Neuro Block 2 Cram Flashcards
What age group is associated with Multiple Sensory Defect Dizziness?
What is it AKA ?
What are the 4 parts that contribute to it?
Elderly when walking w/ impaired sensation in feet and poor vision
Benign Disequilibrium of Aging
Age, Dec Sensation, Poor vision, Light headed
What is the Tx for Vaso Vagal Syncope?
What classification of dizziness is always associated with positional changes?
Supine position w/ feet elevated, conciousness shoult return
Postural/Orthostatic HOTN that causes abrupt decrease of arterial flow
What are some of the underlying causes for Postural or orthostatic hypotension?
Which syncope classification is secondary to increased pressure on carotid sinus baroreceptors?
Chronic Dz or Polypharmaceutics
Carotid sinus hypersenstivity, usually found in Men over 50 w/ tight collar
What classification is associated w/ passing out on the commode while defecating?
What Sx is associated w/ VasoVagal Syncope?
Situational reflex syncope
Regains consciousness rapidly
What differentiates Vestibular Neuronitis from Labyrinthitis?
Name a common over the counter medication that can cause of Toxic Vestibulopathies?
Pure vestibular neuronitis= preserved auditory function Labyrinthitis= syndrome combined w/ unilateral hearing loss from viral origin
ASA
Name a rare cause of reflex syncope associated w/ sharp repetitive pain precipitated by swallowing/chewing?
How is it Tx?
Glossopharyngeal Neuralgia
Carbamazepine (anti-epileptic drug)
Med failure= Microvascualar decompression
Rhizotomy of Glossopharyngeal/Vagal fiber
Exercise induced syncope suggests what type of etiology?
What is the triad for Menier’s Dz?
Cardiovascular etiology
Unilateral hearing loss, Vertigo, Unilateral tinnitus w/ N/V
What is the treatment plan for Menier’s Dz?
Avoid salt intake, caffeine, alcohol, nicotine, monosodium glutamate (MSG) Tx stress/allergic rhinitis Diuretics: HCTZ/Triamterine Tx N/V: Meclizine, Scopolomine Valium (diazepam) Hearing Aid Gentamicin injection Surgery
What causes a Perilymphatic fistula?
How is it Tx?
Physical injury
Extreme barotrauma
Vigorous valsalva maneuvers Cough/Sneeze
Post-middle ear surgery
Bed rest, head elevation, and avoidance of straining
Surgical patch of the oval or round window
What is the most common cause of acute peripheral vertigo?
Acoustic Neuromas present w/ insidious onset of SNHL and can be associated w/ tinnitus/HA/vertigo. What PT population is it common in?
Benign PPV- brief/sudden episodes of vertigo w/ N/V
Middle aged females
Most Acoustic Neuromas are most commonly found on CN ?
What seizure is commonly found in children characterized by staring and lack of awareness?
CN8 in the cerebellopontine angle
Absence Seizure
Focal Seizures WITHOUT Dyscogntive features are characterized by what?
Focal Seizures WITH dyscognitive features are characterized by ?
No LOC, possible aura and body movement
Loss of awareness. Motor findings. Seizures involve impaired consciousness, responsiveness, and memory
A situation in which the duration of seizure is greater than how may minutes is status epilepticus?
What is the most common cause?
5min
Not taking seizure meds Metabolic disturbance- low sugar Drug toxicity CNS Infection/Tumor Head trauma
What are the 3 types of memory?
How is Working memory tested?
Working
Episodic
Lasting
Less than 30 seconds, so Tested w/ “repeat after me… “Neuro. Number. One”
How is Episodic Memory tested?
What is the time course for Delirium?
Word recall after 3-5min or,
Asking trivial events of the day
Acute Onset- acute change in mental status
What is the hallmark description of Delirium?
Wernicke’s Encephalopathy is found in ? PT population?
Waxing and Waning LoC
Chronic alcoholics*
PTs w/ malnutrition- emesis, starvation, renal dialysis, CA or AIDS
What are the risk factors for the most common form of dementia?
What are the 3 most common reversible causes of Dementia?
Alzeihmers
Age
Depression*
Hydrocephalus
Alcohol dependence
What is the single greatest risk factor for cognitive decline?
What abnormal protein is associated with Alzeihmer’s Dz?
Age
Extracellular amyloid beta deposits
What abnormal protein is associated with Lewy Body Dementia?
What abnormal protein is associated with Frontotemoral dementia?
A-synculein
Tau
Macroscopically (on MRI) what are the findings for AD?
How does this differ from Frontotemoral Dementia?
Cortical atrophy leads to compensatory dilation of ventricles
Frontotemporal Dementia is associated with marked atrophy of Temporal and Frontal lobes
Vascular Dementia lacks a uniform set of criteria but what are some findings that are suggestive of the Dx?
Cognitive deficit associated w/ Stroke
Abrupt onset w/ stepwise deterioration
Focal neuro findings on exam c/w stroke
Infarcts on MRI/CT
Alzeihmer’s Dz typically has what early sign?
How does this differ from Frontotemporal Dementia?
Abnormal Short term memory
Speech hesitant
Score of 24-27 on MMSE
Fronto temporal has early Behavioral changes
What is the triad for Normal Pressure Hydrocephalus?
What pseudomentia d/o is most commonly mistaken for dementia?
Cognitive decline
Urinary incontinence/urgency
Gait difficulty
Depression
How is depression Tx?
What are the three inherited forms of Chorea
SSRI/SNRI, CBT, Tx comorbidities
Huntington’s, Wilson’s, Benign hereditary chorea
What is unilateral chorea, with sudden, wild, flail-like movements involving proximal muscle groups?
What word is derived from the Greek word for restless and is abnormal movement w/ slow and writhing movements?
Hemiballismus
Athetosis, if held as prolonged posture is considered dystonia
What are SUSTAINED muscle contractions, frequently causing twisting, & repetitive movements or abnormal postures?
Name a Focal Dystonia?
