Neuro basics Flashcards
Cause of motor conduction defects w/o sensory symptoms
Lead
Causes of sensory conduction defects w/o motor symptoms
Paraneoplastic
HIV
Time required for denervation
10-21 days after injury
Nerve conduction study results for neuropathy
Axonal - nml/mildly slow - toxic, metabolic, DM causes
Demyelinating - very slow - autoimmune, acquired, post-infectious (GBS)
Repetitive nerve stimulation responses
Decremental - Myasthenia gravis
Incremental - Botulism, Lambert-Eaton
Xanthochromia
Yellow CSF due to RBC breakdown 12h-14d after bleed
Cytoalbumino-dissociation
CSF: High protein, low WBC
In demyelinating neuropathies (GBS)
LP CIs
Raised ICP (somnolence, headache, imbalance, N/V, focal neuro deficit, new seizure, papilledema): Tumor, abscess Subarachnoid/intracerebral bleed Posterior fossa mass Low platelet count under 50k INR over 1.5 (warfarin)
Do what before and after LP?
Review HCT/MRI to see:
No mass lesion + 4th ventricle, quadrigeminal cistern are open
Always check serum glucose as reference post-LP (CSF should have over 2/3 serum)
RBCs in CSF means?
Traumatic tap if decreasing concentration with subsequent tubes (or rarely active bleed)
Meningitis treatment
Treat empirically for likely bacteria/virus before LP: 10mg IV dexamethasone q6h for 4d Ceftriaxone/Cefotaxime Vancomycin Acyclovir ADD AMPICILLIN for those over 50y
Reasons for EEG
Assess coma/consciousness
Seizure (vs pseudoseizure)
Creutzfeldt-Jacob disease
Periodic lateralizing epileptiform discharge (PLED) in herpes encephalitis
Seizures
Abnormal, paroxysmal, excessive CNS neuron discharge
Eyes are open
Generalized - abnormal in all leads w/ spikes
Head CT terms
Hyperdensity - white - bone, blood, Ca
Hypodensity - black - CSF, ischemia (abnormal after 6-24h), chronic subdural, edema, tumor
Parts of brain that bleed w/ chronic HTN? Sx?
Aneurysms at branches of cerebral arteries
Lenticulostriate aa
Cerebellar aa
Intraventricular hemorrhage in premature infants;
Focal sx that progress to ICH signs (headache, N/V, AMS)
Metastases to brain that commonly bleed?
Melanoma, RCC
Subarachnoid hemorrhage management
Sedation/valium if conscious Give nimodipine, statin, MCA doppler, and consider angioplasty for vasospasm Keep BP higher to maintain perfusion Operate early on aneurysms Monitor for hydrocephalus
MRI terms
Hypointensity - dark Hyperintensity - white T1, T2 Flair - MS Diffusion weighted imaging - detects ischemia
Glasgow coma scale
Out of 15: Eye opening (4) - spontaneous, voice, pain, none Verbal response (5) - nml convo, disoriented, incoherent, sounds, none Motor response (6) - nml, localized to pain, withdraws from pain, decorticate (flexor), decerebrate (extensor), none 3-8 = Severe 9-12 = Moderate 13-15 = Mild
MMSE
Out of 30: Orientation to time = 5 Orientation to place = 5 Registration = 3 (repeat named prompts) Attention/Calculation = 5 (serial 7s/'world' backwards) Recall = 3 (registration recall) Language = 2 (name pencil and watch) Repetition = 1 (Speak back a phrase) Complex commands = 6 (Varies. Draw figure shown.) Over 24 = Nml Over 19 = Mild cognitive impairment Over 10 = Mod Under 9 = Severe
Seizure etiology
Etiology - Alcohol withdrawal, illicit drugs, meds; Brain tumor/trauma; Cerebrovascular disease (Subdural hematomas, HTN encephalopathy); Degenerative CNS disorders (AZD); Electrolytes (hyponatremia, uremia, liver failure, hypoglycemia); Idiopathic (60%)
Stroke treatment, management, secondary prevention
Maintain elevated, but not very high BP
BMP (Cr for contrast), glucose, CBC, INR, Troponins, ECG, tox screen — Stat CT
If no hemorrhage, thrombolysis/thrombectomy
ECG for arrhythmia, Echo for endocarditis, Carotid U/S, Lipids, HbA1c, TSH, Homocysteine, ESR/CRP, Blood cx
ASA, dipyrimadole, clopidogrel; hold anticoag Carotid revascularization (CEA, stenting)
How to test visual fields
Patient and examiner cover opposite eyes
Test one eye and one visual field at a time
Testing aphasia
What did you have for breakfast?
