Neuro/Neurosurg Flashcards
Location of post dural puncture HA
bifrontal or occipital
What is the tx for severe/persistent post dural puncture HA?
epidural blood patch
What is the classical aura associated with migraines?
bilateral homonymous scotoma- bright flashing, crescent-shaped images with jagged edges
Tx for migraines
sumatriptan or dihydroergotamine 9DHE)- 5HT1 receptor agonist
Prophylaxis for migraines
1st line- TCAs and propranolol (most effective); 2nd line- verapamil, valproic acid/topamax, methylsergide
Most common HA
tension
Presentation of temporal arteritis
constitutional symptoms, HA, visual impairment (25-50% b/c ophthalmic artery involved, optic neuritis, amaurosis fugax, blindness), jaw pain when chewing, tenderness over temporal artery with absent temporal pulse, polymyalgia rheumatica (40%)
Tx of temporal arteritis
high-dose prednisone immediately. If visual loss, admit and IV steroids. Do not wait for Bx results. Temporal artery biopsy. If confirmed, Tx 4 weeks then taper and maintain steroids 2-3 years. ESR levels reveal effective Tx.
What is amaurosis Fugax?
Transient monocular blindness caused by temporary lack of blood flow to the retinas. Classically presents in TIA
Signs and symptoms of cluster HA
Unilateral. Excruciating periorbital pain. Begins few hours after pt goes to bed and lasts 30-90min. awakens pt from sleep. Worse with etoh.ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, and eyelid edema
Acute tx of cluster HA
supplemental O2 or sumatriptan
Prophylaxis for cluster HA
verapamil, steroids
Cause of pseudo tumor cerebri
Results from increased resistance to CSF outflow at arachnoid villi
S/Sx of Pseudotumor cerebri
:young obese woman with papilledema without mass, HA, elevated CSF pressure, deteriorating vision, may have slit-like ventricles, normal scan;
H/A worse when lying down
Papilledema: postural visual field problems (when leaning forward)
MCC of SAH overall vs. sporadic
overall- trauma
sporadic= congenital berry/saccular aneurysm rupture
LP findings in SAH
LP diagnostic. LP shows blood in CSF, xanthrochromia (yellow color that results from RBC lysis and is gold standard of diagnosis of SAH).
Diagnosis of SAH
noncontrast CT. If no papilledema, CT negative, and clinical suspicion high, do LP. LP diagnostic. LP shows blood in CSF, xanthrochromia (yellow color that results from RBC lysis and is gold standard of diagnosis of SAH).
➢ Once SAH diagnosed, order cerebral angiography.
Tx of SAH
surgery – clipping. Medical – bed rest, stool softeners, analgesia, IV fluids, HTN – lower gradually, nifedipine (ca channel blocker) for vasospasm which lowers incidence of cerebral infarction by 1/3rd
MCC of viral encephalitis
Herpes
EEG findings of viral meningitis
slow wave activity
CSF findings in bacterial meningitis vs viral
•Bacterial Meningitis
➢ CSF: ↑ protein, PMN predominate, ↓ glucose, ↑ opening pressure
Viral meningitis
➢ CSF: ↑ lymphocytes, slight ↑ protein, normal glucose and opening pressure
Acute Bacterial Meningitis- neonates
GBS
tx-cefotaxime + ampicillin + vanc
Acute Bacterial Meningitis- children > 3 mo
N. meningitides
tx- cefotaxime + vanc
Acute Bacterial Meningitis- adults
S. pneumoniae
tx- cefotaxime + vanc
Acute Bacterial Meningitis- elderly
S. pneumoniae
tx- cefotaxime + ampicillin + vanc
Acute Bacterial Meningitis- immunocompromised
Listeria monocytogenes
acute bacterial meningitis prophylaxis for close contacts
rifampin or ceftriaxone
Orders needed with acute stroke
Non-contrast CT brain, ECG, CXR, CBC, platelet count, PT, PTT, serum electrolytes, glucose
lateral medullary/Wallenberg findings
✦ Ipsilateral: ataxia, vertigo, cranial nerve weakness (eg, dysarthria, dysphagia, dysphonia, weakness of facial muscles and tongue)
✦ Contralateral: motor weakness (eg, hemiparesis, quadriparesis), homonymous hemianopsia with basilar-PCA lesions
✦ Horner’s
3 Inclusion criteria for tPA
> /= 18 yo
Clinical diagnosis of stroke with NIH stroke scale score < 22
Time of onset of stroke known and is < 3-4.5 hours (defined as completely free of any stroke symptom)
➢ Symptoms of a TIA associated with carotid disease:
o Loss of vision in 1 eye
o Clumsiness or weakness on 1 side of the body
o Problems with speech
➢ Symptoms of a TIA associated with the vertebra-basilar system
o Vision problems affecting both eyes o Vertigo o Ataxia o Diplopia o LOC or temporary amnesia
TIA tx
ASA and antiplatelet medications
Broca’s aphasia
Fluency- nonfluent
Repetition- abnormal
Comprehension- normal
Naming- abnormal
Transcortical motor Aphasia
Fluency- nonfluent
Repetition- good
Comprehension- good
Naming- Abnormal
wernicke’s aphasia
Fluency- fluent
Repetition- abnormal
Comprehension- abnormal
Naming- abnormal
Transcortical sensory aphasia
Fluency- normal
Repetition- normal
Comprehension- abnormal
Naming- abnormal
Conduction apahsia
Fluency-Fluent
Repetition- abnormal
Comprehension- normal
Naming- abnormal
Lhermite phenomenon
seen in MS`– neck flexion produces brief fatiguable electric shock sensations in the spine, legs, or arms
Clinical diagnostic criteria for MS
2 episodes of symptoms and 2 white matter lesions
CSF evaluation in MS
elevated cell count consisting mainly of lymphocytes, elevated myelin basic protein concentration, elevated IgG /oligoclonal bands
MS tx
high dose IV steroids for acute attack., IFN-beta, natalizumab (small risk of PML reactivation) cyclophosphamide, baclofen for spasticity, carbamazepine or gabapentin for neuropathic pain. Daily injections of glatiramer acetate (4 AA-myelin basic protein immunologic decoy).
