neuro shelf Flashcards
surgical evacuation of subdural hematoma if there is evidence of moderate to severe cognitive impairment, if the subdural hematoma is ≥ ?? mm, or if there is midline shift ≥ ?? mm on brain scan.
there is evidence of moderate to severe cognitive impairment, if the subdural hematoma is ≥ 10 mm, or if there is midline shift ≥ 5 mm on brain scan.
Focal deficits involving the contralateral lower limbs indicate involvement of the superior segment of the motor cortex
which herniation?
Subfalcine herniation is the most common cerebral herniation syndrome and is usually due to cingulate gyrus herniation under the falx cerebri, causing compression of the foramen of Monro (leading to hydrocephalus and consequent headache) and branches of the anterior cerebral artery (causing infarction in the ACA territory and consequent contralateral lower limb weakness).
Degeneration of the ???? is the most common cause of subacute or chronic ataxia in patients with alcohol use disorder (seen in 1% of cases). Cerebellar degeneration in this patient group occurs due to the direct toxic effects of alcohol or as a result of thiamine deficiency.
superior cerebellar vermis
This patient presents with periorbital edema, chemosis, high fever, and dysfunction of CN III (bilateral ptosis) and CN VI (impaired lateral gaze) 2 days after the onset of sinusitis.
septic cavernous sinus thrombosis
Intravenous vancomycin, ceftriaxone, and metronidazole
Antibiotic therapy is the mainstay of treatment
This patient has regained normal mental status after her first simple febrile seizure, what to do next?
discharge
Simple febrile seizure
The most common type of febrile seizure. Typically occurs among children 6 months to 5 years of age and is generalized, lasts less than 15 minutes, and does not recur within 24 hours. Usually followed by a quick return to a normal state without focal neurologic deficits, but confusion may be present for a short period of time.
is the most common cause of death in patients with Friedreich ataxia (FA).
heart failure
girl presents with progressive bilateral limb ataxia and weakness, loss of deep tendon reflexes, pallhypesthesia, dysarthria, and skeletal deformities
Inverted feet, hammer toes, and kyphoscoliosis are all typical skeletal deformities
Friedreich ataxia (FA)
The development of focal weakness after a seizure, which typically resolves within 48 hours. Thought to result from exhaustion of the primary motor cortex.`
Todd’s paralysis
darkening of the red reflex, obscuration of the ocular fundus indicate ???
cataracts
form of sensorineural hearing loss, which is identified by a bilateral positive Rinne test and no lateralization on Weber test. It is a multifactorial process caused by the degeneration of the organ of Corti that gradually develops over the course of years, often identified first by difficulty hearing in crowded spaces
Presbycusis
Alcoholic cerebellar degeneration is caused by the degeneration of Purkinje cells in the cortex of the ????
patients present with signs and symptoms of a midline cerebellar lesion, such as gait ataxia (especially on tandem gait), truncal ataxia, dysmetria predominantly affecting the lower extremities (elicited by the heel-knee-shin test), and gaze-evoked nystagmus
cerebellar vermis
Repeated exposure to sounds above a threshold of 85 dB (e.g., motorcycle) or a single exposure to sounds above 120–155 dB (e.g., gunshots, jet takeoffs) can lead to noise-induced hearing loss
Such hearing loss is slowly progressive and affects ?? frequencies (3–4 kHz) first
high
??? test should be performed in all patients with ALS to screen for >>
bedside swallowing test for dysphagia
ALS is characterized by concomitant upper motor neuron and lower motor neuron dysfunction and can manifest with pseudobulbar palsy and bulbar palsy, both of which result in dysphagia.
movement disorder that is associated with rheumatic fever and manifests with speech disorders, neuropsychiatric symptoms (e.g., agitation, anxiety), and involuntary choreiform movements
Sydenham chorea
symptoms of Sydenham chorea typically occur within 6 months after an infection with ??