Name a Generalized Dystonia?
Dystonia
Focal: Torticollis, Blepharospasm
Generalized dystonia: cerebral palsy, acute dystonic reactions
What is involuntary movements of the face and tongue, and very slow in performing voluntary movements?
What drugs can cause Tardive Dyskineisa?
Tardive dyskinesia
Long term Tx w/ antipsychotic drugs (dopamine-receptor blockers), Metoclopramide (reglan)
Define Essential Tremor
Rhythmic oscillatory movement enhanced by emotional stress and gone during sleep
Relieved by meds and alcohol
What are the 4 core Sxs of Restless Leg Syndrome?
What four items can clinically define Parkinson’s Dz?
Urge to move legs w/ or w/out sensations
wWorse w/ rest and at night
Improved w/ activity
Resting tremor
Cogwheel rigidity
Bradykinesia “masked facies”
Gait impairment
What do Pt’s w/ Parkinson’s Dz typically expire from?
What condition is characterized by genetic mutation causing premature apoptosis, atrophy in cerebral cortex and caudate?
Choking, pneumonia, falls
Huntingtons
Characterized by chorea and dementia
What autosomal recessive d/o affects copper metabolism that can cause neurologic manifestations?
What is the classic finding on PE?
Wilson’s Dz
Kayser-Fleisher rings
What unexplained Sxs are consciously produced?
What unexplained Sxs are unconsciously produced?
Factitious d/o (Munchausen’s)
Malingering
Somatoform d/o
Somatization d/o
Hypochondriasis
Conversion d/o- AKA pseudoneurologic syndrome
What are the risk factors for a stroke?
Primary arterial HTN A-Fib Smoking Medical Hx Previous TIA Age
What are the potential c/is for thrombolysis?
BP >185/110 mmHg w/ Tx Bleeding d/o Diathesis (plt <100K, HCT <25%) Head injury/stroke/ hemorrhage (prior 3 months) Surgery- past 14 days GI bleed- past 21 days Recent MI past 3 months
If PT is not a candidate for thromblytic/tPA therapy, what are they given?
How is BP controlled in ischemic strokes?
ASA
Keep BP below 220/120
BB- Esmolol
What is the MOA of Esmolol used in the context of a HTN emergency?
What are the BP goals in a hemorrhagic stroke?
Relaxes vessels and slows HR to improve blood flow and decrease BP
150-22= 140 >220= 160
What is the BP goal for a hemorrhagic stroke w/ subarachnoid hemorrhage?
What meds need to be stopped and what is monitored for?
Keep SBP below 160
Stop all antiplatelet/anti-coag drugs
Use of IV Nicardipine of Esmolo needs monitoring for cerebral hypoperfusion
Which are more common ischemic strokes or hemorrhagic strokes?
What are the three most predictive examination findings for acute ischemic stroke?
80% ischemic
Asymmetric facial paresis
Arm drift/weakness
Dysarthria
What condition is a sudden onset of focal neurologic s/sx that last less than 24 hrs and typically resolve in a single hour?
TIA
After working up a TIA, what is typically out pt Tx?
What is the most common medical cause of SAHs?
Manage HTN w/ ASA, Ticlopidine, Clopidogrel
Ruptured cerebral aneurysm
What is the classic presentation of pts w/ an aneurysmal SAH?
What is the initial study of choice?
Sudden-Onset severe HA “Worst HA of my Life” “Thunderclap HA”
CT w/out contrast
What are relatively compact mass of sinusoidal vessels, typically packed close together?
What are true capillary malformations that often form extensive vascular networks through an otherwise nl brain?
Cavernous angiomas
Telangiectasia
What is the typical course of events for an Epidural Hematoma?
What is the most common cause of an Epidural Hematoma?
Hard blow to head, brief LOC followed by lucid period, when PT is wake/alert. As hematoma expands, PT experiences HA followed by vomiting/lethargy/hemiparesis, may progress to coma
Trauma to the middle meningeal artery
What type of Fx should be suspected in an Epidural Hematoma?
What is the mortality rate of an Epidural Hematoma that is left untreated?
Temporal skull Fx
100% death
Why does a subdural hematoma accumulate slower than an epidural hematoma?
mTBI, AKA concussion has what typical GCS score?
SDH is of venous origin whereas the EDH is arterial
13-15
Do Diffuse Axonal Injuries typically show up on CT?
What is the timeline for post-concussion syndrome?
Severe TIA lesions that contain substantial blood will show on CT, but more commonly, the CT will be negative
Sx for 7-10 days after injury
What is the timeline for For Post concussion d/o?
Know how to measure a GCS on a PT
> 3mon
What are the criterias for pronouncing brain death?
Define the oculocephalic reflex
CNS event compatible w/ dx
Exclude all other potentials
No intoxication/drugs/poisons
Core temp >32C/90F
Doll’s eyes
Assess brainstem function in comatose PT w/ intact brainstem
Head is turned, eyes move toward opposite side
The absence of doll’s eye’s movement in a comatose PT is indicative of ?
What is the next test conducted if Doll’s Eyes are absent?
Lesion of midbrain/pons
Oculovestibular reflex- ice water into EAC. PT w/ intact brainstem= eyes drift TOWARD the irrigated ear
What is the first stage sign of a central herniation?
With which of the herniations can the increased compression of the anterior cerebral arteries may cause the Pt to have leg weakness?
Dec level alertness
Small, reactive pupils
Decorticate posturing
Midposition pupils Decerebate posturing
Transfacial
What are 3 cardinal features of brain death?
Coma/unresponsiveness- no response pain
Absence of brainstem reflexes-
pupils, oculocephalic, gag, grimacing
Apnea- no respiratory attempts even with PCO2 > 60mmHg
Most common form of suppurative CNS infection?
What event greatly improves the Dz outcome?
Meningitis
Early Dx
Most Common cause for Community acquired Meningits?
