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ACNP Certification > Neuro > Flashcards

Neuro Flashcards

1
Q

Cranial Nerves

A

On Old Olympus Towering Tops A Fin and German Viewed Some Hops

1 Olfactory -Smell

2 Optic -Vision

3 Oculomotor -EOM, eyelid opening, pupillary constriction

4 Trochlear -Downward and inward eye movement

5 Trigeminal - Mastication, sensation face, mouth, nose

6 Abducens -Lateral eye movement

7 Facial -facial movement, eye/mouth closing, taste, saliva/tear

8 Acoustic -Hearing and equilibrium

9 Glossopharyngeal -phonation, posterior taste, gag, carotid, reflex, swallow

10 Vagus-Talking, swallow, sensation carotid body, carotid reflex

11 Spinal Accessory- (shrug) trapezious/sternocledomastoid

12 Hypoglossal- moves the tongue

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2
Q

Sensory/ Motor / Both

A

Some

Say

Marry

Money

But

My

Brother

Says

Big

Bras

Matter

Most

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3
Q

WHat is the timeframe for and symptoms of TIA?

A

Periods of cerebral insufficiency with < 24 hours with NO residual effects

TIA indicative of pending stroke (1/3 infarct w/in 5 yrs)

Infarctions more common (80%) than hemmorrhage (20%)

Sx:

  • amaurosis fugax (ipsilateral monocular blindness)
  • Transient aphasia
  • Parathesias of contralateral limbs or face
  • Nystagmus, vertigo, dysphagia, sensory deficits

*Same side eye changes, opposite motor changes

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4
Q

TIA Classifications

A

Vertebrobasilar: inadequate blood flow vertebral arteries

*neuro like symptoms (vertigo, ataxia, dizziness, VF deficits, weakness, confusion)

Carotid:carotid stenosis (more traditional stroke life symptoms including aphasia, dysarthria, altered LOC, weakness, numbness

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5
Q

TIA Dx

A

Dx:

  • CT best for distinguishing between ischemia, hemorrhage, tumor
  • MRI superior to CT for ischemic infarct
  • Echo
  • Carotid Doppler/US
  • Cerebral Angio
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6
Q

TIA Management

A

ASA

Plavix superior choice

Ticlid-needs lab monitoring for agranulocytosis & thrombocytopenia

Assess for HTN *#1 cause heart failure

Carotid endart indicated for >70-80% stenosis in symptomatic pts, decreases risk for stroke/death in recent TIA

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7
Q

CVA Definition

A

Rapid onset of neuro defecits > 24 hrs duration

  • 4th leading cause of death
  • Can be subtle, progressive or sudden onset
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8
Q

CVA causes

A
  • Atherosclerosis
  • Chronic HTN
  • Trauma
  • Aneurysm
  • AV Malformation
  • Tumor
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9
Q

Hemorrhagic CVA

A

Presents with acute onset of focal neuro defecits

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10
Q

Hemorrhagic CVA signs and symptoms

A

Sudden increased ICP including altered mentation, HA, vomiting when extensive

*

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11
Q

Hemorrhagic CVA Diagnostics

A
  • Head CT
  • Cerebral angio
  • Lumbar puncture if Grade I or II aneurysm for blood in CSF (do CT first)
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12
Q

CVA Management

A
  • Surgical evaluation
  • Lower systemic BP while avoiding hypotension
  • Prevent sudden increased ICP:
  • Elevate HOB, Sedation, Oxygen, Analgesic, Laxative
  • MAP 110-130 to treat cerebral vasospasm
  • Intravascular volume expansion and HTN tx to increase cerebral perfusion (CPP=MAP-ICP)
  • Nimodipine (Ca Channel agonist) to counter vasospasm

*Maintain CPP and limit increases in ICP to <20

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13
Q

ICP H’s

A

Hypertension

Hypoxia

Hypercapnia

  • Tx by hyperventilation, keep CO2<35, O2 high and maintain higher MAP’s 110-130 (increases vital organ perfusion and prevents cerebral vasospasm)
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14
Q

Simple Partial Seizures

A

Simple Partial (focal, local)- common with cerebral lesions

  • No loss of consciousness
  • Rarely lasts >1 min
  • Motor sx start with single muscle group and spread to entire side of body
  • Paresthesias, flashing lights, vocalizations, hallucinations
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15
Q

Complex Partial Seizures

A

Any partial seizure followed by impaired LOC

  • May have aura, staring, automatisms such as lip smacking or pulling at clothing
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16
Q

