Neuro Lecture 3 Flashcards
what will an EEG tell you?
What type of epilepsy you have
List the 3 main types of intracranial aneurysms
saccular aneurysm
fusiform aneurysm
Microaneurysms (Charcot-Bouchard)
what type of aneurysms is almost always a result of an inherited weakness?
Saccular aneurysm
What are some conditions that cause saccular aneurysms?
Polycystic kidney disease Marfan syndrome Neurofibromatosis type I Tuberous sclerosis complex Connective tissue diseases
What’s an important questions to ask if someone has a saccular aneurysms?
Has anyone else in your family had an aneurysm?
What are some risks for a saccular aneurysm?
Cocaine/ amphetamine use heavy ETOH use tobacco use HTN obesity
Are saccular aneurysms more common in males or females?
females
are saccular aneurysms common in children?
No, they are rare
Where do saccular aneurysms usually occur?
Circle of Willis
Is it common for patients with saccular aneurysms to have more than one?
Yes, 1/4 will have more than one
What are some signs of “warning leaks” of a saccular aneurysm?
Headaches
dizziness
eye pain and visual deficits
When blood hits the gray matter of the brain what can happen?
Seizures
what type hemorrhage usually happens with the rupture of saccular aneurysms?
Subarachnoid hemorrhage
What occurs when a saccular aneurysm ruptures?
Thunderclap headache
mental status, visual changes
N/V/ stiff neck, photophobia
If the rupture of a saccular aneurysm fatal?
Yes, 60% of people die
What are fusiform aneurysms usually associated with?
HTN and atherosclerosis
Where is the most common location of a fusiform aneurysm?
Basilar artery
second- internal carotid artery
Which rupture more often, fusiform or saccular aneurysms?
Saccular
what can happen with fusiform aneurysms usually by trauma?
Dissection
What is aneurysms of small blood vessels. Usually occur in basal ganglia and grey/white matter junction of the brain
Micro aneurysms
What parts of the eye are parts of the CNS?
Retina, optic nerves
who get microaneursyms?
chronic HTN
coccaine
diabetics
When intracranial aneurysms rupture, what happens?
Focal intraparnechymal hemorrhage
get a focal neurologic deficit
how are most aneurysms found?
Incidentally usually
On a CSF sample, what will you get in the sample with an aneurysm.
Protein will be elevated, will have blood in the sample
How do you test if it was a “dirty tap” or blood in the CSF?
collect 3 samples, if the first has most in it then it was a dirty tap
what do you do for the emergency treatment of a aneurysm rupture?
Breathing support
Reduction of ICP
What are three ways to treat an intracranial aneurysm?
Clipping
Coiling
Stenting
list the four types of intracranial hemorrhages?
Epidural
Subdural
Subarahnoid
Intracerebral
what 2 intracranial hemorrhages are called stroke?
subarachnoid
intracerebral
Bleeding between the dura mater and the skull?
Often due to trauma, frequently fracture
Epidural hemorrhage
what type of hemorrhage may have a lucid period followed by rapid onset of symptoms.
Epidural hemorrhage
What are some signs of an epidural hemorrhage?
Ipsilateral fixed and dilated pupil (CN III)
contralateral weakness, hemianopsia
There is a risk of what type of herniation with epidural hemorrhage?
uncal herniation
What shape will an epidural hemorrhage look like on a CT/ MRI?
Lens shaped
How do you treat epidural hemorrhages?
Burr hole
craniotomy
trepanning
Is prognosis good or bad for a epidural hemorrhage when the patient has a Glasgow Coma Score of 3?
Good prognosis
What is bruised brain tissue?
Concussion
Bleeding between the dura mater and the arachnoid mater
Subdural hemorrhage
what is more fatal, subdural hemorrhage or epidural?
subdural
what does a subdural hemorrhage look like on a CT/ MRI?
crescent-shaped
list the three types of subdural hemorrhage?
acute
subactue
chronic
List some possible symptoms of SDH?
LOC at event, lucid period sedation headache N/V ipsilateral weakness speech difficulties seizure (blood on grey matter)
who is more likely to have a subdural hemorrhage?
Men> women
50 years of age (increases w/ age)
anticoagulation therapy or coagulopathy
intra-cranial hypotension (ex-Post LP)
What are some risk factors of subdural hemorrhage?
