Neuro Flashcards
this tremor is only associated with anxiety and fatigue
Enhanced physiologic tremor
In this movement disorder, a tremor is the ONLY symptom
Benign essential tumor
Patient complaining of tremor in both arms; he notes that he uses alcohol to relieve them, and when he is stressed they get worse. Exam shows normal muscle tone/reflexes and NO bradykinesia; what do you suspect?
Benign Essential Tremor
what is the most common movement disorder?
benign essential tremor
what is the treatment given to patients with benign essential tremor?
Propranolol (Betablocker) or Primidone
botox can help voice and limb tremor too
explain the characteristics of the tremor in benign essential tremor
Postural tremor
Bilateral
symmetric
UPPER EXTREMITIES
T or F: benign essential tremor is worsened by stress, while dystonias are worsened by voluntary movements
TRUE
how would you explain secondary dystonia?
brought on by drugs or other neurologic disorders/medication
This disorder is characterized as involuntary muscle contractions occurring as part of another LARGER neurologic disorder’ the tremors are NOT the dominant feature
Dystonia Plus
What agents would you choose to treat symptoms of dystonia?
Levodopa
Anticholinergics (kids only)
Botox (Tx of choice for focal dystonia!)
Deep Brain Stimulation
A patient with dystonia comes into the ER appearing to be in extreme distress and holding his throat. His mother states that he was supposed to have surgery and has been stressed out lately. On exam, you notice his vocal cords and laryngeal muscles are spasming. What emergency are you concerned about?
Dystonic Storm - Admit to ICU and prepare to stabilize the airway!
what is the most common type of dystonia?
focal dystonia
before confirming dystonia in a child, what major disease needs to be ruled out?
WILSONS DISEASE
This progressive disability is characterized by a RESTING TREMOR, rigidity, and bradykinesia
Parkinson’s Disease
Early-onset parkinsons would be symptoms prior to what agE?
40 years
What are the 4 cardinal signs of Parkinsons
“TRAP”
Tremor (resting, “pill rolling”)
Rigidity (smooth/lead pipe OR oscillating/cogwheeling)
Akinesia/Bradykinesia: slowed movement, decrease in speed with continuous actions
Postural instability
In assessing a tremor in your patient, you stand behind her and quickly pull backwards on her shoulders. She stumbles backward, taking 10 steps and nearly falls. What is at the top of your differential?
Parkinsons
What is diagnostic of Parkinsons?
Substantial response to Dopamine medications
What are the 3 hallmark features of pathology of neurons in a patients with Parkinsons
- Degeneration of dopaminergic neurons in SUBSTANTIA NIGRA
- Reduced striatal dopamine
- Lewy bodies (halos)
Although response to dopamine agonists are diagnostic of parkinsons, what is typically the INITIAL treatment and why?
MAO-B inhibitors: these treat mild symptoms quite well, and dopamine agonists only last 4-6 years, so save for later on
what is the gold standard and most effective treatment for Parkinsons?
Levodopa + Carbidopa: great control for 4-6 years; save for later stages
what is a great surgical option for symptoms in parkinsons
Deep Brain Stimulation
this disorder is characterized by adult-onset, inherited disease with cell loss in the basal ganglia and cortex
Huntingtons
Huntington’s Disease happens as a result of multiple polyglutamine repeats of CAG on the _____ arm of chromosome number ____
short; 4
how would you describe the progression of symptoms in Huntington’s disease?
advance from hyperkinetic to hypokinetic movements
choreiform movements to finally becoming bradykinetic
T or F: Huntington’s disease is curable with DBT
FALSE - incurable
Drug-induced abnormal movements are typically associated with drugs that block which type of receptors?
Dopamine
psych drugs, drug to treat n/v and gastroesophageal disorders
what is the most common type of ACUTE drug-induced abnormal movements?
Dystonia (focal in adults and generalized in kids)
Minutes after giving patient medication to treat his nausea, he begins to experience severe spasms that mimic chorea. You determine that he is experiencing acute drug-induced dystonia. What do you treat him with?
IV Anticholinergics!(diphenhydramine)
can also give benzos or dopamine agonists
What is the most common subacute reaction to drug-induced movements?
Akathisia (motor restlessness with need to move that is alleviated by moving)
What is the term used to describe choreiform movements of the mouth, lips, and tongue that occurs YEARS after initiation of neuroleptic drugs
Tardive dyskinesia
How can you treat tardive dyskinesia?