Touch your L foot with your R hand.
Repeat: The brown dog ran down the muddy hill.
Diffuse petechiae/purpura in meningitis case?
Neisseria meningitidis
Leukonychia
Mees’ lines on nails seen in arsenic (or other heavy metal) poisoning
Alopecia is common in what poisoning?
Thallium (non-standard pattern)
Dysphonia
Difficulty producing voice sounds (laryngeal issue)
Dysarthria
Difficulty articulating individual words (slurred speech)
Dysprosody
Difficulty with melody, rhythm of speech, inflection, intonation (Non-dom hemisphere stroke)
Aphasia
Language problem (Dom hemisphere stroke)
CN2 testing
Perform visual acuity and visual fields first
Perform fundoscopic exam and pupillary light reflex second
CN2 = afferent, CN3 = efferent
Conditions with anosmia
Head trauma
Frontal lobe mass/abscess
PD, AZD
Relative afferent pupillary defect occurs with what?
RAPD in CN2 injury
Eye with defect dilates with swinging light to it
Argyll Robertson pupil
‘Prostitute’s’ - accommodates, but doesn’t react
Neurosyphilis, maybe DM
Horner’s syndrome
Ptosis, miosis, anhidrosis
Dysfunction of SNS to orbit, face
Vertical gaze palsy
No up/down eye mvt
Midbrain lesion
Horizontal gaze palsy
PPRF - brainstem lesion
INO - MLF lesion
CN4 palsy
Head tilt toward unaffected side to compensate
Pupillary light reflex circuit
Light hits either retina, CN2 to pretectal nucleus, bilateral connections to E-W nuclei, PSNS pupillary constriction via CN3
CN3 palsy with blown pupil
Due to mass effect - emergent
Uncal herniation or PcommA aneurysm
CN3 palsy with reactive pupil
DM
INO
Can look to affected side
Affected eye cannot adduct while unaffected has concurrent nystagmus
CN7 lesions
Bell’s palsy = LMN lesion affecting whole 1/2 of face
Stroke = UMN lesion affecting only bottom of 1/2 of face
CN12 lesions
‘Lick your wounds’
Resting tremor
While patient is relaxed
PD specific
Postural tremor
When limb is being held up
Action tremor
When limb is moved
UMN lesion pattern
No initial atrophy
No fasciculations
Hyperreflexive with increased tone
LMN lesion pattern
Atrophy, fasciculations
Decreased reflexes and tone
Tics
Intermittent, stereotyped - face or body
Chorea
Random movements - ‘fidgets’
Dystonia
Sustained abnormal posture
Myoclonus
Lightening-like abrupt jerks
Duchenne muscular dystrophy
XR dystrophin mutations
Dilated cardiomyopathy, muscle pseudohypertrophy
Gower’s sign
Myotonic dystrophy
AD
Myotonia - failure of spontaneous release from handshake
Pacemaker due to arrhythmia (conduction abnmlities)
Insulin resistance, cataracts
Pronator drift (down)
Indicates UMN lesion of contralateral pyramidal tract (or ipsilateral cerebellum if drifting upward)
Screen for mild weakness due to stroke
Cerebellar dysfxn signs
Dysmetria, Dysdiadochokinesis, Titubation, Dysarthria, Nystagmus, Intention tremor, Broad-based stance/gait
Dysmetria
Zig zag to target w/ finger
Dysdiadochokinesis
Impairment making smooth, rapid, alternating mvts
Titubation
Coarse tremor of the trunk
Dysarthria
Impairment of speech motor fxn - NOT language disorder
Cerebellar dysfxn indicates lesion of which side?
Ipsilateral
Heel-shin test performed in what position?
Supine
Romberg sign indicates?