Chronic ETOH use (cerebral atrophy + coagulopathy)
DM
HTN
Arteriosclerosis
What type hemorrhage is a common finding with “shaken” baby syndrome?
subdural hemorrhage
How do you treat subdural hemorrhage?
watchful waiting
trepanning (bedside) or craniotomy
Rebhabilitation
What can you do to the skull when taking it out to keep it perfused?
Put it in the ommentum
Bleeding between the arachnoid mater and the pia mater
subarachnoid hemorrhage
is subarahnoid hemorrhage fatal?
Yes, 40-50% fatal
where does subarahnoid hemorrhage usually occur?
Circle of Willis
What is a good way to visualize a subarachnoid hemorrhage?
CT (hyperdense in the middle)
If the CT is negative and you suspect subarachnoid hemorrhage?
LP with 3 tubes
What is the most common cause of subarachnoid hemorrhage?
rupture of a saccular intracranial aneurysm
How do you treat a subarachnoid hemorrhage?
Stabilize patient address the aneurysm CSF drain if needed for increased ICP calcium channel blocker (vasospasm) Hypertension/hypervolæmia/hæmodilution seizure prophylaxis rehabilitation
If someone has a rupture saccular aneurysm what do you look for?
Look for more saccular aneurysm
How do you keep someone Hypertension/hypervolæmia/hæmodilution?
Pump them up with saline
Bleeding within the brain tissue itself
Intracerebral hemorrhage
2 sub types of intracerebral hemorrhage?
Intraparenchymal (inside brain tissue)
Intraventricular (inside ventricles)
Symptoms of an intracerebralhemorrhage?
Severe headache
Vomiting
Focal neurologic signs
Seizure
What does an intracerebral hemorrhage look like on CT?
A ball
List some risk factors of intracerebral hemorrhage
HTN DM menopause tobacco use ETOH AV malformation rupture aneurysm coagulopathies African American
How do you treat intracerebral hemorrhage?
Stabilize patient/ address underlying problem Surgical removal CSF drain if needed for increase ICP treat inflammation with steroids seizure prophylaxis rehabilitation
What type hemorrhage do you use calcium channel blockers?
subarachnoid hemorrhage
What is permanent CNS damage cause by thrombus, embolus, venous thrombus, systemic hypoperfusion, SAH or ICH?
stroke
What are some stroke symptoms?
imagine not having what different areas of the brain do
headache (hemorrhage stroke)
How do you treat a stroke?
Confirm last known well
Keep O2 >94%, IV isotonic saline is SBP <120
ECG (look for a-fib)
CBC platelets, BMP, INR/PT/aPTT, troponins
Neuro exam
STAT head CT w/o contrast
What do troponins do?
Give a good prognosis, how likely will we get this person rehabed?
If a patient has HTN what should it be brought down to?
<110
If a patient has hypotension what should it be brought up to?
> 120/>80
What is the only FDA-approved pharmacologic therapy for acute ischemic stroke?
Recombinant tissue plasminogen activator (rtPA)
What criteria is used to determine eligibility for rtPA?
NIHSS- National Institutes of Health Stroke Scale
How long within the last known well period can you treat with rtPA?
less than 4.5 hours since LKW
best results within 1.5 hours of LKW
What are some alternatives to rtPA?
thrombectomy
anti-platelet (aspirin) and anticoagulation therapy (heparin/ warfarin)
hemicraniectomy (for ICP)
What is the sequale of stroke?
Disability
mood disorders (depression, anxiety, panic)
sleep disturbances
seizures
What are “mini-strokes” where symptoms resolve w/i 24 hours?
transient ischemic attack
What is the area of at risk tissue around the dead tissue that is damaged but savable?
Peneumbra
If you have a stroke, what are you are you more at risk for?
another stroke
what does the brain tissue look like with a TIA
all penumbra, little necrosis
What are ways to prevent TIAs?
Smoking cessation nutrition (more fruits and veggies, less fat, sodium) moderation of ETOH use regular exercise controlling BP and weight
What can you do for TIA prophylaxis?
Antiplatelet/ anticoagulant meds
talk about preparedness
What is the FAST algorithm?
Face
Arm
Speech
Time
What can you do to look at what is causing a TIA?
carotid duplex- carotid stenosis
EKG (a-fib)
Echo (thrombus in heart)
does blood show in MRI?