S. pyogenes (most commonly pharyngitis)
Sudden, painless, transient monocular loss of vision with discoloration along the retinal arterial supply on fundoscopy is highly suggestive of ???
retinal artery occlusion
The best next step in management for a patient with retinal artery occlusion secondary to atherosclerotic emboli is ??
carotid duplex ultrasonography
?? disturbances are common in the later stages of Alzheimer disease and can result in anxiety and further disruption of patients’ cognitive status
Sleep disturbances
Behavioral and environmental regulation, such as adhering to a regular sleep schedule, maintaining a familiar environment, and removing ambient noise, should always be attempted for patients who are agitated or anxious before resorting to pharmacological treatment
?? tremors worsens under direct observation and diminishes with distraction (e.g., while working on the computer). The condition is often associated with psychiatric disorders (e.g., conversion disorder, anxiety disorder, depression).
quick progression to severe symptoms, significant functional disability, and changing of amplitude, frequency, and/or distribution of movement over time.
functional tremors
a postural tremor that typically affects the hands and head, worsens with voluntary movement and/or an anxious state, and is associated with an otherwise normal neurological examination.
Postural tremor = Tremor that appears when the body part is held in a fixed position against gravity
essential tremor
a coarse hand tremor that is aggravated by goal-directed movements (i.e., increases in frequency during a finger-to-nose tes
intention tremor
which pathogen?? cause nonpurulent conjunctivitis, which manifests with photophobia, pruritus on the periocular area, crusts over the eyelashes, conjunctival injection, redness, and watery discharge from the eye
usually unilateral and often manifests with a vesicular rash and corneal involvement (dendritic keratitis). Additionally, patients with a history of atopic dermatitis are particularly susceptible
Herpes simplex virus (HSV)
?? toxicity manifests with neurological symptoms (altered mental status, dysarthria, decreased muscle strength, coarse tremor).
and gastrointestinal symptoms (nausea, vomiting, diarrhea)
lithium toxicity
can be caused by dehydration (due to severe vomiting and diarrhea for the past 2 days), which predisposes him to acute lithium toxicity.
tx for lithium toxicity
lithium toxicity in patients with an altered mental status, seizures, and/or life-threatening arrhythmias
Hemodialysis
Painless and intermittent otorrhea, hearing loss, and a visible defect of the tympanic membrane in a patient who did not complete antibiotic treatment for acute otitis media (AOM) suggest chronic suppurative otitis media (CSOM)
which TX?
Topical fluoroquinolones, such as ofloxacin, in combination with aural toileting, are the preferred treatment for CSOM
The patient presents with a 5-day history fever and headache followed by the acute onset of altered mental status and focal neurological deficits. In combination with the MRI findings of a temporal hyperintense area (cMRT in T2), these signs and symptoms are highly suggestive of ????
herpes simplex encephalitis (HSE)
an acute or subacute inflammatory myelopathy that results in motor, sensory, and autonomic symptoms below the level of the affected segment
Transverse myelitis
Intermetatarsal neuroma (also called Morton neuroma) is caused by entrapment or enlargement of one of the plantar digital nerves
typically manifests with neuropathic pain in the plantar aspect of the foot that is exacerbated by palpation
which manuever?
Mulder sign
Pain is elicited when pressure is applied to the sole of the foot between the metatarsal heads
first-line abortive treatment for children with migraine.
NSAIDs or acetaminophen
A headache calendar should also be recommended to elucidate environmental triggers of headache (e.g., strenuous exercise, stress, certain food).
While there is no definitive treatment for patients with ALS, ??? can be used to slow down the deterioration of motor function and increase life expectancy by 3–4 months
riluzole
spontaneous, nonbullous subconjunctival hemorrhage (SCH) without other symptoms (e.g., changes in visual acuity, photophobia, eye pain, foreign body sensation) work-up???
reassurance and follow-up
Irritability, poor feeding, vomiting, delayed gross motor milestones, upper motor neuron signs (increased muscle tone and hyperreflexia), macrocephaly, a bulging anterior fontanelle, and an MRI showing symmetrical enlargement of all 4 ventricles indicate a symptomatic ?????
communicating hydrocephalus
tx for symptomatic communicating hydrocephalus in children
A ventriculoperitoneal shunt, which diverts excess CSF from the ventricles to the peritoneal cavity, is the standard of care to decrease intracranial pressure in children with a communicating hydrocephalus
?? is indicated for patients with neurologic deficits from spinal cord compression
neurologic symptoms (decreased leg strength and sensation, hyperreflexia, positive Babinski sign) are concerning for cord compression
IV glucocorticoids (dexamethasone)
Glucocorticoids reduce pain, inflammation, and edema, preventing further neurologic damage until definitive treatment is available (e.g., urgent decompression surgery).
