Neuro Block 2 Cram Flashcards

1
Q

What age group is associated with Multiple Sensory Defect Dizziness?

What is it AKA ?

What are the 4 parts that contribute to it?

A

Elderly when walking w/ impaired sensation in feet and poor vision

Benign Disequilibrium of Aging

Age, Dec Sensation, Poor vision, Light headed

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2
Q

What is the Tx for Vaso Vagal Syncope?

What classification of dizziness is always associated with positional changes?

A

Supine position w/ feet elevated, conciousness shoult return

Postural/Orthostatic HOTN that causes abrupt decrease of arterial flow

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3
Q

What are some of the underlying causes for Postural or orthostatic hypotension?

Which syncope classification is secondary to increased pressure on carotid sinus baroreceptors?

A

Chronic Dz or Polypharmaceutics

Carotid sinus hypersenstivity, usually found in Men over 50 w/ tight collar

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4
Q

What classification is associated w/ passing out on the commode while defecating?

What Sx is associated w/ VasoVagal Syncope?

A

Situational reflex syncope

Regains consciousness rapidly

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5
Q

What differentiates Vestibular Neuronitis from Labyrinthitis?

Name a common over the counter medication that can cause of Toxic Vestibulopathies?

A

Pure vestibular neuronitis= preserved auditory function Labyrinthitis= syndrome combined w/ unilateral hearing loss from viral origin

ASA

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6
Q

Name a rare cause of reflex syncope associated w/ sharp repetitive pain precipitated by swallowing/chewing?

How is it Tx?

A

Glossopharyngeal Neuralgia

Carbamazepine (anti-epileptic drug)
Med failure= Microvascualar decompression
Rhizotomy of Glossopharyngeal/Vagal fiber

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7
Q

Exercise induced syncope suggests what type of etiology?

What is the triad for Menier’s Dz?

A

Cardiovascular etiology

Unilateral hearing loss, Vertigo, Unilateral tinnitus w/ N/V

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8
Q

What is the treatment plan for Menier’s Dz?

A
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
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9
Q

What causes a Perilymphatic fistula?

How is it Tx?

A

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

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10
Q

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?

A

Benign PPV- brief/sudden episodes of vertigo w/ N/V

Middle aged females

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11
Q

Most Acoustic Neuromas are most commonly found on CN ?

What seizure is commonly found in children characterized by staring and lack of awareness?

A

CN8 in the cerebellopontine angle

Absence Seizure

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12
Q

Focal Seizures WITHOUT Dyscogntive features are characterized by what?

Focal Seizures WITH dyscognitive features are characterized by ?

A

No LOC, possible aura and body movement

Loss of awareness. Motor findings. Seizures involve impaired consciousness, responsiveness, and memory

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13
Q

A situation in which the duration of seizure is greater than how may minutes is status epilepticus?

What is the most common cause?

A

5min

Not taking seizure meds
Metabolic disturbance- low sugar
Drug toxicity
CNS Infection/Tumor
Head trauma
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14
Q

What are the 3 types of memory?

How is Working memory tested?

A

Working
Episodic
Lasting

Less than 30 seconds, so Tested w/ “repeat after me… “Neuro. Number. One”

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15
Q

How is Episodic Memory tested?

What is the time course for Delirium?

A

Word recall after 3-5min or,
Asking trivial events of the day

Acute Onset- acute change in mental status

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16
Q

What is the hallmark description of Delirium?

Wernicke’s Encephalopathy is found in ? PT population?

A

Waxing and Waning LoC

Chronic alcoholics*
PTs w/ malnutrition- emesis, starvation, renal dialysis, CA or AIDS

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17
Q

What are the risk factors for the most common form of dementia?

What are the 3 most common reversible causes of Dementia?

A

Alzeihmers
Age

Depression*
Hydrocephalus
Alcohol dependence

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18
Q

What is the single greatest risk factor for cognitive decline?

What abnormal protein is associated with Alzeihmer’s Dz?

A

Age

Extracellular amyloid beta deposits

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19
Q

What abnormal protein is associated with Lewy Body Dementia?

What abnormal protein is associated with Frontotemoral dementia?

A

A-synculein

Tau

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20
Q

Macroscopically (on MRI) what are the findings for AD?

