Neuro

Question 1

Described as sudden, transitory losses of neurologic function that come on without headache and resolve spontaneously leaving no neurologic sequela.

Answer 1

Transient Ischemic Attacks

Question 2

Most common origin of TIAs

Answer 2

high grade stenosis (>70%) of the internal carotid artery, or an ulcerated plaque at the carotid bifurcation

Question 3

Why do we care about TIAs, and what should we do about them?

Answer 3

They are predictive of stroke. Elective endarterectomy can prevent or minimize risk.

Question 4

Workup and tx of TIAs

Answer 4

Duplex scanning (Ultrasound + Doppler). Surgery (endarterectomy) if a plaque explains the symptoms. Angioplasty and stent can be done if you first put in a filter to stop debris from embolizing to the brain.

Question 5

Suspect this in a pt who has a stroke w/o headache, and neurological deficits are there >24 hours and leave permanent sequelae

Answer 5

Ischemic stroke.

P.S. In general, ischemic strokes are painless, while hemorrhagic strokes are painful.

Question 6

Suspect this in a hypertensive pt who gets extreme sudden headache and gets neurological deficits.

Answer 6

Hemorrhagic stroke.

P.S. In general, ischemic strokes are painless, while hemorrhagic strokes are painful.

Question 7

Imaging you order for stroke, both ischemic and hemorrhagic

Answer 7

CT scan

Question 8

Goals in tx of ischemic and hemorrhagic stroke patients

Answer 8

Ischemic: Identify lesions that will cause another, look for hemorrhage, and just rehabilitate. If w/in 90 minutes, tPA can help bust the clot.
Hemorrhagic: Control hypertension, rehabilitate.

Question 9

Suspect this in a pt complaining of extremely severe headache of sudden onset, like no other ever experienced before (a “thunderclap,” a headache that is “sudden, severe, and singular”).

Answer 9

Subarachnoid bleeding from intracranial aneurysms.
Because the blood is in the subarachnoid space (there is no hematoma pressing on the brain), there may be no neurologic findings at all, and the patient is sent home. Luckier patients may have meningeal irritation and nuchal rigidity, and be recognized. Those not recognized often return in 10 days with another bleed, perhaps this time a much worse one (the early one is referred to as the “sentinel bleed”).

Question 10

Workup for subarachnoid bleeding from intracranial aneurysms

Answer 10

CT scan looking for blood in the subarachnoid space (spinal tap can identify old blood or small amounts of current blood, but it should never be the first test; always start with the CT) and follows with arteriogram to locate the aneurysm (a little devil off the circle of Willis)

Question 11

Suspect this in a pt w/ progressively increasing headache for several months, worse in the mornings, and eventually accompanied by signs of increased ICP: blurred vision, papilledema, projectile vomiting-and at the extreme of the spectrum, bradycardia and hypertension (due to the Cushing reflex).

Answer 11

Think Brain tumor.

Question 12

Suspect this brain tumor in a pt w/ inappropriate behavior, optic nerve atrophy on the side of the tumor, papilledema on the other side, and anosmia (Foster-Kennedy syndrome).

Answer 12

Tumor at the base of the frontal lobe

Question 13

Suspect this brain tumor in youngsters who are short for their age, and show bitemporal hemianopsia and a calcified lesion above the sella on X-rays

Answer 13

Craniopharyngioma

Question 14

Suspect this brain tumor in women who have amenorrhea and galactorrhea

Answer 14

Prolactinomas

Question 15

Therapy for prolactinomas

Answer 15

bromocryptine

Question 16

Consider this in a pt w/ huge hands, feet, tongue, and jaws (and in the USMLE exam by the picture of a man showing both hands on either side of his face in the frontal view, and a long prominent jaw in the lateral view). Additionally, there is hypertension, diabetes, sweaty hands, headache, and the history of wedding bands or hats that no longer fit.

Answer 16

Acromegaly

Question 17

What causes acromegaly. How can you treat it?

Answer 17

Overproduction of growth hormone by the pituitary gland. Surgical resection if it’s a tumor.

Question 18

Suspect this in a pt w/ history that suggests pituitary tumor (headache, visual loss, endocrine problems), and the acute episode starts with a severe headache followed by signs of increased compression of nearby structures by the hematoma (deterioration of remaining vision, bilateral pallor of the optic nerves) and pituitary destruction (stupor and hypotension)

Answer 18

Pituitary apoplexy (bleeding into a pituitary tumor)

Question 19

Tx for pituitary apoplexy

Answer 19

Steroid replacement is urgent. Eventually other hormones will need to be replaced too.

Question 20

Suspect this in a pt w/ loss of upper gaze and the physical finding known as “sunset eyes” (Parinaud syndrome)

Answer 20

Pineal gland tumor

Question 21

Classical presentation of brain tumors in children

Answer 21

They are usually in the posterior fossa. They produce cerebellar symptoms (stumbling around, truncal ataxia) and the children often assume the knee-chest position to relieve their headache.

Question 22

Classic presentation of brain abscess

Answer 22

Many of the same manifestations of brain tumors (it is a space-occupying lesion), but a much shorter timetable (a week or two). There is fever, and usually an obvious source of the infection nearby, like otitis media and mastoiditis.