Dorsal column dysfxn, NOT cerebellar
Graphesthesia
Identify number drawn on hand
Stereognosis
Identify object placed in hand
Dermatomal distribution of neuropathy indicates?
Radiculopathy (disk herniation), VZV, spinal cord lesion
REM sleep occurs?
Later at night.
For concussion ask about?
Cause, Loss of consciousness, Imaging, New sx
Peripheral neuropathies treated with?
TCAs, Pregabalin, Gabapentin, Duloxetine (SNRI)
Seizure types
Generalized: Tonic-clonic (grand mal), Absence, Myoclonic
Focal (partial): Simple (no AMS), Complex (AMS)
Focal may become generalized secondarily
Seizure treatments
Treat underlying cause first (metabolic, toxic)
Consider treatment withdrawal if seizure-free w/ nml EEG for 1y
Carbamazepine, Ethosuximide, Gabapentin, Lacosamide, Lamotrigine, Levetiracetam, Oxcarbazepine, Phenobarbital, Phenytoin, Topiramate, Valproate, Zonisamide
Seizure presentation
Aura (t = s-m) Ictal period (s-m): Tonic and/or clonic mvts of body Postictal (m-h): Slowly resolving confusion, disorientation, lethargy. May have focal neuro deficits (Todd's paralysis) Status epilepticus
Status epilepticus
Cts tonic-clonic seizure at least 30m or repeated seizures w/o resolution of postictal encephalopathy.
Complications: neuronal death, rhabdo, lactic acidosis
Epilepsy
Recurrent unprovoked seizures
1% of pop
What immediately threatens brain tissue?
H's: Hypoxia Hyperthermia Hypoglycemia Herniation
PD questions
Tremor? Memory? Gait/falls? Dyskinesias/Freezing? Hallucination (from Dx or SE)?
Headache red flags
Thunderclap headache - SAH Positional headache - CSF leak Exertional headache - (HTN) usually migraine New headache if over 50yo - mass Substantial change in headache pattern Constant headache in same location Aura that is sudden, lasts over 1h, or doesn't resolve Systemic sx - infxn
Transverse myelitis
Inflammation of spinal cord causing UMN signs Due to: Bacterial infxn (Mycoplasma, Borellia, Bartonella) Viral infxn (HSV, VZV, EBV, CMV, HIV) Rare vaccination rxn MS Paraneoplastic syndrome Vascular etiology
Drugs lowering seizure threshold
Theophylline Isoniazid, metronidazole, penicillins (give B6) TCAs, bupropion, 5-HT agents Steroids, insulin Opiates, stimulants Anticholinergics, AChEIs, antihistamines Heavy metals, lithium
Non-Rx causes of lower seizure threshold
Sleep deprivation, stress Fever Rx withdrawal Flashing lights Menstruation Metabolic - electrolyte abnmls, DM
Most common primary cancers metastasizing to brain in order of occurrence
Lung, breast, melanoma, colon
Multi met: Lung, melanoma
Single met: Breast, colon, RCC
Prostate CA rarely goes to brain
Sleep stages
Beta - awake Alpha - eyes closed Theta - N1 Sleep spindles - N2 Delta - N3 (night terrors, sleepwalking, bedwetting) Beta - REM (flaccid paralysis)
Parkinsonism
Associated w/ Lewy bodies (a-synuclein) and loss of dopaminergic neurons of SNpc
May have hallucinations in addition to motor sx
Dementia presents late in PD
On spectrum w/ Lewy body dementia, but more motor involvement first
Huntington’s
AD c4 CAG repeats
(CAG - Caudate loses ACh and GABA)
Neuronal death by glutamate tox
Chorea/Athetosis (writhing), personality changes, dementia
Hemiballismus
Sudden flailing of arm w/ or w/o ipsilat leg
SubThNu stroke contralaterally (lacunar)
Myoclonus
Sudden brief uncontrolled muscle contraction
Metabolic causes - liver, renal failure
Essential tremor
Associated w/ action, not present at rest
May self-Rx w/ EtOH. Propranolol, primidone first line
