Neuro Flashcards
Timeline for AD?
AD is a slow, progressive disease with cortical atrophy that progresses to personality changes, do not confuse with Pick frontotemporal dementia. Slow and gradual.
Does Lewy respond to dop agonism?
Lewy does not respond to dopa agonism
Most common place brain gets mets from?
The MCC of brain mets is lung CA, suspect in multiple brain densities on CT with h/o of smoking and no other abnormalties
S/s of GBS?
GBS causes ascending paralysis with absent DTR, sometimes sensory involed. CSF is normal other than high protein
How is GBS treated?
IVIg and plamaphoresis
First step in suspected Stroke?
CT before anything in suspected stroke
Where do emboli from Amaurosis Fugax come from?
Embolic from Amaurosis Fugax are usually from carotid bifurcation = get U/S of neck (Hollenhorst plaques)
What lesions are seen in spinal cord damage (UMN or LMN)
Spinal cord damage/acute injury is still an UMN as it happens before synapse at anterior horn (it can cause both injury, just remember spinal cord injury caues UMN too)
What do you get for a suspected ant/central/posterior cord syndrome?
For spinal cord, MRI is best imaging
best imaging for spinal cord?
MRI is best
Anterior cord syndrome associated with what breaks and s/s
Burst fracture and P/T sensation
S/s of intracranial bleed
Progressive syx with s/s of ICP which differentiates it, they progress and there is n/v and mental status deltas which DONT happen in ischemic strokes
What is the MOST IMPORTANT risk for ALL types of stroke?
The most important risk for ALL types of stroke is HTN
HTN is a risk for what strokes
The most important risk for ALL TYPES OF STROKE is HTN
what does a pronator drift mena
prontator drift is a UMN sign for upper extremities, may exist in absence of ther findings
Any suspected stroke first thing to do?
CT BEFORE ANYTHING, then Tpa if
When is ASA used and not tPA in stroke?
6 hours = ASA
3-4.5 = tPA
CT first
Add clop or dypyridamole if on ASA and having another ischemic stroke
What is MRI used for in stroke?
MRI is done AFTER CT and after therapy is started to localize a clot/vasculature that CT cannot pick up
What test shows an upper motor neuron lesion in upper extremities when high suspicion and other s/s may be absent?
Pronator drift
+ pronator drift?
Pronation when held out, if it drops without pronation it is only weakness, shows UMN deficit in upper extremities when other s/s absent
What do ALL stroke patients need within 24 hours?
Aspirin is only agent proven to prevent stroke, and is indicated in all stroke patients within 24hr
When do you suspect anterior cord syndrome
complete loss of function below lesion with P/T sensation loss
Central cord syndrome is associated in what demo?
cervical injury/upper extremities with incomplete paresis and some P/T loss in hyperextension of the elderly
Elderly with upper spondylolisis are predisposed to what spinal injury
Cental cord syndrome
what s/s might you see with a fluid filled cavity in the spinal column causing P/T loss?
You might see occipital headache and ataxia from arnold chiari cerebellar herniation
what is related to syringomyelia
arnold chiara- consider CT if synringomyelia diagnosed; P/T and some motor function loss in syringo.
where does anterior spinothalamic tract damage clinically manifest
P/T for spinothalamic tract disease manifests TWO LEVELS below the lesion. Damage at t12, syx at t10 (remember contralateral loss)
What is NOT lost in cerebellar hemorrhage?
There is NO sensory loss in cerebellar hemorrhage
What is the internal capsule
The internal capsule is where lateral corticospinal tract neurons cross over = motor defects
What two things make an internal capsule stroke clear as dx?
Internal capsule is descending lateral cortisopinal tract and is pure motor, and as has NO GAZE/ EYE defects (vs thalamic and cerebral hemisphere)
What causes paresis with characteristic NO EYE DEFECT
NO EYE DEFECT in internal capsule (vs cerebral deviation away and thalamic deviation toward the lesion)
What happens to eyes in internal cap, thalamic and cerebral lobe strokes?
internal = NO EYE SYX
Thal = T = TOWARD PARESIS OF BRAIN
Cerebral lobe = away from paresis of brain and TOWARD INFARCT
Where do eyes deviate for thalamic versus cerebral infarct
Thalamic = TOWARD PARESIS OF BRAIN and Cerebral = AWAY FROM PARESIS OF BRAIN
What are classic s/s of thalamic stroke?
