Neuro Flashcards
1
Q
Dominant hemisphere malfunction symptoms
A
Aphasia
Alexia
Agraphia
Acalculia
Left-right disorientation
2
Q
Non-dominant hemisphere malfunction
A
Hemineglect
Dysprosody (pseudo-foreign accent syndrome)
Amusia (inability to recognize or reproduce musical tones)
Constructional apraxia
3
Q
Cortical vs subcortical (internal capsule) paresis
A
Cortical: different effect on face and arm vs legs
Subcortical: equal face, arm, leg involvement. Contralateral dysmetria, clumsiness. W/O sensory/cortical deficit
4
Q
Thalamus defect
A
Contralateral dense sensory loss, severe pain
5
Q
Subcortical structures
A
Internal capsule
Thalamus
Basal ganglia
6
Q
Brainstem malfunction
A
Crossed hemiplagia or sensory loss:
Ipsilateral face, contralateral body
Ipsilateral cerebellar
Nystagmus toward lesion
INO
Dysphagia
Dysarthria
Hearing loss
Vertigo
7
Q
Scanning speech
A
Cerebellum dysfunction
8
Q
Ocular problems in cerebellum dysfunction
A
Nystagmus
Oscillopsia
Distorted smooth persuit
9
Q
UMN vs LMN in spinal cord lesions
A
LMN at the level of lesion
UMN below the level of lesion
10
Q
Frontal lobe testing
A
Go/no-go test
11
Q
Ammonia smelling tests which CN?
A
V
12
Q
Pronator drift
A
Shows contralateral UMN lesion
13
Q
Efferent limb of pupillary light response via CN ?
A
III
14
Q
CN palsy causing defect in sacadic eye movement
A
III
15
Q
In CN IV palsy, head tilts toward
A
Unaffected side
16
Q
CN V motor function
A
Temporalis, masseter, pterygoid, jaw reflex
17
Q
UMN vs LMN facial motor lesion
A
UMN: contralateral facial weakness, sparing the brow bilaterally
LMN: ipsilateral facial weakness
18
Q
CN IX function
A
Vocal cord function
Gag
Taste of posterior 1/3 if tongue
19
Q
CN X
A
Vocal cord
Gag
Uvula deviation and palatal deviation
Swallowing
20
Q
Pyramidal pattern of weakness
A
Hemiparetic gait
In upper extremity, flexors stronger than extensors. In lower extremity, extensors stronger than flexors
21
Q
Caloric test response
A
COWS
Cold Opposite
Warm Same
22
Q
Pattern of weakness in ALS
A
Segmental
Asymmetrical
Distal to proximal
23
Q
DTR in motor neuron disease (ALS)
A
Increased
24
Q
DTR in neuromuscular junction disorders
A
Normal
25
Neuromuscular disorders with fasciculation
Motor neuron disease (ALS...)
Peripheral neuropathy
26
DTR in myopathies
Normal until late
27
Neuromuscular disorder with abnormal NCS
Peripheral neuropathy
28
Neuromuscular disorder with autonomic symptoms
Peripheral neuropathy
29
Neuromuscular disorder with sensory symptoms
Peripheral neuropathy
30
Autonomic symptoms
Orthostatic hypotension
Anhidrosis
Visual blurring
Urinary hesitancy/incontinence
Constipation
Erectile dysfunction
31
Upper motor neuron tests
Babinski
Hoffmann
Pronator drift
32
Primitive reflexes
Grasp
Rooting
Palmomental
Glabellar tap
Snout
33
Thenar muscles, nerve
Flexor pollicis brevis
Abductor pollicis brevis
Opponens pollicis
Nerve: median (C8-T1)
34
Wasting in first dorsal webbed space
First dorsal interosseus muscle
Nerve: ulna
35
Interpretation of rapid alternating movement problems
If slow: weakness
If uncoordinated: cerebellar disorder
If slow with fatiguing and decreased amplitude: Parkinsonism
36
Cortical sensation functions exams
Graphesthesia
Streognosis
Extinction
2point discreminatiin
37
Coordination axams
Finger to nose
Heel to shin
Rapid alternating movements
Knee taps
38
Tests for stance and gait
Romberg
Pull test
Push and release
Gait
Tandem
39
Contraindications for LP
If suspect mass lesion
Infection over site
Suspect epidural abscess
Plt < 50,000
Tx with anticoagulation (high INR/PTT)
Uncooperative pt
40
Px and Tx of post-LP headache
Onset within 24 h
Worse when upright
Px
Smaller gauge needle
Reinsert stylet prior to needle removal
Blunt-ended needle
Tx:
Symptomatic: caffeine, sodium benzoate injection
Corrective: blood patch (autologus)
41
LP tubes
#1: cell count
#2: chemistry (glucose, protein)
```
#3: smear, culture, gram stain
+/- PCR, acid fast, bacteria Ag, fungal Ag/culture
```
#4: cytology
#5: compare RBC count with tube #1
42
Xanthochromia of CSF
Recent blood: SAH
43
CSF protein
Nl < 0.45 g/L
Viral: 0.45-1 g/L
Bacterial: > 1 g/L
Granulomatous infection: increased, but < 5 g/L (TB, fungal)
44
SCF glucose
Normal:
60% of serum glucose
Or
> 3.0 mmol/L
Viral: normal
Bacterial:
<25% serum
Or
<2
TB/Fungal:
Decreased. < 2-4
45
CSF cells
Normal:
0-5,(000,000)/ L
Viral:
<1000,(000,000)/L, lymphocytes
Bacterial > 1000, PMN
TB, fungal <1000, Lymphocytes
46
Investigations for numbness/altered sensation
```
NCS
glucose
B12
Imaging
HIV
Lyme
```
47
Visual loss gait
Broad based
| Tentative steps
48
Proprioceptive loss gait
Wide-based
High stepping posture
Positive Romberg
49
Periphral vestibular lesion gait
Vestibular ataxia
| Disequilibrium
50
Peripheral nerve disorder gait
Steppage gait
51
Myopathic gait
Waddling: broad based, short stepped, pronounced lumbar lordosis, rotation of pelvis
52
Pyramidal/corticospinal gait
Spastic gait:
Circumduction
Scissoring
53
Basal ganglia gait
Parkinsonian gait:
Small paces
Stooped posture
Reduced armswing
Choreic/hemicallistic/dystonic gait
54
Cerebellar gait
Wide based without high stepping. Veering to side of lesion
```
Alcohol
Hypothyroidism
Vit E deficiency
Hypoglycemia
Hypoxia
Paraneo
```
55
Factors damaging olfactory neuroepithelium
Influenza
HSV
IFN
Leprosy
56
Eye in CN III paresy
Resting down and out
Ptosis
Mydriasis
57
CN III palsy symptoms due to midbrain lesion
Complete unilateral CN III palsy
Bilateral weakness of superior rectus and ptosis
Contralateral pyramidal signs
+/- mydriasis
58
CN III palsy with reactive pupil (pupil sparing)
Vascular event
59
CN III palsy with mydriasis
Compressive lesions
60
CN nerves damaged in cavernous sinus involvement
CN III
CN IV
CN V1, V2
CN VI
+ orbital pain and proptosis
61
Nerve at risk of trauma during surgery involving midbrain
CN IV
62
The only CN decussating at midline
CN IV
63
Jaw deviation in CN V palsy
Toward lesion
64
Head tilt in CN III palsy
Up and rotated away
65
Head tilt in CN IV palsy
Down and flexed away
66
Head tilt in CN VI palsy
Rotated towards
67
Viruses implicated in Bell’s palsy
HSV >>> CMV, EBV, VZV
68
CN with longest intracranial course
CN VI
69
Screening for dysphagia
Pt drinks water,
| Observe: cough, choking, wetness of voice
70
CN XI palsy. UMN vs LMN
UMN: ipsilateral SCM, contralateral trapezius
LMN: ipsilateral SCM and trapezius
71
CN XII palsy. UMN vs LMN
UMN: tongue deviation away from lesion. No atrophy. No fasciculation
LMN: tongue deviates towards lesion. Atrophy. Fasciculation
72
Uvula deviation in LMN CN X palsy
Away from lesion
73
Glossopharyngeal neuralgia Tx
Carbamazepine
Surgical ablation
74
Vision loss in optic neuritis
Rapidly progressive
Monocular
Central vision (acuity/color) loss with recovery
75
Etiologies of optic neyritis