D/C offending medication (may take 3 months to correct)
What is tardive Dystonia?
dystonia with involvement of axial muscles and rocking movement of trunk
T or F: tardive dystonia reverses with D/C of medication
FALSE - this persists despite D/C
Patient present to the clinic complaining of lack of sleep. Upon further questioning, she states that at night her legs feel a “creepy crawly” sensation, that can only be relieved if she gets up and walks around. what is at the top of your differential?
Restless leg syndrome
What are the 2 first-line agents used in treating Restless leg syndrome?
Dopaminergic Agents
Presynaptic alpha 2 agonists
An option for patients with RLS is “Relaxis”. what is this?
a vibratory stimulation device used for treatment that stimulates the legs during sleep, taking away the discomfort
Interestingly, there is an association with what deficiency, that if treated, can sometimes relieve the RLS symptoms
Iron deficiency
always test for this!
A mother brings in her 7 year old child and tells you he has been blinking and jerking his neck constantly for some time, and it’s starting to affect his quality of life. What are you suspecting?
Tourettes (simple motor tic)
complex includes movement of multiple muscle groups - jumping, head banging
What is the difference between simple and complex phonic tics?
simple (grunting)
complex (repeating expressions)
what is Corprolalia?
tourettes with complex phonic tics, specifically with shouting obscene words
when is therapy indicated in Tourettes’ syndrome, and what do you Rx?
when tics are disabling and interfere with QoL
- Clonidine
- Guanfacine
A Thunderclap headache is what type of stroke?
hemorrhagic
What are the 2 types of strokes?
ischemic and hemorrhagic
Ischemic further categorized as embolic, thrombotic, and lacunar infarcts
in embolic stroke, what are the 2 most common sites that the clot breaks and travels from
internal carotids and aortic arch
what is the most common underlying disorder that causes hemorrhagic stroke (rupture of aneurysm)
Hypertension
Patient presents with facial droop, arm weakness, and speech slurring; on further exam, you note weakness and contralateral leg. Where did the stroke happen?
Anterior Cerebral Artery
Patient has signs of a stroke, and upon further exam you note loss of sensation in head, neck, arm, difficulty speaking, and homonymous hemianopia. Where did the stroke occur?
Middle Cerebral artery
most common
what artery would most likely be involved in a stroke that causes sudden, PAINLESS, vision lossq
Ophthalmic/Central Retinal Artery
T or F: if a patient has homonymous hemianopia, their eyes deviate to the affected side
True
which arterial stroke is usually clinically silent and why?
Vertebral artery; circulation is maintained by the other vertebral artery
Patient present with facial droop, arm weakness, and speech slurring. On further exam and questioning, you note hyperpathia (exaggerated pain) that happened spontaneously. Which artery did the stroke happen?
Posterior Cerebral artery
Posterior Inferior Cerebellar Artery occlusion can lead to LATERAL MEDULLARY SYNDROME. what is this characterized by?
vertigo and nystagmus
What is the diagnostic test of choice for assessing stroke?
CT Angiography
Why do we do a CT first in assessing stroke?
to rule out cerebral hemorrhage; this is done first before we administer antiplatelets.
What is the treatment of choice for ischemic/embolic stroke?
tPA; clot buster
what is the time frame for administering tPA
4.5 hours
what are some common causes of hemorrhagic stroke?
head trauma
ruptured aneurysm
arteriovenous malformation
what is the #1 risk factor for hemorrhagic stroke
hypertension
Patient presents with what feels like the worst headache of their life; it has remained unchanged for days. They also have a fever of 101 and elevated BP. What is at the top of your differential?
Hemorrhagic stroke (Thunderclap headache)
What is a Herald Bleed?
an aneurysmal leak; patient reports atypical headache 1-3 weeks prior to SAH
When treating stroke, what medication does EVERY patient get?
antiplatelets (ASA, clopidogrel)
What is the required stenosis amount to qualify for a carotid endarterectomy?
stenosis >70%
what defines Epilepsy?
2 unprovoked seizures that are >24 hours apart
this has to be occurring for >5 months
what type of headache is described as pain with underlying muscular cause (tight neck, shoulder pain)
Tension headache
Patient presents with a headache further described as a band of pain, pointing to both sides of his forehead. He also states sore trapezius muscles. What is at the top of your ddx
Tension headache
treatment tension headache?