What is the triad for meningitis that 2/3rds of PTs will have
Streptococcus pneumonia
Fever, HA, nuchal rigidity
What are the special tests for meningitis?
What is the Tx for Viral meningitis?
Kernig’s and Brudzinkski
Primarily symptomatic-
Analgesics, Antipyretics, Antiemetics, Fluids/E+ monitored
What factors associated with meningitis are associated w/ a poor prognosis?
What is the time frame goal for Abx on board for a patient suspected of bacterial meningitis?
Age- old/young Delayed Dx/Tx Stupor/Coma Seizure Focal neurological signs
60min
Most common type of HA & account for more than ½ all HA’s seen in Primary Care
How does this type of HA present?
Tension HA
Bilateral, “Band-like” distribution
Tight pain in frontal/occipital regions
Dizziness is a term that describes a variety of feelings that includes ? 3
What are the 3 categories dizziness is broken down into?
Vertigo, Disequilibrium, Light headed
Pre/Syncope
Vertigo
Miscellaneous
Define Vertigo
Define Disequilibrium
Sense of rotational motion, indicates dysfunction in vestibular system
Describes feeling of uneasiness, about to fall and associated w/ an abnormal gait
What are the two criteria that can lead to a syncope?
What are the 5 categories of causes of syncope?
Dec blood or O2 to the brain
Vasovagal (neurally mediated) Posture/OHOTN Reflex (Carotid, Situational, Glossopharyngeal) CV d/o Cerebrovascular d/o
Vasovagal syncope is the result of what two events?
Define Vasodepressory syndrome
SNS withdrawal= dilation
Inc PNS- bradycardia
Associated w/ only sympathetic w/drawal
What is AKA the “common faint”
What are the 4 main S/Sxs
Vasovagal/neurally mediated syncope
Diaphoresis, Diuretic, Clonic movement, Retained sphincter
What is the physiology behind glossopharyngeal neuralgia
What is unique about these types of syncopes?
Afferent impulse activation in CN8 terminating in nucleus solitarius in the medulla
Less likely to be benign in origin and more likely in elderly PTs
What other neurological issues does glossophyrangeal neuralgia mimic?
What vessels supply the brain stem structures responsible for consciousness?
Trigeminal neuralgia
Vertebrobasilar arteries
Most PTs w/ CV presyncopal Sxs also experience ?
Define Basilar Artery Migraine
Focal neurological ischemia Sxs: weakness, ataxia, diplopia, dysarthria
Rare d/o causing syncope in adolescents
Syncope when PT is sitting/upright means ?
Syncope when PT is laying down means ?
Syncope when PT was exercising means ?
OHOTN
Cardiac event or seizure
CV etiology
What test is the first one conducted when working a PT up for syncope?
Head up tilt table test w/ Isoproterenol infusion
If PT had a prodromal light headedness prior to passing out suggests ?
If they had aura Sxs or have postical state, this suggests ?
If PT is clearly thinking upon recovery suggests ?
Syncope
Seizure
Faint
Vertigo can be associated with what 4 S/Sxs?
Vertigo can arise from an issue in what 3 systems?
Impulsion
Oscillopsia
N/V
Gait ataxia
Vestibular, Visual, Somatosensory
What is vertigo most commonly caused by?
What must it be differentiated from?
Asymmetry/imbalance between R/L vestibular systems
Central and Peripheral causes
How does Weber and Rinne tests appear on PE w/ PTs what have vertigo
Unilateral conduction
W: hears vibration in Dz ear
R: no AC after BC
Unilateral partial nerve deafness:
W: Vibrations in normal ear
R: hears AC after BC is gone
What are the 3 types of nystagmus?
What can cause physiologic vertigo?
Pendulum Saccade (fast), Pursuit (slow)
Intersensory mismatch- car sickness
Unfamiliar movements- sea sickness
Unusual head/neck position
Post-spinning
What can cause pathological vertigo?
Vestibular dysfunction- most common
Lesion on stabilizing sensory systems
Visual vertigo
Peripheral neuropathy/myelopathy
What are the difference in Sxs of Peripheral and Central vertigo?
Peripheral= short, movement dependent, horizontal, nystagmus
Central= long, not movement dependent, vertical or horizontal nystagmus
What are the peripheral vertigo causing d/os?
What are the central vertigo causing d/os?
BP MAG
BPPV, Peripheral vestibulopathy, Meniere’s, Acoustic Neuroma, Gentamycin toxicity
Wernicke’s CAMIS
Intoxication, Wenicke’s, MS, Alchoholic cerebellar degeneration, TIA/stroke, Cerebellar ataxias
What are the characteristics of peripheral vertigo d/os?
What are the 7 types of vertigo?
Lesion outside of brain
Sudden, lasting days w/ intense Sxs
Exacerbated by movement
Distress but no neuro PE findings
Vestibular neuronitis, Labrynthitis/Concussion, Meniere’s, Perilymph fistula, Bening positional, Cervical, Vestibular migraine
What is seen on PE of Vestibular Neuronitis in the acute phase?
How is it Tx?
Nystagmus and absent response to caloric testing
Supportive
Diazepam, Meclizine, Vestibular therapy
Refer to ENT
How is Labyrinthitis Tx?
What is the most common cause of vertigo after a concussion?
ABX if febrile/sign of infection
Diazepam, Meclizine
Labyrinthine Concussion Traumatic Vertigo
What type of injury is Labyrinthine Concussion Traumatic Vertigo associated with?
This form of vertigo can also result from ?
Basilar skull fracture causing vertigo, deafness in affected ear
Cupulolithiasis- causes episodic position vertigo
How is Labyrinthine Concussion Traumatic Vertigo Tx?
What is the relation to deafness and vertigo in Meniere’s?
Supportive, Vestibular suppressant/therapy
Deafness gets worse vertigo gets better
All Meniere’s suspected PTs get what work up?
What inner ear issue can be seen in PTs w/ BPPV?