If any alarm symptoms or features (immunocompromise, focal neurological deficits, abnormal level of consciousness, seizure at initial presentation, history of CNS disease) are present for meningitis
what to do?
dminister empiric antibiotic therapy until LP can be performed
**also do CT head first to make sure there is no herniation
a crescent-shaped, concave hematoma that crosses suture lines would be seen on CT scan.
subdural hematoma
which hematoma
epidural hematoma
apidly progressive dementia and myoclonus with associated aphasia and agnosia are suggestive of ??
Creutzfeldt-Jakob disease
???? are usually the first-line drugs for long-term prophylaxis of migraine headaches
Beta-blockers (e.g., propranolol)
Other drugs that may be used for migraine prophylaxis include antiepileptic drugs such as topiramate, sodium valproate, and sodium divalproate, tricyclic antidepressants (e.g., amitriptyline), and calcium channel blockers.
?? is recommended for all patients with a TIA as secondary stroke prevention.
Antiplatelet therapy with aspirin or clopidogrel
A noncontrast CT should be performed beforehand to rule out intracranial hemorrhage. Additional strategies for preventing recurrent TIA or stroke in this patient include lifestyle modifications (e.g., exercise, dietary interventions, and weight loss), optimizing blood pressure control, and initiation of statin therapy.
Symptoms include a cape-like distribution of decreased sensitivity to pain and temperature and flaccid atrophic paralysis in the upper extremities.
syringomyelia
(central cord syndrome, can be secondary to whiplash)
risk of expansion of syringomelia
expansion of the syrinx can damage descending hypothalamic fibers in the T1 to T4 segments, which carry sympathetic fibers from the hypothalamus to the intermediate horn, resulting in central Horner syndrome.
??? autoantibodies are seen in 10–25% of patients with CIDP
Progressive ascending motor and sensory deficits for greater than 2 months are characteristic of chronic inflammatory demyelinating polyneuropathy (CIDP).
Anti-GM1
??? indicated for severe or refractory post lumbar puncture headaches from cerebrospinal fluid (CSF) leak syndrome
epidural blood patch: autologous blood injected at the site of the lumbar puncture seals the hole in the dura and resolves the CSF leak that causes the postural headache.
The risk of hemorrhagic transformation is significantly increased in patients who have received thrombolytic medications (e.g., alteplase), antiplatelet therapy (e.g., aspirin, clopidogrel), and/or thrombosis prophylaxis (e.g., heparin, enoxaparin). Other risk factors for HT include hyperglycemia, hypertension, advanced age, delayed initiation of reperfusion therapy, and ??? infarct size.
large
Hemorrhagic transformation (HT) is a common complication of ischemic stroke and typically manifests with neurologic deterioration (e.g., new confusion, worsening neurological deficits) within ?? hours of the inciting ischemic event.
24–48
typically present with symptoms of hydrocephalus/increased ICP and involvement of the cerebellar vermis such as vomiting, morning headaches, ataxia, and cranial nerve dysfunction.
tumor in children
medulloblastoma is most common malignant in children
Ependymomas are often located in the posterior fossa and may also manifest with signs of hydrocephalus, as well as ataxia and cranial nerve dysfunction. However, these tumors are less common than medulloblastomas, accounting for ∼ 10% of pediatric brain tumors.
asymptomatic patients with relatively small (< 3 mm) linear, nondepressed skull fractures workup?
sent home
which patients require further observation for small linear, non-compressed skull fracture? (4)
- signs of potentially elevated ICP require further inpatient observation
- evidence of traumatic brain injury on imaging (e.g., intracranial hemorrhage)
- signs of physical abuse
- caregivers who are unreliable or unable to return if neurological deficits develop within 24 hours after release.
