Neuro Flashcards
number one risk factor for Parkinson’s
aging2-4% risk >60 years
do males or females get Parkinson’s more
Males 3:2 (M:F)
what does Parkinson’s often start with/first sign
UUNILATERAL resting tremor (don’t HAVE to start our with but often do 75%)
when looking at brain, what is a hallmark to Parkinson’s
progressive Lewy Body accumulationstarts in brainstem and then goes up to frontal cortex and then works it’s way back to occipital cortex (most found in brainstem)
list four classical clinical features of Parkinson’s
Bradykinesia
Muscular Rigidity
Postural Instability
Resting Tremor
describe rest tremor
“pill-rolling”
UNILATERAL/symmetric
common appearance of gait in Parkinson’s
narrow stance, small-shuffling steps, stooped over
common non-motor features of Parkinson’s
fatigue, saliva, nocturia
how to tell if Parkinsonism due to Parkinson’s or drugs
are features presenting symmetrically or asymmetrically
symmetrically due to drugs
asymmetrically due to Parkinson’s
why do you want to get definitive dx of Parkinson’s when looking at neurodegenerative disorders when treatment basically the same for all of them
prognosisquality of lifeParkinson’s could still live 30 yearsOther neurodegenerative disorders 8-10 years
T/F diagnosis of Parkinson’s is clinical
true
T/F diagnosis of Parkinson’s is from good hx and physical
true
define Parkinsonism
bradykinesia in combination with at least 1 of rest tremor or rigidity
are reflexes impaired in those with Parkinson’s
no
diagnostic criteria of Parkinson’s
see picture
Parkinson’s diagnostic pearls
see picture
what best slows down the progression of Parkinson’s
exercise
goals of management of Parkinson’s
optimal quality of lifepatient-specific
T/F medication adjustment over time is the norm when treating Parkinson’s
true
Management strategies of Parkinson’s
see picture
Parkinson’s medications
see picture
rule when starting medications in Parkinson’s
start low and go slow
common side effects of selected dopaminergics
see picture
potential side effects of dopamine agonists like pramipexole (mirapex)
impulse controle disorders so impulsive shopping, gambling, hypersexuality, or binge eating
define Parkinson’s
neurodegenerative disorder associated with loss of dopaminergic neurons in brainstem and accumulation of Lewy bodies throughout brain
mainstay of pharmacotherapy for Parkinson’s motor symptoms
dopaminergic medications
mechanism of Parkinson’s
dopamine neurons die so less dopamineless dopamine (inhibitory) means failure to inhibit Ach (excitatory) in basal gangliathus increase GABA release (inhibitory)
where is loss of pigment cells seen in Parkinson’s
substantia nigra which projects to the striatum
age of onset of symptoms in Parkinson’s
45-65 years
facial involvement in Parkinson’s
relatively immobile face/fixed facial expressionskinda giving you the death stare
drug treatment of Parkinson’s
see picture (from pance prep pearls)
define tremor
involuntary, rhythmic, oscillating movements
is tremor hyperkinetic or hypokinetic
hyperkinetic
what kind of tremor occurs when the body is relaxed and supported by gravity
rest tremor
name the two types of action tremors
kinetic and postural
what kind of tremor would be seen in someone trying to complete a finger-to-nose test?
intention tremor (type of kinetic)
what kind of tremor is seen with someone that occurs when the walk forward?
task-specific tremor
what descriptors are important in determining phenomenology of a tremor (5 things)
locationlateralityfrequencyamplitudesituation in which it occurs
what is an essential tremor?
postural + kinetic
are men or women more likely to develop head tremors?
women
epidemiology of essential tremor
bimodal age onset5% of populationno gender preference
what tremor improves with alcohol
essential tremor
does essential tremor have increased mortality?
no, but 2-4 times the risk of developing parkinson’s
treatment of essential temor
reduce caffeinesleeppropanolol 40mg BID (can titrate up to 320mg)Primadone 12.5- 25mg (can titrate up to 250mg)
define dystonia
sustained of intermittent muscle contractions causing twitching postures, repetitive movements, or both.