Generalized Seizures

A

Absence (petit mal)

  • Sudden arrest of motor activity with blank stare
  • Common in children/adolescents
  • Begin and end suddenly

Tonic-Clonic (Grand mal)

  • May have aura
  • Begins with repetitive involuntary contraction of muscle (tonic clonic)
  • Ususally lasts 2-5 min
  • Incontinence possible
  • Followed by post-ictal period
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17
Q

Status Epilepticus

A

Series of Grand-Mal seizures of >10 minutes duration

  • Medical emergency
  • May occur when awake or asleep but no regaining of consciousness between attacks
  • *most uncommon, but most life-threatening
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18
Q

Seizure Diagnostics

A

Assesment

  • Presence of aura, onset, spread, type of movement, body parts involoved, pupil changes and reactivity, duration, loss/LOC, incontinence, behavioral and neuro changes after cessation of sz activity
  • Note HA, fever, personality changes

EEG *most important test in determining sz classification

CT head for new onset seizures to r/o brain tumor

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19
Q

Seizure Management

A

Initial tx is supportive as most sz are self-limiting

  • Maintain open airway, nothing in mouth

Parenteral anticonvulsants for rapid cessation of sz

  • Benzos- Diazepam 5-10 mg IV (to break & status)
  • Lorazepam (ativan) 2-4 mg IV at 1-2 mg/min to break
  • Phenytoin (dilantin) loading dose 20mg/kg @ 50mg/min continuous infusion
  • Fosphenytoin (cerebyx) Prodrug of dilantin
  • Phenobarbitol (Luminol) Used if phenytoin is unresponsive
  • Barbituate coma or GA with nueromuscular blockade
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20
Q

Subsequent Seizure Prevention

A

Maintenance dosage long-acting anti-convulsants

  • Carbemazepine
  • Phenytoin
  • Phenobarbitol
  • Valproic acid
  • Primidone
  • Clonazepam

Titrate dosage

Never abruptly withdraw, taper

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21
Q

Myasthenia Gravis

A

Autoimmune disorder resulting in reduction of acetylcholine receptors at the neuromuscular junction

  • Weakness is worse after exercise and better at rest
  • Variable course
  • Age 20-40 at onset, incidence peaks in 30’s women, 50-60 for men
  • Women> men
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22
Q

Myasthenia Gravis signs and symptoms

A
  • Ptosis
  • Diplopia
  • Dysarthria
  • Dysphagia
  • Extremity weakness
  • Fatigue
  • Respiratory difficulty
  • Sensation and DTR WNL

*Visual changes with extremity weakness are characteristic

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23
Q

Myasthenia Gravis Diagnostics

A
  • Antibodies (AchR-ab) found in >85%
  • Edrophonium (Tensilon) test differentiate btwn MG and cholinergic crisis (weakness gets better with Tensilon, worse in a cholinergic crisis)
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24
Q

Myasthenia Gravis Management

A
  • Neuro referral
  • Acetylcholinesterase ihibitor drugs (pyrostigmine bromide=Prostigmin)
  • Immunosupressives
  • Plasmapheresis
  • Ventilator support in a crisis
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25
Q

Multiple Sclerosis

A

Autoimmune disorder characterized by numbness, loss of muscle coordination, vision, speech and bladder control issues

  • Attacks myelin sheath which controls transmission of nerve signals
  • Variable course
  • Onset 20-50 years
  • More common Western European descent in temperate zones
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26
Q

MS Signs & Symptoms

A
  • Weakness, numbness, tingling or unsteadiness in limb
  • Spastic paraparesis
  • Diplopia
  • Disequilibrium
  • Urinary urgency or hesitancy
  • Optic atrophy
  • Nystagmus (rapid eye movements)
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27
Q

MS Diagnostics

A
  • Multifactorial dx, not on labs alone
  • Mild lymphocytosis
  • CSF: elevated protein, IgG
  • MRI of brain
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28
Q

MS Management

A
  • Neuro referral
  • No tx to prevent progression
  • Steroids for relapses
  • Anti-spasmodics
  • Interferron therapy
  • Immunosuppressives
  • Plasmapheresis
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29
Q

Guillain-Barre

A

Acute, rapidly progressive form of inflammatory polyneuropahty characterized by demyelinization of peripheral nerves resulting in progressive symmetrical ascending paralysis

  • Ususally preceded by suspected viral infection with fever 1-3 weeks prior to onset of BLE muscle weakness
  • Flaccid paralysis can occur within 48-72 hours of onset
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30
Q