How does this differ from Frontotemoral Dementia?

A

Cortical atrophy leads to compensatory dilation of ventricles

Frontotemporal Dementia is associated with marked atrophy of Temporal and Frontal lobes

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21
Q

Vascular Dementia lacks a uniform set of criteria but what are some findings that are suggestive of the Dx?

A

Cognitive deficit associated w/ Stroke
Abrupt onset w/ stepwise deterioration
Focal neuro findings on exam c/w stroke
Infarcts on MRI/CT

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22
Q

Alzeihmer’s Dz typically has what early sign?

How does this differ from Frontotemporal Dementia?

A

Abnormal Short term memory
Speech hesitant
Score of 24-27 on MMSE

Fronto temporal has early Behavioral changes

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23
Q

What is the triad for Normal Pressure Hydrocephalus?

What pseudomentia d/o is most commonly mistaken for dementia?

A

Cognitive decline
Urinary incontinence/urgency
Gait difficulty

Depression

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24
Q

How is depression Tx?

What are the three inherited forms of Chorea

A

SSRI/SNRI, CBT, Tx comorbidities

Huntington’s, Wilson’s, Benign hereditary chorea

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25
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
26
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
27
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)
28
Define Essential Tremor
Rhythmic oscillatory movement enhanced by emotional stress and gone during sleep Relieved by meds and alcohol
29
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
30
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
31
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
32
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
33
What are the risk factors for a stroke?
``` Primary arterial HTN A-Fib Smoking Medical Hx Previous TIA Age ```
34
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 ```
35
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
36
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 ```
37
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
38
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
39
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
40
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
41
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
42
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
43
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
44
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
45
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
46
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
47
What is the timeline for For Post concussion d/o? Know how to measure a GCS on a PT
>3mon
48
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 >32*C/90*F Doll's eyes Assess brainstem function in comatose PT w/ intact brainstem Head is turned, eyes move toward opposite side
49
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
50
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
51
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
52
Most common form of suppurative CNS infection? What event greatly improves the Dz outcome?
Meningitis Early Dx
53
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
54
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
55
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
56
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
57
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
58
# 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
59
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 ```
60
Vasovagal syncope is the result of what two events? Define Vasodepressory syndrome
SNS withdrawal= dilation Inc PNS- bradycardia Associated w/ only sympathetic w/drawal
61
What is AKA the "common faint" What are the 4 main S/Sxs
Vasovagal/neurally mediated syncope Diaphoresis, Diuretic, Clonic movement, Retained sphincter
62
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
63
What other neurological issues does glossophyrangeal neuralgia mimic? What vessels supply the brain stem structures responsible for consciousness?
Trigeminal neuralgia Vertebrobasilar arteries
64
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
65
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
66
What test is the first one conducted when working a PT up for syncope?
Head up tilt table test w/ Isoproterenol infusion
67
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
68
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
69
What is vertigo most commonly caused by? What must it be differentiated from?
Asymmetry/imbalance between R/L vestibular systems Central and Peripheral causes
70
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
71
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
72
What can cause pathological vertigo?
Vestibular dysfunction- most common Lesion on stabilizing sensory systems Visual vertigo Peripheral neuropathy/myelopathy
73
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
74
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
75
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
76
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
77
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
78
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
79
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
80
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
81
What Sx is always present in BPPV? How are Sxs reproduced on PE?
Positional nystamus Dix-Hallspike Test/Barany Maneuver
82
How is BPPV relieved? What causes cervical vertigo?
Epley reposition maneuver Meclizine Valium Scopolomine patch Neck hyperextension or DJD
83
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
84
Vestibular Migraine has a similar presentation to ? How is it Tx?
Meniere's Migraine Tx/prophylaxis Diet change Anti-emetics
85
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
86
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
87
Central d/os causing vertigo are lesions located where? What other S/Sxs do they present w/
Cerebellum Pons Ataxia, Nystagmus
88
What are the 6 common causes of central vertigo?
``` Vertebrobasilar ischemia/insufficiency Vertebrobasilar TIA/stroke Acoustic neuroma Toxic vestibulopathies MS Neurodegeneration involving vestibulocerebellum ```
89
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
90
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
91
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
92
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
93
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
94
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
95
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
96
# Define Ictus Define Provoked Seizure
Seizure Seizure in otherwise healthy brain from altered levels of glucose, Na, drugs
97
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
98
What are 5 causes of seizures that can occur to anyone?
``` Hypoglycemia Hyonatremia Hyperosmolar Hypocalcemia Uremia ```
99
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
100
What imaging is better for seizure exploration? Characteristics of Focal Seizures w/out Dyscognitive features?
MRI No LoC Aura/smell Body jerking
101
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
102
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
103
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
104
All anti-convuslant meds can lead to ? What derm issue can arise?
Hematologic/Hepatic toxicity Stevens-Johnson syndrome
105
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)
106
What meds are used for focal seizure management?
``` Lamotrigine Carbamazepine Oxcarbazepine Phenytoin Levetiracetam ```
