Neuro Flashcards
How do you demonstrate brain death on exam?
Absence of deep brain reflexes
Can a brain dead patient move?
Yes, can have spontaneous movements from the peripheral nervous system or spinal cord
In myasthenia gratis, Ab attack what receptor?
Acetylcholine
Wernicke encephalopathy is d/t a deficiency in?
Thiamine
AMAS + oculomotor dysfunciton + ataxia
Pt is treated for Wernicke, now having retrograde amnesia and confabulation (making up stories). Why?
Korsakoff syndrome
Late stage complication of chronic thiamine deficiency
Mammillary body atrophy on MRI
The patients rarely improve
Kiddo with hearing loss and SubQ skin masses
Neurofibromatosis
Acoustic neuromas (from Schwann cells)
Schwann cells - myelinated PNS axons and CN axons
Side effect of carbamazepine (anti-eleptic)?
Neutropenia/bone marrow suppression
Elderly also get SIADH
Also - glaucoma, urinary retention, constipation
1st line therapy for prolactinoma (regardless of size)?
Dopaminergic receptor agonist (bromocriptine, cabergoline)
Can decease tumor size in a few days which can help visual symptoms
New onset depression at age >65 increases the pts risk of?
Alzheimer dz
Pt with acute severe unilateral HA
Dilated pupil on same side
Blurry vision on same side
Concerning for?
Carotid a. dissection
get a CTA head/neck
Gets compression on the superior cervical sympathetic ganglion
What should be measured in someone with Guillain Barre
Vital capacity to monitor respiratory status
Treatment of Guillain Barre?
Therapeutic plasma exchange or IVIG
Pt with new onset lower extremity weakness and loss of bowel/bladder control
Dx and what next?
Transvere myelitis
Different from GBS because they have flaccid paralysis, hyporeflexia
Need spinal MRI
Tx - steroids
Pt has symptoms of intracerebral hemorrhage + CN III palsy in the weeks before the event, where is the lesion?
PCA aneurysm
Pt has symptoms of intracerebral hemorrhage + ataxia. Where is the lesion?
Posterior inferior cerebellar a. aneurysm
Pt with lower extremity weakness, numbness, + Romberg, constricted pupils on exam
Late neurosyphilis
Tabes dorsalis - sensory ataxia, lancinating pains
Argyll Robertson pupils - constriction w/ accommodation but not with light
Most common cause of b/l diaphragmatic paralysis?
ALS Respiratory weakness (worse when supine), lower extremity atrophy, tongue fasciculation's
Young person with DVT now has a stroke. What should be part of the workup?
Bubble study to look for intracardiac shunt
Preferred test to dx MS?
MRI
ovoid periventricular white matter lesions
Tx for acute MS flare?
IV solumedrol
po steroids has high rate of recurrence
Can pursue plasmapheresis if no response to treatment
Long term tx for MS?
Beta-interferon or flatiramer
Decreases the frequency of exacerbations
Reduces the number of brain lesions in its with relapsing-remitting MS
How should you counsel a woman with MS that wants to get preggo?
Typically have lower disease activity during pregnancy
Higher activity in postpartum period
Most therapies are low risk of harm to fetus
What can you give a MS patient that is having a hard time with spasticity?
Baclofen
Cancers with high rate of metastasis to spine?
prostate breast lung non-Hodgkin's lymphoma RCC
Dementia + 2 or more of the following: Fluctuating cognition Visual hallucination Shuffling gait, increased tone Rapid eye movement during sleep
Dementia w/ Lewy bodies
What treatment can make a Lewy body dementia pt prone to orthostatic?
Anti-psychotics especially first generation
Dementia
Difficulty walking, lower extremity parathesia
Hyperreflexia
Vit B12 deficiency
Prone to hemolytic anemia d/t poor erythropoiesis
Pt with decreased sensation over anterolateral thigh but nl reflexes and strength
Meralgia paresthetica
Lateral femoral cutaneous nerve entrapment
Tx - weight loss and avoid tight clothing
Teenager presenting with symptoms of paralysis after campling
High suspicion for tick paralysis
toxin is in tick saliva
Six start 4-7 days after attachment
Progressive gait ataxia and ascending paralysis
exam: NL sensation, absent DTRs, afebrile
Tx - remove the icky thing
Headache + papilledema. Now what?