Audiometry
Vestibular tests
MRI
Otolithic crystals made of calcium carbonate in semi-circular canals
What Sx is always present in BPPV?
How are Sxs reproduced on PE?
Positional nystamus
Dix-Hallspike Test/Barany Maneuver
How is BPPV relieved?
What causes cervical vertigo?
Epley reposition maneuver
Meclizine
Valium
Scopolomine patch
Neck hyperextension or DJD
How is Cervical vertigo Tx?
How does vestibular migraine present and what is it temporarily related to?
Neck exercises, collar, muscle relaxers
Episodic vertigo w/ temporary HA
Vestibular Migraine has a similar presentation to ?
How is it Tx?
Meniere’s
Migraine Tx/prophylaxis
Diet change
Anti-emetics
What vestibular orders last the least to the longest w/ auditory Sxs?
Seconds- perilymphatic fistula
Hrs- Meniere’s, Syphillis
Days- Labrynthitis/Labyrinthine concussion
Months- acoustic neuroma, ototoxicity
What vestibular orders last the least to the longest w/ NO auditory Sxs?
Seconds- Positional vertigo/Cupulolisthiasis, Certebrobasilar insufficiency, Cervical
Hrs- recurrent vestibulopathy, vestibular migraine
Days- vestibular neuronitits
Months- MS, cerebellar degeneration
Central d/os causing vertigo are lesions located where?
What other S/Sxs do they present w/
Cerebellum Pons
Ataxia, Nystagmus
What are the 6 common causes of central vertigo?
Vertebrobasilar ischemia/insufficiency Vertebrobasilar TIA/stroke Acoustic neuroma Toxic vestibulopathies MS Neurodegeneration involving vestibulocerebellum
What vessel is involved by TIA that causes central vertigo?
What 3 underlying conditions must be r/o when working a PT up for central vertigo?
Medial branch of PICA
Anemia, Pregnancy, Glucose derangement
What is the preferred imaging modality for suspected central vertigo?
How is Wernicke’s Tx?
How is MS flare up Tx?
MRI
Thiamine replacement
Prednisone burst
What are the S/Sxs of an Acoustic Neuroma
These types of tumors account for 80% of ? tumors
Tinnitus, HA, Vertigo, Facial weakness
Unilateral sensorineural hearing loss
Cerebellopontine angle tumors
Acoustic neruomas are made of ? cells that form ?
What is the preferred imaging for these?
Uniform spindle cells
Palisades called Verocay bodies
MRI w/ contrast
How are acoustic neuromas Tx?
What 4 drugs can cause toxic vestibulopathies?
Sxs, non-compressible and <3cm- stereotactic radio surgery via Gamma knife
Gentamycin
Salicylates
Quinine
Cis-platinum
Balance is maintained by what 3 senses?
Loss of consciousness occurs when ?
Vision, Proprioception, Vestibular
Function of both cerebral hemispheres or brain stem RAS are compromised
What are the 3 major causes of LoC?
Define seizure and how it is defined
Seizure, Syncope, damage to RAS
Shift in normal balance of excitation and inhibition
Defined by area of brain that’s involved
Define Ictus
Define Provoked Seizure
Seizure
Seizure in otherwise healthy brain from altered levels of glucose, Na, drugs
What types of injuries have high likelihoods of suffering from chronic seizures?
What are the 2 key features of a seizure?
Penetrating head wound
Blasts
Aura, Postictal confusion
What are 5 causes of seizures that can occur to anyone?
Hypoglycemia Hyonatremia Hyperosmolar Hypocalcemia Uremia
What benefit do EEGs have?
EEGs are conducted under what conditions?
Confirm seizures if positive but don’t rule them out if negative
Physiologic stress- sleep deprivation
What imaging is better for seizure exploration?
Characteristics of Focal Seizures w/out Dyscognitive features?
MRI
No LoC
Aura/smell
Body jerking
Characteristics of Focal Seizures w/ Dyscognitive features?
Loss of awareness, repetitive movements, smacking, shouting
Olfactory hallucinations or deja vu are common and originate from the temporal love
What are the 3 phases and events of a Tonic Clonic/Grand mal seizure?
What type of seizure is considered normal in it’s physiologic form?
Tonic- opisthotonus, apnea, tongue biting
Clonic- sphincter relaxation
Recovery- postictal confusion, HA, fatigue
Myoclonic- when falling asleep
What is the first step and mainstay of seizure Tx?
When is lab monitoring needed
Fist- classify correctly
Mainstay- medication
CBC and LFTs 2wks, 1mon, 3mon, 6mon, Q6mon
All anti-convuslant meds can lead to ?
What derm issue can arise?
Hematologic/Hepatic toxicity
Stevens-Johnson syndrome
What meds are used for acute seizure management?
What meds are used for absence seizure management?
Carbamazepine, Phenytoin, Valproic acid
Valproic acid, Ethosuximide (s/e=bone marrow suppression)
What meds are used for focal seizure management?
Lamotrigine Carbamazepine Oxcarbazepine Phenytoin Levetiracetam
What are the first line agents used for Tonic-Clonic seizures?
Status epilepticus are a medical emergency due to the potential fo the development of what 3 things?
Lamotrigine
Valproic acid
Cardiorespiratory dysfunction
Hyperthermia
Metabolic derangement
What labs and studies are done during Status Epilepticus work up?
What drugs are used for medical therapy of Status epilepticus?
ABG, CBC, E+, Glucose, BUN, Creatinine, Ca/Mg, Toxicology, Anticonvulsant levels, ECG, LP
Lorazepam/Diazepam
Phenytoin w/ ECG monitoring
Fosphenytoin
Referral to neurology is needed if seizures aren’t controlled by meds within ?
If first line drugs achieve partial control fo seizures, what drugs can be added for better control?
3mon
Topiramate, Zonisamide, Lacosamide, Tigabine
Confusion can be broken down into what 3 issues?