GB Signs & Symptoms

A
  • Rapidly progressive ascending paralysis
  • CN impairment AEB difficulties in speech, swallowing, mastication
  • Reflexes hypoactive or absent
  • Respiratory muscle impariment possible
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31
Q

GB Diagnostics and Management

A

Diagnostics

  • CSF protein elevated
  • CBC: leukocytosis with left shift
  • LP, MRI, CT sometimes used in dx

Treatment

  • Supportive while myelin regenerates
  • Sx recede w/in 2 weeks, resolve w/in 2 years
  • Neuro consult
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32
Q

Meningitis

A
  • Should be considered in any patient with fever and neurologic symptoms, especially if history of other infection (PNA) or head trauma
  • Acute, bacterial meningitis is a medical emergency

Causes

  • Strep pneumoniae, H. Influenze, N. Meningitidis in 80-90% of cases
  • Most common in the hospital is Staph Epidermis
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33
Q

Meningitis Signs & Symptoms

A
  • Fever (101-103)
  • Severe HA
  • N/V
  • Nuchal rigidity
  • Positive Kernig’s Sign (pain and spasm of hamstring muscles)
  • Positive Brudzinski’s Sign (legs flex at hips and knees in response to flexion of the head and neck to the chest)
  • Photophobia
  • Seizures
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34
Q

Meningitis Diagnostics & Management

A

Diagnostics

  • Lumbar Puncture - Bacterial presentation: CSF cloudy or xanthocrhomic (yellow) with elevated pressure, protein, decreased glucose (bugs eat sugar) and presence of WBC’s
  • Viral Presentation-normal to elevated opening pressure, normal protein and glucose, some WBC
  • CT head is indicated

Management

  • Control S&S, maintain electrolyte balance
  • High dose parenteral ATB therapy ASAP for suspected bacterial cases
  • Aqueous PCN G, vanc with a third gen cephalosporin until C&S is available, or fluoroquinolones
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35
Q

Head Trauma

A
  • Men< 35 years, accidents leading cause of death
  • Over 70% accidents involve head injury
  • Leading cause of death in all trauma cases

Monroe-Kellie Doctrine: when 1 content of brain goes up (blood, CSF, Brain tissue), another goes down

S&S:

  • Assess: time and place of injury, how it occured, LOC, occurence of a lucid interval (suggests bleed *Epidural hematoma), sz activity, amnesia (indicates severity of blow)

Decompensating pts may show Cushing’s Triad:

  • Widening pulse pressure (SBP increases in attempt to maintain CPP (CPP=MAP-ICP))
  • Decreased RR
  • Decreased HR

Battle’s sign -bruising at mastoid

Raccoon eyes

Otorrhea or Rhinorrhea

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36
Q

Head Trauma Diagnostics/Management

A

Diagnostics:

  • C Spine films all pts
  • Skull films and Head CT

Management:

  • ABC’s assessed in any significant head trauma or altered LOC
  • Stabilization of VS and ongoing Neuro eval
  • Neurosurgery consult
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37
Q

Spinal Cord Trauma

A
  • 1/2 of all spinal cord injuries occur above T1
  • More common in young males

Four P’s:

  • Paralysis
  • Paresthesias
  • Pain
  • Position
38
Q

Levels of Vertebral Damage

A
  • C4 or above- Quad, may need vent
  • C4-C5: Quad, control of head/neck, shoulders, trapezius, elbox flexion
  • C5-C6: Quad, some extension of wrist, index finger/ thumb
  • C6-C7: Elbow extension, capable of feeding and dressing
  • C7-T1: Hand movement
  • T1-T2: Para, upper extremity control, no trunk control
  • T3-T8: Some trunk control
  • T9-T10: Bowel and bladder reflex, moves trunk and upper thigh
  • T11-L1: Most leg and foot, ambulation possible
  • L1-L2: Lower legs, feet, perineum, bowel, bladder and sexual function if S2-4 nerves involved
  • *C=arms and hands, T=trunk
39
Q

Strength Grades

A

5/5 normal

4/5 Full ROM against moderate resistance and gravity

3/5 Full ROM against gravity, not against resistance

2/5 Can move but not against gravity (roll, not lift)

1/5 Muscle contracts, no movement of extremity

0/5 Flaccid

40
Q

Spinal Cord Injury Diagnostics/Management

A

Diagnostics:

