Neuro Review Flashcards
VF losses
Papilledema = peripheral constriction, enlarged blind spot
Optic Neuritis = central scotoma
Fundus ON = normal or swollen
PRES= cortical blindness
Cenral retinal vein occlusion
TIA episodes, if hyperviscous blood
Pizza fundus
Cavernous Sinus Thrombosis
EOM abnormal, from sepsis, neoplasia, hypercoag
Migraine w/ aura risks?
Stroke risk is 2-3X, worse if on OCP or in smokers!
PFO prevalence
25% in general pop, up to 35-50% in unexplained stroke pts
Lateral medullary syndrome
Crossed sensory deficit, palate lack of elevation, no babinski! Vertebral occlusion (PICA 2nd most likely), risk of proximal propagation, so use HEPRIN
Brainstem
crossed sensory/motor w/ cranial nerves
Crossed sensory = lateral, crossed mtor = medial
Consciousness impaired with reticular activating
Cerebellopontine angle
V, VII, VIII (first hearing)
L4-5
Lateral disc herniation = loss of patellar, weak foot dorsiflex + weak knee extension + sensory loss in claf (l4 root)
Medial herniation = L5, food drop and toe raising issue
Cauda equina
From CMV radiculitis
Muscle wasting, weak dorsiflex/plantar flex, absent reflexes, sacral numb/decresed sphincter…asymmetry/multiple roots, only LMN signs! asymmetric, painful w/ early sphincter involvement
C7 radic
Neck/arm pain, triceps weak, absent tricep reflex, hyperreflexic legs- OPERATE
Cervical spondylotic myelopathy
Neck pain to L hand, difficulty w/ balance, hand atrophy, increased leg tone, absent tricep, increased reflexes in LE, babinski, stiff/broad gait!
Dried diisc…cervical level!
Tractopathies
b12, Cu, syphilis @ posterior cord
Polio/WNV at anterior horn
Diabetes
distal small fibers, proximal amyotrophy, mononeuropathies (single and multiplex), pupil sparing 3rd nerve
Diabetic amyotrophy
Pain, msucle wasting, paraspinous muscle involvement, denerved quad
Patellar response/thigh atrophy
Get diabetes under control!!
Femoral neuropathy = nerve infarct w/ pain/numb
Musculocutaneous nerve
Innervates bicep + lateral aspect of volar forearm (wrist to forearm)
Radial nerve issues
Below spiral groove = no tricep involved, difficulty with wrist/finger extention and supination, BR 1+ (Saturday night palsy)
Handcuff neuropathy= bilateral loss of dorsum hand sensation from thumb to dorsal digit II above PIP
CIDP
Elevated protein CSF, NCS velocities slowed, weakness and numbness of legs, 4/5 strength, no pain/temp/vibration, no reflexes
Patholog in the myelin! Can respond to steroids
Complex regional pain syndrome/RDS
1 year following injury, have extensive ecchymosis and swelling, maybe positive bone scan
Give neuropathi pain tx (post trauma, burns, frostbite, immobility)
Try regional symp nerve block (cns and Pns), and sympatholytics (propanol, prazocin, aeds, tca)
Eaton Lambert
Constipation, dry mouth, weight loss, weak hip flex/knee extend, IMPROVES w/ repetitive activity! No reflexes/babinski!
NMJ issue- pre-synaptic disease- hits nicotinic and muscarinicbut not bulbar!
Normal aging
Dimished/absent ankle reflexes, loss of andme gait (arthirits + vibratory), NORMAL
tentorial herniation
unilateral expanding mass at medial edge of temp lobe through tentorial hiatus, as IcP rises, central herniation
subfalcine
brain extends under falx cerebri, h/a and contralat LEG weakness
shift of the septum pellucidum, effacement of the anterior horn of the lateral ventricle, and compression of the anterior cerebral artery against the falx
uncal = lateral transtentorial
uncus into suprasellar cistern, hits cn III, dilated and unreactive pupil, LOC
contralat hemiparesis b/c ipsi cerebral peduncle compression
opposite midbrain pushed against tentorium => kerhnahan’s notch: contralat CST and pupil hit!