2 most important risk factors for cerebral palsy
Preterm birth and low birth weight
child has signs of UMN injury (positive ankle clonus, extensor plantar response), persistent Moro reflex, feeding difficulties, and developmental delays (all milestones are delayed except for rolling over, a sign of spasticity), as well as an MRI of the head showing periventricular leukomalacia. These features are all consistent with ???
cerebral palsy
Moro reflex?
Recurrent headaches and visual changes in a young woman with obesity and a history of vitamin A use raise concern for ????
Papilledema and an empty sella on MRI support the diagnosis.
idiopathic intracranial hypertension (IIH)
?? can be caused by axonal disorders (e.g., diabetes, alcohol use disorder, HIV, Charcot-Marie-Tooth disease) or demyelinating diseases (e.g., Guillain-Barré syndrome).
Polyneuropathy
??? is required in patients with myasthenic crisis and signs of impending respiratory failure (e.g., pallor, anxiety, tachycardia, tachypnea, cyanosis)
Early endotracheal intubation
The exacerbation of myasthenic symptoms is commonly triggered by infections (evidenced in this patient by the history of a sore throat, runny nose, and fever), surgery, anesthesia, pregnancy, or certain medications.
?? can cause nonpurulent conjunctivitis, which manifests with photophobia, pruritus on the periocular area, crusts over the eyelashes, conjunctival injection, redness, and watery discharge from the eye
usually unilateral and often manifests with a vesicular rash and corneal involvement (e.g., dendritic keratitis). Additionally, patients with a history of atopic dermatitis are particularly susceptible
Herpes simplex virus (HSV)
??? in combination with aural toileting, are the preferred treatment for chronic suppurative otitis media (CSOM
Painless and intermittent otorrhea, hearing loss, and a visible defect of the tympanic membrane in a patient who did not complete antibiotic treatment for acute otitis media (AOM)
Topical fluoroquinolones, such as ofloxacin,
5-day history fever and headache followed by the acute onset of altered mental status and focal neurological deficits. In combination with the MRI findings of a temporal hyperintense area (cMRT in T2), these signs and symptoms are highly suggestive of ???
herpes simplex encephalitis (HSE).
spontaneous, nonbullous subconjunctival hemorrhage (SCH) without other symptoms (e.g., changes in visual acuity, photophobia, eye pain, foreign body sensation), require what diagnostic workup or treatment??
Spontaneous SCH typically occurs as a result of maneuvers that increase venous pressure in the eyeball (e.g., coughing, straining, heavy lifting, vomiting, Valsalva maneuver).
NONE
Irritability, poor feeding, vomiting, delayed gross motor milestones, upper motor neuron signs (increased muscle tone and hyperreflexia), macrocephaly, a bulging anterior fontanelle, and an MRI showing symmetrical enlargement of all 4 ventricles indicate a symptomatic
communicating hydrocephalus
tx for communicating hydrocephalus
A ventriculoperitoneal shunt, which diverts excess CSF from the ventricles to the peritoneal cavity
Emergent administration of ??? is indicated for patients with neurologic deficits from spinal cord compression
glucocorticoids
?? are usually the first-line drugs for long-term prophylaxis of migraine headaches.
Beta-blockers (e.g., propranolol)
?? is recommended for all patients with a TIA as secondary stroke prevention.
Antiplatelet therapy with aspirin or clopidogrel, lifestyle modifications (e.g., exercise, dietary interventions, and weight loss), optimizing blood pressure control, and initiation of statin therapy.