Question 23

Suspect this in an older (60’s) patient with extremely severe, sharp shooting pain “like a bolt of lightning” in the face, brought about by touching a specific area and lasting about 60 seconds. Normal neuro exam, but they might have an unshaven area in the face (the trigger zone, which the patient avoids touching)

Answer 23

Trigeminal neuralgia (tic douloureaux)

Question 24

Suspect this in a patient who, several months after a crushing injury, develops constant, burning, agonizing pain that does not respond to the usual analgesics. The pain is aggravated by the slightest stimulation of the area. The extremity is cold, cyanotic, and moist.

Answer 24

Reflex sympathetic dystrophy (causalgia)

Question 25

Dx and Tx of reflex sympathetic dystrophy

Answer 25

Successful sympathetic block is diagnostic.

Surgical sympathectomy is curative.

Question 26

Most common cervical spine level involved in trauma?

Answer 26

C2. Followed by C6-7

Question 27

This cervical level supplies the shoulders

Answer 27

C4

Question 28

What dermatome is: Shoulders? Nipples? Umbilicus? Knees? Perianal area?

Answer 28

Shoulders = C4
Nipples = T4
Umbilicus = T10
Knees = L4
Perianal = S4-5

Question 29

What spinal level is responsible for: biceps reflex? Brachioradialis reflex? Triceps reflex? Patellar tendon? Achilles tendon?

Answer 29

Biceps = C5/C6
Brachioradialis = C6
Triceps = C7
Patellar tendon = L4
Achilles = S1

Question 30

Term: Sensory or Motor Dysfunction Caused by Pathology of a Nerve Root.

Answer 30

Radiculopathy

Question 31

Clinical Signs and Symptoms Associated with Radiculopathy?

Answer 31

Main sign: burning, tingling pain that radiates down the limb.
Other signs: lower motor neuron signs such as loss of reflexes, weakness, and diminished sensation along dermatomal distributions

Question 32

Term: Sensory or motor dysfunction caused by pathology of the spinal cord

Answer 32

Myelopathy

Question 33

Clinical signs and symptoms associated with Myelopathy

Answer 33

Intermittent neck pain that radiates into the shoulders or occiput.
Clinical findings: bilateral upper motor neuron signs such as diffuse hyper-reflexia, weakness and numbness in the extremities, and upward-going toes (Babinski’s sign)

Question 34

What is spinal shock

Answer 34

temporary, concussive-like syndrome associated with flaccid paralysis below the level of injury with loss of all reflexes, as well as urinary and rectal tone.

Question 35

What is SCIWORA

Answer 35

Spinal Cord Injury With Out Radiographic Abnormalities

Question 36

Most common complication following exposing the anterior spine for decompressive surgery

Answer 36

Recurrent laryngeal nerve injury -> hoarse voice, dyspnea. Risk of aspiration.

Question 37

This type of hemorrhage results in hemotympanum

Answer 37

epidural hemorrhage

Question 38

Criteria of TBI

Answer 38

a period of loss of consciousness, loss of memory for events immediately before or after the accident, alteration in mental state at the time of the accident, and/or focal neurologic deficit.

Question 39

What can it mean when a pt has Raccoon Eyes? Battle’s Sign?

Answer 39

Raccoon eyes are bilateral periorbital ecchymosis. Battle’s sign is retroauricular ecchymosis. These signs should raise the suspicion of a basilar skull fracture.

Question 40

type of herniation when you have an ipsilateral blown pupil and contralateral paralysis.

Answer 40

Uncal herniation

Question 41

What Is Cushing’s Triad? What Does It Mean?

Answer 41

Hypertension, bradycardia, and an irregular respiratory rate. It’s the response to increased intracranial pressure (ICP).

Question 42

At what point in the GCS is a person considered to have severe head trauma?

Answer 42

8 and below

Question 43

What test should you do on a person who you suspect has an intracranial hemorrhage?

Answer 43

CT without contrast

Question 44

Why should you not use succinylcholine or ketamine on a TBI patient

Answer 44

They increase ICP. Use Rocuronium or etomidate itself

Question 45

Normal ICP. When is treatment indicated?

Answer 45

5-15 mmHg.

>20 mmHg treatment is indicated

Question 46

When hyperventilating for increased ICP, what pCO2 should you aim for?

Answer 46

30-35 mmHg

Question 47

Why give mannitol for increased ICP?

Answer 47

Mannitol is an osmotic diuretic. It increases the tonicity of the extracellular space, which causes a shift of water from
the intracellular space (brain parenchyma) to the extracellular space. By expanding the plasma volume, it also reduces hematocrit and blood viscosity which increases cerebral blood flow (O2 delivery) and reduces ICP.

Question 48

Do you give corticosteroids to a trauma pt w/ brain edema?

Answer 48

No. Won’t work.

Question 49

Conditions when you need a craniotomy for a brain hematoma

Answer 49

midline shift >10 mm, hematoma thickness >5 mm, or ICP >20 mmHg.

Question 50

What is brain death

Answer 50

Irreversible cessation of the entire brain function including the brain stem.

Question 51

Criteria for brain death

Answer 51

Pt must be: GCS of 3, euthermic (>32.2 °C), PaO2 greater than 90 mmHg, SBP greater than 100 mmHg, and pt cannot be sedated or paralyzed.
Declaration of brain death requires absence of brainstem reflexes (corneal, gag, oculocephalic, and oculovestibular), no response to deep central pain, and the agreement of two physicians. If the above criteria are met, an apnea test is performed.
The patient is disconnected from the ventilator and observed for respiratory effort. If there is no evidence of spontaneous respirations with a PaCO2 >60 mmHg, and the other criteria are met, the patient meets the criteria for brain death.