Define Dysarthria
Delirium
Dementia
Amnestic d/o
D/o of articulation
Define Aphasia
Define Global Aphasia
Inability to produce or comprehend language
Global- fluency, repetition, comprehension impaired w/ possible R hemiparesis from lesion in L hemisphere
Define Conduction Aphasia
Define Transcortical Motor Aphasia
Fluency and Comprehension is preserved, Repetition, naming and writing impaired
Fluency impaired
Repetition, Comprehension preserved
Lesion near Brocas causing R hemiparesis
Define Transcortical Sensory Aphasia
Define Subcortical Aphasia
Fluency and Repetition preserved
Comprehension impaired
Lesion in Wernickes
Repetition preserved
Fluency, comprehension variable
Hypophonia from lesion in left basal ganglia or thalamus
Define Psychogenic Amnesia
Define Organic amnesia
Can’t remember emotional events
Can remember facts and events
Can’t remember objective facts
Define Retrograde amnesia
Define Anterograde amnesia
Loss of memory for events immediately prior to d/o
Inability to store retain or recall knowledge
An acutely confused PT will have impaired ? and inability to ?
A demented PT has a normal ? but problems with ?
Attention
Learn new material
Normal attention span
Recent memory
Executive function is mental activities involved in what 3 things?
What is this also considered as?
Planning, Initiating and regulating behavior
Central organization function of the brain
What is the “ I WATCH DEATH” acronym for causes of delirium and dementia
Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia
Deficiencies Endocrinopathies Acute vascular Toxins Heavy metals
How does an acutely confused PT w/ alcohol intoxication present?
How long does it take for alcohol withdrawal to begin?
Nystagmus, dysarthria, limb and gait ataxia
5-10hrs- tremor, tachy, HTN
Day 2- seizure
Day 3-5- DTs
What drugs are used during alcohol withdrawals?
How does B12 deficiency induced confusion present?
Benzos and Atenolol
Confusion to dementia or psychosis
What is the most common cause of Wenicke’s Encephalopathy?
What is the triad?
Thiamine deficiency
Ophthalmoplegia/Nystagmus, Gait ataxia, Global confusion
All PTs w/ undiagnosed AMS< oculomotor d/os or ataxis should receive?
What learning deficit can occur in Wernicke’s?
Thiamine and glucose
Korsakoff psychosis
What type of cognitive impairement interferes w/ daily life?
What does this type of impairment usually turn into?
Mild cognitive impairment
Frank dementia
What are the risk factors for developing Frank Dementia Alzheihmers type?
Memorry deficit 1.5 SD from norm
Apolipoprotein E4 allele
Small hippocampal volume
What are the 4 types of dementia and the abnormal protein associated with each?
Which one is the most common cause of dimentia?
AD- AB42
Fronto Temporal- Tau
Lewy body- A-syncuclein
Prion d/o- CJacob Dz
AD
What macro and micro changes are seen in AD?
Define Anosognsia
Macro- cortical atrophy
Micro- AB42 plaques, tangles in cytoplasm and amyloid accumulation in vessels
Lack of insight
Pathology of AD is localized to what three structures?
What are the key findings?
Hippocampus
Lateral termporal cortex
Lateral septum (nucleus basalis of meynert)
Neuritic plaques (not seen on MRI) Nerofibrillary tangles
What will be seen on MRI/CT in late AD while PT is alive?
What test is useful to confirm Dx in an otherwise demented PT?
Enlarge ventricles
Widened sulci
Hippocampal atrophy
Apo E genetic test
What meds are used in AD Tx?
Donepezil
Rivastigmine
Galantamine
NMDA antagonist- Memantine- mod/sev AD, expensive, GI s/e
What are the two types of Vascular Dementia
What is the first Sx noticed in Dementia w/ Lewy Bodies?
Multi infarct and
Diffuse white matter make up a quarter of cases
Parkinsonian Sxs
Delirium response to L-Dopa
Visual hallucinations
What is seen on imaging in PTs w/ normal pressure hydrocephalus?
How is it treated?
Large lateral ventricles w/ little or no cortical atrophy
Shunt
Where is damage seen in B1 deficiency dementia?
What are the roles of the basal ganglia?
Thalamus and midline structures
Central processing center involved in movement, cognition, emotion and learning
What 3 chemicals are involved in feedback loops?
What causes resting tremors?
Dopamine, glutamate, GABA
Idiopathic
Parkinsons
What causes postural tremors
What causes action potentials
Physiologic tremor
Cerebellar outflow tract dysfunction
Tremors can be described and categorized as what 3?
What is Chorea mean in Greek?
Resting
Postural
Action
Dance
Define milkmaide grasp and dancing gait
Milkmaid- intermittent grip relaxation
Irregular, unsteady gait causing PT to suddenly dip/lurch to tone side
Hemiballismus is most often due to ?
How is it Tx?
Vascular Dz in contralateral subthalamic nucleus
Dopamine depletion/blocking
Pallidotomy in severe cases
What causes dystonia to go away and become worse?
What are the 3 types of focal dystonia?
Absent during sleep
Worse w/ voluntary movement
Torticollis
Blepharospasm
Writer’s cramp
What are the 2 types of generalized dystonia?
Myoclonus are classified into what 4 categories?
Cerebral palsy
Acute dystonic reaction
Generalized
Focal
Mutlifocal
Segmental
Pathological myoclonus are associated with ?
Define Coprolalia
Define Echolalia
Hypoxemia
Tic of profanity
Tic of repetition
Who was Dr Mort Doran
Define Parkinsonian tremor
Surgeon w/ Tourettes who had no tic when performing surgery, usually disappears during sleep
4-6Hz tremor usually at rest in hand/foot
Inc w/ stress, improved w/ activity
Define Cerebellar Tremor
Define Rubral of Holmes
Slow tremor of extremity usually at the end of a purposeful movement
Combo of rest, action and postural tremors associated w/ Cerebellar tremors
Psychogenic tremors are usually associated with ?