Resting tremor
Present in Parkinsonism
Pill-rolling, alleviated by intention
Intention tremor
Zig-zag of intentional mvt to target
Cerebellar dysfxn
Homunculus organization
Head = lateral, inferior
Lumbar, sacral = medial, superior
Broca’s area
Anterior to cranial primary motor cortex in dominant (L) frontal cortex
Stroke = good comprehension, poor language formation
Broca’s broken boca
Wernicke’s area
Dominant (L) temporal lobe posterior to primary auditory cortex
Stroke = poor comprehension, can form language but it is incoherent
Wacky Wernicke
Amygdala lesion
Kluwer-Bucy syndrome: Hypersexuality, hyperorality, disinhibition
HSV-1 assoc
Frontal lobe lesion
Disinhibition, concentration deficits, poor judgment
Primitive reflex reemergence
Gerstmann syndrome
L (dom) parietal-temporal cortex stroke
Agraphia, acalcula, finger agnosia, L-R disorientation
R (non-dom) parietal-temporal cortex lesion
CL agnosia (hemispatial neglect)
Midbrain (reticular activating system) lesion
Reduced arousal
B/l mammillary body lesion
Wernicke-Korsakoff syndrome: Confusion, ataxia, ophthalmoplegia; memory loss, confabulation, personality change
EtOH assoc - always give B1 before glucose to suspected EtOH px to prevent this
Basal ganglia lesion
Resting tremor/chorea/athetosis
PD
Cerebellar hemisphere lesion
Ipsilateral intention tremor, fall towards affected side
Cerebellar vermal lesion
Truncal ataxia, dysarthria
Peripheral neuropathy lab tests
B12, TSH, HbA1c, blood glucose, SPEP
B/l hippocampus lesion
Anterograde memory loss
PPRF lesion
Look away from lesion
FEF lesion
Look towards lesion
Cerebral pontine myelinosis
From low to high (Na), pons will die – Locked-in syndrome
Global aphasia
Lesion of Broca + Wernicke areas
Conduction aphasia
Poor repetition, but fluent speech and intact comprehension
Lesion of arcuate fasciculus
Cerebral perfusion controls
PCO2 increase causes increased cerebral blood flow
Low PO2 only inceases cerebral flow once under 50
Charcot-Bouchard microaneurysms
Chronic HTN effect on lenticulostriate aa (thalamus, basal ganglia)
Post-stroke pain syndrome
Neuropathic pain due to thalamic lesion causing wk-mth of allodynia
Intraparenchymal hemorrhage
Due to HTN. Assoc w/ amyloidosis (AZD), neoplasm, vasculitis
Typically into internal capsule. Can be lobar
Communicating hydrocephalus
Down CSF absorption – up ICP, papilledema, herniation
Post meningitis
Hydrocephalus ex vacuo
Appearance of up CSF space from brain atrophy
No wet, wobbly, wacky sx
Werndig-Hoffmann and poliomyelitis lesions
LMN lesions only
W-H = floppy baby
MS lesions
Random and asymmetric Demyelination Scanning speech, nystagmus, intention tremor High CSF protein w/ oligoclonal bands Periventricular plaques
ALS lesions
Combined UMN and LMN lesions w/o sensory or cortical loss
Presbycusis
Age-related gradual hearing loss
Friedreich ataxia
AR c9 GAA repeat causes multiple tract degen – weakness, DTR loss, vibr loss, proprio loss
Presents in children w/ kyphoscoliosis, hypertrophic cardiomyopathy
Brown-Sequard syndrome
Cord hemisection
I/L UMN signs below lesion
I/L loss of FT, Pr, V 1-2 lv below lesion
C/L Pa, T, CT loss below lesion
I/L loss of all sensation at lesion level
I/L LMN signs at lesion
Horner’s if lesion above T1 due to oculo-SNS path damage
Parinaud syndrome
Conjugate vertical gaze palsy due to superior colliculus lesion
Acute angle closure glaucoma presentation
Painful sudden vision loss, halos around lights, frontal headache