Viral
MS
76
Inv for optic neuritis
MRI with gado
77
Fundus in optic neuritis
Disc swelling if anterior
Normal if retrobulbar
78
Vision in papilledema
Late visual loss
79
Fundus in papilledema
Bilateral swelling
Retinal hemorrhage
No venous pulsation
80
Inv for papilledema
Emergent CT
If normal CT: LP for opening pressure
81
Pain in optic neuritis
Painful esp with eye movement
82
Pain in AION
Not painful
83
Fundus in AION
Pale segmental disc edema
Retinal dot
Flame hemorrhages
84
Etiologies of AION
GCA
atherosclerosis
85
Inv for AION
CBC
ESR, CRP
Temporal artery Bx
86
Pain in CRVO
No pain
87
Vision loss in AION
Painless
Unilateral
Acute
Field defect
Hours to days
88
Vision loss in CRVO
Painless
Unilateral
Variable
89
Fundus in CRVO
Swollen disc
Venous engorgement
Retinal hemorrhage
90
Inv in CRVO
Fluorscein angiogram
Coherence tomography
91
Drug causing non-arteritic anterior ischemic optic neuropathy
Sildenafil
92
DDx of optic disc edema and RAPD
Optic neuritis
AION
CRVO (+/-)
93
Tx of optic disc atrophy
Non
94
Location of lesion in:
Rt anopsia and left upper quadrantanopsia
Rt junctional scotoma
95
Location of lesion in:
Bilateral hemianopsia
Chiasma
Children: craniopharyngioma
Middle ages: pituitary adenoma
Elderly: meningioma
96
Location of lesion in:
Left homonymous hemianopsia
Rt optic tract
More congruent deficit = more posterior lesions
If occipital lesion, macular sparing
97
Location of lesion in:
Left upper quadrantanopsia
Rt temporal lesion
98
Location of lesion in:
Left lower quadrantanopsia
Rt parietal
99
Location of lesion in:
Homonymous hemianopsia with macular sparing
Occipital lesions
100
If hemiplegia with eyes looking away from hemiplegia, location of lesion?
Cerebral hemisphere
Lesion in FEF: can be overcome with doll’s eye maneuver
Seizure involving FEF: eyes deviate away from the focus
101
Hemiplegia with eyes lookin toward the side of the hemiplagia, location of lesion?
Brainstem
Lesion in PPRF
cannot be overcome with doll’s eye maneuver
102
INO
MLF lesion
Gaze away from the side of lesion: ipsilateral adduction defect, contralateral abduction nystagmus
Cannot be overcome by caloric reflect
Accommodation intact
103
Inv for INO
MRI
104
Inv for diplopia
If isolated CN IV or CN VI palsy: observe for a few weeks
If persistent or other symptoms present: W/U
Neuroimaging if:
Bilateral
Multiple nerve involvement
Severe sudden onset headache
105
Diplopia worstat the end of the day suggests
MG
106
Gaze fixation in peripheral vs central nystagmus
Peripheral: relieved with gaze fixation
Central no relief
107
Direction of nystagmus in peripheral causes
Fast phase away from the lesion
108
If diplopia only on extremes of gase, which eye is pathological?
Cover each eye in isolation during extremes of gaze.
| The covered eye which makes the lateral image disappear is the pathological one
109
Clinical manifestations of B12 deficiency
The most common initial symptoms:
Paresthesia
Sensory ataxia
Others:
```
Myelopathy
Weakness with UMN findings
Peripheral neuropathy: distal numbness/paresthesia
Memory impairment
Change in personality
Delirium, confusion
Psychosis
Optic neuropathy
```
Diarrhea, anorexia
110
Inv for B12 deficiency
Serum cobalamin
Serum methylmalonoc acid
Serum homocysteine
111
Tx of Vit B12 deficiency
Vit B12 IM 1000 microgram/d x 5 d then 1000/mo
Or 1000 oral/d
112
Folate deficiency symptoms
Myelopathy
Peripheral neuropathy
113
Inv for folate deficiency
Serum folate
Serum homocysteine
114
Copper deficiency symptoms
Myelopathy
Pyramidal signs (brisk muscle stretch reflexes)
Severe sensory loss
115
Copper deficiency inv
Serum copper
Ceruloplasmin
Urine copper
116
Tx of copper deficiency
D/C zinc
Oral copper
117
Vit E deficiency symptoms
Ophthalmoplegia
Retinopathy
Spinocerebellar syndrome, cerebellar ataxia
Pripheral neuropathy
118
Inv for vit E deficiency
Serum Vit E
Serum vit E/ Chol+TG
119
Thiamine deficiency symptoms
Beriberi (wet, dry)
Infantile beriberi
Wernicke Korsakoff
120
Dx of B1 def
Clinical
Brain MRI
121
B6 deficiency symptoms
Painful sensoryneural peripheral neuropathy
122
Dx of B6 deficiency
Serum peridoxal phosphate
123
B3 deficiency
Dementia
Encephalopathy
Coma
Peripheral neuropathy
124
Dx of B3 deficiency
Urinary metabolites of niacin
125
Effect of organic solvents on nervous system
Cognitive impairment
Encephalopathy
126
Effect of pesticides on nervous system
Increased risk of Parkinson’s disease
127
Effect of lead on nervous system
Delayed/reversed development
Permanent learning disability
Peripheral neuropathy
Seizures
Coma/death from encephalopathy
128
Effect of mercury on nervous system
Ataxia
Visual loss
Hearing loss
Memory/psychiatric problems
Tiredness
129
Effect of manganese on nervous system
Hallucination
Dystonia
Parkinsonism
130
Effect of aluminum on nervous system
Alzeimer
131
Effect of arsenic on nervous system
Sleeplessness
Sleepiness
irritability
Muscle spasm/fatigue
132
Neurologic complications of bariatric surgery
Deficiencies of fat-soluble and water-soluble vitamins
Should be monitored
133
The most common cause of late-onset seizures
Stroke
134
Psychiatric symptoms with simple partial vs complex partial seizures
Rarely occur with simple partial
More common with complex partial
135
Awareness in seizure
Generalized: loss of awareness
Simple partial: intact
Complex partial: appears awake, but impaired awareness
136
Petit mal seizure
Generalized
Children
Unresponsive 5-10 sec
Arrest of activity, blinking, eye-rolling, staring
3Hz spike and Slow wave activity on EEG
No post-ictal
137
Grand mal seizure
May have prodrome (unease, irritability, hours to days before the episode)
Tonic, clonic, post ictal
Post-ictal: flaccid limbs, extensor plantar reflexes, headache, confusion, aching muscles, sore tongue, amnesia, elevated serum CK, focal paralysis (Todd’s paralysis)
138
Temporal lobe epilepsy
Aura: fear, olfactory/gustatory hallucinations, visceral sensations, déja vu
139
Frontoparietal cortex seizures
Contralateral sensory/motor phenomenon
140
Alcohol withdrawal seizures
Up to 48 h from the last intake
Seizure common
status epilepticus rare
141
Inv for seizures
```
CBC
Lytes, Ca, Mg
FBS
ESR
Cr
Liver enzymes
CK
PRL
Toxicology screen
EtOH level
AED level
```
+/-:
CT/MRI
LP
EEG
142
Indication for LP in seizure
If fever, meningismus
143
Indication fo imaging in seizure
New seizure without identifiable cause
Known seizure history with new neurologic signs/symptoms
144
Seizures and driving
License suspended util 6 mo seizure-free
Longer for commercial drivers
145
Tx of seizures. Issues to consider
Stigma
Educate pt and family
Status of driver’s license
Safety issues
Pregnancy
Avoid precipitating factors
AED
146
Indications for AED drugs
EEG with epileptiform activity
Remote symptomatic cause (organic brain disease, prior head injury, CNS infection)
