Neuro Flashcards
First line tx for pseudotumor cerebri (looks like pt has mass but don’t actually see one when imaging)
Acetazolamide (decreases CSF production by inhibiting choroid plexus anhydrase)
T/F: GBS is always preceded by GI illness/diarrhea
false, can be after URI
Tx for GBS
IVIG or Plasmapharesis
CSF fluid in GBS pt
Increased protein, normal wbc, normal glucose, normal rbc
+ Ice pack test
Myasthenia Gravis…ice pack leads to improvement of ptosis
Dementia + hallucinations/cognitive fluctuations/parkinsonism
Lewy body dementia
Abortive tx for migraines
Sumatriptan, NSAID, Metoclopromide (anti-emetic)
Prophylactic (preventative) for migraines
Topiramate, Propranolol
Patient is having a suspected stroke. Next step in mgmt?
CT head without contrast: Rule out intracranial hemorrhage
Sxs of Subarachnoid hemorrhage (i.e. hemorrhagic stroke)
Sudden-onset of severe headache that may be ass. with brief loss of consciousness, N/V, meningismus
(ischemic stroke has acute onset neuro sxs w/o HA or LOC)
T/F: You expect to see neuromuscular (asterixis, bradykinesia) and focal neuro deficits in metabolic encephalopathy
False, no neuro deficits
Ataxia, encephalopathy, ocular dysf(x)
Wernicke Encephalopathy –> most commonly seen in malnourished pts/alcoholics
Riluzole is a _____ inhibitor used to tx ______
Glutamate inhibitor; ALS
What is myasthenic crisis and what precipitates it?
Increased general/oropharyngeal weakness + respiratory insufficiency/dyspnea. ppt by infection, surgery, meds. Tx = intubation + Plasmapharesis/IVIG (not increasing MG drugs)
weakness, fatigue, muscle cramps, flat t waves, diuretic use
Hypokalemia
fluid-filled cavity within cervical and thoracic spinal cord most commonly ass. with Chiari I
Syringomyelia
Areflexic weakness in UE + sensory loss in a cape distribution
Syringomyelia
Degeneration of the dorsal and lateral white matter/tracts of spinal cord
= Subacute combined degen = B12 def
impaired vibration/proprioception + spastic muscle weakness
Tx for tic doulereux (trigeminal neuralgia)
Carbamazepine
T/F: Weakness and muscle wasting is seen in LMN lesion, not UMN lesion
False, it can be seen in both `
How to tx cancer pain?
Mild/moderate: nsaids/acetaminophen
Severe: SHORT acting opioids (morphine, hydromorphone). can later add long-acting.
Patient with altered brain function likely has ______itis, not _______itis
encephalitis, not meningitis
CSF findings of lymphocytic pleocytosis (increased lymphocytes), normal opening pressure, increased protein and rbc, normal glucose
HSV encephalitis
bacterial has decreased glucose and increased neutrophils
most common site ulnar nerve entrapment
elbow (medial epicondylar groove)…decrease 4/5 digit sensation + weak grip (interosseous mm)
Parkinsons tremors are more pronounced with ______ and _______
Distractibility (performing mental tasks) and re-emergence (tremor goes away with movement and comes back once you stop)
–>due to loss of DA neurons in basal ganglia
Papilledema, HA, vision loss, CN 6 palsy, normal CT
Pseudotumor cerebri (idiopathic intracranial htn)
medications than cause pseudotumor
Growth hormone
Tetracyclines
Excessive vitamin A and derivs (Isoretinoin, ATRA)
unilateral foot drop (steppage gait) is caused by:
Peroneal neuropathy or L5 radiculopathy
rapid dementia, possibly young patient, and +Myoclonus and triphasic discharges on EEG
CJD
Early onset dementia (30-50), grimacing, ataxic gait, progressive choreoform movements
Huntington’s Dz (AD chrom 4 defect, striatal neuro degen)
how can you differentiate spinal cord compression from GBS in a patient with LE weakness/neuropathy?