LOCALIZE based on pupil, not hemiparesis
central herniation
diencephalon (thal/hypothal) through notch in tentorium,
due to general edema, effacement of the perimesencephalic cisterns and loss of gray- white matter
differentiation
decreasing consciousness, cheyne-stokes breathing, small pupils but dilate
later LOC, decorticate =>decerebrate, w/ fixed midsize pupils and extensor posture
tonsillar
respiratory and cardiac dysfunction
Posterior circulation TIA
basilar artery thrombosis = unresponsive, ocular bobbing, pinpoint reactive pupils, no VO reflex, quadriplege
worse than locked in! yikes
Brain death declaration
Need established cause of COMA
late recoveries of minimally conscious state is usually traumatic (not hypox/ischemic)
Decerebrate posturing means you havve brain stem function (not allowed), but triple flexion/DTRs are from spinal cord and are possible w/ brain death
MRI scan in migraine
Uidentified bright objects
Intra v. Extra-Axial
glioblastoma = intra-axial ring enhancing, heterog, necrotic center meningioma = homog enhancing, durally based, full of calcium (in subgrontal can mess up taste, and give h/a)
Chiari Malformation I
hx of worsening bioccipital headaches when running/coughing/sneeze/bend/lifting
Unsteady on romburg
Associated w/ syrinx (cough headache is bad!- need decompression of p.fossa)
Bacterial meningitis
don’t wait for dx, give tx: dex 10 mg q6X4 days, abx 15 min later, CT, and LP within 4 hours of abx (cipro or rifamp for meningo coverage)
Hypoglycorrachia = cancer
Low sugar + lymphocytic pleocytosis
s. aureus = worst bacterial endocarditis
Tuberculus meningitis treated w/ roids early, thick basilar exudates can => cranial neuropathies. EWWW
ampicillin for listeria (babies and oldies), vanc if staph/drug resistanct, aminoglycos for GNR
VZV in immunocomp
give IV acylcovir!
Drugs/toxins
cholinergic = soman/OP antichol = TCA, urologic, benztropine EPS = metaclopromide (reglan), anti-em, antipsych, VALPROATE Seritonin s = sweaty, flush, myoclonus NMS = rigid NMJ = botulism, M gravis, lambert eaton
Chemotherapy toxicities
PRES!!! periph nerve = vincristine, taxane, plat, thalidomide cerebellar = 5 FU, cytarabine Mening = intrathecal methotrex, ara-c Encephalopathy = ifosfamid Leukoenceph = methotrex
PRES = RPLS
Bilat occiptal abnoramlities, cortically blind, recovery in 24 hours
Bevacizumab (Avastatin) = VEGF inhibitor!
NLP OU (normal pupils!)
Cholinergic toxicity
Diplopia, dysphagia, dysphonia, unsteady gait, flaccid motor paralysis DESCENDING! normal sensory! (from soman gas!)
Benzo withdrawal
Longer half life (except lorazepam), after one week see agitation and seizure
Vs. alcohol withdrawal in 24 hours
NMS
Temp 104, rigid, CK 1500, myoglobinuria, b/c of not enough dopamine!
increased risk of sudden cardiac death, problonged QR interval!
Lithium issues
Nasty tremor, cerebellar toxicity (tx w/ hemodialysis)
Also tremors in neuroleptics, antiemetics, reserpine, SSRI beta ag, theophylline, cafein, roids, thyroid, tracro, cyclo, amphetamines
EPS w/ haloperidol, VALPROATE
Topiramate to quell action tremor
Nortriptylie s/e
Neuropathic pain med might cause urinary retention in diabetic male
Seizure risk
After 1 seizure, 20-30% risk of recurrence! normal EEG tells you nothing! Oh n o! Cocaine association
OCP + drug interactions?
CMZ = potent P450 inducer, increases metabolism of OCP
Oxcz and topamax do it too!
OCP => decreased lamictal levels!
Valproate benefits/bad stuff
Bad = no pregos, no PCOS, maybe infert, anov, teratogenesis
Broad spectrum drug if unclear epilepsy syndrome (also topamax and lamictal), but only valpro can be IV loaded rapidly!
Don’t use keppra unless clear epilepsy syndrome?
Status epilepticus
Stroke, both remote/acute hemorrahge/ischemic = 60% of all status, less common causes = enceph, metabolic derange (hyponat/hypogly)
Absence seizures
Activation of T calcium channels
Ethosuximide!
Cmz, oxcz, phenytoin might precipitate absence status!
Early onset absence = best prognosis, but 33% get GTC in young adult!
REM sleep behavior disorder
Clonzepam = first line, 90% effective
If progress to PD, give Ropinirole and amantadine
Restless legs = different, tx w/ pramipexole /other direct dopamine agonist post iron deficiency
Subclavian steal syndrome
months of weakness in arm/lightheaded w/ exertion, with cool arm and hand, and decreased pulse in that arm
Dx w/ MRA
Cerebral aneurysm
Assoc with Polycystic Kidney Disease, or if 2 + first degree relatives had SAH/aneurysm
Cranipharyngioma
H/a, vom, visual problems, growth issue, bilat temp hemianopia, cystic mass
Need to resect and then give hormone replacement
Alzheimers disease
Inital do cbc, b12, lft, thyroid
Maybe RPR
Ask about depression! No need for PET/SEPCT…might get worse after illness, thats still AD
donepezil + galantamine, TAU proteins are the problem!