Abnormal neurologic examination
Abnormal findings on neuroimaging
Nocturnal seizure
147
Seizure most similar to pseudoseizure
Frontal (odd motor activity)
148
Tongue biting in pseudoseizure
At the tip (lateral in seizure)
149
Motor activity in pseudoseizure
Opisthotonos
Rigidity
Eye closure, geotropic eye movement
Irregular extremity movements
Pelvic thrust
Crying
150
Status epilepticus
No return to baseline state for > 5 min
R/O status epilepticus in any pt who is still unconcious > 20 min post-ictal
151
Complications of status epilepticus
```
Anoxia
Cerebral ischemia
Cerebral edema
MI
Arrhythmia
Cardiac arrest
Rhabdomyolysis
Renal failure
Aspiration pneumonia/pneumonitis
Death
```
152
Initial measures for status epilepticus
```
ABC
V/S
Monitors
Capillary glucose (STAT)
ECG
nasal O2
IV NS
glucose
IV thiamine
ABG (if respiratory distress/cyanotic)
```
153
Blood work for status epilepticus
```
CBC
Lytes, Ca, PO4, Mg
Glucose
Toxicology
EtOH
AED levels
```
154
Post-treatment stabilization for status epilepticus
```
CT head
EEG
Foley
Urine toxicology
Monitor for rhabdomyolysis
IV fluid
```
155
The most common causes of status epilepticus
Failure to take AED
First presentation of epilepsy
156
Tx fir absence seizures
Ethosuximide
157
Highest risk of teratogenicity with AEDs
Valproic acid
Or
2+ concurrent AEDs
158
Pregnancy with AED
Folic acid 5/d preconception
Pre-conception AED levels
Monthly AED levels during pregnancy (maintain preconception levels)
Referal to OB for intrapartum fetal screening
159
Medication steps in Mx of status epilepticus
1. Lorazepam
2. Fosphenytoin or phenytoin
3. Phenobarbital
4. ICU. Midazolam/propofol/phenobarbital
160
If suspicious of SAH but normal CT, next step?
LP
If normal:
Angiography
161
Definition of mild NCD
Not meeting criteria for major NCD
Measurable deficit in at least one cognitive domain
Reported by pt or others
No impairment of ADLs
non-Amnestic vs Amnestic form, precursor to AD
Pts with mild NCD often troubled by memory symptoms in comparison to pts with dementia
162
RFs for mild NCD
HTN
DM
Obesity
Cardiac disease
Apolipoprotein E epsilon4 genotype
163
Clinical features of mild NCD
Cognitive impairment
Neuropsychiatric symptoms:
Depression, irritability, anxiety, aggression, apathy
164
Investigations for mild NCD
Establish a baseline for F/U
Clinical interview with pt and caregiver (cornerstone)
Neuropsychological testing: MMSE, MoCA (should not be used in isolation)
neuroimaging: non-contrast brain CT
Exclude treatable conditions
165
If abnormal neuropsychiatric testing, next step?
F/U in 1 y
166
Tx of mild NCD
Watch and wait
No evidence for anything!!
167
Cognitive domains
Complex attention
Language
Memory and learning
Executive function
Perceptual-motor
Social cognition
168
Head turning sign
Pt looks at caregiver for answers after being asked a question in clinical interview
Seen in cognitive impairmant
169
Inv fir NCD
```
CBC
Glucose
TSH
B12
RBC folate
Lytes
LFT
Renal function
Lipid
Ca
CT head
MRI
SPECT
+/-
VRRL
HIV
ANA
Anti-dsDNA
ANCA
Ceruloplasmin
Copper
Cirtisol
Tixicology
Heavy metals
```
170
Alzheimer disease sumptoms
Memory impairment
Aphasia
Apraxia
Agnosia
171
Symptoms of dementia with lewy bidy
Visual hallucination
Parkinsonism
Fluctuating cognition
172
Frontotemporal dementia (pick)
Behavioral: disinhibition, perseveration,
Decreased social awareness, mental rigidity
Memory relatively spared
Language: progressive non-fluent aphasia, santic dementia
173
Vascular dementia features
Bradyphrenia ( without parkinsonism): slow thinking, slow learning, slow gait
dysexecutive syndrome
Abrupt onset
Stepwise deterioration
Progressive deterioration more common
174
Clinical features of syphilis dementia
Ataxia
Tabes dorsalis
Myoclonus
175
Dementia with myoclonus
CFJ
Syphilus
176
Ab positive in neoplastic dementia
Anti Hu
177
Typical presentation if AD
Mild phase:
Impaired memory and learning
+/- deficit in executive function
Mod-sev phase:
Visuoconstructional
Peceptual-motor
Language
Anterograde amnesia, Aphasia, Apraxia, Agnosia, Disturbance in executive function
178
RFs for AD
Age (the largest RF)
Down syndrome
E4 polymorphism for APOE
FHx
Traumatc brain injury
Low education
Vascular RFs
179
AD pathology
Senile plaques (extracellular, grey matter)
Loss of synapses
Neurofibrillary tangles
Loss of cholinergic neurons in Meynert
180
AD clinical features
```
Cognitive impairment:
Memory for newly acquired information
Language
Abstract reasoning
Executive function
```
Behavior and psychiatric manifestations:
MDD/Apathy
Psychosis, irritability, agitation, combativeness, wandering
Motor manifestations:
Gait, dysphagia, incontinence, myoclonus, seizures
182
Inv for AD
EEG: may show generalized slowing
MRI: preferential atrophy of hippocampi and precuneus of parietal lobe, dilation of lateral ventricles, widening of cortical sulci
SPECT: hypoperfusion in temporal and parietal lobes
PET: using PIB as a tracer to image beta-amyloid plaque
183
Tx of AD
Acetylcholinesterase inhibitors:
Donepezil
Rivastigmine
Galantamine
NMDA-receptor antagonist:
Memantine (for later stages)
Neuroleptics (agitation)
Trazodone (sleep disturbance)
SSRI
Redirection, behavior modification, family support, day car facilities
184
Effect of Acetylcholinesterase inhibitors in AD
Slow cognitive decline
Improve morbidity
Do not prolong life expectancy
185
Acetylcholinesterase inhibitors contraindications
```
Relative:
Bradycardia
Heart block
Arrhythmia
CHF
CAD
Asthma
COPD
Ulcers
RFs for ulcers/ GIB
```
186
Cognitive effect of atypical antipsychotic meds
Long-term use for behavioural symptoms, associated with greater rate of cognitive decline
187
NCD with Lewy body features
Early:
Impaired complex attention,
Impaired executive function
Complex visual hallucinations
Fluctuating cognition
Parkinsonism (resting tremor may be absent)
REM sleep behavior disorder
Severe sensitivity to neuroleptic meds (NMS, rigidity, extrapyramidal symptoms)
Repeated fall/syncope/loss of consciousness
Hallucination (auditory)/ delusion/ depression
188
Lewy body dementia pathology
Eosinophilic intracytoplasmic inclusions
Both cortical and subcortical structures
189
Inv in Lewy body dementia
CT/MRI:
Relative preservation of medial temporal structures
SPECT/PET: low striatal dopamine transporter uptake
190
Tx of Lewy body dementia
Acetylcholinesterase inhibitors
191
frontotemporal dementia movement disorder
Corticobasal degeneration
Progressive supranuclear palsy
192
Pathology of FTD
Severe atrophy
Gliosis, swollen neurons, microvacuolation , Specific neuronal inclusion bodies
Atrophy in frontal and anterior temporal lobes
193
Vascular NCD clinical features
Onset of cognitive disease temporally related to one or more cerebrovascular events.
