Neuro Flashcards
hypertensive bleeds occur most commonly in?
basal ganglia (cerebellum, thalamus, and pons likely too)
4 things that must be tested when mental status change is observed?
- syphilis
- HIV
- TSH
- B12
subdural hematoma is rupture of?
bridging veins (see HA and gradual LOC)
stroke involving sensory ONLY
thalamus
essential tremor vs parkinson tremor
essential tremor stops at rest and becomes noticeable when the patient attempts a fine motor task
when is carotid endarterectomy recommended?
when stenosis is 70-99% and the patient is symptomatic
treatment for Guillain-Barre syndrome?
IVIG and plasmapheresis
Primadone use and side effects
One of two meds used for essential tremor (the other is propanolol). This is an anticonvulsant that converts into phenylethylmalodamide and phenobarbital. It may precipitate acute intermittent porphyria (abd pain, psych sx)
treatment for restless leg syndrome
DA agonist
sensation of cornea?
trigeminal V1 distribution
traits of fronto-temporal dementia
personality changes
compulsive behavior
impaired memory
**Previously known as Pick’s Disease
Inclusions of hyperphosphorylated tau
normal pressure hydrocephalus
DECREASED CSF absorption 1. Gait disturbances 2. Incontinence 3. Dementia (wet wobbly wacky)
pure motor stroke…think what?
lacunar infarct (rarely embolic). Comprise 25% of ischemic strokes and have a favorable prognosis HTN and DM are major risk factors
why is cauda equina so sensitive?
poorly developed epineurium
*lesion is noted in spinal nerve roots. MUST obtain emergent MRI
Drug induced myopathy. what drug most common and how present??
steroids and can occur weeks to months after initiation
Presents with painless proximal muscle weakness. Will improve if med is discontinued (can see after temporal arteritis). Unlike PMR which is painful and has increased ESR
body temp >105 what the heck do you do?
evaporation cooling of the pt (the body’s main method of heat dissipation is via evaporation of sweat).
–> spray NAKED pt with LUKEWARM WATER and FAN them.
tx for trigeminal neuralgia
carbamazepine (aplastic anemia can occur with prolonged use)
- second line is other anticonvulsant drugs
- third line is surgical percutaneous radiofrequency ablation and microvascular decompression
speech, language, and calculation what lobe?
dominant frontal lobe
weakness, fatigue, muscle cramps, U waves, flat T waves
HYPOkalemia
Right sided down and out ptosis in DM pt…whats goin on?
oculomotor lesion due to CN3 ISCHEMIA
Remember that parasympathetic and somatic CNIII aspects have different blood supplies and the diabetic CNIII neuropathy only affects the somatic aspect. Accommodation and pupil response to light remain intact
If had nerve compression, would see BOTH somatic and parasympathetic deficits
absence of forehead furrows?
indicates bells palsy (peripheral 7th nerve palsy) and rules OUT a central facial paresis. Central lesions still have the forehead furrow because the contralateral is still intact and can compensate
contraindications of triptans (sumitriptan)
- uncontrolled HTN
- coronary artery dz
- prinzmetal angina
- pregnancy
- Ischemic stroke
- Basilar migrane
hemineglect is what and where?
ignoring the left side, from a right sided parietal infarct (non-dominant)
Riluzole
glutamate inhibitor used in ALS. Prolongs survival and time to trach
best test to monitor resp function in an impending resp failure pt? (ie guillon-barre pt)
vital capacity
CSF in Guillon-Barre
High protein, normal WBC RBC Glucose. tx IVIG, plasmaphoresis
bilateral periorbital edema, CN 3,4,5,6 deficit, severe HA…think what?
cavernous sinus thrombosis
pronator drift specific for?
UMN lesion
painless loss of vision from emboli is called?
amaurosis fugax….this is warning sign of impending stroke
what type of nystagmus would you expect to see in a pt with benign positional paroxysmal vertigo?
a combined vertical and torsional nystagmus
tx of benign positional paroxysmal vertigo?
epley maneuver (appropriate for pts with posterior canal BPPV)
- Start with head 45 degrees turned toward affected side.
- move head to 45 degrees laterally and tiled 30 degrees back over edge of bed when supine.