Yes, but bone doesn’t show as well
inability to initiate movements?
akinesia
slow movements
bradykinesia
dystonia
involuntary sustained contractions
feeling stuck in a particular position or blocked from moving for a few seconds?
freezing
increased muscle tone
rigidity
inability to sit still
akathesia
lack of muscle coordination
ataxia
slow, writhing movements
athetosis
large involuntary movements
ballismus
small, rapid movements flowing unpredictably from one body part to another
chorea
difficulty with speech articulation
dysarthria
unintentional bilateralization
mirror movements
sudden, brief movement of muscle group
myoclonus
compulsion/ repeated (same word over and over)
tic/ sterotypy
rhythmic alternating movement of flexor/extensor, pronator/supinator, etc.
tremor
what makes a physiologic tremor worse?
stress
fatigue
caffeine
“enhanced physiologic tremor”
what part of the brain is involved in ataxia?
cerebellum
how many people have a physiologic tremor?
all of us
tremor that appears during voluntary movements (kinetic tremor/action tremor)
essential tremor
What makes a essential tremor worse?
physical or emotional stress/ fatigue
when does a essential tremor get more prominent?
with age
Essential tremors follow what genetic pattern?
Autosomal dominant pattern
If you have essential tremor you are more likely to get what?
Parkinson Disease
What causes an essential tremor
abnormality of Purkinje cell synapses in the cerebellum, and/or of cerebello-thalamo-cortical circuits.
(similar problem caused by ETOH)
If it is a real essential tremor, what will make it better?
drinking a bit of ETOH
What makes an essential tremor temporarily worse?
Caffeine
How do you medically treat essential tremor?
Beta blockers (propranolol, nadolol)- gets rid of adrenaline anticonvulsants (PRM, GBP, TPM)
Who is propranolol contraindicated in?
allergic rxn who have an epi-pen
For severe cases of essential tremor what can you do?
Depp brain stimulation (DBS)
Thalamotomy
What is a degenerative neurologic and psychiatric disorder that leads to progressive death of the dopamine-generating cells of substantia nigra in the midbrain?
Parkinson’s Disease
What are the main motor symptoms of Parkinsonism?
Resting tremor
Cogwheel (or lead-pipe) rigidity
Bradykinesia
other motor symptoms
Is parkinson’s disease present in sleep?
No
What is very common symptom of Parkinson’s Disease?
Pill-rolling and voice changes
What is cogwheel rigidity a combination of?
Tremor and rigidity
What is lead pip-rigidity?
Arm feels like a lead pipe
Patients without tremor
asymmetric, descending
If bradykinesia for parkinson’s disease equal for tasks?
No, it is unequal
Ex- can ride a bike but unable to walk
may be able to walk backward not forward
what is difficulty initiating and executing movement?
Bradykinesia
what is rapid shuffling common in PD?
festination
What is typical posture with PD?
Flexed posture (elbows, wrists, knees, hips, spine)
What are some PD symptoms?
festination flexed posture dysarthria masked facies micrographia (write very small) dysequilibrium/falls
What are some neuropsychiatric symptoms of PD?
Cognitive disturbances (executive, attn., memory)
Mood disturbances (anxiety, depression, apathy)
Impulse control (hypersexuality, gambling…)
Dementia (2-6× risk)
Psychosis (usually iatrogenic)
Is brain imaging helpful with PD?
Usually unremarkable early on
What are some PD+ disorders?
Progressive supranuclear palsy Multiple system atrophy Corticobasal degeneration Pick Disease (Alzheimer Disease)
Do people with PD+ have a irregular resting tremor at onset?
No, not usually but have additional symptoms and typically poor response to dopaminergic meds
Treatment for PD
Levodopa
only 5-10% crosses BBB
What can peripheral dopamine cause?
Dyskinesias
naseau
stiffness
What are some drugs you can do with levo-dopa to reduce the peripheral metabolization of levodopa. Don’t cross the BBB
Carbidopa
Benaserazide
What is a drug that reduces the metabolization of dopamine that is used w/ carbidopa/ benaserazide.
Entacapone
WHat can levodopa cause?
Dopamine dysregualtion syndrome
What is dopamine dysregulation s yndrome
Compulsive use of the medication
“Punding”- compulsive fascination w/ assembling/disassembling, sorting collection
what can happen with long term use of levodopa
Get “on-off” states not related to dosing/ formulation
delay use of levodopa as much as possible and keep doses low to help prevent this from happening
what causes iatrogenic dyskinesias?