MRI
don’t do LP in use there is herniation
Premature infant, spasticity, hyperreflexia, not meeting gross motor milestones
Dx and workup?
Suspicious for CP
Get an MRI
2 days after removal of a parathyroid adenoma pt has b/l facial asymmetry
Hungry bone syndrome
If unilateral think of an alternative dx
LP with high RBC w/o xanthochromia is?
A traumatic tap
High risk features of head trauma in a kid < 2
AMS LOC Severe mech (>3ft, MVA) Nonfrontal scalp hematoma Palpable skull fracture
How do you counsel people to return to sport after concussion?
rest for 24 hours after injury. After that gradually increase activity level each 24 hour period if asymptomatic. Maybe able to return to full play in 1 wk
Absent cremaster reflex but all other strength and sensation intact. C/f?
Isolated loss of Cremasteric reflex is suggestive of diabetic neuropathy
L1-L2
Teenager
Upper extremity twitching x months
No GTC seizure
Cx?
Juvenile myoclonic epilepsy
Tx - Valproic acid
can initially present as absence as well
Aggrevated by sleep deprivation and alcohol
EEG b/l polyspike and slow wave discharges during ictal period
Side effect of Valproic acid?
Thrombocytopenia
Hepatotoxicity
Teratogen –> NTD
Can brain dead people have DTRs?
Yes, because these are peripheral reflexes
infectious cause of SAH in a sexually active young adult?
Syphillis
Causes intracranial arteritis
Tx - PCN
Six of phenytoin toxicity?
Earliest - nystagmus on lateral gaze
blurred vision, diplopia, ataxia, slurred speech, lethargy, AMS
Late - coma
Best way to visualize head injury 2/2 trauma in an infant?
CT
no ultrasound - this is better for intraventricular hemorrhage in premies
1st line to prevent cluster HA?
Verapamil
Teenager describing feeling sleepy all the time, falls asleep at inappropriate times, hallucinations surrounding sleep, or cataplexy
c/f narcolepsy, needs a sleep study
1st line tx for narcolepsy
Modafinil
Sleep hygiene
Narcoleptic patient has cataplexy triggered by emotion. Dx?
Venlafaxine
ipsilateral face loss of pain/temperature
Contralateral body loss of pain temp
ipsilateral body weakness
Vestibular syx - Nystagmus, vertigo, ipso limb ataxia, Horner’s syndrom
Face motor function spared
What is this?
Wallenberg syndrome
Lateral medullary infarct d/t occlusion of PICA or vertebral a.
Tongue deviates toward lesion
Contralateral body with paralysis
Where is the lesion?
Medial Medullary syndrome (alternating hypoglossal hemiplegia)
occlusion of vertebral or ACA
Contralateral ataxia
Hemiparesis of face, trunk, limbs
Where is the lesion?
Medial mid-pontine infarction
Ataxic hemiparesis
What should be ruled out if you are concerned about dementia?
Anemia
Folate/B12 levels
hypothyroidism
Depression
Common age range for febrile seizure?
3month - 6 years
Progressive weakness following URI
Loss of sensory, urinary retention
Dx?
Transverse myelitis
Cushing’s triad of intracranial hemorrhage
Bradycardia
HTN
Respiratory depression
eye with down and out palsy
CN III
dementia with lots of personality changes
Frontotemporal dementia
Tx for Parkinsons
Dopa agonist (pramipexole) or Levodopa Prefer pramipexole in younger pmts because of the long term side effects of levodopa
If you suspect NPH wait is the first step in management?
LP
If syx get better –> VP shunt
Pt has involuntary closing of R eye in response to bright light
Dx, Tx?