Decline in complex attention
Decline in frontal executive function
Personality and mood changes
Abulia (absence of will power)
Depression
Emotional lability
Psychomotor slowing
194
RFs for vascular NCD
```
HTN
DM
Smoking
Obesity
High cholesterol
High homocysteine
RFs for AF
```
195
Second most common cause of NCD
Vascular
Higher prevalence in African-Americans
M>F
196
CJD
Prion
Spongiform changes, astrocytosis, neuronal loss
Sporadic > hereditary
197
Inv for CJD
CSF analysis
MRI brain : cortical/ subcortical FLAIR
EEG: periodic complexes
Brain Bx: definitive Dx
198
Tx of CJD
No Tx
199
Broca’s area
Posterior inferior frontal lobe
Language production
200
Wernicke’s area
Posterior superior temporal lobe
Language comprehention
201
Angular gyrus
Relays written visual stimuli to Wernicke’s area
Reading comprehension
202
Arcuate fasciculus assiciation bundle
Connects Wernicke and Broca
203
Aphasia localizes the lesion to which hemisphere?
Dominant hemisphere
204
Broca’s aphasia:
Non-fluent
Good comprehension
Poor repetition
Poor naming
205
Wernicke’s aphasia
Fluent
Poor comprehension
Poor repetition
Relatively spared naming
206
Apperceptive visual agnosia
Distorted visual perception.
Bilateral temporo-occipital cortex
207
Impaired streognosis
Inability to identify by touch
Anterior parietal lobe (in the hemisphere opposite the affected hand)
208
Prosopagnosia
Inability to recognize familiar faces
Bilateral temporo-occipital
209
Hallmarks of brain concussion
Confusion and amnesia
210
Loss of consciousness in concussion
Must be less than 30 min
Initial GCS must be 13-15
Post-traumatic amnesia must be <24h
211
Does extent of retrograde amnesia correlate with severity of concussion?
Yes
212
Dominant parietal lobe lesion symptoms
Acalculia
Agraphia
Finger agnosia
Left-right disorientation
213
Non-dominant parietal lobe lesion
Neglect
Anosognosia (loss of self-awareness)
Asomatognosia (loss of recognition or awareness of part of the body)
214
Indications for hospitalization of concussion
GCS < 15
Seizures
Bleeding diathesis
Abnormal CT
215
Inv for concussion
Neurological exam
Neurocognitive assessment
+/-
Skull Xray
CT
MRI
216
Tx of concussion
Observe for 24 h in all pts
If any loss of consciousness/oersistent symptoms, -> ED
Early rehabilitation (PT, OT, SLP, vestibular therapy, driving, therapeutic recreation)
Meds for headache, pain, depression
CBT
Relaxation therapy
217
Post-concussion syndrome
Dizziness
Headache
Neuropsychiatric symptoms
Cognitive impairment
Resolves within weeks to months
218
Post-traumatic headache starts within
7 d
219
Post-traumatic epilepsy
2% prevalence
Not prevented by prophylactic anticonvulsants
220
Frontotemporal NCD features
Behavioral variant(more common):
Behavioral disinhibition
Apathy or inertia
Loss of sympathy/empathy
Preservative, stereotyped or compulsive/ritualistic behavior
Hyperorality and dietary changes (binge eating, increased consumption of alcohol/cigarette, inedible objects)
Language variant:
Decline in language ability (speech production, word finding, object naming, grammar, word comprehension)
221
Location of lesion in hemiballismus
Vascular lesion of the contralateral subthalamic nucleus
222
DDx of resting tremor
PD
parkinsonism
Wilson
Mercury poisoning
223
DDx of Action-postural tremor
```
Physiologic
Essential
Hyperthyroidism
Hypoglycemia
Heavy metal poisoning
CO poisoning
Drug toxicity
Sedative/alcohol withdrawal
```
224
DDx for Action-Intention tremor
```
Cerebellar disorders
Wilson
MS
AED
Alcohol
Sedatives
```
225
Tx of resting tremor
Carbidopa-levodopa
Surgery
DBS
226
Tx of postural tremor
Propranolol
Primidone
Topiramate
AED
227
Tx of intention tremor
Treat underlying cause
228
Hiccup movement disorder
Physiologic myoclonus
229
Infectious disease with myoclonus
CJD
AIDS-Dementia
230
Inv in young pt with tremor
TSH
Ceruloplasmin
CT/MRI
...
231
Most common cause of chorea
Drug therapy for PD (L-dopa)
232
RFs for PD
FHx
Male
Head injury
Rural living
Exposure to certain neurotoxins
233
Protective factors against PD
Coffee
Smoking
NSAIDs
Estrogen replacement in post-menopausal women
234
Location of pathology in PD
Decreased dopaminergic neurons in pars compacta of substantia nigra
235
Speech in PD
Aprosody (monotonus)
Hypophonia
Dysarthria
236
Writing in PD
Micrographia
237
Gait in PD
Shuffling
Decreased arm swing
Freezing of gait
Postural instability (late)
238
Bradyphrenia
Slow to think or respond
Seen in PD
239
Tx of Parkinson’s disease
Mainstay:
levodopa/carbidooa
Or
Levodopa/benserazide
Early:
dopamine agonist
Amantadine
MAOI
```
Adjunct:
Dopamine agonists
MAOI
Anticholinergics (esp if tremor)
COMT inhibitors
```
240
Surgical Tx for PD
Thalamotomy
Pallidotomy
DBS
241
Psychiatric treatment for PD
SSRIs
(First line)
TCA (fall risk, cognitive impairment, worsening symptoms of PD)
242
Progressive supranuclear palsy
Parkinsonian disorder with limited vertical gaze (downgaze more specific)
Early falls
243
Corticobasal syndrome
Unilateral parkinsonism
Alien limb
244
Multiple system atrophy (Shy-Drager)
Cerebellar or parkinsonian symptoms
+ early autonomic dysfunction
245
Vascular parkinsonism
Multi-infarct presentation
Gait instability
Lower body Parkinsonism
Tremor less likely
246
Dopamine agonist vs Levodopa for PD
Dopamine agonists have:
Fewer motor side effects
Worse symptom control
Increased other side effects
247
Atypical parkinsonism features (consider other diagnoses)
Poor response to levodopa
Abrupt onset of symptoms
Rapid progression
Early falls
Early autonomic dysfunction
Symmetric symptoms at onset
Early age of onset (<50y)
Early cognitive impairment
FHx of psychiatric/dementing disorders
Recent diagnosis of psychiatric disease
Hx of encephalitis
Unusual toxin exposure
Extensive travel Hx
248
Huntington disease
Heredity: AD
Pathology: accumulation of abnormal protein in neurons. Global cerebral atrophy
Onset: 35-44 yr
249
Symptoms of huntington
```
Insidious
Clumsiness
Fidgetiness
Irritability
Progression
Psychosis, NCD, chorea
Depression, impulsivity, bouts of violence
```
250
Chorea in huntington disease
Movement of eyebrows and shoulders
Progression to dance-like ballism
Dystonia, rigidity in late stages
251
Inv for Huntington
MRI:
Atrophy of cerebral cortex and caudate nucleus.