- *Goal is to move canaliths from the posterior semicircular canal to the vestibule**
meniere disease
episodic vertigo with nausea and vomiting. Fluctuating but progressive hearing loss, tinnitis, and a sensation of fullness or pressure in the ear.
vermis vs hemispheric cerebellar lesions
vermis –> truncal and gait ataxia
hemispheric –> ipsilateral limb ataxia
paraneoplastic cerebellar degeneration (PCD)
pancerebellar syndrome most often associated with small cell lung cancer or a gyn malignancy.
- truncal, limb, and gait ataxia
- anti-Yo, anti-Hu
Miller Fischer Syndrome
triad of ataxia, areflexia, opthalmoplegia (paralysis of muscles within or surrounding the eye)
- Varient of guillon barre
- IgG and anti-GQ1b autoantibodies are elevated (90% pts)
inheritance of Fredreich ataxia and some fun facts
AR (mutation on FXN gene on chr 9, GAA trinucleotide)
Damage to cerebellum and peripheral nerves
Onset between age 10-15
cluster headache
unilateral trigeminal nerve distribution pain accompanied by prominent ipsilateral autonomic symptoms.
**almost invariably accompanied by autonomic sx such as lacrimation, conjunctival injection, facial or forehead swelling, eyelid edema, signs of horner syndrome
idiopathic intracranial hypertension =
pseudotumor cerebri.
primarily affects obese females who have menstrual irregularities
*elevated CSF pressure in the absence of an identifiable intracranial mass lesion
-also can see 6th nerve palsy
-most severe first thing in the morning
to dx IIH, must exclude
venous sinus thrombosis (r/o with venous sinus imaging)
pathophys of trigeminal neuralgia
compression of trigeminal nerve root at cerebellopontine angle, most often by an abberant vascular loop
what is invariably a manifestation of all aphasias
anomia: the inability to name.
apraxia
inability to carry out a learned motor task despite preservation of the primary motor, sensory and coordination functions needed for a task
definition of epilepsy
two unprovoked seizures
complex partial seizures
have a focal onset that is most commonly in the temporal lobe (some in frontal too) and they involve an impairment of awareness
EEG of absence seizure
three per second spike and wave EEG
-hyperventilation is a common trigger
side effects of keppra
insomnia, anxiety, irritability
first and second line tx of status epilepticus
- lorazepam
2. phenytoin, phenobarbital, propofol
5 parkinsonian syndromes
- progressive supranuclear palsy
- corticobasal ganglionic degeneration
- diffuse lewy body disease
- vascular parkinsonism
- multiple system atrophy
4 cardinal clinical features of idiopathic PD
- resting tremor
- rigidity
- bradykinesia
- postural instability
carbidopa
peripheral decarboxylase inhibitor
brocas aphasia location
left FRONTAL lobe
unprovoked first seizure tx?
non-con CT to exclude acute neurologic problems (intracranial or subarachnoid bleeds)
elderly and demented pt, what med use to calm down ACUTELY?
Haloperidol (risperidone and quetiapine can also be used)
sudden onset vertigo, vomiting, and occipital HA in hypertensive pt is suggestive of what?
cerebellar hemorrhage
Blepharospasm
any abnormal contraction or twitch of the eyelid. In most cases, symptoms last for a few days then disappear without treatment, but sometimes the twitching is chronic and persistent, causing lifelong challenges
idiopathic intracranial hypertension can be caused by what med?
isotretinoin
4 stages of pressure ulcers
- nonblanching redness of skin, skin still intact
- shallow open ulcer with partial thickness loss of dermis
- poss visualization of subq fat with full thickness tissue loss
- exposed bone tendon or muscle
shy-drager syndrome
aka multiple system atrophy
-pt has parkinsonism sx with orthostatic hypotension, impotence, incontinence, or other autonomic symptoms
treatment for shy-drager syndrome (multiple system atrophy)
anti-parkinson drugs are usually ineffective
-tx is aimed at intravascular expansion with fludrocortisone, salt supplementation, alpha-adrenergic agonists, and application of constrictive garments to the lower extremity.
first line tx for idiopathic intracranial hypertension
acetazolamide (carbonic anhydrase inhibitor that inhibits choroid plexus CSF production)
triad of Wernicke’s and what is cause
triad: encephalopathy, oculomotor dysfunction, gait ataxia (no lab or imaging is necessary)
- caused by thiamine deficiency
cerebellar tumor presentation
ipsilateral ataxia, nystagmus, intention tremor, loss of coordination
trihexyphenidate
drug used for parkinsons and drug-induced extrapyramidal symptoms (same class as benztropine) It is an anticholinergic (hot as hare, mad as hatter, full as flask...)