Don’t give epinephrine b/c of mydriasis
Papilledema
Increased ICP: Bigger blind spot, elevated optic disc, blurred margins on fundoscopy
Pick disease
Frontotemporal dementia and atrophy
Personality changes, parkinsonism, dementia, aphasia
Spherical tau aggregates
Lewy body dementia
Initially dementia and visual hallucinations, followed by parkinsonism
On spectrum w/ PD, but dementia first
Due to a-synuclein defect
Creutzfeldt-Jakob
Rapidly progressive dementia w/ myoclonus
Specific 3Hz EEG
14-3-3 protein in CSF
GBS
Autoimmune Schwann cell destruction = LMN motor and sensory neuropathy May have autonomic dysfxn - give steroids if SNS failure Albuminocytologic dissociation (high CSF protein w/ nml cell count) Treat w/ plasmapheresis, IVIG ***Steroids are not demonstrated to improve outcomes
PML
Oligodendrocyte (CNS) destruction due to reactivated JC virus
Seen in AIDS, natalizumab
Rapidly progressive and fatal
Postinfectious encephalomyelitis
Multifocal perivenular inflammation and demyelination
Commonly after measles, VZV, rabies/smallpox vax
Metachromatic leukodystrophy
AR lysosomal storage disease
Arylsulfatase A deficiency – Impaired myelin production
CNS + peripheral demyelination, ataxia, dementia
Charcot-Marie-Tooth disease
AKA Hereditary Motor and Sensory Neuropathy
Usually AD defective myelin protein production
Assoc scoliosis, foot arch deformities
Krabbe disease
AR lysosomal storage disease
Galactocerebrosidase deficiency
Peripheral neuropathy, dev delay, optic atrophy, globoid cells
Adrenoleukodystrophy
XR defect of very long chain FA metabolism – buildup in nerves, adrenals, testes
Coma, adrenal gland crisis
Sturge-Weber
GNAQ acquired activation
Port wine face stain, Ipsilateral leptomeningeal angioma, Seizures, Intellectual disability, Early onset glaucoma
Tuberous sclerosis
Hamartomas, Angiofibromas/renal Angiomyolipoma, MR, Ash-leaf spots/Shagreen patches, Rhabdomyoma, AD, Mental retardation, Seizures
NF1
AD c17 mutation
Cafe-au-lait, Iris hamartomas, Neurofibromas, Optic gliomas, Pheochromocytomas
VHL
AD c3 VHL mutation – angiogenesis
Cavernous hemangiomas in skin, organs; B/l RCC; Hemangioblastomas of CNS (cerebellum); Pheochromocytomas
Partial seizures
1 brain area, most often medial temporal lobe w/ preceding aura
Simple partial - consciousness ok
Complex partial – impaired consciousness
Generalized seizures
Diffuse brain involvement Absence (staring) - 3Hz, no post-ictal Myoclonic - quick repetitive jerks Tonic - stiffening Tonic-clonic - alternating stiffening/mvt Atonic - drop to floor (not fainting)
Status epilepticus causes
All demos - fever (infxn), trauma, metabolic
Children - genetic/congenital
Adults - tumors, stroke
Elderly - stroke
MCA stroke
Upper limb + face
Motor + sensory cortex
Wernicke + Broca areas
Hemineglect if non-dom side, Aphasia if dom side
ACA stroke
Lower limb
Motor + sensory cortex
Lenticulostriate aa stroke
Striatum + Internal capsule
C/l hemiparesis/hemiplegia
Common location of lacunar infarcts secondary to uncontrolled HTN
ASA stroke
Lat corticospinal tract + Medial lemniscus
CN XII if caudal medulla
C/l hemiparesis of upper + lower limbs, C/l down proprioception, I/l CN XII dysfxn
Medial medullary syndrome from ASA br infactions
PICA stroke
Lat MEDULLA (VesNu, Sp5Nu, NuAmb, LatSpThTr)
Vomiting, vertigo, nystagmus (VesNu); Down P/T/CT to I/l face (Sp5Nu) + C/l body (LatSpThTr); laryngeal dysfxn (NuAmb specific); Horner’s syndrome.