107
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
108
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
109
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
110
Confusion can be broken down into what 3 issues? Define Dysarthria
Delirium Dementia Amnestic d/o D/o of articulation
111
# 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
112
# 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
113
# 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
114
# Define Psychogenic Amnesia Define Organic amnesia
Can't remember emotional events Can remember facts and events Can't remember objective facts
115
# Define Retrograde amnesia Define Anterograde amnesia
Loss of memory for events immediately prior to d/o Inability to store retain or recall knowledge
116
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
117
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
118
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 ```
119
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
120
What drugs are used during alcohol withdrawals? How does B12 deficiency induced confusion present?
Benzos and Atenolol Confusion to dementia or psychosis
121
What is the most common cause of Wenicke's Encephalopathy? What is the triad?
Thiamine deficiency Ophthalmoplegia/Nystagmus, Gait ataxia, Global confusion
122
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
123
What type of cognitive impairement interferes w/ daily life? What does this type of impairment usually turn into?
Mild cognitive impairment Frank dementia
124
What are the risk factors for developing Frank Dementia Alzheihmers type?
Memorry deficit 1.5 SD from norm Apolipoprotein E4 allele Small hippocampal volume
125
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
126
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
127
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 ```
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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
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What meds are used in AD Tx?
Donepezil Rivastigmine Galantamine NMDA antagonist- Memantine- mod/sev AD, expensive, GI s/e
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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
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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
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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
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What 3 chemicals are involved in feedback loops? What causes resting tremors?
Dopamine, glutamate, GABA Idiopathic Parkinsons
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What causes postural tremors What causes action potentials
Physiologic tremor Cerebellar outflow tract dysfunction
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Tremors can be described and categorized as what 3? What is Chorea mean in Greek?
Resting Postural Action Dance
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Define milkmaide grasp and dancing gait
Milkmaid- intermittent grip relaxation Irregular, unsteady gait causing PT to suddenly dip/lurch to tone side
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Hemiballismus is most often due to ? How is it Tx?
Vascular Dz in contralateral subthalamic nucleus Dopamine depletion/blocking Pallidotomy in severe cases
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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
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What are the 2 types of generalized dystonia? Myoclonus are classified into what 4 categories?
Cerebral palsy Acute dystonic reaction Generalized Focal Mutlifocal Segmental
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Pathological myoclonus are associated with ? Define Coprolalia Define Echolalia
Hypoxemia Tic of profanity Tic of repetition
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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
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# 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
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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
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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
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How are physiologic tremors treated?
Withdrawal of offending agent and BBs
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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
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How are essential tremors treated?
``` Propanolol Gab/Pregablain Benzos High frequency thalamic stimulation Surgery ```
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What drugs can cause dystonic reactions?
``` Antipsychotic Phenothiazine anti-emetics Cocaine/LSD TCAs Lithium Anticonvulsants ```
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How are acute cases of dystonia treated? What causes primary restless leg syndrome?
Diphenhydramines Baclofen Genetics
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What can cause secondary restless leg syndrome?
``` TCAs/SSRIs Hypoglycemia Opiate withdrawal Pregnancy Animea Ferritin deficiency Renal failure Peripheral neuropathy ```
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How are the different stages of restless leg syndrome treated?
``` mild- sleep hygiene Mod-sev= dopamine agonist (Pramipexole, Ropinirole) Opiates Gabapentin Analgesics ```
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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 ```
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What are the 4 causes of Parkinsonism?
Neuroleptic drug exposure Cerebrovascular dz MPTP Von Economos Dz (encephalitis lethargica)
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Pathology of Parkinson's shows damage in what area? How are Sxs revealed?
Substantia nigra No dopamine allows increased amounts of GABA output
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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
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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
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What are the 3 surgical options for parkinsons?
``` Thalamotomy Pallidotomy Deep brain stimulation of subthalamic nucleus PT Speech therapy ```
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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
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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
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What meds are used to Tx Huntingtons?
``` Haloperidol Reserpine SSRIs Benzos Xenazine- inhibits vesicular monoamine transoporter 2 ```
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How to PTs w/ Huntingtons usually die?
Infection, Fall related injury, suicide
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# Define Stiff Person Syndrome Where does the stiffness begin?
Paraneoplastic- small cell lung/breast cancer Trunk and legs
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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
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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
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Why does copper accumulate in Wilson's? What is the most sensitive screening test?
No conversion to Cerulosplasmin 24hr urine
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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
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What clues suggest pseudoparalysis?