?? is indicated for severe or refractory post lumbar puncture headaches from cerebrospinal fluid (CSF) leak syndrome
An epidural blood patch
Autologous blood injected at the site of the lumbar puncture seals the hole in the dura and resolves the CSF leak that causes the postural headache. Additional management includes sufficient fluid intake, oral analgesics, and bed rest.
patient’s dilated pupils, labored breathing, speech and swallowing difficulties, and flaccidity suggest a descending paralysis, likely due to ??
botulism
irreversibly inhibiting ACh release from motor endplates in the neuromuscular junction
Botulinum toxins are most often found in home-canned foods and packed meats
Medulloblastoma is the most common malignant brain tumor in children, with a peak incidence between 3–5 years of age. The mass is characteristically located in the ??
cerebellum
The metastasis of a primary central nervous system (CNS) neoplasm inferiorly, typically via cerebrospinal fluid (CSF). Typically presents as nodules along the spine and cauda equina that can cause back pain with neurologic symptoms (e.g., limb weakness). Can be detected by lumbar puncture
spinal drop metastases
A 3-week history of headaches, difficulty sleeping, difficulty concentrating, irritability, and fatigue after a mild traumatic brain injury (mTBI) is consistent with ??
postconcussion syndrome (PCS)
Reassurance and symptomatic therapy are the most appropriate management for patients with PCS
Contact lens use is an important risk factor for bacterial keratitis and is most commonly associated with what pathogen ??
Pseudomonas aeruginosa
A ??? should be performed on all patients following a syncopal episode to rule out cardiac syncope
electrocardiogram (ECG)
Lower extremity radiculopathy that worsens with standing or walking downhill is consistent with ??
lumbar spinal stenosis
In spinal stenosis, different postural changes can widen or narrow the spinal canal and thereby alleviate or worsen symptoms. By leaning forward, the spinal canal is widened and compression of the spinal cord is reduced
Status epilepticus can cause potentially irreversible tissue damage of the CNS, resulting in ??
cortical laminar necrosis (CLN)
seems to be associated with repeated seizures, hypoxia, and hypoglycemia
Following a grand mal seizure, a patient has what acid-base disorder??
postictal lactic acidosis, an anion gap metabolic acidosis that leads to a consequential decrease in serum bicarbonate.
A grand mal seizure is a highly exertional event, during which muscles utilize anaerobic respiration due to inadequate oxygen delivery
chronic ?? deficiency typically present with sensory peripheral neuropathy and hypochromic, microcytic anemia (sideroblastic anemia)
can be result of isoniazid toxicity
pyridoxine (vitamin B6)
?? are the most common cause of acquired hypopituitarism among children.
Craniopharyngiomas
Orbital cellulitis can be distinguished from preseptal cellulitis by the presence of
pain with ocular movements and vision changes
tricyclic antidepressants are generally considered a first-line treatment for postherpetic neuralgia
they are contraindicated in which patients? (give gabapentin instead)
caution in a patient with pre-existing heart disease because they may prolong the QRS and/or QT interval, and thus may lead to arrhythmias.
?? is characterized by sudden, painless loss of vision and an afferent pupillary defect, which manifests with no perception of light in the affected eye and an abnormal swinging flashlight test
Central retinal artery occlusion
The most common organism causing bacterial conjunctivitis in adults is
Staphylococcus aureus, followed by Streptococcal pneumoniae and Haemophilus influenzae. Erythromycin is effective against gram-positive and some gram-negative organisms, making it the empirical antibiotic of choice in patients with bacterial conjunctivitis.
Chronic inflammation and scaling at the eyelid margins associated with eye irritation and visual abnormalities is consistent with a diagnosis of
blepharitis
Warm compresses, lid massage, and gentle lid cleansing are the cornerstones of therapy
Typical symptoms caused by ?? tumors include gait ataxia, truncal ataxia, dysarthria, nystagmus, dysmetria, dysdiadochokinesia, and pronator drift
cerebellar
a rare inherited disorder characterized by the combination of primary brain tumors and colorectal cancer or polyposis.
Turcot syndrome
Mismatch repair cancer syndrome, Turcot syndrome
A rare inherited disorder characterized by the combination of primary brain tumors and colorectal cancer or polyposis. Associated with familial adenomatous polyposis (mostly medulloblastomas) and Lynch syndrome (mostly gliomas).