Analgesics: Tylenol, NSAIDs, Aspirin
avoid tobacco, alcohol
what is the difference between common migraine and classic migraine?
Common: no aura
classic: aura
female presents to clinic complaining of a severe headache, described as unilateral in the front of her forehead. She states it has been ongoing for the past 12 hours, and it’s worse with activity. Only sleep relieves it. What are you thinking?
Migraine
how long do tension headaches last?
> 30 minutes
how long do migraines last?
4-72 hours
Your patient with migraines states that NSAIDs and Aspirin “don’t touch the pain”. What can you prescribe her?
Abortives - TRIPTAN
your patient is complaining of an excruciating headache. He says that it feels like it is behind one eye and radiated just to the same side. When asked if this was the first time he’s had this, he states that they happen at the same time every day and last 45 minutes. He can’t take it anymore. What are you thinking?
Cluster headache
of the headache types, which are unilateral
migraines
cluster headaches
(tension are bilateral)
T or F: a migraine is commonly mistaken for a sinus headache or eye strain due to visual symptoms
True
T or F: if a person has a thunderclap headache, try a trial of Triptan. If it relieves the headache, it was simply a migraine
False!! Triptan can mask the symptoms of headache due to a Subarachnoid hemorrhage! Don’t assume it’s a migraine!
a Coma is described as dysfunction in what areas of the brain?
cerebral hemisphere
reticular activating system
patient c/o “electric shock” pain that comes and goes, especially when she is brushing her teeth. Pain is unilateral. what are you thinking?
Trigeminal Neuralgia
what is a major risk factor to trigeminal neuralgia
Multiple Sclerosis
After diagnosing a patient with trigeminal neuralgia, you prescribe them which treatment?
Carbamazepine (2-3x daily)
patient presents with paroxysmal attacks of pain in the throat that is provoked by swallowing. Similar to trigeminal neuralgia, you’re thinking this patient has ____
glossopharyngeal neuralgia
what is the disorder caused by acute facial nerve paralysis due to inflammation at geniculate ganglion
Bell’s Palsy
Maximal weakness of bell’s palsy peaks how many days after onset?
3-7 days
improves within 3 weeks
T or F: in Bell’s palsy, the forehead is NOT involved
FALSE - if forehead is NOT involved, think STROKE!
patient presents with unilateral pain that started behind his ear last night, and now he is unable to wrinkle his forehead, facial pain, and numb feeling in face. Sensation preserved
Bell’s Palsy
which organ is most vulnerable in someone with Bell’s Palsy?
the eyes; prescribe artificial tears and tape eye shut at night
on exam you note hammer-toe dysformity. What is at the top of your ddx?
charcot-marie Tooth
patient presents with aching pain and numbness in his feet. It has began to travel upwards to his shins, and he became worried. What history question could you ask him regarding his health in the past?
have you had any GI or respiratory illness 6 weeks prior?
Guillain - Barre
What do you do when you diagnose a patient with Guillain-Barre syndrome?
ADMIT TO ICU!
could lose respiratory function and need vent
what is the treatment of choice for patients with Guillain-Barre (after admission to ICU)
IVIG or plasma exchange
NO STEROIDS!!!!
T or F: demyelinating disease such as multiple sclerosis affects the CNS and the PNS
FALSE - affects CNS and spares the PNS
What are the 2 kinds of multiple sclerosis, and which is most common?
relapsing and remitting (most common) & Progressive
This neurological disorder has a strong association/risk factor with vitamin D deficiency
multiple sclerosis
chronic inflammation and demyelination causes lesions in the CNS, eventually leading for scarring/sclerosis
Multiple Sclerosis
Dawson’s fingers are seen in MRI of the brain in MS. What does that mean?
lesions located around the ventricular surface in perivenous pattern of demyelination
there is no treatment that reverses MS. Instead you can treat acute attacks and give disease-modifying agents. What are those?
Glucocorticoids
Immunomodulators
which disease of the lower motor neurons is also considered a pediatric disorder?
Duchenne’s Muscular Dystrophy
this disorder is progressive muscle degeneration and weakness caused by the absence of DYSTROPHIN
Duchenne’s muscular dystrophy
on examining a patient with suspected muscular dystrophy, you have him lie down on the floor; he needs to walk his hands up his body in order to stand. What is this test called?