Spinal: possibly back pain. +UMN sxs i.e. + Babinski, hyperreflexia. Sensory findings and motor
GBS: Motor. no UMN signs.
Tremor thats exacerbated by caffeine, anxiety, or other SNS activity
Physiologic tumor
Tx of restless leg syndrome (usually worse at night)
Dopamine agonists (pramiprexole, ropinorole). Also, Iron supplementation if IDA.
most common cause of intracranial hemorrhage in children
AV malformation rupture
rupture of meningeal artery
Epidural hematoma (2 to trauma)`
ruptured saccular (berry) aneurysms cause:
subarachnoid hemorrhage
vertigo, tinnitius, sensorineural hearing loss
Menieres dz
weakness more pronounced in upper extremities, following hyperextension injury in elderly with pre-existing degenerative changes
Central Cord syndrome
-b/c UE motor fibers are closer to central part of Corticospinal tract
bilateral LMN spastic paresis following anterior spinal artery occlusion
Anterior Cord syndrome
Sxs in thrombotic vs embolic ischemic strokes
thrombotic: sxs fluctuate…stuttering progression with periods of improvement
embolic: rapid onset with maximal sxs @ onset
monocular vision loss, painful eye movements, afferent pupillary defect
Optic neuritis (first sx of MS)
most common cause of CN III palsy in adults
Ischemic neuropathy secondary to Diabetes
-Ptosis, Down-and-out gaze (lost EOMs), preserved pupillary response (vs Nerve compression you lose pupillary response!)
how do you differentiate btwn CN III nerve compression vs ischemia? (palsy)
compression: impaired pupillary response (b/c parasympathetic fibers)
ischemia: preserved pupillary response
both have down and out gaze, ptosis
why get a chest CT whens suspecting myasthenia gravis?
Thymoma (anterior mediastinal mass)
major cause of death from SAH within 24 hours
rebleeding
major cause of delayed morbidity and mortality (3-10 days) after SAH
Vasospasm
how do you prevent post-SAH vasospasm (usually days 3-10)
Nimodipine
Xanthochromia in CSF (LP)
SAH
Patient with myasthenia gravis develops respiratory insufficiency after recent infection, surgery, pregnancy, or meds (fluoroquinolones, beta blockers, etc)
Myasthenic Crisis….life-threatening
unilateral retro-orbital pain + ipsilateral autonomic manifestations (ptosis, rhinorhea, miosis). Has redness with tearing but no visual changes.
cluster headaches
how can you differentiate btwn thiamine deficiency (wernicke) and b12 def in an anorexic patient with neuro sxs?
Thiamine: +oculomotor sxs, mental status changes
B12: mental status changes without oculomotor sxs
who gets Wernicke Encephalopathy?
Alcoholics, but ALSO
Anorexics
Hyperemesis Gravidarum
clinical features of wernicke encephalopathy?
Oculomotor changes (i.e. nystagmus)
Postural/gait ataxia
Encephalopathy
T/F: Presence of hallucinations makes a psychotic disorder more likely than delirium in an elder adult
False, hallucinations can occur during delirum
risk factors for delirium
Age Prior stroke Dementia Parkinson's dz sensory impairment
How can you differentiate btwn alzheimers and NPH in a patient that is wet, wobbly, wacky?
Initially memory problems: Alzheimers
Initially gait difficulties: NPH
I.e. if urinary incontinence for years and then memory problems and last gait, still alzheimers
damage to optic nerve vs opthalmic branch of trigeminal
Optic: Monocular blindness! and afferent pupillary defect
Ophtalmic: loss of sensation over eye, i.e. corneal abrasion but not feeling eye pain.
what is positional claudication and when is it seen in relation to back pain?
Pain that is positional…_when upright with exercise but relieved by sitting. Seen in Spinal stenosis i.e. lumbar stenosis. Need an MRI
When would you suspect spinal stenosis (i.e. lumbar stenosis) and what would be your next step?