Define Orthostatic tremor
Conversion s/o
Psych issues
High frequency rhythmic contraction after standing, decreases w/ sitting, walking or lifting extremity off ground
What type of tremor can follow excessive exercise or sleep deprivation
When is this a common finding
Physiologic tremor
Alcoholics/drug abusers during withdrawal
Thyrotoxicosis/poisoning
How are physiologic tremors treated?
Withdrawal of offending agent and BBs
What causes half of essential tremors?
What causes these to worsen and improve?
Involuntary 6-10hz oscillation movement worse w/ activity due to ETM1/ETM2 gene mutation w/ dominant transmission
Worse w/ caffeine, nicotine or fatigue
Better w/ alcohol
How are essential tremors treated?
Propanolol Gab/Pregablain Benzos High frequency thalamic stimulation Surgery
What drugs can cause dystonic reactions?
Antipsychotic Phenothiazine anti-emetics Cocaine/LSD TCAs Lithium Anticonvulsants
How are acute cases of dystonia treated?
What causes primary restless leg syndrome?
Diphenhydramines
Baclofen
Genetics
What can cause secondary restless leg syndrome?
TCAs/SSRIs Hypoglycemia Opiate withdrawal Pregnancy Animea Ferritin deficiency Renal failure Peripheral neuropathy
How are the different stages of restless leg syndrome treated?
mild- sleep hygiene Mod-sev= dopamine agonist (Pramipexole, Ropinirole) Opiates Gabapentin Analgesics
What mental issues are often assicated with the autosomal dominant Gilles de la Tourette Syndrome?
What meds can be used for Tx?
OCD and ADD
Halopreidol Pimozide Clonidine Flupheazine Botulism Toxin A
What are the 4 causes of Parkinsonism?
Neuroleptic drug exposure
Cerebrovascular dz
MPTP
Von Economos Dz (encephalitis lethargica)
Pathology of Parkinson’s shows damage in what area?
How are Sxs revealed?
Substantia nigra
No dopamine allows increased amounts of GABA output
What are the presenting Sxs of Parkinson’s Dz?
Define the festinating gait?
OH LOOK TRAP Tremor Rigidity Akinesia Postural instability
PT has to walk quicker to prevent from falling over
How is Parinson’s Dx’d?
How are the different types treated?
Clinic basis only
Dopamine- bradykinesis and rigidity (Carbidopa/Levodopa)
Anti-Ach- rigidity, tremor (Benztropine)
Dopamine agonist- young PTs or mild cases (Pramipexole, Ropinirole)
Amantadine- dopamine augment
Neuroprotection w/ Selegeline, Coenzyme Q10
What are the 3 surgical options for parkinsons?
Thalamotomy Pallidotomy Deep brain stimulation of subthalamic nucleus PT Speech therapy
Why do Sxs of Huntingtons Dz become visible?
Autosomal dominant trait causing increased concentration of GABA and ACh in basal ganglia from increased levels of dopamine
What test can be done to assess for Huntington’s Dz?
What will be seen on CT or MRI?
Tongue protrusion
Atrophy of cerebral cortex and caudate nucleus
What meds are used to Tx Huntingtons?
Haloperidol Reserpine SSRIs Benzos Xenazine- inhibits vesicular monoamine transoporter 2
How to PTs w/ Huntingtons usually die?
Infection, Fall related injury, suicide
Define Stiff Person Syndrome
Where does the stiffness begin?
Paraneoplastic- small cell lung/breast cancer
Trunk and legs
What spine issue is seen in Stiff Person Syndrome?
What lab results may be seen since CSF is usually normal?
Hyperlordosis- causes tin man gait
Abs against Glutamic Acid Decarboxylase
How is Stiff Person Syndrome Tx?
Cerebral palsy is a chronic impairment of what 4 things?
GCCs
Baclofen
IVIg and plasma exchange
Tone, Strength, Coordination, Movements
Why does copper accumulate in Wilson’s?
What is the most sensitive screening test?
No conversion to Cerulosplasmin
24hr urine
What Dx is considered if a PT answers “bothered a lot” in 3 or more Sxs on a certain screening questionnaire?
What PT population are pseudoseizures more common in?
Somatoform d/o
Sexual abuse or trauma
What clues suggest pseudoparalysis?
Weakness not following anatomic pattern
Give away weakness
Hysterical gait
Pain stimulation causes withdrawal of numb area
What are Waddell Signs?
Define Pseudocoma?
ID non-organic causes of back pain
PT slumps to floor to prevent hitting head usually w/ observer present
What clinical clues suggest pseudocoma?
Eyes drift up w/ lid openin
Response to pain stimulus
Hand will just miss face w/ drop test
Caloric test causes nystagmus and N/V
Define Pseudotremor
Define Psychogenic Parkinsonism
Abrupt onset, disappears w/ distraction
Hysterical gait
Define psychogenic myoclonus
Define Psychogenic dystonia
Periods of spontaneous remission
Abrupt onset w/ inconsistent exam
Define Pseudoneuro-Ophthalmologic Syndrome
What PE clues can suggest this?
Sudden blindness w/ diplopia being a common complaint
Normal pupil response
Normal optokinetic nystagmus/mirror response
Normal fundoscopic exam
What structures does the anterior/carotid circulation supply?
What does the posterior/vertebro-basilar circulation supply?
Cerebral hemispheres except- medial temporal and portion of occipital lobe
Brainstem
Thalami
Cerebellum
Posterior cerebral hemispheres
How does the brain get blood supplied to it?
Strokes are the second most common ? and most common ?
Internal carotids and vertebral arteries
2nd most common cause of death
Most common disabling neuro d/o
What are the steps of events during a brain herniation?
Midline shift
Down displacement of cranium
Uncus and hippocampus herniate into tentorial notch
Cerebellar tonsils herniate through foramen magnum causing death
Define Neurosis
What structures are involved during an anterior circulation stroke?