T/F: sensation is intact with GBS
T
GBS dx
CSF – elevated protein, normal cell count ➢ Cytoalbuminologic dissociation: ↑ CSF protein, nl cell count; NCV-decreased motor nerve conduction velocity
GBS tx
plasma exchange and IVIG
➢ Never give Corticosteroids
pathology in Vit B12 neuropathy
➢ Demyelination in posterior columns, in lateral corticospinal tracts and spinocerebellar tracts
➢ Classic symptom of lead toxicity
foot drop
Most commonly affected area in cervical radiculopathy
C6 and C7
Most commonly affected area in lumbar radiculopathy
L5-S1
Wernicke Encephalopathy: symptoms
ophthalmoplegia, ataxia, global confusion, and nystagmus
Korsakoff Psychosis symptoms
mental status changes, confabulation, and anterograde and retrograde amnesia
Usually irreversible
S/Sx of peripheral vertigo
sudden onset, severe n/v, severe intensity, no associated neuro findings, unilateral nystagmus, positional change has a great effect, pt falls to the same side as the lesion
abnormal sensation of motion that is elicited by certain provocative positions that triggers specific nystagmus
benign paroxysmal peripheral vertigo
BPPV diagnosis
Dix-Hall pike manuever
BPPV tx
watchful waiting, vestibulosuppressant medication, vestibular rehabilitation, canalith repositioning, and surgery
vertigo, nystagmus, hearing loss; attacks last minutes-hours
Meniere’s disease
How does Central Vertigo differ from peripheral vertigo?
other brainstem symptoms are present (weakness, hemiplegia, diplopia, dysphagia, facial numbess); gradual onset, mild intensity, mild n/v, associated neuro findings, mild nystagmus, position change has mild effect, no refractoriness, patient falls to same side as lesion, nystagmus multidirectional and vertical.
causes of central vertigo
- MS
- Cerebrovascular (VBI, TIA, Wallenberg’s)
- migraine-associated vertigo
JME EEG findings
generalized 4- to 6-Hz spike or polyspike and slow wave discharges lasting between 1-20 seconds.When absence seizures are also present, 3-Hz spike and wave activity may be seen in addition to the polyspike and wave pattern. The ictal EEG associated with myoclonic jerks typically reveals 10- to 16-Hz polyspike discharges. These may be preceded by spike and wave activity and often are followed by 1- to 3-Hz slow waves
JME tx
Treat with valproic acid for life
early findings of uncal herniation
➢ Dilation of pupil of ipsilateral eye
➢ Contralateral hemiplegia
➢ May be ipsilateral hemiplegia due to compression of contralateral cerebral peduncle against tentorial notch…Ipsilateral weakness is false localizing sign (due to Kernohan’s notch)
Late findings of uncal herniation
➢ Loss of reflex movements in contralateral eye
➢ Bilateral decerebrate posturing
➢ Central neurogenic hyperventilation
What is the definition of a coma?
Coma = GCS ≤ 8 (4 weeks)
Definition of vegetative state.
It is called a vegetative state when a coma persists past 4 weeks – it is a permanent vegetative state when this state can be confidently established as irreversible. If the state lasts more than 12 months after a head injury or 6 months after another type of insult it is pretty much certain that it is irreversible.
What are the 7 criteria for brain death?
- No pupillary response
- No corneal response
- No vestibulo-ocular response (COWS = cold → opposite; warm → same)
- No motor response in cranial nerve distribution (painful stimulus to glabella)
- No gag response
- No respiratory reaction to hypercapnea
- 2 exams by 2 doctors must be performed to confirm brainstem death
What must be ruled out before declaring brain death?
➢ A metabolic or drug-induced state must be excluded
➢ A neuromuscular blocking agent must be excluded as the cause of loss of motor function
➢ Retesting of brainstem reflexes should be repeated after 24 hours
➢ Hypothermia must be controlled so that the patient’s temperature is >35 C when testing
➢ A specific cause for the coma should be ID’d
➢ Certain spinal reflexes may still be present even in the absence of brainstem function – DTRs, plantar responses, flexion of limbs triggered by neck flexion