When patient has positional claudication in reference to back pain (worse when standing better when sitting).
MRI MRI MRI MRI MRI MRI
what is transverse myelitis and who gets it?
MS patients (after optic neuritis). -sensorimotor loss below level of lesion with bowel and bladder dysf(x). Initiallly flaccid paralysis, then hyper reflexia and spastic paralysis
what is internuclear opthalmoplegia and who gets it?
MS patients (after optic neuritis) -demyeline MLF = impaired conjugate gaze so ipsilateral eye can't adduct
compression of spinal nerve roots i.e. from metastatic prostate cancer, disc herniation, spinal stenosis, etc
Cauda equina syndrome
what is the function of the Cauda Equina?
lumbosacral nerve roots below L2, so sensory to saddle area, motor to sphincters (anal/urethral), parasympathetic to bowel/bladder
Sxs of cauda equina syndrome
bilateral severe radicular back pain, saddle anesthesia, LMN signs only, asymmetric motor weakness, hyporeflexia, late-onset bowel/bladder dysf(x)
Sxs of conus medullaris syndrome
sudden-onset severe back pain, perianal anesthesia, symmetric motor weakness, HYPERreflexia, (UMN and LMN signs), late-onset bowel/bladder dysf(x)
Cauda equina syndrome shows only LMN signs, but Conus medullaris syndrome shows both UMN and LMN. Why?
Cauda equina: compression of lumbosacral nerve roots = peripheral nerves = LMN
Conus medullaris: conus is part of the spinal cord to both UMN and LMN
for both, emergency MRI + steroids + neurosurg consult
lipohyalinosis and microatheroma of small vessels leading to stroke
Lacunar infarct. Risk factors = diabetes, htn, hypercholesterolemia and smoking
complications of heat stroke
defined as T>40C + AMS
-rhabdomyolysis, ARDS, coagulopathic bleeding (perisistent epistaxis i.e)
T/F: symmetrical proximal weakness is seen in Lambert Eaton and not MG
False, can be seen in both
most common cause of intraparenchymal hemorrhage
hypertensive vasculopathy
2 most common organisms for brain abscess (non-HIV)
Staph aureus and Strep Viridans
Patient is stabbed, and they now have loss of motor and reflexes in muscles on right LE, loss of MVP on right and loss of pinprick sensation on left below umbilicus
Brown-Sequard Syndrome
Loss of ipsilateral Corticospinal (motor) and DC-ML (MVP including light touch) and contralateral Spinothalamic
Parkinson’s patient receives first-line medication. What side effects?
So they got Carb/Levodopa. Expect confusion/somonlence and HALLUCINATIONS since its a dopamine agonist #psych
Is NPH due to increased CSF production or decreased CSF absorption?
Decreased absorption
Tremor thats absent at rest and worsens with movement
Essential tremor
sxs of lacunar infarct, which are commonly associated with HTN
acute unilateral motor weakness w/o sensory/cortical deficits. usually affect posterior limb of internal capsule
Atrophy of the caudate nucleus, seen as enlarged lateral ventricles
Huntington’s dz
what is the big risk with prolonged seizure/status epilepticus?
Cortical laminar necrosis
how does PCA thrombosis present?
Occipital ischemic stroke = contralateral homonymous hemianopsia with macular sparing
Night time headaches, papilledema, nausea, focal neuro deficits
think brain tumor. If CT negative, think pseudotumor cerebri
Who gets pseudotumor?
FAT CHICKS
Tx for pseudotumor?
Weight loss and Acetazolamide
Sxs of pseudotumor aka idiopathic intracranial htn?
HA (especially night time), transient vision loss, pulsatile tinnitus, diplopia. look for papilledema and negative CT
What autonomic dysf(x) is seen in 70% of Guillain Barre patients?