Weakness not following anatomic pattern Give away weakness Hysterical gait Pain stimulation causes withdrawal of numb area
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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
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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
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# Define Pseudotremor Define Psychogenic Parkinsonism
Abrupt onset, disappears w/ distraction Hysterical gait
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# Define psychogenic myoclonus Define Psychogenic dystonia
Periods of spontaneous remission Abrupt onset w/ inconsistent exam
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# 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
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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
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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
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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
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# 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
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What structures are involved in a posterior circulation stroke
``` Lateral medulla Bilateral pontine base Medial tegmentum Cerevellar infarction L/R PCA terriotory Lacunar syndromes ```
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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 ```
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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 ```
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Stopped on
Lect 9 Slide 72
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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
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What causes subdural hematoma? What causes the bleeding?
Blow to front or back of head Hitting windshield Veins between dura and arachnoid torn
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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
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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
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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
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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 ```
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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
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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
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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
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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
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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
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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
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What separates the two cerebral hemispheres? What is the most common form of herniation?
Falx Anterior/Posterior fosae by the tentorium Central- AKA Transterntorial
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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 ```
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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
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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
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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
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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
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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
200
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
201
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
202
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
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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
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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
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What are the 6 acute HA syndromes?
``` Glaucoma Hypersensitive encephalopathy Meningitis Encephalitis Drug rebound HA Sinusitis ```
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# Define Meningitis Define Encephalitis
Men- infection of subarachnoid space Enceph- infection of brain tissue
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How can meningitis invade the blood stream? How is it directly spread?
Bacteremia, Viremia (aseptic meningitis), Fungemia, Parasitemia Sinusitis Otitis media
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What is the pathognomonic sign of meningeal irritation? What is the most common form of suppurative CNS infection?
Nuchal rigidity Bacterial meningitis
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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
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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
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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
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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
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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
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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
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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
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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
217
What causes Hypertensive Encephalopathy How is it treated?
Secondary to sudden BP increases Pheo, Sex or MOA/Tyrosine foods (cheddar cheese) Anti-hypertensive drugs
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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
219
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
220
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
221
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
222
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
223
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
224
What is the MOA of Ergotamine? Where is the use c/i?
Non-selective 5HT agonist, old school constrictor w/ caffeine Pregnancy, CADz
225
Why is Metoclopramide used for migraines? What opioid is used?
Relieves nausea Butorphanol nasal
226
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
227
How are cluster HAs Tx? What meds can be used for prophylaxis?
100% O2, Sumatriptan, DHE Prednisone stops cluster attacks Verapamil, Triptan, DHE
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Low Pressure HA
Tear in dura causes low pressure CSF/subarachnoid space Pain worse upright, better laying down Tx: Fluids, Caffeine Sodium Benzoate
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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
230
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)
231
How are brain tumors Dx? What test needs to be avoided?
CT/MRI w/ contrast No LPs
232
What meds are used to Tx post-traumatic HA? Trigeminal Neuralgia is AKA ?
Analgesic Amytriptyline, Propanolol, Egot derivatives Tic Douloureux
233
How is Trigeminal Neuralgia Tx?
Carbemazepine Lamotrigene Phenytoin Baclofen
234
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
235
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