Thalamic stroke can cause severe pain syndrome, hypersensitivity to pain and athetosis with ballistic movements and eyes DEVIATE TOWARD PARESIS OF BRAIN
What are the s/s of lacunar stroke
lacunar strokes are deep penetrating arteries and usually just involve motor syx
What are some manifestations of lacunar stroke
lacunar usually involves internal capsule with pure motor syx and clumsy-hand syndrome affecting face/arms/legs
Associated lacunar stroke with what area of brain
internal capsule
MC site of HTN hemorrhage?
Putamen as it lies directly next to the internal capsule which is almost always involved
Total sensory stroke seen in what
Thalamus commonly may also have ballistic and athetosis
what part of thalamus is responsible for total sensory stroke?
VPL of the thalamus is why they get hypersensitivity to pain and pure sensory stroke
What are signs of vertebro basilar stroke?
There are many brain nuclei there that affect the cranial nerves and bulbar signs like dysphagia. Look for CN nerve signs and dysphagia along with paralysis
What is the gold number for endarectomy in men and wom ?
70%
what is the gold number for endarterectomy in men without syx?
60% in men asyx or 70% in either sex
what does vasospasm cause in SAH?
Vasospasm causes ischemic stroke in SAH
why give nimodipine in SAH and what timeline for cx does it prevent?
Namodipine is a CCB that presents vasospasm at 3d after SAH which would result in ischemic stroke
Ischemic stroke s/s 3d after SAH, why
Vasospasm causes ischemic stroke
Amyloid angiopathy in the brain results in what type of bleeds
Amyloid deposition causes lobar hemorrhages because all the blood vessels are extremely fragile, expect in elderly patients with dementia or RA or leukemias and CLL
What color is hemorrhage on CT
CT scan with hemorrhage is white (think epi and subdural hematoma)
what color is ischemia on CT
ischemia is dark (think of examples)
Subdural hematoma in ?
Alcs, warfarin elderly
what is damaged in subdural hematoma
crescent shaped, low pressure bleed of bridging veins
epidural hematoma in
trauma to middle meningeal
s/s of epidural hematoma
lucid period with convex mass and then sudden deterioration, high pressure arterial bleed, look for s/s of herniation
tx epidural
immediate neurosurg consult with relief of potential causes for herniation
can subdural hemorrhage be long-term
subdural is low-ressure bleed whcih can be chronic and cause dementia syx in elder versus epidural which kills from herniation suddenly after a lucid period
why does cavernous sinus syndrome happen
the cavernous sinus syndrome usually happens due to infection spread because the opthalmic vein system is valveless
what do you look for in cavernous sinus?
prior preseptal celluliitis which worsens to fever with pain with eye movements and s/s of neural ICP like n/v, papilledema
what is convern with cavernous sinus thrombosis
the concern with cavernous sinus thrombosis following infection form valvless optho system is that there will be brian herniation, you need to treat with IV antibiotics for several weeks and monitor for s/s of neural herniation and ICP like papilledema and n/v + down and out puil
How is sinus cavernous syndrome diagnosed?
Dx with MRI to find the internal carotid thrombosis (versus CT in sinusitis that is recurrent and don’t need to find specific artery)
s/s of cavernous sinus
papilledema, prior preseptal cellulitis, orbital pain and edema, n/v, FEVER
dx with MRI to find internal carotid
tx IV antibitoics for severeal weeks to avoid herniations
What are s/s of migriane
migraine is aura, pulsating headahce, worse with light and noise, triggers of food, stress and menses
how is migriane treated
try NSAID and then triptans
what is “abortive” therapy for refractory migraines
refractory migraines can be treated with triptans and TCAs early, other wise need antiemetcis like chrlopramzine, metochloprmaide in n/v
what headaches are promazines used for
promazines are used for migrines and hel with nausea and vomiting
when are SSRI and triptans used in migriane
SSRI and triptans are used in migraines early as abortive therapy, do not work late in course with n/v
what can be used for n/v in migraines
n/v in migraines can be treated with promazines and perazines
promazines and perazines treat what part of what headache?
they treat the s/s of n/v of migraine (promazines and perazines)
What is trigem neuralgia treated with
trigeminal neuralgia is treated with carbamazepine
why is trigeminal neuralgia treated with carbamazepine
trigem is really a simple, partial seizure of the CNV, and is treated with anticonvulsant carbamazepine
what do you have to worry about when treating with anti convulsant carbamazepine in trigem patient?