HIV positive male with altered mental status with EBV DNA in the CSF and a solitary weakly ring-enhancing lesion mass on MRI…what suspect?
CNS lymphoma
Toxoplasmosis is unlikely given there is only one single lesion. Remember that a positive Toxoplasma serology is NOT specific for toxoplasmosis
what is the hallmark of status epilepticus from a brain pathophys point of view?
cortical laminar necrosis (remember that status is a seizure lasting >5 min or a cluster of seizures where the pt does not come back to normal between seizures)
anterior cerebral artery stroke presentation
contralateral motor and/or sensory deficits which are more pronounced in the LOWER limbs than the upper limbs
middle cerebral artery stroke
contralateral motor and/or sensory deficits which are more pronounced in the UPPER limb and exhibit homonomous heminopia. If dominant involved, may exhibit aphasia. If nondom is involved, may have neglect or anosognosia (unawareness of illness)
calcarine cortex
visual hallucinations
cerebral salt-wasting syndrome
may occur in pts with SAH. pathophys involves:
1. inappropriate secretion of vasopressin (water retention)
2. increased secretion BNP
Both result in cerebral salt wasting resulting in HYPONATREMIA.
SIADH is also common in SAH pts
CPK in Myasthinia Gravis
normal
most commonly involved muscles in Myasthinia Gravis
extraocular muscles –> presenting as double vision
sudden onset of eye pain, photophobia and mild-dilated pupil…think what and what is best test
think glaucoma and best test is tonometry
pt presents with focal symptoms of stroke that rapidly progress to signs of elevated intracranial pressure (vomiting, nausea headache, decreased alertness), think what?
intracerebral hemorrhage (most often from HTN, coagulopathy, ilicit drug use that occurs in basal ganglia, thalamus, pons, and cerebellum)
can reflexes still be present with brain death?
you bet, the spinal cord may still be functioning
abx causing ototoxicity and what does it cause specifically?
aminoglycoside (gentamycin) that can cause ataxia and vertigo (vestibular insult)
upper limit of intracranial HTN in CSF opening pressure?
20 mm Hg
sensory loss to one half of face and same half of body
thalamus or cortex
sensory loss to one half of face and contralateral side of body
brainstem lesions (usually involve the cranial nerves)
periodic sharp waves on EEG that are bi or triphasic
Creutzfeldt Jacob disease: think of in fast progressing dementia, myoclonus
MMSE score of less than what is indicative of dementia
24 (of 30)
MRI findings in PML
multiple demyelinating non-enhancing lesions that do not produce mass effect
-mean survival from time of dx is 6 months (HIV pts)
closed angle glaucoma presentation
rapid onset of severe pain and vision loss. Pts may complain of seeing halos around lights. The affected eye will appear injected and the pupil will be dilated and poorly responsive to light.
-severe and permanent vision loss in 2-5 hours if left untreated
3 treatments available for myasthinia gravis
- pyridostigmine (ACHE-I)
- immunosuppressive agents
- thymectomy
during gate assessment, pt very prominently flexes his hip and knee and his right foot slaps the floor with each step
pt is “high-stepping” due to right foot drop. Most commonly caused by peripheral neuropathy or radiculopathy to spinal nerve roots that contribute to common peroneal nerve.
-could also be congenital like in charcot marie tooth disease
spastic paresis gate cause
corticospinal tract lesions. If unilateral, may cause hemiplegic gate where the spastic leg is held extended and internally rotated
most important risk factor for stroke.
HTN (increases risk for all types of strokes) 4x the risk to non-hypertensive pts
genetic defect in neurofibromatosis type II
nonsense and frameshift mutations
the only HA syndrome that is more common in men than women
Cluster HA
- usually at same time of day, frequently awake pt from sleep, always unilateral, sudden in onset, retro-orbital pain that spreads to hemicranium, ipsilateral autonomic sx
- tx 100% O2
pseudodementia
elderly patient that presents with depression and memory loss. CT will be normal. DST will be abnormal 50% of the time
INR<5
INR 5-9
INR >9
INR<5 omit next warfarin dose
INR 5-9 stop warfarin temporarily
INR >9 stop warfarin, give vit K
contraindications for tPA
BP > 185/110 Hemorrhagic Stroke Recent Surgery Active bleeding Pregnancy
motor involvement without any cortical dysfunction or visual field defects…where is da lesion?