Lateral medullary (Wallenberg) syndrome
Don’t PICA ho[a]rse that can’t [eat]
AICA stroke
Lat pons (CNNu, VesNu, 7Nu, Sp5Nu, CocNu)
Vomiting, vertigo, nystagmus (VesNu); Facial paralysis + gland dysfxn (CNNu); Deafness (CocNu)
Lateral pontine syndrome
FACIAL DROOP means AICA is pooped
PCA stroke
Occipital and visual cortex
C/l hemianopia w/ macular sparing
Basilar a stroke
Medulla, pons, lower midbrain, CorSp, CorBulb, Ocular CNNu, PPRF lesions
Locked-in syndrome
Preserved consciousness and blinking w/ loss of all other mvt
ACom lesion
Usually aneurysm
Visual field defects
PCom lesion
Usually aneurysm
CN3 palsy with ptosis and pupil dilation
Akathisia
Restlessness, motion assoc w/ 1st gen antipsychotics and PD
Seen in low dopaminergic state
NT changes in AZD
Low ACh
NT changes in anxiety
High NE
Low GABA, 5-HT
NT changes in depression
Low NE, 5-HT, dopamine
NT changes in Huntington’s
Low GABA, ACh
High dopamine
NT changes in PD
Low dopamine
High seratonin, ACh
NT changes in schizophrenia
High dopamine
NE synth site, changes in diseases
Locus ceruleus (pons) – Stress, panic
High in anxiety
Low in depression
Dopamine synth site, changes in diseases
VTA, SNc – Reward, pleasure
High in HD
Low in PD, depression
5-HT synth site, changes in diseases
Raphe nuclei
High in PD
Low in anxiety, depression
ACh synth site, changes in diseases
Basal nucleus of Meynert
High in PD
Low in AZD, Huntington’s
GABA synth site, changes in diseases
Nucleus accumbens – Reward, pleasure
Low in anxiety, Huntington’s
Delirium treatment
Address underlying cause – infxn, metabolic, etc
Optimize brain condition w/ O2, hydration, pain control
Antipsychotics such as haloperidol
Neuroleptic malignant syndrome sx, treatment
Rigidity, myoglobinuria, autonomic instability, hyperpyrexia due to dopamine antagonism
Treat w/ dantrolene, D2 agonists (e.g., bromocriptine)
FEVER: Fever, Encephalopathy, unstable Vitals, high Enzymes, Rigidity
Tardive dyskinesia, Rx, and development
Stereotypic oral-facial movements as a result of long-term antipsychotic use. Potentially irreversible.
Seen w/ high potency 1st gen antipsychotics especially: Trifluoperazine, Fluphenazine, Haloperidol
Evolution of EPS side effects: 4 hr acute dystonia (muscle spasm, stiffness, oculogyric crisis) 4 day akathisia (restlessness) 4 wk bradykinesia (parkinsonism) 4 mo tardive dyskinesia
Tethered spinal cord
Urinary, bowel control issues
Low back pain
B/l muscle weakness, abnml gait
Foot, spine abnmlities
Assoc w/ spina bifida, Chiari malform
Once neuro sx develop, they may become irreversible
Bell’s palsy
Idiopathic or as a complication in AIDS, Lyme, Sarcoid, Tumors, Diabetes
LMN lesion leads to paralysis of entire side of face
Treatment involves steroids
Most cases resolve spontaneously
Patients with Bell’s usually experience:
Pain in ear preceding weakness
I/l numbness + weakness in face
Hearing unaffected
Normal pressure hydrocephalus presentation
Psychomotor slowing
Incontinence
Enlarged ventricles
Serial therapeutic agents order for status epilepticus
Glucose, lorazepam, fosphenytoin, phenobarbital
EMG results in carpal tunnel syndrome
Prolonged distal latency of median nerve conduction velocity across wrist
Immediate Rx for TMJ
High dose prednisone
Treatment of increased ICP due to head trauma
Steroids
BZD effects in elderly delirious patients
Increased SE risk, prolonged action, and may cause paradoxical agitation
Use haloperidol if absolutely necessary, but watch for NMS
Putamen hemorrhage sx
C/l hemiparesis, C/l hemiplegia, conjugate gaze deviation toward side of lesion
Obtain what in patients with neuropathy and borderline B12?