AE of carbamazepine is aplastic anemia
what is the main AE of carbamazepine?
carbamazepine is used for trigem neuralgia and causes aplastic anemia
what does chrlopromazine and prochlorperazine and IV metoclopramide do for n/v
treats n/v in migraine
what are classic s/s of cluster headaches
cluster headaches present with retroorbital pain, lacrimation, Horner’s syndrome and awakening from sleep
can neuro deficits be present in cluster headaches?
yes they can have Horner’s syndrome along with night awakenings
how is cluster treated acutely
cluster acute tx is O2 100%
what is cluster prophylactic tx
cluster prophylactic tx is verapamil, Lithium or ergotamine
Horner’s is associated with what headahce syndrome treated prophylactically with verapamil, Li or ergotamine?
horners, eye pain, lacrimation recurring = think cluster, acute tx is 100% O2 prophylax with verapamil, ergotamine, Li
how is IIh diagnosed
You need to r/o tumor with CT or MRI and if WNL you can do an LP to relieve presure and document the elevated opening pressure and relieve some syx then give acetazolamide or furosemide
who gets IIH
young, obese women with OCP, tetracycline and vit A (tretinoin) derivatives
S/s of IIH
Like a tumor with vision changed, HA, diplopia, papilledema, CN VI defects, tinnitus and diplopia
How is IIH diagnosed and why
First you need to rule out mass lesions in IIH, then after the MRI/CT is normal you can do LP even if there is s/s of ICP being raised because it is due to CSF and there won’t be herniation, unlike kids if they have papilledema you cannot do LP
2 associations with lacunar infarcts?
think internal capsule and HTN
HTN, internal capsule, pure motor think?
Lacunar infarct = HTN= motor= internal capsule
How is cortisol - induced myopathy different from Polymyalgia Rheumatica myopathy
cortisol induced has lower extremity weakness with normal ESR and CK while PMR has increased ESR and when treated for and associated with Temporal arteririts, goes away with steroids. it also involves upper extremities
Steroid muscle disease
Painless, lower extremity, normal ESR and CK
NPH s/s and CT results and why
There is stretching of the ventricles permitting increase in CSF without increase in pressure. There is gait abnormalities, progressive dementia and urinary incontinence. Tx with LP or shunt if refractory. Opening pressure is NORMAL
What is the opening pressure in NPH?
IT IS NORMAL PRESSURE CSF PRESSURE IS NORMAL ON LP, the ventricles expand to accomodate the volume
HOw is NPH treated?
Treat NPH with large volume LP and IF IT WORKS, then do a shunt as these are curative
When is shunt used in NPH
Use shunt IF SERIAL LP REDUCE SYX
How is spinal abscess treated?
If suspected, you get MRI with gadolinium and treat with antibiotics and surgical debridement
does spinal abscesss need surgery?
yes it, needs surgery for spinal abscess within 24 hours
What CN is affected in IIH
IIH has CNVI palsy (lateral recture)
what eye muscle is affected in IIH?
In IIH, the lateral rectus, CN VI is affected
Common s/s of IIh
Headache, pulsatile tinnitus, diplopia, CNVI lateral rectal palsy, papilledema, double vision, h/o high BMI, isotretinoin / Vit A use and cyclnes
VPL thalamic stroke causes
Athetosis/hemiballistic and extreme pain /sensory defect with touchgin post-stroke
what is dysesthesia?
dysesthesia is characteristic of stroke in thalamus and is extreme pain afterward with touching
AD signs that are not due to aging?
most important is loss of daily function; other key ones are lost in familiar places (visuospatial defects), and late behavior changes
Essential tremor shows what with movement
Increased tremor with movement for ET
PD shows what with movement?
Decreased tremor with purposeful movement
How is essential tremor treated?
BB or primidone
What type of hearing loss is prebycussis
prebycussis is high pitched sensorineural
prebycussis is senosorinueral hearing loss of high pitched sounds common in elderly (bilateral), what is otosclerosis
otosclerosis is scarring of the middle ear bones causing conductive hearing loss common in middle aged people
what are s/s of prebycussis
older person with issues with background noise hearing and high-pitch loss with inability to tolerate loud noises, it is bilateral and sensorineural
what is the pathology of prebycussis
CNVIII cochlear damage leading to bilateral sensorineural hearing loss
When is a brain tumor that is metastic resected?