Enlarged ventricles
Genetic testing (CAG repeat in HTT gene on chromosome 4)
252
Tx of Huntington
No disease altering Tx
Psychiatric Sx: anti drpressant, anti paychotic
Chorea: neuroleptic, BDZ
Dystonia: botulinum toxin
253
Most common movement disorders
PD > essential tremor > dystonia
254
Dystonia
Co-contraction of agonist-antagonist muscles
255
Factors exacerbating/ relieving dystonia
Exacerbation:
Fatigue
Stress
Emotion
Relief:
Sleep
Specific tactile/proprioceptive stimuli
256
Poor prognostic factors for dystonia
Young age
Leg dystonia
257
Tx of dystonia
Local meds: botulinum toxins
```
Systemic meds:
Benztropine (anticholi)
Baclofen ( muscle relaxant)
BDZ
Dopamine depletors (tetrabenazine)
Dopamine (for dopa-responsive dystonia)
```
```
Surgical:
Denervation of affected muscle
Stereotactic thalatomy
Posteroventrsl pallidotomy
DBS
```
258
Criteria for tic
Present for an extended period of time
Onset before 18
Not attributable to substance effect/ medical condition
259
Tic types
Tourette syndrome:
Both motor and vocal tics for more than 1 yr
Persistent motor/vocal tic disorder (not both) more than 1 yr
Provisional tic disorder: less than 1 yr
Secondary tic disorder: trauma, CJD, encephalitis, drugs, Sydenham, mental retardation syndromes.
260
Tic Tx
Dopamine blocker
Dopamine depletor
Clonidine
Clonazepam
DBS
261
Tourette Syndrome
Both multiple motor and one or more vocal tics (not necessarily concurrently)
May wax and wane
Can be suppressed voluntarily.
Preceded by unpleasant sensation
> 1yr
No tic-free period for more than 3 mo
Onset before 18 (4-6 yr)
Not due to substance/ medical condition
M>F
Associated with: OCD, ADHD, rages, sleep-wake disturbances, learning disabilities
50% tic-free by 18
262
Cerebellar dysfunction symptoms
Nystagmus (gaze evoked)
Dysarthria (scanning/slurred speech)
Ataxia: broad based, uncoordinated, lurching
Dysmetria
Dysdiachokinesia
Postural instability: truncal ataxia, titubation, difficulty with tandem
Intention tremor
Hypotonia
Pendular patellar/triceps reflex
Rebound phenomenon (overcorrection of displaced limb)
Hypometric/hypermetric saccades
263
Which part of brain is affected in Wernicke-Korsakof?
Cerebellum
264
Friedrich ataxia
Gait ataxia
Limb ataxia
Weakness
Areflexia
Extensor plantar reflex
Impaired proprioception and vibration
Dysarthria
Cardiomyopathy
Kyphoscoliosis
265
Spinocerebellar ataxia
AD
Ataxia
Dysarthria
Chorea
Polyneuropathy
Pyramidal Sx
Extrapyramidal Sx
Dementia
CAG repeats (most common type)
266
ALS pathology site
Anterior horn cells of spinal cord
Cranial nerve nuclei
Corticospinal tract
267
ALS Sx
UMN and LMN
Dysarthria
Dysphagia
Tongue atrophy and fasciculation
Facial weakness and atrophy
Pseudobulbar affect
Frontotemporal dementia
Sparing of: sensation, ocular muscles, bowel, bladder, fasciculation
268
Inv for ALS
EMG:
Chronic denervation and re-innervation
Fasciculation
NCS:
R/O peripheral neuropathy
CT/MRI:
R/O cord disease/compression
269
Interventions in ALS which can extend survival
Riluzole
BiPAP
270
Tx of ALS
Riluzole (slows disease progression)
For spasticity/cramping:
Baclofen, tizanidine, regular exercise, PT
Sialorrhea:
TCA, sublingual atropine, parotid/submandibular botox
Pseudobulbar affect:
Dextrometorphan/quinidine, TCA, SSRI
```
Non-pharmacologic:
High caloric diet,
ventilatory support (BiPAP)
Early nutritional support
Rehabilitation
Psychosocial support
```
271
Red flags inconsistent with ALS
Sensory Sx
Predominant pain
Bowel/bladder incontinence
Cognitive impairment
Ocular muscle weakness
272
Progressive muscular atrophy
Only LMN Sx
Later onset than ALS
273
Primary muscular atrophy
UMN
later onset than ALS
Not fatal
274
Spinal muscular atrophy
Pediatric
Symmetric LMN
275
Infection DDx of ALS
Post-Polio syndrome
West Nile
276
Diabetic neuropathies
Peripheral neuropathy:
Glove and stocking pattern (pain, numbness)
```
Autonomic:
Anhidrosis,
Orthostatic hypotension
Impotence,
Gastroparesis,
Bowel/bladder dysfunction
```
Mononeuropathy multiplex:
Infarct, compression
```
Cranial neuropathy:
CN III (pupil sparing) > IV > VI
```
Lumbosacral plexopathy
277
Pattern of poly neuropathy
Stocking-glove sensorymotor deficit
Symmetrical
Diseases affecting longer fibers first
DDx:
DM, Renal disease, substances, toxins, genetics, SLE, HIV, leprosy, alcohol, B12 deficiency, uremia
278
Chronic inflammatory demyelinating polyneuropathy
Chronic
Relapsing
Sensory motor
Increased CSF protein
Demyelination
Fluctuating course
Tx:
1st line: prednisone
Others: plasmaphresis, IVIG, azathioprine
279
Inv for polyneuropathy
Glucose
B12 level with metabolites
SPEP
Serum protein immunofixation
280
The most common antecedent infection in GBS
Campylobacter jejuni
281
GBS
Acute
Rapidly evolving
Demyelinating
Inflammatory. (AI attack to myeline)
Polyradiculoneuropathy
Starts in the distal lower limbs and ascends
282
GBS Sx
Sensory:
Distal symmetric paresthesias
Loss of proprioception and vibration sense
Neuropathic pain
Motor:
Weakness. Starting distally in legs. Areflexia.
