Neuro/Ophtho Flashcards
Risk factors for stroke
same as MI: HTN, DM, HLD, and tobacco
MCA stroke presentation
1) contralateral weakness or sensory loss
2) homonymous hemianopsia (loss of visual field on opposite side of the stroke, eyes look towards lesion)
3) aphasia
ACA stroke presentation
1) personality/cognitive defects
2) urinary incontinences
3) leg > arm weakness
PCA stroke presentation
1) ipsilateral sensory loss of face, 9th and 10th CNs
2) contralateral sensory loss
3) limb ataxia
Patient presents less than 3 hours since stroke onset
give them TPA (may give up to 4.5 hours in some places)
Patient presents more than 3 hours since stroke onset
ASA, if already on ASA add dipyridamole OR switch clopid (never give ASA and clopid together)
What does every patient with a stroke get started on?
statin
What score do you use to determine an A fib/flutter patient’s risk of stroke?
CHA2DS2VASc Score CHF HTN >/= 75 DM Stroke/TIA/thromboembolism (h/o...) Vascular disease 65-74 Female
> /= 2 - anticoagulate
If patient with stroke has normal ECG…
place on Holter monitoring to detect arrhythmias (e.g. A fib) with greater sensitivity
What do you do with symptomatic 50%, 70%, and 100% carotid stenosis/occlusion?
70% - endarterectomy
50% / 100% - no endarterectomy
Carotid angioplasty and stenting for stroke patients consensus …
have no proven value
Most common HA
tension headache - dx of exclusion
Migraine triggers include
food, emotions, menses
Cluster HA features
frequent, short duration, high intensity
Pseudotumor cerebri asso with
obesity, venous sinus thrombosis, oral contraceptives, and vitamin A tox
Giant cell arteritis physical exam finding
tenderness of the temporal area
Giant cell arteritis significant lab
elevated ESR
Migraine abortive thx
Ergotamine or triptan
Cluster HA abortive thx
100% O2, prednisone, lithium
Cluster HA ppx
Verapamil
Migraine ppx
Propranolol; give if 3 attacks/month
Trigeminal neuralgia tx
Carbamazepine, oxcarbazepine, last resort: gamma knife surgery
Seizure of unclear etiology is called…
epilepsy
Confusion is to coma and seizure as …
angina is to MI
Status epilepticus tx
1) IV benzo (lorazepam, diazepam)
2) fosphenytoin
3) general anesthesia - give succinylcholine or vecuronium –> intubate –> give propofol or midazolam
4) phenobarbital
Which anti epileptic drug has the cleanest profile?
levetiracetam
Tx of atonic (no LOC; loss of tone) and myoclonic (no LOC, increase in tone) seizures
valproic acid
Standard of care when d/c’ing seizure medication
patient must be seizure free for 2 years, test for possibility of recurrence (e.g. sleep deprivation EEG)
Xanthochromia definition
yellow discoloration in CSF from breakdown of RBCs
Normal ration of WBCs to RBCs
1 to 500/1000
Most accurate test to dx subarachnoid hemorrhage
LP showing blood
Nimodipine use
CCB, prevents subsequent ischemic stroke
Spine disorder that results from B12 def and neurosyphilis
subacute combine degeneration of the cord, leads to loss of position and vibratory sensation
Brown-Sequard syndrome
unilateral hemisection of spinal cord, loss of motor and position/vibratory sense on ipsilateral side right below the lesion, loss of pain/temperature on contralateral side 1-2 segments below lesion
How to distinguish brain abscess from cancer?
biopsy
Empiric tx for brain abscess (while waiting for bx results)
penicillin + metronidazole + ceftriaxone +/- vancomycin
Tuberous sclerosis features
a neurocutaneous disorder
H - Hamartomas of CNS and skin A - Angiofibromas (red nodules on the face) M - Mitral regurg A - Ash leaf spots (hypopigmented) R - cardiac Rhabdomyoma T - Tuberous sclerosis O - autosomal dOminant M - metal retardation A - renal Angiolipoma S - Seizures, Shagreen patches (leathery plaques on trunk)
Tx - control seizures
Neurofibromatosis types I and II
a neurocutaneous disorder
Type I
1) neurofibromas - soft, flesh-colored lesions attached to peripheral nerves
2) cafe au last spots (hyper pigmented)
3) meningiomas and gliomas
Type II
1) bilateral acoustic shwannomas
2) cataract
Sturge-Weber syndrome
portwine stain on face, seizures, CNS deficits (homonymous hemianopsia, mental retardation), glaucoma
Treatment of Parkinson’s (mild vs severe)
Mild:
1) anticholinergics (benztropine, trihexyphenidyl) - relieve tremor/rigidity
2) amantadine - increase release of DA
Severe:
1) dopamine agonists (pramipexole, ropinirole, rotigotine)
2) levodopa/carbidopa - asso w on/off phenomena (episodes of bradykinesia/dyskinesia)
3) COMT inhibitors (tolcapone, entacapone) - prevent peripheral metabolism of L-dopa; extend duration of 2
4) MAO-B inhibitors (rasagiline, selegiline) - block DA metabolism; only drugs with possibility of retarding the progression of Parkinsonism
5) deep brain stimulation
Only drugs with possibility of retarding the progression of Parkinsonism
MAO-B inhibitors (rasagiline, selegiline)
Shy-Drager syndrome
Parkinsonism predominantly with orthostasis
Tx of Restless legs syndrome
DA agonists (pramipexole, ropinirole)
Nucleotide repeat in Huntington’s
CAG, on chromosome 4
Radiologic finding in HD
Head CT or MRI shows caudate nucleus involvement
VMAT inhibitors used to treat dyskinesias
tetrabenazine and reserpine - lower DA versicle packing and release
MS diagnostic tests and findings
MRI - periventricular white matter or plaques