Resect it when they have good functionability and have a single lesion, then follow it with whole brain radiation
Difference between s. aureus brain abscess and s. viridans brain abscess?
Brain abscess due to direct extension (i.e ethmoid sinus) is commonly due to s. viridans, versus s. aureus which is puncture and surgery related
What is classic sign of SiADH
suspect SiADH in lung disease or head trauma and presents with high urine osmo and low serum osmo, with high urine sodium; none of which corrects with fluid bolue
how is SiADH treated?
Treat SiADH with fluid restriction and dememocycline and conivaptan
What are demecocyline and conivaptan used for?
Demecocyline and conivaptan are anti-SiADH-R moleculres
How is Nephro DI treated
Treat with fluid restriction and HCTZ
What is the MCC of secondary AI
secondary AI is due to exogenous steroids meaning normal aldosterone axis with low ACTH and low cortisol
Exogenous steroids use over time causing Cushing appearance is associated with what
Secondary adrenal insufficiency, aldosterone ok
How is unilateraly hyperaldosternoism treated?
Eplerenone > spironolactone
What is Conn’s syndrome
Hyperaldosteronism is Conn syndrome
When and in what patients is total thyroidectomy indicated?
Medullary CA of thyroid happens in MEN2A/B and prophy thyroidectomy indicated with a positive RET oncogene test
What is a partial seizure
partial seizure is a discrete region of the blrain
what is complex seizure
complex seizure involves temporal lobe (different than generalized which is both hemispheres) and results in loss of consciousness
what is a simple partial seizure example
conscious and aware of a muscle twitching
What is general seizure
loss of consciouss and both hemispheres invovled (tonic clonic, absence, myoclonic, etc
No postictal phase in absence, why unique?
because absence are actually generalized seizures involving both hemispheres and consciousness is lost
First workup of seizure
ALl blood tests + CT, no need for EEG or MRI fi there is a reason
Pediatric first line seizure prophylaxis?
Phenobarb
Second line absence seizure tx?
It is generalized, can use valproic acid if not tolerating ethosuximide
when to treat status epilepticus
seiuzre over 5m cause classic cortical necrosis, treat staticus at 5m mark with BDZ
Lab values after seizure?
Lactic acidosis and elevated PRL that self resolve
What type of hearing loss is otosclerosis
Conductive
what type of hearing loss is prebycusis
bilateral high-pitch sensorineural
how is benign positional vertigo treated
BPPV is due to otoliths and is positional and diangosed with dix hallpike and treated with epley maneuver, meclezine doesn’t work as it is a stone problem
Dx of BPPV?
Nystagmus on Dix Hallpike maneuver. Tx is with Epley
What is vestibulo-ocular reflex?
It diagnosis veticulopathy versus meniere/BPV, people cannot keep their eyes fixed on a target when rotating the head away; a + sign is veticulopathy, not Meniere and not BPV
What is the way to tell if there is a MG crisis or a cholinergic crisis (too much pyridostigmine)
use edrophonium and see if it worsens it or improves it
how is MG crises treated?
Intubate + IvIg + steroids
How is MG treated first line?
Pyridostigmine for MG first line
What is optic neuritis
Common in MS with pain on movmeent, scotoma, color cahnges and pupil defects and even swollen optic disks with diplopia
What is LP used for in MS
MS presents with optic neuritis, bilateral trigemenal neuralgia, relapsing remiting loss of function and LP is used when clinical dx is not a enough and it shows NORMAL everything other than IgG increased index
What is CSF like in MS
Normal, just some oligoclonal IgG bands
Best imaging for MS
Best imaging for MS is T2 weight MRI, not CT
is CT or MRI better for MS diagnosis
MRI is better for MS diagnosis, weighted T2 MRI is better for MS
How is acute MS treated?
Acute MS is treated with IV steroids and plasma exchange if refractory and then glitarem,er IFN, MTx otherwise
What is Glitarimer and IFN used for in MS?
Glitarimer and IFN prevent frequency/reduce frequence
How is GBS treate
GBS is treated with IVIG and plasmaphoresis not steroids
Why is GBS treated with IVIG and not steroids?
Treat GBS with IVIG and not steroids because antibody cross reaction, not cells is the issue
What is the defect in Alz disesae?