Serum methylmalonic acid (more sensitive for deficiency than B12 alone)
Diffuse axonal injury
Most significant cause of morbidity in TBI. CT shows numerous minute punctate hemorrhages w/ blurring of grey-white interface
Hypokalemia signs + ECG
Weakness, fatigue, cramps
Paralysis, arrhythmia if severe
ECG: Us, flat/broad Ts, PVCs
ICH sx, treatments
AKA pseudotumor cerebri
Presents as headache, (N/V, AMS), papilledema suggestive of mass in young obese female w/ nml CT and elevated CSF pressure.
Treat w/ weight loss, acetazolamide
Shunt or CN2 fenestration to prevent blindness w/o resolution
NO INCONTINENCE
Risks for CVA
HTN - strongest
Smoking, DM - strong
High cholesterol - marginal
EtOH - protective if mild/mod
Improvement of ptosis w/ ice suggests …?
Myasthenia gravis: AChE inhibited at cold temps –> Better competition w/ autoAbs
Cluster headache sx, Rx
Acute, severe retroorbital pain that may awaken, be assoc w/ i/l eye erythema, secretions, Horner’s
Acute: O2 (best), ergots, NSAIDs
Ppx: CCBs, steroids, ergots, NSAIDs
Cushing reflex sx? Suggests?
HTN, bradycardia, resp depression
Suggests brainstem compression
Lumbar spinal stenosis sx
Assoc w/ degenerative joint disease
“Neuropathic claudication” - exacerbated w/ walking + relieved by spinal flexion (opens canal), worsened by extension (closes)
Found on MRI
Wilson’s disease, sx, labs
Abnml copper deposits in tissue (liver, basal ganglia, cornea)
Pres w/ liver or psych disease
Rings on slit lamp exam, up urine Cu, down ceruloplasmin
Primary CNS lymphoma
Suspect w/ single periventricular weak ring lesion on MRI + HIV + EBV DNA in CSF
RLS labs, Rx MOA
Always check Fe Dopamine agonists (rupinirole, pramipexole) or gabapentin
Posterior internal capsule CVA sx
U/l weakness w/o sensory loss or cortical sx
Cauda equina syndrome sx, management
Severe low back pain, unilateral radiculopathy, saddle anesthesia, hyporeflexia, asymmetric motor weakness, late onset incontinence/retention
Emergent MRI, steroids, neurosurg
Conus medullaris syndrome sx
Severe back pain, perianal anesthesia, hyperreflexia, mild bilateral motor weakness, early onset incontinence/retention
Emergent MRI, steroids, neurosurg
Spinal cord compression sx, management
Back pain, B/l LE weakness + sens loss, ataxia, late bowel/bladder
May acutely develop spinal shock, hyporeflexia, flaccid paraplegia
Emergent MRI, neurosurg, may add steroids
Riley-Day syndrome
AKA familial dysautonomia
AR, esp Jewish
Gross ANS dysfxn w/ severe orthostatic hypotension
Multiple system atrophy sx
Parkinsonism + orthostatic hypotension, impotence, incontinence, other ANS sx
Exertional heat stroke sx, management
Over 104F, CNS dysfxn
Treat w/ rapid cooling, preferably ice water immersion
Tick-borne paralysis sx, management
Rapidly progressive ascending (asymmetric) paralysis w/o fever, sensory sx, or CSF findings
Remove tick for spontaneous improvement
Opioid OD sx
Pinpoint pupils, resp depression (usually under 12/m)
Cerebellar hemorrhage pres
HTN hx, AMS, focal occipital headache, w/ Xa inhibitor/anticoag use
MG sx, Rx, management
Anti-AChR autoAbs
Ptosis, fatigue, gen weakness. May have thymic mass–removal may improve sx
Treat w/ AChEIs, steroids for flares
Intubate + plasmapheresis/IVIG for acute crisis
Management of metastatic brain tumors
Solitary: Resect if good status and stable disease
Multiple: Whole brain radiation therapy
Sydenham’s chorea
Rapid uncoordinated jerks of face, hands, feet w/o LoC after GABHS/ARF
AZD requirements for diagnosis
After eliminating other causes by H/P, must do head CT/MRI
Endolymphatic fistula sx
Vertigo associated w/ pressure changes to head/environment
Meniere’s sx
Episodic vertigo w/ u/l tinnitus, hearing loss, ear fullness
HTN crisis treatment
Nitroprusside
Not CCBs