LP - oligoclonal IgG
EMG - evoked potentials
Drugs that prevent relapse and progression of MS
glatiramer, beta-interferon, fingolimod
MRI gadolinium contrast reaction
nephrogenic systemic fibrosis (collegen deposits in soft tissues and fibrotic nodules develop in skin, heart, lung, liver), occurs in renal insufficiency
ALS stands for
amyotrophic lateral sclerosis
ALS features
loss of upper and lower motor neurons, sensory neurons and sphincter function spared
ALS tx
riluzole - reduced glutamate build up in the neurons and may prevent progression of the disease
baclofen for spasticity
CPAP/BiPAP/tracheostomy and maintenance on ventilatory if respiratory difficulties
Charcot Marie Tooth disease
genetic disorder of both motor and sensory innervation, leads to distal weakness and sensory loss, waiting in the legs, pes cavus, decreased DTRs, and tremor
Ulnar nerve damage
wasting of hypothenar eminence
Radial nerve damage
Saturday night palsy, using crutches, wrist drop
Lateral cutaneous nerve of thigh damage
obesity, pregnancy, crossing legs
Tarsal tunnel damage
worse with walking, pain/numbness in ankle and sole of foot
Peroneal nerve damage
high boots, weak dorsiflexion and eversion
Face paralysis (Bell’s vs stroke) and additional features
stroke - spares forehead
Bell’s - patient cannot wrinkle forehead
additional features:
hyperacusis (stapedius muscle)
taste disturbance (chorda tympani - anterior 2/3’s of tongue)
Another name for GBS
GBS = Guillain-Barre Syndrome
aka acute inflammatory polyneuropathy
GBS features
autoimmune damage of peripheral nerves, ascending weakness + loss of reflexes, may include autonomic dysfunction (hypo/hyperTN, tachycardia), leads to respiratory failure
GBS - CSF finding
increased protein, normal cell count
Important test to r/o respiratory involvement in GBS
PFTs - forced vital capacity and peak expiratory pressure - if both are decreased –> impending respiratory failure
Tx of GBS
1) intubate 2) IVIG or plasmapheresis
NEVER STEROIDS
Myasthenia gravis pathophys
antibodies against acetocholine (nicotinic) receptors at the neuromuscular junction, muscles that are used the most fatigue first (extra ocular, mastication)
Myasthenia gravis dx
acetylcholine receptor antibodies > anti-MUSK (muscle specific kinase) > edrophonium
Tx of myasthenia gravis
neostigmine and pyridostigmine, in patient under 60 with thymoma –> thymectomy (curative), in patient over 60 and disease refractory –> steroids or something that suppresses T cell function (azathioprine, tracrolimus, cyclophosphamide, mycophenolate)
Tx of acute myasthenic crisis
IVIG or plasmapheresis
Creutzfeldt-Jacob Disease
rapidly progressive dementia and myoclonus, CSF 14-3-3 protein, EEG periodic sharp wave complex
Personality changes localize to which brain lobe?
frontal lobe
List most common sites of hypertensive hemorrhage in descending order
1) basal ganglia (putamen)
2) cerebellar nuclei
3) thalamus
4) pons
5) cerebral cortex
what are the 3 muscular dystrophies by inheritance and onset?
the x-linked recessives ones: Duchenne (early child) and Becker (child to teen)
the one autosomal recessive: Myotonic (teen to early adult)
features of the x-linked recessive muscular dystrophies
Duchenne - early child onset; progressive weakness, Gower sign, calf pseudohypertrophy; develop scoliosis and cardiomyopathy; death from respiratory failure by 30
Becker - child to teen; mild Duchenne; develop cardiomyopathy; death from HF by 50
features of autosomal recessive muscular dystrophy
Myotonic - teen to early adult onset; facial weakness, hand grip myotonia, dysphagia; develop arrhythmias, cataracts, balding and testicular atrophy/infertility; death from respiratory or HF
different head swellings in newborn
Cephalohematoma - subperiosteal hemorrhage; does not cross suture lines; no skin discoloration
Caput succedaneum - hematoma superficial to periosteum; crosses suture lines
Subgaleal hemorrhage - blood between periosteum and aponeurosis d/t shearing fo emissary veins (connect extracranial veins with intracranial venous sinuses) during delivery; fluctuant, crosses suture lines
workup for febrile seizure
none; if longer than 5 mins –> abort
CN III palsy causes
ischemia/DM –> inner somatic fiber ischemia –> down and out gaze
compression –> outer parasympathetic fiber compromise –> impaired pupillary light reaction
hypokalemia presentation and ECG findings
weakness, fatigue, muscle cramps; severe: paralysis and arrhythmias (U waves, flat and broad T waves, PVCs)
early personality and behavioral changes (disinhibition, apathy), compulsive behaviors (hoarding, hyperorality), and executive dysfunction; memory deficits later
frontotemporal dementia
open angle glaucoma
more common in African Americans, usually asx, high intraocular pressure, cupping of optic disc with loss of peripheral vision, initial mgmt with timolol eye drops, if continues to get worse, do trabeculo-plasty/-ectomy
angle closure glaucoma
sudden osent blurred vision, severe pain, N/V, on exam: red eye with hazy cornea and fixed, dilated pupil
situational syncope
is a form of reflex or neurally mediated syncope associated with specific triggers (micturition, defecation, cough); these triggers cause an alteration in the autonomic response and can precipitate a predominant cardioinhibitory, vasodepressor, or mixed response