Mental d/os involving distress but neither delusion or hallucination
L and R cerebral hemisphere
What structures are involved in a posterior circulation stroke
Lateral medulla Bilateral pontine base Medial tegmentum Cerevellar infarction L/R PCA terriotory Lacunar syndromes
What are the results of L cerebral hemisphere involvement from an anterior stroke?
R hemiparesis R hemisensory loss Aphasia Eye deviation L monocular vision loss
What are the results of R cerebral hemisphere involvement of an anterior stroke?
L hemiparesis L hemisensory Poor drawing/copying Neglect of visual field Eyes deviate to R R monocular vision loss
Stopped on
Lect 9 Slide 72
Epidural hematomas typically present with what 3 S/Sxs?
What type of injury affects ? artery and how does it appear on CT?
Trauma, Progressive coma, Lucid intervals
Middle meningeal artery from temporal skull Fx appearing as convex hyper density brain tissue
What causes subdural hematoma?
What causes the bleeding?
Blow to front or back of head
Hitting windshield
Veins between dura and arachnoid torn
How do subdural hematomas appear on imaging?
What is the most common PT and MOI for young and old individuals?
Crescent shaped hyperintensity between brain and skull
MVA
M>W
Falls
W>M
What’s the definition of TBI?
Alteration in brain function caused by external force characterized by:
Dec/LoC
Loss of memory
Alteration in mental state at time of injury
What type of injury is from Coup/Countercoup injuries?
The mechanisms of this injury causes the body to release what two things?
Cortical contusion causing a TBI causing a disruption of axon transport causing axon swelling
Neurotransmitters
Free radicals
If the brain is ‘slapped against the cranium’ then the PT has a ?
What are the two types of bleeds that can occur?
TBI
Vein= subdural Artery= epidural
What is the most recognized and widely used method for grading TBI severity?
What are the 3 parts to the assessment?
GCS
Eye Voice Motor
How are mild, moderate and severe TBIs scored with GCS?
What type of amnesia is common and bad in TBIs?
Mild= 13-15 AKA Concusion Mod= 9-12 Sev= 3-8
Retrograde- common
Antegrade- bad
What are the worsening signs of a TBI that indicate a bleed?
Diffuse axonal injury is associated with ?
Worsening HA
Focal neuro signs
Worsening confusion
Impaired consciousness
4 or more areas of severe axonal injury from trauma
What is the first imaging choice for diffuse axonal injury?
Post concussion d/o timeline
Post concussion syndrome time line
CT- only shows severe TIA lesions though
7-10days
3mon
Post traumatic seizures and epilepsy are divided into what two stages?
What are the 4 herniation syndromes?
Early- within 1 wk of trauma
Late- after 1wk of injury
General
Central/Transtentorial
Uncal
Subfalcine
What are the 4 components of a General herniation syndrome?
What separates the cranial cavity?
Shift in brain contents
Compression of parenchyma
Compression of ventricles
Comprised cerebral blood flow
Foldings of dura
What separates the two cerebral hemispheres?
What is the most common form of herniation?
Falx
Anterior/Posterior fosae by the tentorium
Central- AKA Transterntorial
What causes Central/Transterntorial herniations?
What are the stages of events?
Cerebral edema
Large intracranial masses
Herniation of diencephalon into tentorial notch Dec LoC, Small pupils Decorticate Mid-position pupils Decerebrate Motionles and death
What are the events of Uncal herniation?
Anterior medial temporal gyrus impacts into anterior portion of tentorial opening causing medial shift in temporal lobe
Hemiparesis
LoC
Ipsilateal hemiplesia/Kernohan’s Phenomenon
What is the first sign of Uncal Herniation?
What causes a transfalcial herniation?
3rd Palsy
Herniation of cingulate gyrus beneath the falx and across midline
What happens to PTs w/ transfalcial herniations as the anterior cerebral arteries are compressed?
What is the midway point between alert and coma?
Leg weakness
Stupor
Stupor may be a sign of injury to the ? or ?
Coma is a ? state that leads to ? or ?
Injury to RAS
Damage to cerebral hemispheres
Transitional
Recovery, vegetable
What’s the difference between Decorticate and Decerebrate posturing?
Same: plantar flexion, knee extension, wrist flexion, upper arm adduction
Decorticate- elbow flexion,
Decerebrate- elbow pronation/extension
What are the initial management steps for PTs with stupor/coma?
Irreversible loss of brain function can be the result of what 2 processes?
IV NS, Thiamine, Naloxone, Dextrose
Hypoxic-ischemic brain
Fulminate hepatic failure
What are the 4 pitfalls of Dx Brain Death?
Can PAs pronounce PTs dead?
Facial trauma
Papillary abnormalities
Toxic levels of drugs
Sleep apnea/pulmonary Dz
Yes in combat but only in remote locations
What documentation must happen if a PA pronounces someone dead?
Etiology and irreversibility of condition
Absence of brain stem
Absence of motor response to pain
Absent respiration w/ PCO2 60mm or more
Confirmatory testing
Repeated neuro exams- 2 apnea tests 6hrs apart
Posterior circulation comprises of what 4 structures?
1/3 of PTs who survive a TIA will have a full stroke within ?
SCA, PICA, AICA, Basilar artery
5yrs
What is the most common cause of brain ischemia?
Brain ischemia/stroke material arises ?
Atherosclerosis commonly effecting large neck vessels and internal carotids
Proximal- most commonly from heart, aorta, ICA, VA
What are the 6 acute HA syndromes?
Glaucoma Hypersensitive encephalopathy Meningitis Encephalitis Drug rebound HA Sinusitis
Define Meningitis
Define Encephalitis
Men- infection of subarachnoid space
Enceph- infection of brain tissue
How can meningitis invade the blood stream?
How is it directly spread?
Bacteremia, Viremia (aseptic meningitis), Fungemia, Parasitemia
Sinusitis
Otitis media
What is the pathognomonic sign of meningeal irritation?
What is the most common form of suppurative CNS infection?