Once-monthly episodes of nonpulsating, pressing, band-like headache accompanied by a singular autonomic symptom (e.g., phonophobia) and pericranial muscle tenderness lasting 30 minutes to 7 days in conjunction with a normal neurologic examination are characteristic of episodic ????
tension-type headaches (TTHs)
typically starts with a prodrome (fever, headache, malaise) followed by unilateral painful impaired vision with reduced corneal sensation and vesicular skin lesions in the area innervated by the ophthalmic nerve (forehead, bridge, and tip of the nose)
Herpes zoster keratitis
Treatment with ??? is indicated for extracranial carotid artery dissection once a thrombus has been identified and intracranial hemorrhage has been ruled out by CT scan
antithrombotic agents (either anticoagulants such as heparin or antiplatelet drugs)
The presence of severe ipsilateral head and neck pain and partial Horner syndrome (ptosis and miosis) in combination with duplex ultrasonography of the neck showing absent flow in the left internal carotid artery, indicates a ???
carotid artery dissection
type of parasomnia characterized by short (< 60 seconds) dream enactments (e.g., yelling, moving limbs, walking, punching) due to loss of REM sleep atonia, which may lead to injury to self or others
Affected individuals are typically alert and orientated after awakening and remember their dreams.
REM sleep behavior disorder (RBD)
The gradual development of asymmetric lower limb weakness, reduced reflexes in both the knees and ankles, saddle anesthesia, bladder dysfunction, decreased anal tone, and severe back pain with radiation to the lower limb is the classic clinical picture of ??
cauda equina syndrome
what is characteristic of symptoms of Conus medullaris??
Symptoms occur symmetrically
??? in the thoracic spinal cord segments would produce symmetrical lower limb weakness, as well as loss of pain and temperature sensation
Sensation around the buttocks, inner thighs, and genitalia, as well as anal sphincter tone, are classically spared
Central cord syndrome
manifests with symmetrical lower limb weakness and loss of pain and temperature sensations in all areas below the level of the lesion
Anterior spinal cord syndrome
Stroke in this area most commonly manifests with contralateral homonymous hemianopia with macular sparing
The posterior cerebral artery
If the PCA of the nondominant (usually the right) hemisphere is affected, patients may present with
prosopagnosia
because the ??? also supplies the lateral parts of the thalamus, patients with lesions may also report contralateral hemisensory abnormalities such as numbness or paresthesia in the limbs, trunk, and/or chest. Further manifestations include memory deficits, vertigo, and nausea.
posterior cerebral artery (PCA)
If the PCA of the dominant (usually the left) hemisphere is affected, patients may also present with ???
alexia without agraphia, anomic aphasia, and/or visual agnosia due to ischemic damage to the splenium of the corpus callosum, which carries visual information from the visual cortex to the Broca area and Wernicke area
vision loss in the right halves of the visual field (nasal field on the left and temporal field on the right), which is consistent with right-sided ???
This finding suggests the involvement of the visual pathways behind the optical chiasma.
homonymous hemianopia
Bilateral periorbital ecchymosis (“raccoon eyes”) is a classic sign of which fracture?
basilar skull fracture involving the anterior cranial fossa
This man has blood-tinged fluid draining from his nose after trauma that shows a halo sign (rapidly expanding clear ring of fluid surrounding blood), indicating ??
the most likely explanation is a basilar skull fracture of the anterior cranial fossa.
CSF rhinorrhea
The presence of soft drusen near the macula is consistent with
age-related macular degeneration (AMD)
Wet vs nonexudative age-related macular degeneration
Exudative AMD (wet AMD) makes up 10% of cases and is associated with retinal neovascularization, retinal hemorrhage, and/or loss of vision that progresses more rapidly
Nonexudative AMD (dry AMD) is the most common type of AMD and leads to a slowly progressive central or pericentral loss of vision.
Timely drainage of a larger (≥ 2 cm) auricular hematomas < 7 days prevents the formation of a ???
cauliflower ear
which medication for essential tremors can cause acute intermittent porphyria:
elevated urinary levels of aminolevulinic acid and porphobilinogen and 5 P’s of AIP: Painful abdomen, Polyneuropathy, Psychologic disturbances, Purple pee, Precipitated by triggers (like drugs).