Gower’s Maneuver
what gold standard diagnostic lab will neurology test for to diagnose Duchenne’s muscular dystrophy?
Serum CK (elevated 20-100x)
will also do genetic testing for 427kDa
in this slowly progressing disorder, tremor is the only symptoms. it is relieved by alcohol and worsened by stress
Benign essential tremor
the treatment for benign essential tremor is usually just reassurance, but you CAN prescribe which 2 medications?
Propranolol
Primidone
what is the most common of the movement disorders?
benign essential tremor
T or F: on physical exam of benign essential tremor, you will see bradykinesia and/or rigidity
FALSE - exam is unremarkable; bradykinesia and rigidity are signs of parkinsonism
this movement disorder is brought on by voluntary movements and relieved by relaxation and sensory tricks
Dystonias
this nonprogressive neurological disorder is due to either prenatal development malformation or perinatal/postnatal CNS damage
Cerebral palsy
what exam findings might you see in a patient with cerebral palsy
spasticity (stiff)
dyskinesia (involuntary movement)
ataxia (shakiness)
what is the diagnostic for cerebral palsy?
MRI and genetic testing
T or F: meningitis is most commonly caused by viruses
FALSE: bacterial
what is the triad of symptoms of meningitis
headache + fever + nuchal rigidity
What is Kernig sign?
passive knee extension; painful in patient with meningitis
What is Brudzinski sign?
flexion of hips and knees inward in pain when neck is flexed toward chin (positive for meningitis)
What is diagnostic of Meningitis
CSF analysis (via lumbar puncture)
this disorder is caused by inflammation of the parenchyma of the brain. (sometimes with meningeal inflammation)
Encephalitis
is encephalitis commonly viral or bacterial?
VIRAL
what is diagnostic of encephalitis?
MRI
also get CSF analysis
Treatment of encephalitis
Acyclovir (empirical viral therapy)
Antimicrobial empiric therapy as well
what is the disorder characterized by an intracerebral collection of pus as a result of many factors such as cranial infection, head wound, hematogenous spread
Brain abscess
patient complains of unilateral headache, vomiting, and a recent dental infection. What is the next best option via diagnosing what you think it is?
MRI with gadolinium (suspected brain abscess)
culture the pus aspirate if possible
treatment for brain abscess?
Cefotaxime or metronidazole (empiric)
If your comatose patient is experiencing Cheyne-stoke or biot breathing, where is the dysfuntion?
both hemispheres
if your comatose patient is hyperventilating, where is the dysfunction?
midbrain
if you patient who is comatose has inspiratory gasps with pauses, where is the dysfunction?
pons/medulla
you witness a person having a syncopal attack. what is the FIRST thing you do?
check for pulses- if absent perform CPR
if present, lay person supine with legs in air to end the attack
what is bells palsy strongly linked to?
herpes virus
patient has bell’s palsy - you tell him that the symptoms (weakness) may be maximal at ______ days but should subside by _____
3-7 days
3 weeks
at what time frame does the progression of Guillain-Barre syndrome PEAK?
2-4 weeks
T or F: severe Guillain-Barre syndrome can result in quadriparesis and respiratory arrest requiring vent
True
what CSF findings might you see in someone with guillain-Barre?
protein >0.55 (no elevation in WBC)
what might EMG (electromyogram) show in a person with guillain-barre
slowing of nerve conduction >60%
what 3 exam findings will be in a patient with cerebral palsy?
stiff (spastic)
dyskinesia (movement)
ataxic (shaky)
what will the CSF show in a patient with bacterial meningitis?
elevated protein
low glucose
although meningitis and encephalitis are similar, their diagnostic studies are different. what are they?
Meningitis: lumbar puncture
Encephalitis: MRI
What are some red flags regarding headache/migraine that indicate further imaging?
age < 40 first or worst treatment not working change in severity neurological signs
Horner’s syndrome is seen in 30% of patients with what disorder?
cluster headaches
what 2 things to give patient with cluster headaches?
IV triptans
oxygen
if a patient has EXTREME hypotension following an injury, what do you need to be mindful of?
possibility of a spinal cord injury
should you give a patient who has a concussion NSAIDs/Aspirin?
NO - can make symptoms worse
how long must seizures persist in order to Dx epilepsy?
5 months
patient presents with extremely severe headache. On physical exam he has BP 160/110 and is running a fever. What are you thinking
SAH