  • Spinal XR series
  • CT scan, MRI, myelography

Management

  • Methylprednisone 30 mg/kg IV bolus followed by infusion of 5.4 mg/kg/hr 23 hours improves neurologic recovery when administered w/in 8 hrs of injury
  • Neuro consult
41
Q

Spinal Cord Injury 2 major complication types by Level

A

C4 or above- resp compromise

T4-T6 - autonomic dysreflexia, emergency condition (seen in full bladder or annoying type problem like a wrinkled sheet)

  • exagerated autonomic response to stimulus
  • diaphoresis and flushing above level of injury
  • chills and vasoconstriction below injury
  • HTN
  • Bradycardia
  • HA-severe
  • Nausea
  • Tx -antihypertensives and removal of stimulus

T6 or above: Neurogenic shock

  • During transmission of sympathetic impulses, unoppsed parasympathetic stimulation leading to loss of vasomotor tone inducing vasodilation
  • Hypovolemia, decreased venous return, decreased cardiac output
  • Sympathomimetic vasopressors
42
Q

Cause of Parkinson’s Dz

A

Degenerative disorder resulting from insufficient dopamine in the body

  • Onset 45-65, idiopathic, equal gender distribution, all ethnic groups
43
Q

Parkinson’s Signs/Symptoms

A

Most common are top three:

  • Tremor, enhanced by stress
  • Rigidity
  • Bradykinesia (slow movement)

Additional sx:

  • Wooden facies
  • Dysphagia
  • Drooling, decreased blinking
  • Myerson’s sign (tapping over bridge of nose produces sustained blink response)
44
Q

Parkinson’s Diagnostics/Management

A

Diagnostics:

  • None

Lung problems/infection usually is cause of death

Management

Increase dopamine (If difficulty moving, like feet sticking to flr)

  • Carbidopa-Levodopa (Sinemet), Amatadine (Symmetryl), Tolcapone (Tasmar), Pramipexole (Mirapex), Ropinirole (Requip)- all are used in combination, not alone

Anticholinergics (for worsening tremor)

  • Benzoropine (Cogentin), Trihexyphenydyl (Artane)

Selegiline (Edepryl) or Depranyl

45
Q

Drug Abuse/ Alcoholism Pneumonic

A

C- need to Cut down?

A- people Annoyed you by criticizing your drinking?

G- felt Guilty?

E- need for Eye-opener drink in the morning?

Managment:

  • Consult regarding tx and detox
  • Therapuetic communication “I’m concerned about alcoholism”, not you have a drinking problem
  • Treatable dz
  • AA referral, Al-Anon (family) /Ala-Teen
46
Q

Confusion- Delerium vs Dementia

A

Delerium: sudden, transient onset of clouded sensorium, occurs at any age, associated with physical stressor

Causes:

  • Toxins, alcohol/drugs, trauma, Fecal impaction, poor nutrition, electrolye imbalance, anesthesia

Dementia: Gradual memory loss, not recoverable with decreased intellectual functioning, >60 years of age

Causes:

  • Atherosclerosis, neurotransmitter defecits, cortical atrophy, ventricular dilation, loss brain cells, viral, Alzheimer’s
47
Q

Alzheimer’s

A

Development of multiple cognitive defects characterized by both memory impairment and:

Aphasia (difficult speech)

Apraxia (Inability to perform previously learned task)

Agnosia (Inability to recognize object)

Inability to plan, organize, sequence and abstract thought

Other findings: limb rigidity, flexion posture, gait disturbance

*Most common cause of dementia

*acetylcholine deficiency

Diagnostics:

Draw labs to r/o other diseases

CT/MRI r/o tumor

Management:

Meds to increase ACTH (acetylcholinesterase inhibitors)

Donazepril (Aricept), Galantamine (Razadyne), Rivastigmine (Exelon)

Referral for counseling

48
Q

Gerontology Considerations

A

Increased risk of sleep disorders, delerium, neurodegenerative diseases, falls, loss of independence with ADL’s

Physiologic changes: decreased neurons and neurotransmitters, decreased thermoregulation, peripheral nervous changes, decreased dopamine receptors, increased alpha responses

Impaired muscle strength, sense of touch, increased pain tolerance, slowed motor skills, diminshed balance, temp sensitivity, blunted temp response, slowed cognitive response but not intelligence

49
Q

Dysarthria

A

Not able to articulate

50
Q

Apraxia

A

Inability to perform a previously known task

51
Q

Amaurosis Fugax

A

Ipisilateral, monocular blindness

52
Q

Time limit for TPA/thrombolytics

A

3 hours

53
Q

Want CO2 low in the head?