Autonomic:
Blood pressure dysregulation
Arrhythmias
Bladder dysfunction
283
Inv for GBS
EMG/NCV:
Conduction block
Slowing (motor > sensory)
Sural sparing
284
Tx of GBS
IVIG
Plasmaphresis
Pain management
Monitor vital signs and vital capacity
285
Course of GBS
Peak: in 2-3 weeks
Resolution: 4-6 weeks
286
Miller-Fischer
Variant of GBS
Ophthalmoplegia
Ataxia
Areflexia
287
Fatigability test
Holding the arms out
Holding the gaze in the upward position
Improves with: rest, ice
288
Myasthenia gravis pathogenesis
AI against AChR or Musk (anti-AChR or anti-Musk Ab)
15% thymic neoplasm
85% thymus hyperplasia
289
MG age of onset
F: 20s
M: 60s
290
MG Sx
Symmetric/Asymmetric proximal weakness
Fatigable
No reflex changes
No sensory changes
No anticholinergic Sx
No coordination abnormality
Diplopia/prosis (ocular)
Dysarthria/dysphagia (bulbar)
Respiratory muscle weakness
291
Factors exacerbating MG
Infection
Pregnancy
Menses
Various drugs
292
Inv for MG
Edrophonium (Tensilon) test
EMG (decremental response on repeating)
Spirometry (use forced vital capacity to follow adequacy of respiratory efforts)
Anti-AChR (70-80 % sensitivity). If negative, Anti-MuSK
CT/MRI for thymoma/thymic hyperplasia
293
Tx of MG
Thymectomy
Acetylcholine esterase inhibitor: pyridostigmine. (Symptomatic relief)
Mainstay: steroids.
Others: AZA, CyP, MMF (adjunct. Steroid sparing)
For crisis:
IVIG, plasmaphresis
294
Lambert-Eaton Myasthenic Syndrome pathogenesis
AI
Ab against presynaptic voltage-gated Ca channels
Decreased ACh release at the NMJ
50-66% associated with SCC of the lung
295
Lambert-Eaton Myasthenic Syndrome Sx
Weakness, esp proximal lower
No sensory Sx
No coordination Sx
Reflexes: diminished or absent
Reflexes increase after active muscle contraction
Bulbar Sx, Ocular Sx (less often than MG)
Autonomic symptoms (anti-cholinergic), esp dry mouth
Fatigability
296
Inv for Lambert-Eaton Myasthenic Syndrome
Edrophonium test: no response
EMG: incremental response to repetitive stimulation
Screen for malignancy
297
Tx of Lambert-Eaton Myasthenic Syndrome
Tumor removal
3,4-diaminopyridine
Pyridostigmine
Steroids
Plasmaphresis
IVIG
298
Most common form of botulism
Infantile
Honey or corn syrup ingestion
299
Botulism Sx
Onset: 6-48 h after ingestion
```
CN paralysis:
Ptosis
Extraocular muscle weakness
Dilated, poorly reactive pupils
Dysarthria
Ja weakness
Dysphagia
```
```
Autonomic dysfunction:
Nausea
Orthostatic hypotension
Constipation
Bladder distention
```
Anticholinergic:
Dry mouth...
Symmetric weakness, paralysis
DTR: absent/decreased
300
Pattern of paresis in botulism
Starts with GI symptoms
Then extraocular muscles
Then dysphagia
Then limbs and resporatory
All associated with dry mouth
301
Inv for botulism
Blood test for toxin
Stool culture
CT/MRI to R/O stroke, lesion
302
Tx of botulism
Anti-toxin
Supportive
303
Bx of different myositis
Polymyositis: endomysial infiltrate
Dermatomyositis: perifascicular atrophy
Inclusion body myositis: inclusion body
304
Endocrinopathies causing myopathy
Hypo/hyperthyroidism
Hypo/hyperparathyroidism
Cushing
305
Key feature of inclusion body myositis
Weakness of quadriceps and deep finger flexors
306
Critical pt myopathy
ICU
Hx of steroids/nom-depolarizing paralyzing agent
Bx: selective loss of myosin
307
Meds causingmyopathy
```
Steroids
Statins
Anti-retrovirals
Thyroxine
Fibrates
Cyclosporine
Ipecac
```
Ethanol
Cocaine
Heroin
308
McArdle myopathy
Herditary metabolic
Exercise-related myalgia, cramping, myoglobinuria
Increase lactate
Increased serum/urine myoglobin
(Post-exercise)
309
Most common adult muscular dystrophy
Myotonic dystrophy
310
Myotonic dystrophy
AD
unstable CTG repeats (number correlates with severity)
311
Myotonic dysthrophy Sx
Ptosis
Bifacial weakness
Frontal baldness
Triangular face (drooping/dull appearance)
312
Pattern if weakness in myotonic dystrophy
Distal weaker than proximal
Steppage gait
Delayed relaxation of muscle after exertion
Myotonia test: tapping on tenar muscles with hammer
Cardiac conduction defect in 90%
Hypoventilation 2° to muscle weakness
Subcapsular cataract
Retinal degeneration
Decreased intraocular pressure
DM, infertility, testicular atrophy
313
Inv for myotonic dystrophy
EMG
314
Myotonic dystrophy Tx
No cure
Progressive
Death around 50
Phenytoin for myotonia
315
Adjuvant treatments for pain
```
TCA
SSRI
AED: gabapentin, pregabalin, carbamazepine
Baclophen
Phenoxybenzamine
Clonidine
```
316
Mx of neuropathic pains
Treat underlying
1st line:
Gabapentinoids, TCA, SNRI
2nd line:
Tramadol, opioid analgesics
3rd line:
Cannabinoids
```
4th line:
Topical lidocaine (2nd line for PHN)
Methadone
Lamotrigine
Locasamide
Tapentadol
Botulinum toxin
```
Non-pharma:
CBT, psychotherapy, PT
317
Trigeminal neuralgia territory
V3 > V2 >> V1
F> M
Middle aged, elderly
318
Etiology of Trigeminal neuralgia
Idiopathic
Compression by tortuous blood vessels (SCA)
CPA tumor
MS
Secondary causes more likely if: bilateral or sensory loo
319
Inv for Trigeminal neuralgia
1st line:
Carbamazepine
Oxcarbazepine
2nd line:
Baclofen
Lamotrigine
Surgery if resistant
320
Distribution of PNH
Thoracic, trigeminal, cervical > lumbar > sacral
321
Pathogenesis of PHN
Destruction of sensory ganglion neurons (dorsal root, trigeminal, geniculate)
322
RFs for developing PHN
Older age
Greater acute pain
Greater rash severity
323
Prevention of PHN
Varicella vaccine in childhood
Herpes zoster vaccine after 60
324
Tx of PHN
```
TCA
Pregabalin
Gabapentin
Opiates
Lidocaine patch
Intrathecal methylprednisolone
Topical capsaicin
```
Surgical
Early treatment of zoster with antivirals
CS does not decrease PHN
325
Pain in DM. First thing toconsider?
