept
Dx for MG
Anti-AChR antibody positive in 75%, Antistriated muscle Ab
Anti muscle-specific receptor tyrosine kinase
MG is associated with?
Associated w/ autoimmune dx (commonly hypothyroid) and thymoma
Proximal, symmetric muscle weakness»_space; distal
Upper extremity»_space; Lower extremity
Progresses downward over weeks to months
Normal sensory exam and deep tendon reflexes
MG
Epilepsy defined by
2 unprovoked seizures at least 24 hours apart
Absence seizures medication
ethosuximide
Tonic, atonic, myoclonic or generalized tonic-clonic medications
○ valproate, lamotrigine, topiramate
Partial seizure medications
○ carbamazepine, lamotrigine
Status Epilepticus
any type of prolonged seizure (>30mins) start treatment within 10 mins
treatment for status epileptics- ongoing seizure
1st line :lorazepam, diazepam, usually try 3 doses
● 2nd line: fosphenytoin or phenytoin
○ if seizures continues x 20min then Phenobarbital
● 3rd line :midazolam drip, proposal, pentobarbital coma
● Treat fever electrolytes or withdrawal
what is PANAS
Post-strep autoimmune neuropsychiatric disorder
● Clusters of patients who develop tics
○ Higher incidence of recent strep in new tics
recovery plan for concussions
24 hr asymptomatic then return in increasing activity
post concussion syndrome dx after symptoms last more than
3 months
anti epileptic drug avoided in pregnancy
valproate acid should be AVOIDED because of higher trends noted of congenital malformations.
cerebral palsy must to dx before what age?
3 (it is non-progressive)
facts about cerebral palsy
brain lesions and #1 cause of child disability (premature babies)
hypotonic–spasity —contractures and missed milestones
CP
tx CP
botox, antidepressants, tendon release, parkinson’s drugs
Locked-in-syndrome is classically caused by injury to which portion of the brain
bilateral brainstem. pt can still blink their eyes
simple seizure is described as
focal neuro deficits with preserved consciousness
complex seizure is described as
Confusion and bizarre behavior
why is the vasodilator nimodipine given when a Subarachnoid hemorrhage is dx?
Clinically significant vasospasm complicates 20-30 percent of aneurysmal subarachnoid hemorrhage, and nimodipine has been shown to improve neurologic outcomes. Treatment is started within the first 4 days post-SAH and is continued for 21 days.
diagnosis of Narcolepsy
Multiple sleep latency test
An MRI with gadolinium contrast is the study of choice for suspected ________. Periventricular plaques is considered the classic finding for ______________
MS
Complex seizures are most often found when the ____ lobe is affected.
temporal lobe
most common skull fracture
linear
Charcot-Marie-Tooth is an inherited demyelinating polyneuropathy most commonly seen during what period of life?
1st and 2nd
the most important initial steps after establishing an IV and placing the patient on a monitor for altered mental status?
Blood glucose testing
A 23 year old female present to the emergency room complaining of the ‘worst headache of her life’ for the past 3 hours. She tried ibuprofen without relief. She denies nausea or vomiting, and vision changes. A head CT reveals no apparent abnormalities. A lumbar puncture is performed and the CSF analyzed. Which of the following findings would confirm your suspected diagnosis?
must think subarchnoid hemorrhage with worst HA of life.
LP with show RBC (erythrocytes)
A 34 year old male presents to the clinic complaining of feeling emotionally unstable, and having frequent headaches. He also states that he has noticed a resting tremor that improves with purposeful actions, and some stiffness or rigidity to his movement. These symptoms have gradually worsened over the last few months. Examination of the eyes is remarkable for dark rings that appear to encircle each iris. Which of the following tests, if abnormal, confirms this patient’s likely underlying condition?
parkinson like symptoms-in a young person, should prompt the dx of Wilson dz.
Serum ceruloplasmin, a copper binding protein, levels are typically reduced in these patients. If this test is positive, or you have a high clinical suspicion of the disease, a 24-hour urine copper test (with elevated levels) and a slit lamp exam for Kayser-Fleischer rings should also be performed. Kayser-Fleischer rings are the pathognomonic sign of Wilson’s Disease
huntington’s dz presents between what ages
This condition is inherited in an autosomal dominant fashion, and symptoms usually begin to be manifest between the ages of 30-50
Which of the following results is most helpful in diagnosing a Subarachnoid hemorrhage?
In SAH, the bleeding occurs into the space that is occupied by the CSF. Thus, RBC’s in the CSF is the most helpful of the options listed in making this diagnosis. ~95% of cases will show an abnormality on CT scan.
jacksonian march is associated with which type of seizure?
‘Jacksonian March’ is due to discharges in the sensorimotor cortex causing rhythmic jerky movements that spread throughout the entire side of the body. This classic finding is most often associated with simple seizures.
best imagining for CP
MRI is the preferred imaging test in diagnosing CP.
bilaterally intranuclear ophthalmoplegia is associated with?
intranuclear ophthalmoplegia is paresis of the medial rectus muscle (slowness or loss of adduction) and when bilateral in nature, especially in a younger patient, is most likely caused by Multiple Sclerosis.
What cluster of features make up Cushing’s Triad and indicate increased intracranial pressure?
Hypertension, bradycardia, respiratory depression
58 year old male presents to the emergency department with a temperature of 103.1 F ( 39.5 C), a headache and has had persistent vomiting over the course of the last two hours, and his wife reports what sounds like seizure activity. He is currently showing signs of altered mental status, has a positive Kernig sign. What is the most appropriate next step in the management of this patient?
vancomycin plus ampicillin, plus cefotaxime. Dexamethasone may be added to improve meningeal penetration and decrease morbidity. CT head should then be pursued to determine presence or absence of space-occupying lesions, prior to the lumbar puncture.
Which of the following is most effective as a primary monotherapy used to treat Partial seizures?
Carbamazepine is considered to be a first-line monotherapy drug effective in treating partial seizures with or without secondary generalization.
What is the drug of choice in treating patients with Myasthenia Gravis?
Pyridostigmine
Crescent shape tracking along brain is seen is what head bled?
subdural
Patients suffering from Multiple Sclerosis tend to exhibit a variety of symptoms. Which of the following medications is used in the treatment of spasticity associated with this disease?
baclofen
Which of the following is the most common artery involved in epidural hematoma?
The middle meningeal artery is involved in more than 75% of cases of epidural hematoma. Its course carries it over the lateral side of the head, and its superficial location predisposes it to injury.
What is the diagnostic test of choice for bronchiectasis?
High resolution chest CT showing dilated tortuous airways is diagnostic of bronchiectasis.
The CT scan reveals blood vessels leading to nodules within the lung, and he has a positive ANCA test, but otherwise labs are non-contributory.
Wegener’s Granulomatosis
what is the workup for Diagnose new effusion in toxic-appearing patient
Suspected parapneumonic effusions (including patients with previously diagnosed effusions)
Thoracocentesis with analysis
“ongoing or intermittent seizure activity without convulsions for at least 30 minutes, without recovery of consciousness between attacks.”
Non-convulsive status epilepticus
is Flexion teardrop fracture an unstable cervical spine injury?
yes
Trigeminal neuralgia, or tic douloureax, has been found to respond well to
carbamazepine.