difference between the movements in dystonia vs chorea or myoclonus
longer in duration, patterned
treatment of dystonia
chemodenervation, oral medications (dopaminergics, anticholinergics, dopamine depleting, muscle relaxants), and deep brain stimulation
define tic
brief, stereotyped movement or vocalization
3 key features of a tic
urgereliefsuppressible
when does a tic not always warrant a work up
in children- can be transient
define Tourette’s
multiple motor ticsat least one vocal ticstarts before age 21occurs at least daily for at least one year
list of drugs we have to know for hyperkinetic movement disorders (from the neuro section drug list, just an FYI)
RopiniroleLevodopaRisperidoneOlanzepinePropranolol
Rx treatment for tics
risperidone
olanzepine
in restless leg syndrome what does U.R.G.E. stand for
urge
rest (makes worse)
getting active (makes better)
evening (makes worse)
what are the physical exam findings with restless leg syndrome
none, it is normal
what are the common secondary causes of restless leg syndrome
pregnancy, iron deficiency, peripheral neuropathy, ESRD, chronic lung disease, gastric surgery, parkinson’s
what is the primary cause of restless leg syndrome
unknown,more common in elderlygenetic probably (3-5 times higher risk with a 1st degree relative)
treatment of restless leg syndrome
iron
dopamine agonist
off-label drugs (gabapentin, levodopa, pregabalin, opiates, benzos, topiramate)
what is wilson’s disease
rare, autosomal recessive disorder50% present with movement disorder50% present with liver disease
fatal if untreated
Ischemic Stroke
Loss of blood supply/perfusion to an area of the brainCan be the result of hypoperfusion/hypotensionAKA “blockage stroke”
Medical Risk Factors for Stroke
Hypertension
Atrial Fibrilation
Hyperlipidemia/Hypercholerestemia
DiabetesCarotid Stenosis
Behavior Risk Factors
Cigarette smoking
Physical Inactivity
Illicit Drugs
Heavy Alcohol Consumption
What are the three subtypes of ischemic strokes?
Large Artery Atherosclerosis
Cardioembolism
Lacunar Infarctions (Small Vessel)
What is the significance of getting a Head CT for an ischemic stroke?
You want to rule out a hemorrhagic stroke. CT are good for viewing blood, but are not good at determining blockages.
What diagnostic method is sensitive and specific for detecting an ischemic stroke?
Diffusion Weighted Imaging MRI
What is a TIA
Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.
Where in the arteries is atherosclerosis most commonly found?
In the bifurcations because there is a lot of turbulent flow.
A 68-year old patient comes into the ER with CC of right-side facial weakness and slurred speech. You order a CT scan first, which shows no sign of a hemorrhagic stroke. What would you do next and how long do you have to act?
Order for the patient to have tPa and you have 3 hrs from the onset of the stroke. Giving tPa increases the likelihood of recovery at 90 days.
A 72-year old patient comes in with stroke symptoms. You are doing your H&P and learn that he suffers from thrombocytopenia. Can he receive tPa?
NO. This is one of the exclusion criteria
What is the most common cause of intraparenchymal hemorrage (IPH)?
HYPERTENSION
What is an intraparenchymal hemorrhage (IPH)?
Bleeding into the parenchyma of the brain which may extend into the ventricular system.
Where does IPH most commonly occur?
Basal ganglia, pons, cerebellum, thalamus
Clinical presentation of IPH?
-Rapidly progressive focal neurological deficits-Vomiting, systolic BP >200 mmHg, severe headache, depressed mental status (not specific though)-Hard to distinguish from ischemic strokes
Definition of Subarachnoid Hemorrhage?
Bleeding into the space between the arachnoid membrane and and the pia mater surrounding the brain.
Common cause of subarachnoid hemorrhage?
Trauma
Common cause of non-traumatic subarachnoid hemorrhage?
Rupture of cerebral aneurysm
What are the symptoms of subarachnoid hemorrhage?
“Worst headache of my life”Nausea/vomiting, depressed mental status, meningeal irritation/neck stiffness
What are the signs of subarachnoid hemorrhage?
The patient is often hypertensive and drowsy and exam is NON-FOCAL
What is the common site of cerebral aneurysm?
Anterior communication artery
The patient you are seeing has a CT scan that comes back negative. You highly suspect a cerebral aneurysm based on your exam findings. What do you do next?
Lumbar puncture
Gold standard for diagnosing cerebral aneurysm?
Conventional Cerebral Angiogram
After doing that lumbar puncture, you see that they are positive for subarachnoid hemorrhage (not due to trauma). What are two surgical options that you do for this patient
Coiling (endovascular approach)Clipping (surgical approach)
This complication of SAH occurs in 25% of patients and results in ischemic stroke. What is it?
Vasospasm
What drug is given to reduce the morbidity and possible mortality associated with vasospasm?
Prophylactic Nimodipine
REVIEW:
What are the three layers
of the meninges and
what spaces lie between them?
Skull
Epidural
Dural
Subdural
Arachnoid
Subarachnoid
Pia
Brain
Review:
What are the primary functions
of each lobe of the cerebrum?
Frontal: Motor functions,
behavior, emotions, higher intellect
Parietal: sensory
Temporal: hearing, speech
Occipital: Visual
REVIEW;
What are the three components
of the brainstem and
what do they do?
Midbrain: visual & auditory reflex centers
Pons: connection between cortex, cerebellum and medulla
Controls chewing, biting, swallowing, facial expressions, sensation
Medulla Oblongata: cardiac, vasomotor and respiratory centers
REVEIW:
What does the Cerebellum do?