A

It causes vasoconstriction to cerebral vessels

CO2 Level should be 35

54
Q

Cerebral perfusion pressure equation

A

CPP= MAP-ICP

Keep MAP high 110-130

55
Q

CCB used to prevent vasospasm in head bleed?

A

Nimodipine/Nimotop

56
Q

What is difference between a simple partial and complex partial sz?

A

Loss of or impaired consciousness

57
Q

How to differentiate tonic-clonic from complex partial?

A

Tonic clonic- blue, loss of bladder control, change in LOC but will be POST-ICTAL

58
Q

Name two out-pt anti-sz drugs

A

Tegretol and dilantin

59
Q

Wihch hemisphere presents with left hemiparesis, right visual field changes, spatial disorientation (can’t determine true body postition)

A

Right hemishpere hemorrhagic stroke

60
Q

brudzinski sign

A

head to chest and they curl up knees and hips (like a baby)

61
Q

Kernig’s sign

A

Pain and spasms of the hamstring muscles

62
Q

With fast onset, suspect viral or bacterial meningitis?

A

Bacterial

63
Q

Brown sequard syndrome

A

ipsilateral symptoms, contralateral pain

64
Q

Raccoon eyes

A

Basilar skull fx

65
Q

Lucid interval

A

Epidural hematoma

(arteries are outside, arterial bleed)

66
Q

Slow onset, bonk on head, weird behavior, on blood thinner

A

Subdural hematoma

67
Q

Cushings triad

A

1) widening pulse pressure (BP up)
2) decreased HR (vagal stimulation)
3) respiratory rate decreased, irregular

Herniation of brainstem

68
Q

c 4

A

breathe no more

On the vent

69
Q

Quad

A

Cervical spine

70
Q

Lumbar

A

Lower legs

71
Q

spinal

A

sexual function

72
Q

2/5

A

zero against gravity

73
Q

are steroids used in spinal cord injury?

A

yes if within 8 hrs of injury

Methylprednisone 30 mg IV bolus

74
Q

Which hemisphere hemorrhagic stroke presents with right hemiparesis, aphasia, dysarthria, difficulty reading/writing

A

Left (dominant) hemisphere

75
Q

Thromobolytic criteria for ischemic CVA

A

fibrinoltyic therapy if <3 hrs onset

76
Q

Goal for ICP with CVA?

A

Maintain CPP and limit increases in ICP to <20

77
Q

How to prevent cerebral vasospasm?

A

Nimodipine (Ca Channel agonist) to counter vasospasm

MAP 110-130 to treat cerebral vasospasm

78
Q

Which type of seizure is common with cerebral lesions?

A

Simple partial

79
Q

Autonomic dysreflexia

A

Bladder or rectal stim causing HTN or other syndromes

80
Q

In which disease are steroids contrindicated?

A

guiliian-barre

81
Q

Central Cord Syndrome

A

Hyper extension injury with discord between upper and lower symptoms

Can walk across the room but can’t shake hands

82
Q

Mini-Mental status exam pneumonic

A

O rientation to place and time

R egocnition (3 objects)

A ttention (7’s backward)

R ecall (recall the 3 objects 5 min later)

Language

2 identify 2 names of objects

3 Follow 3 step command

R eading a statment and doing it without saying it aloud

W riting a sentence

D rawing a design (copy)

83
Q

MMMS exam scoring

A

Max 30

No impairment 24-30

Delerium/Dementia or both: 18-23 mild, 0-7 severe

84
Q

Hemianopia

A

1/2 visual field loss

85
Q

CPP= MAP-ICP

A
86
Q

Drug of choice to prevent/counteract vasospasm in CVA?

A

Nimodipine (CCB)

87
Q

Eventual capabilities in SCI by level

A

C4 breathe no more

C1-T1: Quadraplegia, may have use of arms

T1-L1: Paraplegia

T9-L1: May eventually ambulate

L1-L2: bowel and bladder

If S2-S4 involvement, may have sexual dysfunction

88
Q

Myerson’s sign

A

Parkinson’s -

tapping over bridge of nose produces sustained blink response

89
Q

Dementia Pneumonic

A

D- Drug reaxn

E- Emotional disorder

M- Metabolic/endocrine

E- Eye/ear disorder

N- Nutritional problem

T- Tumors

I- Infxn

A- Atherosclerosis

90
Q
A
91
Q

*Most common cause of dementia

A

*acetylcholine deficiency

ACNP Certification (17 decks)

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