Nuchal rigidity
Bacterial meningitis
What are the top two most common causes of community acquired bacterial meningitis?
What microbe causes recurrent epidemic outbreaks of meningitis every 8-12yrs and what is the characteristic finding of this microbe
Strep pneumo
Niesseria meningitidis
Niersseria meningitidis- purpuric rash that doesn’t blanch w/ pressure
What will lab results on CSF w/ bacterial meningitis show?
What does the loss of sulci mean in meningitis?
PMNs, Dec Glucose, Inc protein and opening press
Edema + pus
What ABX are used for different aged groups of PTs w/ meningitis?
What is the timeframe goal for ABX Tx?
1mon-3mon= Amp + Cefotax/Ceftriax
3mon-55y/o= Vanc + C/C/C
+55y/o alcoholic or Dz= Amp + Ceftriax/ Vanc + Ceftriax
Impaired cellular= Amp + Ceftaz + Vanc
W/in 60min
What 3 steps are taken when bacterial meningitis is suspected?
What are the top two causes of viral meningitis?
Blood cultures, Empiric ABX, Dexamethasone therapy started w/out delay
Enterovirus
Arbovirus
What will lab results of CSF w/ viral meningitis show?
Encephalitis is usually viral in origin and caused by ?
Inc cell count- Pleocytosis
Normal protein, glucose, opening pressure
Herpes, Enterovirus, Arbovirus
What’s the difference between Primary and Secondary Encephalitis
What imaging modality is preferred?
Primary- virus infects spine or brain
Secondary- AKA post-infectious encephalitis, virus infects other body tissues
CT w/out contrast done before LP
What will CSF lab results show for viral encephalitis?
What are two major components for Tx?
Normal protein, glucose
Pos lymphocytes
Head elevation w/ mannitol
Control hyperthermia
What two meds can be given during a PTs withdrawal period to treate rebound HAs?
What med is given prophylactically for coitus HAs?
Sumatriptan or Dihydroergotamine
Indomethacin
What causes Hypertensive Encephalopathy
How is it treated?
Secondary to sudden BP increases
Pheo, Sex or MOA/Tyrosine foods (cheddar cheese)
Anti-hypertensive drugs
What might be seen on imaging in PTs w/ hypertensive encephalopathy?
What are the 3 recurrent HA syndromes?
Posterior white matter changes
Tension, Migraine, Cluster
Tension HAs
Non-throbbing HA after 20y/o from contraction of scalp/neck muscles and can hint underlying depression/anxiety
Most common type of HA, half of HAs seen in clinic
Bilateral band at temporal/occipital lobes
Tx w/ daily stretches as important FIRST step
TCAs, not SSRIs
Migraine HAs
Second most common HA in US w/ F>M predominance
Syndrome of HA, N/V, Neuro Sxs w/ onset at 20-30y/o
Can be w/, w/out aura or complicated
Scotomata- common
Usually in the morning w/ gradual/crescendo onset w/ dull/pulsatile progression
What is the most frequent type of vascular HA?
What is the POUND acronym mean and what is it’s value?
Migraine w/out aura
Pulsatile, Onset (4-72hrs), Unilateral, N/V, Disabling
4/5= 92% probability of migraine
What are the steps of migraine Tx?
What NSAIDs can be used for mild migraines?
1st- NSAID w/ caffeine
2nd= Serotoning agonist: Tryptan, Ergots, DHE
3rd= antiemetic/dopamine blocker: Prochlorperzine, Metoclopromide
Toradol, Naproxen
What meds are used for migraine abortive Tx?
How often can this med be re-administered and where is it c/i?
Selective 5HT agonists- Tryptans at onset of pain
Repeat once after 1-2hrs
C/i in pregnancy, cardiac and cerebrovascular Dz
What is the MOA of Ergotamine?
Where is the use c/i?
Non-selective 5HT agonist, old school constrictor w/ caffeine
Pregnancy, CADz
Why is Metoclopramide used for migraines?
What opioid is used?
Relieves nausea
Butorphanol nasal
What are indications PTs need migraine prophylaxis?
What meds are used?
More than one a week or predictable (menses)
Propanolol, Timadol, CCB, ACEI/ARB
Antidepressant: amitriptyline
Anticonvulsant: valproic acid, topiramate, gabapentin
How are cluster HAs Tx?
What meds can be used for prophylaxis?
100% O2, Sumatriptan, DHE
Prednisone stops cluster attacks
Verapamil, Triptan, DHE
Low Pressure HA
Tear in dura causes low pressure CSF/subarachnoid space
Pain worse upright, better laying down
Tx: Fluids, Caffeine Sodium Benzoate
Idiopathis Intracranial HTN is AKA?
What causes it?
Pseudomotor cerebri
Inc ICP causing HA, Papilledema, Pulsatile tinnitus, Visual loss/diplopia
Pain worse in morning and relieved by sitting up
CN6 Palsy
Tx: LP
How do brain tumors present?
These present as one of what 3 syndromes?
HA w/ pain worse in morning/waking from sleep
Pain worse w/ valsalva/exertion and N/V
Focal neuro deficit
Seizure
Nonfocal neuro d/o (HA, dementia, personality change)
How are brain tumors Dx?
What test needs to be avoided?
CT/MRI w/ contrast
No LPs
What meds are used to Tx post-traumatic HA?
Trigeminal Neuralgia is AKA ?
Analgesic
Amytriptyline, Propanolol, Egot derivatives
Tic Douloureux
How is Trigeminal Neuralgia Tx?
Carbemazepine
Lamotrigene
Phenytoin
Baclofen
How does glossopharyngeal neuralgia present?
How is it Dx?
How is it Tx?
Pain at tongue/tonsil base or auditory meatus
Reproduction of pain
Carbamazepine
What causes the Sxs of a subdural hematoma?
What lab test is done for seizure PTs to tst for syphilis?
Stretch= HA
Inc ICP= contralateral weakness
FTA-Abs for Treponema Pallidum