Major regulator of motor activities
Integration of:
Sensory impulses from spinal cord and vestibular organ
Motor impulses of Cerebral Cortex
REVIEW
Where is the gray matter
and white matter
in the brain and spinal cord?
Brain: generally gray on the outside, white on the inside (but some gray on the inside as well.
Spinal Cord: gray on the inside, white on the outside
REVIEW:
What are key differences
between neurons and glial cells?
Neurons:
Nondividing, postmitotic, permanent cells
Glial Cells:
facultative, mitotic (labile), capable of dividing
What are the six types of cells in the nervous system,
what do they do,
and what do you call their tumors?
Neurons: signalling/information, neuroma
Glial Cells: support, glioma
Astrocytes: support, blood brain barrier, astrocytoma
Oligodendrocytes, myelination in brain, oligodendroma
Ependymal Cells: lining ventricles, ependymoma
Schwann cells: peripheral myelination, Schwannoma
Microglia, immune response, NO tumors!
What are the nine major types of diseases
of the nervous system?
- Developmental, genetic diseases
- Malformations
- Trauma
- Circulatory (vascular) disorders
- Infectious diseases
- Autoimmune diseases
- Metabolic, nutritional diseases
- Neurodegenerative and demyelinating diseases
- Brain tumors
What is a dysraphic disorder?
Incomplete closure
of the embryonic neural tube
What are three types of
dysraphic disorders
occuring at the hind end?
Spina bifida: incomplete closing of the backbone and membranes around the spinal cord. Three types:
Spina bifida occulta: outer part of vertebrae slightly open
Myelomeningocele: spinal cord and meninges protruding
Meningocele: meninges protruding
What happens
when the head end of the neural tube
does not close properly?
Anencephaly: absense of a major part of the brain and skull
Encephalocele: protursions of the brain through the skull that are coverered with membrane
What are four types of
CNS hemorrhages
and their causes?
Epidural Hematoma: middle meningeal artery rupture
Subdural Hematoma: bridging vein rupture
Subarachnoid Hematoma: 1. Trauma, 2. Aneurism
Intercerebral Hemorrhage: 1. Trauma, 2. HTN
What is the fifth leading cause of death in the US?
Hint: it used to be number 3!
Cerebrovascular Disease
What are the two types of stroke and their incidence?
Ischemic (85%)
atherosclerosis, occlusion of blood vessels
Hemorrhagic (15%)
often a complication of HTN
REVIEW:
What are the three large cerebral arteries?
What part of the brain to they perfuse?
Where do they originate?
Anterior Cerebral Artery (ACA) from Internal Carotid,
perfuses medial surface of frontal and parietal lobes
Middle Cerebral Artery (MCA) from Internal Carotid
perfuses lateral surfaces of frontal, temporal, parietal lobes
Posterior Cerebral Arteries (PCA) from Vertebral Artery
perfuses posterior aspect of temporal, occipital lobes
A patient has an MRI
showing an intracerebral hemorrhage
in the basil ganglia.
What is the likely cause?
Hypertension
(Trauma is most common cause
of intracerebral hemorrhage though)
What causes cerebral herniations?
Cerebral Edema
Where are the four most common locations
for cerebral herniations?
Which is most serious?
Tonsillar Herniation (most serious)
(cerebral tonsil exits skull through foramen magnum)
Transtentorial (uncinate) herniation
(cerebral uncus at cerebral-pontine angle)
Subfalcine herniation
(cingulate gyrus at falx)
Herniation through opening in broken skull
Which is more serious,
a concussion or a brain contusion?
A contusion is more serious.
Concussion: transient loss of consciousness
Contusion: disruption of blood supply, can lose consciousness later, produce neurological deficit
What is Coup and Counter Coup?
Coup (a “blow” in French) is the damage to your brain near where your head is hit
Counter Coup (on Contre Coup) is the damage where your brain hits the opposite side in response to the coup
What are three ways
an infection can get inside the brain?
Penetrating trauma
Hematogenous Spread (blood vessels)
Nearby infections (otitis media, sinuses)
NOTE: if you squeez a pimple, it drains into your sinuses!
What are the four most common organisms
causing as infection
in the nervous system?
Bacteria
Viruses
Fungus
Protazoa
What bacteria
can cause an infection
in the nervous system?
Neisseria meningitidis,
S. pneumo,
E. coli,
H. influenza,
Treponema pallidum
(Hematogenous Route or Septic Emboli)
What viruses
can cause an infection
in the nervous system?
Measles
Rubella
Adenovirus
Herpesvirus
Cytomegalovirus
Rabesvirus
(via Hematogenous Route)
What fungi
can cause an infection
in the nervous system?