Tachycardia, urinary retention, and arrythmias. Occurs over days/weeks (not hours)
CSF findings for GBS
albuminocytologic dissociation = high protein with few cells
major complication of pseudotumor if not treated?
blindness
signs of cerebellar dysf(x) commonly seen in alcoholics
Note: getting neuro signs in alcoholic but not wernickes
gait instability, truncal ataxia, difficulty with rapidly alternating movements (dysdiadochokinesia), hypotonia, intention tremor
tx for NPH
Serial LPS, and possibly VP shunt
3 cardinal signs of parkinsons
Resting tremor
Bardykinesia (i.e. takes longer to get out of bed)
Rigidity
2/3 = dx
Postural instability also occurs = falls, loss of balance when when turning or stopping
what does + Pronator drift indicate?
Pyramidal tract/Corticospinal tract or UMN lesion
vs Romberg test is for proprioception
non-pharm mgmt of delirum
reduce night time noise/disturbance, verbal orientation, reassurance, interactions with family members, trained sitter @ bedside
patient with foot drop due to compression from prolonged immobilization, leg crossing (i.e. meditation or sitting), or protracted squatting. Which nerve?
Common peroneal/fibular. Presevered plantar flexion, unilateral foot drop, impaired dorsiflexion (cant walk on heel), numbness/tingling
how soon do you start aspirin and heparin after stroke?
NO HEPARIN AFTER STROKE SON.
Aspirin is started now (w/in 48 hours) for future stroke prevention if cause is atherosclerotic. if it is septic embolus, i.e., wouldn’t be used.
tx of menieres dz (vertigo, tinnitus, hearing loss)
diuretics and salt restriction
FND + Vertigo
Central lesion
central lesions responsible for vertigo
Posterior Fossa!!!! Tumor, CVA (stroke), MS, abscess/seizure/migraine, meds
Patient with Parkinsonism experiencing impotence, orthostatic hypotension, incontinence, dry mouth, etc (autonomic sxs)
Multiple System Atrophy (Shy-Dragler syndrome)
impaired heel-to-shin, difficulty with balance and wide-based gait, preserved finger to nose in an alcoholic
Cerebellar degeneration (not b12). Get postural incoordination but intact limb coordination (finger to nose)
Patient with Bell’s palsy and forehead sparing
Intracranial lesion!!! Bilateral UMN innervation means that it will be intact even if one side fucked, so only lower facial weakness (won’t see inability to raise eyebrow or close eye). If LMN lesion this side of the forehead is fucked.
what is Presbycusis?
age-related hearing loss. note: tinnitus can be present
triggers for vasovagal (neurocardiogenic) syncope
prolonged standing
emotional distress
painful stimuli
T/F: Patients may experience general feeling of warmth, dizzyness, nausea, diaphoresis, abdominal pain prior to vasovagal syncope
true. Excess vagal tone causes profound hypotension and bradycardia due to autonomic reflex
patient with prior hallucinations presenting with rigidity, profound fever, AMS, autonomic dysregulation
Neuroleptic Malignant Syndrome
MMSE < ___/30 = dementia
24
how do you differentiate btwn alzheimers and frontotemporal dementia
- Age: Pick’s is 40-60yo, AD usually >60
- Sx progression: Picks starts with more personality changes/loss of social restraints, and then followed my the memory loss/confusion. AD starts with memory loss.
tx of fibromyalgia
TCA (amytryptiline) or snri + regular exercise
side effects of amitryptiline
TCA so interacts with everything:
- anticholinergic effects: dry mouth, constipation, urinary retention
- antihistamine: lethargy, wt gain
- anti-alpha: Orthostatic Hypotension,
tx for cluster headache (abortive)
100% O2. can use sumatriptan if needed
tx for cluster headache (prophylactic)
verapamil, lithium
1st and 2nd line tx for essential tremor
1st: beta blocker
2nd: benzo (clonazepam), alcohol, primidone (anticonvulsants). obvi not used unless BB fails
family history + of slowly worsening tremor that increases with action/movement
essential tremor
what does MRI show for toxoplasmosis
MULTIPLE ring-enhancing lesions in BASAL GANGLIA
what does MRI show for primary CNS lymphoma
SINGLE ring-enhancing lesion PERIVENTRICULAR
+ EBV DNA in the CSF
Primary CNS Lymphoma. MRI will show single periventricular ring-enhancing lesion
who gets MG?