There is decreased ACh in AD
How is AD treated
Treat AD with reversible AChE-inhibitors as ACH is low in this disease
What are the AChE-inhibitors names used in Alz Disease?
Rivastigmine, deonpezil
What is galamantine?
NMDR inhibitor used in AD, otherwise use irvastigmine and donepezil AChE-i’s
Pick disease affects what
frontotemporal dementia
S/s of picks
frontotemporal dementia with family history and early behavior changes
what is seen on NPH imaging
dilated ventricles
how is pressure in NPH
NORMAL pressure that ventricles dilate to accommodate pressure at normal still – LP is NORMAL pressure
How is NPH treated?
LP and CSF drainaged due to decreased CSF absorptoin and if suscessful then you can do a surgical shunt
What part of brain is PD affecting?
Basal ganglia decreased dopamine
How is RLS treated
treat RLS with DOPAMINE AGONISM (pramipexole) iron and gabapentin
what dopamine agents are used in RLS
RLS = tx with dopamine agonism prampixole and iron and gabapentin
What is trihexyphindyl used for?
trihexyphenidyl is used for resting tremor in PD
what type of drug is trihyexyphenidyle and benztropine
trihexyphenidyle and benztropine are anticholinergics that are used to treat the syx of tremor only
what treats tremor in PD
in PD, tremor is treated with anticholinergic trihexyphenidyl and benztropine which cause classic anticholinergic AE, but reduce the syx of tremor
How is meningioma treaed?
Resect meningioma, epidural based masses with tails, resection is curatie
Most common location of brain mets?
Most common location brain mets is from the lung
why does medulloblastoma cause drop met?
It is cerebellar and in the fourth ventricle
pilocytic astroma cytoma location, marker and staing?
GFAP, cerebellar, cystic and solid
Whoe commonly gets craniopharyngioma?
Kids with Rathke pouch remnant and visual syx
COmmon syx in craniopharyngioma
COmpression of the optic chiasm
Brain lesions/tumors in non acute setting such as for veticular shwannoma are diagnosed how
diagnose brain lesions with MRI for tumors/not acute s/s (i.e shwanomma with tinnitus, hearing loss and vertigo)
What is a complication of IIH
there is papilledema and CNVI defect and blindness is a complication of IIH
s/s of cluster
retroorbital pain and horners, lacrimation isn’t alway spresent, commonly awakens patient from sleep
Hy: male awoken from sleep with retrorbital pain and ptosis and miosis on the same side,cause?
Cluster headache
What is biggest risk factor for any type of stroke?
Any stroke risk goes up with HTN, HTN, HTN, HTN biggest stroke risk
MC place of ulnar nerve entrapment?
MC place of ulnar nerve entrapment is medil condylar groove at elbow
What lies in medial epicondylar groove and commonly gets entrapped there? HY
The ulnar nerve lies in the medial epicondylar groove and commonly gets entrapped there HY
How might dystonia due to metoclopramide bet treated?
dystonia due to metoclopramdie might be treated with benztropine or diphenhydramine
Hemineglect invovles ignoring what side
Hemi neglect ignores the left side of their body and things (because right non-dom is infarcted)
What is a common symptom of MG? (muscles not under voluntary control)
Bulbar syx with chewing/swallowing regurg are common in MG, don’t confuse with heart burn of sclerosis
Lambert syndrome is due to?
Ab at presynaptic calcium channels
S/s of lambert
weakness, smoker/lung CA, repetitive simulation increases response on EEG, normal CK
Do Infective endocarditis patients need anticoagulation?
NO. In IE the antibiotics prevent the vegetations from forming and no anticoagulation is needed
Brain death characterized by?
Loss of brain stem and cortical function
What is Shy Drager syndrome?
Multiple system atrophy is Shy Drager syndrome and characterized by PD with autonomic dsyfunction and incontinence
What are cx of heat stroke other than death?
heat stroke occurs in young individuals in military/sports/heat and complications are rhabo/renal failure and coagulation (epistaxis)
what does heat stroke do to the blood
it causes rhabdo and renal failure and often results in coagulation deficiencies presenting as things such as nose bleeds
S/s of MG that is overlooked?
Bulbar syx like dysphagia, dysarthyria and fatigable chewing can happen in MG
What is seen in nuerons in PD?
PD shows alpha synuclein bodies in the substantia nigra pars compacta