Candida albicans
Aspergillus flavus
Cryptococcus neoformans
(Hematogenous route)
What protazoa
can cause an infection
in the nervous system?
Toxoplasma gondii
(Hematogenous route)
Name four types of infections
of the Nervous System
Encephalitis:
inflammation of the brain parenchyma, usually viruses
Myelitis:
inflammation of the spinal cord, usually viruses
Cerebral Abscess:
suppurative cavitary lesion
from pyogenic bacteria, fungi or both
Meningitis:
Inflammation of meninges, viral or bacterial
What is Multiple Sclerosis?
What is its incidence,
signs/Sx and
disease course?
Chronic, degenerative demyelinating disease
Incidence: women 2x men, genetic factors
Signs/Sx: loss of sense of touch, muscle weakness, unsteady gait, sphincter abnormalities
Course: exacerbation and remission
What is the difference
between and early and late lesion
in MS?
Early: Lymphocytes attack myelin,
macrophages consume the debris.
Late: Astrocytes and surviving axons
What are two congenital metabolic disorders
of enzymatic deficiency?
Tay-Sachs Disease
Neimann-Pick Disease
What is a common cause
and result
of a Vitamin B1 defiency?
Vitamin B1 (Thiamine) deficiency:
excessive, chronic alcohol intake can cause
Wernicke-Korsakoff Syndrome
(uncoordinated movements, progressive mental deterioration, memory and concentration loss, irritability, confusion)
What are the signs and symptoms
of Vitamin B12 (Cobalamin) deficiency?
Uncoordinated movements
Sensorimotor peripheral neuropathy
spinal cord disease
abnormal gait
psychiatric sx
What are the signs/sx
of nicotinic acid deficiency?
Dermatitis
Diarrhea
Delirium
(The three “D”s)
What are the effects of alcholism and B1 deficiency?
Wernicke Korskoff Syndrome
Subdural hematomas from falling
Pontine myelinolysis
Delirium tremens upon withdrawal
Degenerative changes to hypothalmus and mammillary bodies
Neuropathy
Myopathy
Name four neurodegenerative Diseases
Alzheimer’s disease
Parkinson’s Disease
Huntingon’s Disease
Amyotrophic Lateral Sclerosis (ALS)
Of the four key neurogenerative disorders,
what parts of the brain do they impact?
Alzheimer’s disease: diffuse (all over)
Parkinson’s Disease: substantia nigra
Huntingon’s Disease: cortex and subcortical nuclei (caudate, putamen)
Amyotrophic Lateral Sclerosis (ALS): motor neurons in the cerebral cortex, midbrain and spinal cord (lateral cerebrospinal pathways)
What is Alzheimer’s Disease?
Progressive loss of cognitive functions and memory due to diffuse cortical atrophy caused by deposits of beta-amyloid. Genetic factors include Chromosomes 19 and 21
(Recall that Down’s Syndrome is Trisomy 21)
Note: serious diagnosis with no cure
so be sure to rule out other causes of Sx.
What are the gross and histologic changes
in the brain of
an Alzheimer’s patient?
Gross: atrophic, narrowing gyri, widening sulci
Histologic: neuritic plaques, neurofibrillary tangles, granovacuolar degeneration, amyloid deposits
What is Parkinson’s Disease?
Subcortical neurodegenerative disorder
affecting mainly the elderly
Decreased dopaminergic neurons in the substantia nigra
What are the Signs/Sx
of Parkinson’s Disease?
Tremor/twitchin muscles
Cogwheel rigidity
Unstable walking
Depression
Dementia (10%)
What are the gross and histologic changes
to the brain
of a patient with Parkinson’s
Gross: substantial nigra is pale (not black)
Histologic: loss of melanin rich neurons,
presence of Lewy bodies
What is Huntington’s Disease?
Autosomal dominant neurodegenerative disease
affecting men more than women
What are the signs/sx of
Huntington’s Disease?
Involuntary, gyrating movements
Progressive dementia
First Sx do not appear until midlife
Most are mentally incapacitated by 50-60 yo
What are the gross and histological changes
to the brain
of a patient with Huntington’s
Gross: Atropy of cortex and subcortical nuclei,
especially the caudate and putamen
Enlarged and rounded ventricle
Histological: atrophy, degeneration, loss of neurons, reactive gliosis
What is
Amyotrophic Lateral Sclerosis (ALS)
Rare neurodegenerative disease
of motor weakness and
progressive wasting
affecting older men and women
What are the symptoms of ALS?
Motor weakness
progressive wasting in extremities (small hand muscles)
fasciculations
slurred speech
intact intellect!
Death in a few years.
how to tell if Parkinsonism due to Parkinson’s or drugs
are features presenting symmetrically or asymmetrically
symmetrically due to drugs
asymmetrically due to Parkinson’s