women 20-30
men 60-80
1st line tx for MG
PYRIDOGSTIGMINE = ACHE Inhibitor
NOT IVIG…this is used for myasthenic crisis when theres respiratory failure
who get bilateral internuclear opthalmoplegia and describe what it is
- MS patients
- lesions of MLF
- conjugate horizontal gaze affected…ipsilateral eye cant adduct. so when looking left, left eye abducts properly but right eye stays midline. same vice versa since bilat
mydriasis, ptosis, and down and out eye
Oculomotor nerve palsy
cause of oculomotor nerve palsy
Nerve compression via PCA aneurysm (would include mydriasis b/c PNS on periphery ) or microvesicular nerve ischemia (Diabetes)
stepwise decline in executive function and memory
vascular dementia
rapidly progressive dementia, myoclonus, possibly young
CJD (prion)
how can you differentiate btwn vascular dementia and NPH in a wet, wobbly, wacky patient who started wobbly?
Unilateral FND are common in Vascular, but not NPH
pupils that constrict when looking at finger on nose but poorly constrict when light flashed
Argyll-Robertson pupils: Tabes Dorsalis aka tertiary neurosyphillis
Sensory ataxia aka +Romberg, lancinating/shooting pains in the face and back, irregular pupil constriction, neurogenic urinary incontinence. Tx?
Tabes Dorsalis aka neurosyphillis. Give IV penicillin
Tx for delirium patient with lots of agitation
Anti-psychotics, usually Haldol. Avoid benzos
t/f: Lewy body dementia patients will ddisplay some parkinsonism features
True beta
eosinophilic intranuclear inclusion bodies composed of alpha-synuclein
Lewy Bodies. seen in PD and Lewy body dementia. Look for +visual hallucinations to make dx LBD. Also, LBD has early dementia, vs PD has very very late dementia
T/F: Occipital HA is caused by occipital lobe hemorrhage
False, usually cerebellar hemorrhage
bilateral trigeminal neuralgia
MS !!! Demyelination of the nerve nucleus
what do you expect on CSF studies of GBS patient?
Increased protein, normal wbc
Patient comes in with stroke. What do you need to do before giving tpa/alteplase? Assume it has been less then 4.5 hours
Must r/o hemorrhagic stroke by getting non-contrast CT
also check for CI’s
What is another word for shuffling gait, seen in _____ Disease?
Hypokinetic gait seen in Parkinsons dz
dilated, non-reactive pupil
unilateral orbitofrontal HA with N/V
unilateral eye pain with conjunctival injection
Acute angle-closure glaucoma
first line tx for alzheimers dementia
Cholinesterase inhibitors
–>Donepezil, galantamine, rivastigmine
How do you abort a seizure?
Bens Phunny Midwife-Pro Barb
- Benzo (lorazapem/diazepam). if still:
- Phenytoin
- Midazolam + Propofol
- Phenobarbital
- ->once aborted, draw labs and reverse any underlying cause
Chronic therapy to decrease risk of seizures in epileptic
Options are valproate, lamotrigine, levitracetam
- Partial: Carbamazepine Phenytoin
- Generalized: Valproate or Lamotrigine
- Atonic (no LOC): Valproate
- Myoclonic: Valproate
most common common stroke (vessel)
MCA (90%) -->weakness/sensory loss on CONTRALATERAL SIDE. Upper Limb and Face (sensory-motor) -->vision on loss opposite to lesion... EYES will deviate TOWARD LESION side -->clue its on left side: Aphasia. -->Wernicke: Temporal; Broca: Frontal
random neuro arteries
AAA: Affects Anterior Spinal A = spastic paralysis and loss of proprioception
Locked in Syndrome: Basilar artery
Berry/Saccular Aneurysm: PCom (CN III Palsy)
The 2 Vertebrals (AICA and PICA come off it) form the Basilar, which goes and forms the circle of willis with PCA first branch, PCom to MCA etc
AICA and PICA stroke
AICA: Facial droop means AICAs pooped…Paralysis of face, dec lacrimation/salivation/taste.