Levo-dopa
it is constant movement
what are some psychiatric effects of dopamine (from levodopa)?
confusion, agitation, hallucinations, , irritability, panic, paranoid delusions, mental depression, dementia, mania, and psychosis
What can dose reduction or withdrawal of levodopa lead to?
neuroleptic malignant-like syndrome
What is an alternative to levodopa? Consists of selegiline and rasagiline. Makes it so receptors don’t break down dopamine.
Monoamine oxidase B (MAO-B) inhibitors
What are 2 other PD treatments that are more invasive?
Deep Brain Stimulation (DBS)- stimulate places that tend to release dopamien (thalamus, globus pallsidus or subthalamic nucleus)
Pallidotomy- surgical destruction of the globus pallidus to control dyskinesias
how does PD progress
gets worse as it goes along but doesn’t necessarily kill you
when is the most common onset of PD?
60 years
higher risk with pesticide/insecticide exposure
(well water, grow up on farm, exposure to agent orange)
What can help prevent Parkinson’s DIsease.
Caffeine intake
NSAID use
Tobacco use
Disease that involves Initially restlessness, small unintentional movements, poor coordination, saccadic eye movements. Dominant inheritance pattern.
Huntington’s Chorea
what are some main symptoms of HD?
ataxia
dysarthria
dysphagia
unstable gait
what are some psychiatric syndromes of HD?
mood disorders cognition (executive function) Obsessions and compulsions psychosis dementia
where is huntington protein highly concentrated?
nerves and testes
What are some physical symptoms of HD?
testicular atrophy
muscle atrophy, osteoprossis, weight loss
impaired glucose tolerance
cardiac failure
What is the typical onset of HD?
35-44 years
onset earlier with successive generations
CAG is a CAt who’s a _______ for ______ with a really long tail.
Glutton
glutamine
Huntington’s disease is a ____ repeat sequence?
CAG on chromosome 4
What type of HD has chorea briefly, it at all. rigidity is the dominant symptom and seizures are common.
Juvenile HD
What does a MRI of HD show?
atrophy of caudate nuclei or may be unremarkable
What drug can be given for chorea?
Tetrabenazine
neuroleptics and benzos may be helpful
Lifespan of HD is usually ____ years post diagnosis.
20 years
An acute cognitive impaired with onset w/i a matter of hours / days. Usually fluctuates in intesity and will have attentional deficits. Confusion and decreased awareness/ orientation.
Delirium
What will you find in delirium but not dementia?
Onset within a matter of days/ hours
Usually fluctuates
Attentional deficitis
what are some causes of delirium
Dehydration Hypothyroidism Hypercalcemia Chronic liver and kidney disease Hypoglycemia pernicious anemia folate/ thiamine deficiency
what infections can cause delirium?
UTI
pneumonia
skin and abdominal infections
HIV, chronic meningitis, syphillis
what are some toxic causes of delirium?
ETOH/ drug abuse
ETOH/ drug withdrawal
How do you manage delirium?
Identify the causing factors (there may be more than 1)
What is a chronic cognitive impairment. Commonly becomes slowly and steadily progressive. Typically an insidious onset. Hallmarks include memory loss and language dysfunction.
Dementia
Onset before ___ years is considered early onset dementia?
65 years
are awareness and attention typically normal in early stages of dementia?
Yes
What can you do to test for dementia?
MMSE
trailmaking test (connect 1 to 2 to 3 etc)
clock drawing test
questionnaires
full neuropsychometric testing (takes 10 hrs)
what are some useful imagings for dementia?
SPECT and PET are more useful than head CT and MRI
What scan is good at predicting the development of AD within the next 2 years?
PET scan
Progressive dementia associated with tangles and plaques in the gray matter of the brain
Alzheimer Disease
What are the tangles in AD?
aggregates of intraneuronal τ protein
What are plaques in AD?
extracellular deposits of β amyloid
what is often an early sign of AD?
difficultly remembering recent events
Is there currently a treatment for AD?
No- currently no cure, or symptomatic treatment to affect the progression of the disease qWhat can be
What can be helpful for AD?
Acetylcholinesterase inhibitors (mild to moderate disease)
What drug can be helpful in moderate to severe AD?
Memantine (NMDA receptor agonist)
What is the main treatment for AD?
Caregiving
What needs to be provided for the caregiver of someone with AD?
Psychosocial support and cognitive behavioral therapy for the caregiver need to be provided.