Focal dystonia (blepharospasm)
Older women are predisposed
Tx - Botox
Pt has stroke symptoms and cannot lift the affect eyebrow or corner of mouth
Bells palsy (CN VII), CVA has preservation of forehead and eyebrow movements because upper motor portion of CN VII is in a different location than the lower branch
Unilateral lower extremity weakness Muscle cramping in same extremity Atrophy on exam, fasciculation's in face and tongue difficulty chewing Dx?
ALS
What is Riluzole?
ALS treatment
Glutamate inhibitor
Doesn’t cure, but prolongs survival and delays need for trach
Cut off for carotid endarctectomy?
Symptomatic stenosis 70-99%and life expectancy > 5years
Infant with developmental delay, seizures, hypopigmented “ash-leaf spots”
Tuberous scleorsis
AD
de novo in 80% of cases
EEG is indicated as their seizures worsen over time
Usual cause of death in tuberous sclerosis?
Neurologic problems
epilepsy
Pt with headaches lost pupillary reaction Vertical gaze restriction loss of balance while walking dx?
pituitary adenoma
Parinaud’s syndrome
Some can also secrete HCG and cause precocious puberty in males
IF you suspect a brain bleed and pt has down and out eye finding, ptosis, anisocoria, where is the bleed likely to be?
PCA aneurysm
lesion in CN III
How do you assess respiratory effort in a pt suspicious for Guillain-Barre?
Check tidal volume and negative inspiratory force (vital capacity)
Who should receive plasma exchange in Guillain- Barre?
If non ambulatory and six present <4 wks
Shortens the time to full recovery
Most common complication in spina bifida?
Neurogenic bladder - nearly universal
Result of folate deficiency during pregnancy
Elevated alpha-fetoprotein on maternal screenings
Over half of patients will have hydrocephalus after repair and require a VP shunt
Neurogenic bowel also common and require a bowel regimen
Workup for suspected SAH
CT - can be negative especially if >6 hours since symptom onset
followed by LP
b/l band HA without throbbing
Tension type HA
throbbing headache
Migraine
After a Carotid endarterectomy pt has tongue deviation. Which nerve is affected?
Hypoglassal
Pt has dysphonia after a carotid endarterectomy is d/t damage to?
Recurrent Laryngeal
Asymetric smile after carotid endarterectomy is damage d/t?
Facial nerve
Pt has absent CN. How do you confirm brain death?
Apnea testing
sudden onset but transient monocular blindness
Amaurosis fugax
Caused by carotid archery atherosclosis
Often have a carotid bruit
Need carotid dopplers
Bells palsy + hepatosplenomegaly suggests?
Sarcoid
Can have uveitis, arthritis, CNS findings with infiltrate of organs
what confirms dx of sarcoid?
LN Bx with noncaseating granulomas
work up for reversible causes of dementia?
CBC
CMP
TSH
B12
1st line tx for dementia?
Acetylcholinesterase inhibitors
Donepezil, rivstigmine, galantamine
2nd line - NMDA receptor antagonist; memantine
h/o febrile seizures increases risk of?
Recurrence
Epilepsy
What is construction apraxia?
Pt is unable to copy a drawing.
Lesion in non dominant parietal lobe
Can also have dressing apraxia (difficulty putting on a coat or pants)
Unable to do math, name fingers, write, and confuses R/L
Dx and location of lesion?
Gerstmann syndrome
Dominant parietal lobe
deficit in visual field, unable to interpret complex sounds
Where is lesion?
non dominant temporal lobe
deficit in visual field
aphasia
Dx and location?
Wernicke’s aphasia
Dominant temporal lobe
Parkinson’s patient with psychomotor slowing and blunted affect. Tx?
Add SSRI, underlying depression
best way to dx epidural abscess?
MRI
what medications increase risk of pseudo tumor?
acne treatments, irsotretinoin and minocycline
leg with generalized spike and wave
absence sz
how is management after spa different from non spa cva
no anti platelet
keep bp <185/100 to avoid hemorrhagic conversion