- ->Ipsilat loss of pain/temp face
- ->Contralat loss of pain/temp body
PICA (comes off vertebral): Lateral Medullary syndrome aka Wallenberg
- ->Vomiting, vertigo, nystagmus. Dysphagia. Hoarseness. Ataxia. Dysmetria
- ->Ipsilat HORNERS syndrome
- ->Ipsilat loss of pain/temp face
- ->Contralat loss of pain/temp body
Posterior circulation is composed of 2 _____ arteries forming the _____ artery. Strokes here cause
vertebral
basilar
cerebellar deficits, change in mental status, and blindness
Anterior circulation is composed of :
deficits here:
MCA and ACA
feed teh speech centers, motor and sensory strips (homunculus)
first part of stroke management
non-contast CT to r/o hemorrhage
what do you give to all stroke patients (acute management meds)?
ASPIRIN ASPIRIN ASPIRIN STATIN STATIN STATIN
Aspirin allergy? sub Clopidogrel
Seizure on asp (aka already on aspirin)?
–>Do Aspirin + Dipyramidole
NEVER HEPARIN NEVER HEPARIN NO HEPARIN
mgmt of hemorrhagic stroke
Neurosurg
SBP <150
FFP!!!
After a stroke is acutely managed, which of the following tests are needed: ECG, ECHO, Carotid US
all, in order to prevent the next stroke
ECG: check afib. Yes? Anticoagulate (Warfarin no bridge)
Echo: thrombus? Anticoagulate (Heparin bridge to Warfarin)
US Carotid: <70% meds; >70% = stent/carotid endarterectomy
(remember, this is after the acute episode is over. You don’t use heparin/warfarin in the acute setting. This is for long-term prevention)
dizziness caused by central lesions are _____ and _____ (quality) and usually a structural lesion of the ____ ___
chronic and progressive; Posterior Fossa: Look for cranial nerve deficits. GET AN MRI
(Stroke, Posterior fossa tumor, MS, meds, abscess, migraine, seizure)
dizziness caused by peripheral lesions are _____ (quality) and are usually in the ______
acute
EAR EAR EAR EAR EAR EAR EAR EAR: hearing loss/tinnitus
(Labryinthitis, Menier’s, BPPV)
FND + Vertigo =
Central Lesion (CVA, Posterior Fossa Tumor, MS, meds, abscess/migraine/seizure). GET AN MRI -->Vertebrobasilar insufficiency.
_____ is caused by otolith (which irritates the hairs) of the semicircular canals
Benign paroxysmal positional vertigo (BPPV).
Vertigo and rotary nystagmus on head movement thats usually transient (<1) min. Dz and tx
BPPV (otolith).
- ->can be reproduced by Dix-Hallpike
- ->Movement exercises dislodge/break up the stone = cures the patient
- ->Epley manuever is curative
Vertigo, n/v, hearing sxs for 4 weeks after a URI
Labrynthitis/vetibular neuritis. Give steroids or meclizine. may have on/off sxs for months
Vertigo + hearing loss + tinnitus. unrelated to movement.
Meniere’s
what differentiates menieres from BPPV
time. BPPV usually transient (<1 min)
Menieries usually dizzyness around 30 min
treatment for menieres disease (vertigo, hearing loss, tinnitus)
DIURETICS AND LOW SALT DIET
how do you differentiate syncope from vertigo
Syncope: Black out/light headed/chest pain/SOB (LOSS OF CONSCIOUSNESS) –> cardiac
Vertigo: Room spins/unsteady. no LOC. Diff central vs peripheral based on FND (central) vs tinnitius/hearing loss/ear stuff (peripheral)