Is pain neuropathic or vascular)
Neuropathic: present at rest, improved with walking, sharp/tingling, more in feet than calves
326
Tx of diabetic neuropathic pain
Level A: pregabalin
Level B: venlafaxine, duloxetine, amitriptyline, gabapentin, valproate, opioids, capsaicin
327
Complex regional pain syndrome Sx
An initiating noxious event (MI, stroke)
Disproportionate pain, allodynia, hyperalgesia
Edema, changes in skin blood flow, abnormal vasomotor activity, osteoporosis, hyperhidrosis, hair loss, fascial thickening
328
Types of CRPS
Type I: minor injuries of limb or lesions in remote body areas precede onset of pain (reflex sympathetic dystrophy)
Type II: injury of peripheral nerves precedes the onset of syndrome
329
Inv for CRPS
Trial of differential neuronal blockade
Autonomic testing (sympathetic dysfunction)
Bone scan
Plain Xray
MRI
330
Tx of CRPS
Goal: to facilitate function
Education
Support groups
PT/OT
Smoking cessation
```
Topical capsaicin
TCA
NSAIDs
CS/lidocain injection in tender points
Gabapentin/ pregabalin/lamotrigine
Calcitonin
Bisphosphonates
Oral CS
```
Surgery
Pain management clinic
331
Headache red flags
New-onset headache
Quality worse/different than previous headaches
Sudden and severe (thunderclap)
Immunocompromised
Fever
Focal neurological deficits
Trauma
Papilledema
Altered LOC
meningismus
332
Tension headache Sx
F>M
Worse in PM
Bilateral frontal/ Nuchal-occipital
Band-like, constant
Triggers: depression, anxiety, noise, hunger, sleep deprivation
Relieved with rest
333
Tx of tension headache
Psychological counseling
Physical modalities (heat, massage)
Simple analgesics
TCA
334
Migraine Sx
F>M
FHx +++
Unilateral > bilateral
Fronto-temporal
N/V, photo/phonophobia, aura
Worse in PM
Throbbing
Triggers: noise/light, caffeine/alcohol, hunger, stress, sleep deprivation/excess, chocolate, tyramine, nitrite, hormonal changes
Relief with: rest
335
Acute Tx of migraine
ASA
NSAIDs
Triptans
Ergotamine
336
Prophylaxis for migraine
TCA
AED (valproate, topiramate)
Propranolol
337
Cluster headache Sx
M>F
FHx +
Retro-orbital
Early AM or late PM
Wakes from sleep
Worse with light, EtOH
Palliation with: walking around
Red watery eye, nasal congestion, rhinorrhea, unilateral horner
338
Tx of acute cluster headache
O2
| Sumatriptan (nasal, injection)
339
Prophylaxis for cluster headache
Verapamil
Lithium
Methylsergide
Prednisolone
340
Headache with Horner
Cluster
341
Headache worse by caffeine
Migraine
342
Headache worse By EtOH
Cluster
343
Headache worse by hunger
Migraine
| Tension
344
Headache prevented by prednisolone
Cluster
345
Headache prevented by lithium
Cluster
346
Headache prevented by TCA
Migraine
Tension
347
Headache due to meningeal irritation is worse in which time of the day?
AM
Provoked by: head movement
348
Drugs triggering migraine
Estrogen
Nitroglycerin
349
Migraine aura
Fully reversible
Focal cerebral dysfunction
Lasts < 60 min
350
Waking state characteristics
EEG: Alpha wave (high frequency, low voltage)
EOG:rapid, blinking
Muscle tone: high
351
Stage N1 sleep characteristics
EEG: alpha < 50% + slow wave
EOG: slow, roving
Muscle tone: High, gradually droping
352
Stage N2 sleep characreristic
EEG: K complex. Sleep spindles
EOG: still
Muscle tone: high
353
Stage N3 sleep characteristics
EEG: Delta waves (low frequency, high voltage)
EOG: still
Homeostatic sleep.
Reduced BP, HR, CO, RR.
Growth hormone release.
354
REM characteristics
EEG: sawtooth, mixed frequencies, low voltage
EOG: rapid eye movement
Muscle tone: very low
Irregular respiration
Arrhythmias
Heart rate variation
Classical dreaming state
355
Dreaming happens in which state of sleep?
REM
356
Effect of BDZ in sleep
Reduce slow wave sleep
357
Effect of antidepressants (TCA, SSRI, MAOI) on sleep
Prolong REM latency
Reduce REM
358
Effect of alcohol on sleep
Hastens sleep onset
Associated with increased arousals
359
Etiology of RLS/PLMS
Central (spasticity)
Peripheral (radiculopathy, plexopathy)
Pregnancy
Iron deficiency
Alcohol use
B12 deficiency?
360
Tx of RLS/PLMS
Remove underlying (iron, B12)
1st line: dopaminergic agonists
Clonazepam (causes tachyphylaxis)
Opioids (exceptional curcumstances)
DO NOT USE: levodopa/carbidopa (worsens)
361
Narcolepsy Sx
Narcolepsy
Cataplexy
Sleep paralysis
Hypnogogic hallucination
362
Onset of narcolepsy
Adolescence/early adulthood
Lifelong
363
Etiology of narcolepsy
AI attack on orexin/hypocretin system
MS
Head trauma
Hypothalamic tumors
Familial
364
Dx of narcolepsy
Hx
Sleep latency test: short sleep latency < 8 min
REM within 15 min of sleep onset
365
Tx of narcolepsy
Sleep hygiene
Scheduled brief naps
Restricted driving
Alerting agents: modafinil
Stimulants: methylphenidate
Anticataplectic:
TCA, SSRI, sodium oxybate
366
In elderly REM sleep behavior disorder may be associated with
PD
367
In children, slow wave sleep arousal may be associated with
Sleep disordered breathing
368
Amaurosus fugax
Transients monocular painless vision loss (TIA)
369
Hypertensive encephalopathy Sx
BP > 200/130
```
Abnormal fundoscopic exam:
Papilledema
Exudate
Cotton wool
Hemorrhage
```
Focal neurological symptoms
N/V
Visual disturbances
Change in LOC
370
Stroke mechanism in pts with chronic DM or HTN
Small vessel/lacunar
Due to vessel wall thickening
Mainly small penetrating arteries
Basal ganglia, internal capsule, thalamus
371
Most common cause of ICH
HTN
Esp in: putamen, thalamus, pons, cerebellum
372
Cerebral venous thrombosis Sx
Headache
Focal neurological deficit
CN palsies
Seizures
Dx: MRV, CTV
Tx: heparin then warfarin
373
ACA Stroke symptoms
Contralateral leg paresis/sensory loss
Cognitive deficit: apathy, confusion, poor judgment
374
MCA stroke Sx
If proximal:
Contralateral weakness/sensory loss of face and arm
Cortical sensory loss
Contralateral homonymous hemi/quadrantanopia
Aphasia (if dominant hemisphere)
Neglect (if non-dominant hemisphere)
Eye deviation towards the side of lesion
375
PCA stroke
Contralateral hemi/quadrantanopsia
Midbrain findings:
CN III, CN IV palsy
Pupillary changes
Hemiparesis
Thalamic findings:
Sensory loss
Amnesia
Decreased level of consciousness
If bilateral:
Cortical blindness
Prosopagnosia
Hemibalismus
376
PICA stroke Sx
Lateral medullary or Wallenberg syndrome
```
Ipsilateral ataxia
Ipsilateral Horner
Ipsilateral facial sensory loss
Contralateral limb pain and temperature impairment
Nystagmus
Vertigo
N/V
Dysphagia
Dysarthria
Hiccup
```
377
Basilar artery stroke Sx
```
Proximal:
Impaired EOM
Vertical nystagmus
Reactive myosis
Hemi/quadriplegia
Dysarthria
Locked-In syndrome
Coma
```
Distal:
Somnolence
Memory/behavior abnormalities
Oculomotor defect
378
Medial medullary infarct Sx
Anterior spinal artery
Contralateral hemiparesis (facial sparing)
Contralateral impaired proprioception/vibration
Ipsilateral tongue weakness
379
Lacunal infarcts
Posterior limb of internal capsule:
Pure motor hemiparesis: contralateral arm, leg, face
Ventral thalamic:
Pure sensory loss: hemisensory loss
Ventral pons or internal capsule:
Ataxic hemiparesis: Ipsilateral ataxia and leg paresis
Ventral pons or genu of internal capsule:
Dysarthria, facial weakness, dysphagia, mild hand weakness/clumsiness
380
Inv for stroke
Capillary glucose
Non contrast CT
ECG
Carotid doppler, echocardiogram
CBC, lytes, Cr, blood glucose, lipid profile, PTT/INR
+/- MR/CT angio
381
CT Findings in stroke
Loss of white-gray differentiation
Sulcal effacement
Hypodensity of paranchyma
Insular ribbon sign
Hyperdense MCA sign
382
Acute stroke management
ABC
V/S monitoring
Capillary glucose
rtPA within 4.5 h of ischemic stroke
Anti-platelet:
At presentation, if rtPA not given
After 24 h, if rtPA given
Anti-coagulant:
If AF and rtPA not received. IV heparin. Then warfarin.