Hypothyroid
weight gain, myopathy, low voice
Problem in PD/ALS
PD = alpha synuclein AlS = superoxide dismutase
Frontotemp Dementia
Behavior and lnguage changes, largely speaking in stock phrases, poor word retrieval, but good memory! MRI w/ temporal atrophy (not symmetric is OK!)
Bilateral hippocampal abnormalities
HSV if seems infectious
anti-NMDA paraneoplastic or anti Hu or Ma from lung or testicular tumor…
Do a pet scan to figure out whats up
AVN of hip
Left leg pain/weakness fo rmonths, on prednisone w/ multiple meloma…pain on STANDING means w/ weight baring, think hip MRI!
NFII
less common, with bilateral schwanommas, with Rinne lateralizing to the better side
NPH
memory issue, gait MAGNETIC glued to floor, urinary difficulties
Apathetic to urinary issue/indifference b/c voiding center in brain, has failure to inhibit voiding reflex! Just pees
Ventricular size enlarged (no pleo, and no nigral pathology)
Cushins signs
increasing BP and decreased pulse b/c of raised ICP (maybe epidural hematoma)
Tx = mannitol infusion and emergent operation (no time for dex!)
CADASIL
Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy”) is the most common form of hereditary stroke disorder, and is thought to be caused by mutations of the Notch 3 gene on chromosome 19. The disease belongs to a family of disorders called the Leukodystrophies.
Huntington’s details
CAG on chromo 4p16, maybe asx, children inherit larger expansion
degen of striatal GABA neurons (caudate atrophy)
Delirum tx
reorient, then do quetiapine or haldol
NO lorazepam b/c paradoxical resp depression or oversedation! (only give for withdrawal, pd, or NMS)
Epilepsy tx details
if failed 2 drugs, only 5-10% chance of getting control w/ a third drug
Eval for surgery, best for hippocampally derived seizures
Back pain!
If normal exam and no bowel/bladder problems, just give analgesics
If numbness, incontinece, decreased pp, decreased anal tone, probably Cauda equina!
Delirium tremens
Elevated temp, resting tremor, tachy, disoriented, hallucinating bugs, at 3 days after last drink
Give thiamine
Alcohol hallucinosis is earlier
Slow subdural?
at 2 weeks, papilledema, weak ocular abduction, L babinski, hyperreflex??!
Aduction weakness b/c nonlocal 6th nerve up ICP
Rhabdo
Bilateral leg swelling, inability to move legs, hyperkalemia is possible so treat w/ calcium if EKG changes, check for oliguria/blood in urine
Narcolepsy
w/wout cataplexy, early REM onset at sleep
tx Provigil or Ritalin
Cataplex tx w/ sodium oxybate
Make sure it’s not ictal
Kleine-Levine = different w/ lots of eating and sex and dissociation…?
Sensory ataxia
Poor prioprioception, posterior column or peripheral neuropathy, loss of vib, + Romberg, diffculty with RAM with eyes closed
If rapid onset, think about anti-hu with SCLC
Are there reflexes?
Epilepsy impt facts
Pts who respond well to tx w/ complete control can discontinue (70% kids and 60% adults can stop!)
20% refractory pts should be considered for surg (70% get free, 15-25% get reduced freq)
20% pts w/ epilep have depression with higher suicide rates
2-3X increased mortality, sometimes from SUDEP and status
2x risk of suicide on AEDS (black box)
Women w/ epilepsy lower fertility rates b/c less marriage and less sex steroids on the drugs..AED polytherapy = infert!!! Buproprion lowers seizure threshold, so do others
Acromegaly
Growing patient! ACTH secreting adenoma and Cushin syndrome => weight gain and striae, less libido! No periods!
Prolactin adenomas also => bitemp hemianop (tx galctorrhea = bromocriptime)
Compartment syndrome!
PPPPP, acute sweeling and fracture => risk, with tissue necrosis
Diabetic 3rd nerve
Pain behind eye, hard to keep it open, partial ptosis, PERRLA, diplopia/incomplete elevation/depression of eye!
Spares the pupil!!! microinfarction w/ good prognosis
Paroxetine withdrawal
Irritable, anxious, labile affect, loose associations, vivid dreams
Baclofen withdrawal?!
SEIZURE if dose is greater than 40 mg/day!
Cerebral Venous Sinus Thrombosis
Can look like pseudotumor with small ventricles, LP OP of 300, CSF normal, and papiledema. Compromised venous outflow leads to up ICP! Also headaches, irregular menses and weight gain!