internal capsule
side effects of levodopa/carbidopa
somnolence, confusion, hallucination, dyskinesia (impairment of voluntary movement)
bilateral trigeminal neuralgia
MS
Parkinson’s tremor hz
4-6 hz
Tx of acute exacerbation of MS
Corticosteroids
Long term therapy with steroids does NOT prevent future relapses and shows no benefit
torticollis
focal dystonia of the SCM muscle (sustained muscle contraction, resulting in twisting and repetitive movements or abnormal postures)
-can be medicine related (typical antipsychotics, metaclopramide, prochlorperazine
Glatiramer acetate
MS drug: long term disease modifying agent that modulates T-cell mediated autoimmunity to myelin basic protein
3 key features of Lewy Body Dementia
- fluctuations of alertness
- visual hallucinations
- extraordinary sensitivity to neuroleptics (worsening of sx with drugs like haloperidol)
clinical presentation of progressive supranuclear palsy
supranuclear ocular palsy (failure of vertical gaze), dysarthria, dysphagia, extrapyrimidal rigidity, gait atazia, and dementia
Nystagmus:
left/right, torsional/rotational –>
upbeat, downbeat –>
Nystagmus:
left/right, torsional/rotational –> “peripheral” vestibular dysfunction
upbeat, downbeat –> “central” vestibular dysfunction
bladder problem in Parkinson
detrusor hyperreflexia (occurs in 40-70% of pts)
what are some spastic bladder (hyperactive bladder) treatments?
Remember these are stroke, frontal lobe dysfunction, suprasacral spinal cord lesions, and MS pts
- Anticholinergic agents (tolterodine, oxybutynin)
- TCA (imipramine, amitryptyline)
- Desmopressin (reduction in voiding frequency)
- Intravesical capsaicin
- Sildenafil, Botulinism, Nerve stim
what are some stress incontinence drugs (involuntary loss of urine during coughing, sneezing, laughing)
Remember these are multiparous women with weak pelvic floors
- Alpha adrenergic agonist drugs (midodrine, pseudoephedrine)
- Estrogen therapy
- Duloxetine
what are some atonic bladder treatments (LMN lesion at conus medullaris, cauda equina, sacral plexus)
- Crede maneuver or valsalva (to empty bladder)
- Self-cath
- Bethanechol (stimulate cholinergic receptors increasing detrusor muscle tone)
bilateral LMN facial weakness…think what
sarcoidosis
-also an important cause of lymphocytic meningitis
allodynia
pain provoked by normally innocuous stimuli
lower limit of FVC that indicates intubation necessary
15ml/kg
most common cause of polyradiculitis or cauda equina syndrome in an HIV pt
cytomegalovirus (occurs in about 2% of AIDS pts)
- characterized by subacute onset of a flaccid paraparesis, sacral pain, paresthesias, sphincter dysfunction
- tx with ganciclovir or foscarnet
multiple sleep latency test used to detect….
narcolepsy (treat with modafinil)
“crossed signs”
unilateral lesions in the pons results in ipsilateral facial weakness and contralateral limb weakness
side effects of carbamazepime
hyponatremia, agranulocytosis, SJS
enhancement of brain MRI in homogeneous manner?
meningioma (bright and mainly homogeneous manner)
- Glioblastoma, metastatic lesions, brain abscess, toxo, granulomas, demyelinating lesions ALL show ring enhancement*
- CNS lymphoma can be BOTH homogeneous or ring enhancing
MRI of HSV infection
temporal lobe edema and contrast enhancement
symptoms of small fiber neuropathy
neuropathic pain
-exam shows impaired temperature and pinprick sensation
treatment of advanced sleep phase disorder
light therapy and melatonin
PD tremor and rigidity is symmetric or asymmetric?
asymmetric
MRI sequence most sensitive for presence of blood breakdown products
susceptibility (gradient echo imaging)
CK level in Deuchene Muscular Dystrophy
HIGH (Becker is high, but not as high)
locked in syndrome
base of pons lesion
sensory impairment in thumb can be 2 things
- median neuropathy
2. C6 radiculopathy
spine complication of abdominal aortic surgery
anterior spinal artery syndrome (ASAS)
-everything BUT the posterior column (preservation of joint position sense)
vitamin deficiency associated with ataxia
Vitamin E deficiency may cause ataxia, myelopathy, and polyneuropathy.