Early thrombectomy if large artery occlusion of the proximal anterior occlusion
383
Hyperglycemia in stroke
Can increase infarct size.
Avoid hyperglycemia
384
Stroke and fever
Think septic amboli
Lower temperature
385
Stroke and dysphagia
NPO
386
Bed bound stroke pt
DVT Px
387
Stroke and HTN
DO NOT LOWER BP
D/C anti-hypertensives for 48-72 h
```
Tx if:
BP > 220/120
Acute MI
Renal failure
Aortic dissection
```
1st line: IV labetalol
388
Contraindications to rtPA
```
Improving Sx
Minor Sx
Seizure at stroke onset
Recent major surgery or trauma (within 14 d)
Recent GI/urinary hemorrhage (within 21 d)
Recent LP
Recent arterial puncture at non-compressible site
PMHx of ICH
Sx of SAH/MI/pericarditis
Pregnancy
sBP > 185
dBP > 110
Aggressive Tx to decrease BP
Uncontrolled serum glucose
Thrombocytopenia
Hemorrhage or mass on CT
High INR or aPTT
```
389
Etiological Dx
Critical for secondary prevention
MRI
CTA/MRA
Echo
Holter
390
Prevention of ischemic stroke with anti-platelet therapy
Primary prevention:
No firm evidence in low-risk pt without prior history
Secondary prevention:
Initial choice: ASA
if ineffective or contra: aggrenox, clopidogrel
391
Prevention of ischemic stroke in pt with carotid stenosis
```
Primary prevention (asymptomatic pt):
Carotid endarterectomy controversial
```
Secondary prevention:
Clearly beneficial in symptomatic pts with severe stenosis 70-90%
Less beneficial for moderate stenosis (50-69%)
392
Prevention of ischemic stroke in pt with AFib
CHADS2
0: antiplatelet
1: antiplatelet or anticoagulation
2 and higher: anticoagulation
Warfarin (INR 2-3), Factor X inhibitor, dabigatran
393
Prevention of ischemic stroke in pt with HTN
Primary prevention:
Target: < 140/90. If DM or renal disease, < 130/80. If high risk pt, < 120.
ACEI
Secondary prevention:
ACEI and thiazide
394
Prevention of ischemic stroke in pt with hypercholestrolemia
Primary:
Statin if CAD or high risk of CAD
Secondary:
Statin- high dose
395
Prevention of ischemic stroke in pt with DM
HbA1C < 7%
| FBS 4-7
396
Prevention of ischemic stroke in pt with smoking
Primary prevention:
Increases risk in a dose dependent manner
Secondary:
Smoking cessation declines risk of stroke to baseline within 2-5 years
397
Prevention of ischemic stroke with physical activity
Dose-related benefit
398
Stroke rehab
Dysphagia assessment, dietary modification
Communication rehab
Cognitive/psychological assessment
Exercise programs
Assessment of ambulation
Assistive devices, splints, braces
Vocational rehab
399
Inv for ICH
General inv
+
LP (if suspect SAH but normal CT)
Cerebral angiogram (if suspect aneurism, AVM)
If typical location for hypertensive hemorrhage, repeat CT in 4-6 wko
400
Tx of cerebral hemorrhage
Lower BP with IV meds to 140-160 systolic
ICP lowering if indicated
401
The most common form of MS
Relapsing-remitting
402
Benign MS
Retrospective Dx
Made after 15 years
Mild disease with no evidence of worsening (functional, MRI)
403
Devic’s variant of MS
Neuromyelitis optica
Severe optic neuritis
+
Extensive transverse myelitis extending > 3 vertebral segments
Ab positive
404
Clinically isolated syndrome
Single MS-like episode
May progress to MS
Early Tx with IFN may delay potential second attack
405
Tumefactive MS
Solitary lesion > 2 cmm
Mimicking neoplasm on MRI
406
Fulminant MS
Rapidly progressive and fatal
Severe axonal damage, inflammation and necrosis
407
Pediatric MS
Before 18
Rare
Presentation:
Isolated optic neuritis
Isolated brainstem syndrome
Symptoms of encephalopathy
Relapsing-remitting course
408
MS etiologies
HLA DRB1
Less sun exposure
Low Vit D levels
Certain viruses (EBV)
409
Dx for RRMS
Dissemination in time
Dissemination in space
410
Lhermitte’s sign indicates
Cervical cord lesion
411
Uhthoff’s phenomenon
Worsening of symptoms in heat
412
Symptoms Not commonly found in MS
Visual field defect
Aphasia
Apraxia
Progressive hemiparesis
413
Higher disease activity of MS during its course
1st year
414
Inv for MS
MRI:
Demyelinating plaque= hyperintense lesion on T2
Active lesions enhance with gadolinium
Dawson fingers
Cranial MRI more sensitive than spinal MRI
CSF:
Oligoclonal bands. Increased Ig G
Evoked potentials (visual/auditory/somatosensory):
Delayed but well-preserved wave forms
415
Typical locations of lesions on MRI
Periventricular
Corpus callosum
Cerebellar peduncles
Brain stem
Juxtacortical
Dorsolateral spinal cord
416
Acute Tx of MS
Methylprednisolone 1000/ d IV x 3-7 d
If poor response, plasma exchange
417
Chronic Tx of MS
Disease modifying therapy:
```
1st line:
Teriflunomide
Interferon-B
Glatiramer acetate
BG-12
```
2nd line:
Natalizumab
Fingolimod
No proven efficacy for PPMS, SPMS
418
Symptomatic Tx of MS
Spasticity:
Baclofen, dantrolene, BDZ, botulinum toxin
Bladder dysfunction:
Oxybutinin
Pain:
TCA, carbamazepine, gabapentin
Fatigue:
Amantadine, modafinil, methylphenidate
Depression:
Anti-depressant, lithium
Constipation:
High fiber intake, stool softener, laxatives
Sexual dysfunction:
Sildenafil
Education
Counseling
419
Good prognostic factors for MS
```
F
Young
Presenting with optic neuritis
Low burden on MRI
Low rate of relapse early in disease
```
PPMS: poor prognosis, higher disability rate, poor response to Tx
420
MS med with risk of PML
Natalizumab
Esp if:
Positive anti-JC Ab
Lengthy treatment with natalizumab
Prior use of immunosuppresant