Barbiturates (like primidone) trigger acute intermittent porphyria by inducing synthesis of cytochrome P-450 enzymes that contain heme components, thereby reducing heme levels and leading to stimulation of δ-aminolevulinate synthase, which leads to increased levels and accumulation of δ-aminolevulinate and porphobilinogen
folate vs. Vit B12
folate: increased homocysteine levels, and normal methylmalonic acid levels
nystagmus is not typically seen in vitamin B12 deficiency, and levels of both homocysteine and methylmalonic acid would be increased
Headache that worsens when leaning forward, engorged veins over the anterior chest, and swelling limited to the head, neck, and upper extremities are consistent with
superior vena cava (SVC) syndrome
SVC syndrome is most commonly caused by
lung cancer (usually small cell lung cancer or squamous cell carcinoma) or non-Hodgkin lymphoma (particularly in younger patients)
which antipsych meds cause metabolic syndrome?
olanzapine and clozapine
donepezil and galantamine considered first line for?
Alzheimer disease
Also rivastigmine
Acetylcholinesterase inhibitors promote an increase of acetylcholine concentration on the synaptic gap and have been shown to improve cognition and the ability to perform everyday activities.
?? is appropriate additional therapy for patients with moderate to severe AD, which is defined as an MMSE score ≤ 18/30.
Memantine
An NMDA receptor antagonist used to treat moderate to severe dementia. Although the mechanism of action is unclear, memantine is thought to be neuroprotective. Glutamate agonizes NMDA receptors in certain neurons linked to memory in the hippocampus; excessive stimulation of these neurons may lead to damage (i.e., excitotoxicity). By blocking NMDA receptors, memantine may prevent excitotoxicity.
33-year-old female patient presents with acute, unilateral color blindness, a decrease in visual acuity, and pain with eye movements, all of which are consistent with ???
optic neuritis, which is often the first manifestation of multiple sclerosis (MS)
bilateral buttock pain with walking that is relieved by sitting and leaning forward suggests ??
spinal stenosis
tx for phantom limb pain?
gabapentin
multimodal approach is typically recommended, including mirror therapy, transcutaneous electrical nerve stimulation, NMDA receptor antagonists
combination of acute nausea, imbalance, and vertigo is concerning for acute vestibular syndrome (AVS)
The Head Impulse, Nystagmus, and Test of Skew (HINTS) exam is used to differentiate between central and peripheral causes of AVS. This patient’s negative head impulse test and vertical nystagmus are consistent with a ?? cause of AVS.
central
can be caused by cerebrovascular accident, a stroke affecting the cerebellum or brainstem
or demyelinating diseases of the CNS
common peroneal neuropathy presents with a foot drop (high stepping gait, weakness of foot dorsiflexion) and numbness in the distribution of both the superficial and deep peroneal nerves (dorsum of the foot and first web space, respectively)
foot eversion or inversion?
normal foot inversion because the primary muscle responsible for foot inversion (tibialis posterior) is not innervated by the peroneal nerve
superficial branch of the peroneal nerve controls foot eversion
A tremor that worsens as the hand reaches for an object (intention tremor) and overshooting of the target (hypermetria) indicate a lesion where?
cerebellar dysfunction
most likely cause of cerebellar dysfunction in a woman in her 40s is multiple sclerosis
sudden onset of flaccid paralysis and respiratory failure in a logger from Washington is highly suggestive of
tick paralysis
a neurotoxin produced in the tick’s salivary gland prevents acetylcholine release at the neuromuscular junction. Symptoms typically occur within 2–7 days. Patients present with very rapid ascending paralysis (over 24–48 hours) and ataxia, though mental status remains intact. The treatment simply consists of removing the tick and administering supportive measures (e.g., assisted breathing).
palpitations, dizziness, chest pain, dyspnea, syncopes, and urinary urgency together with the ECG findings (narrow QRS complex with no discernible P waves) suggest ?
paroxysmal supraventricular tachycardia (PSVT)
most commonly caused by atrioventricular nodal reentrant tachycardia (AVNRT) - AV node with slow and fast pathway
management of cervical fracture that is complicated by altered mental status with respiratory insufficiency (respiratory rate of 8/min) ??
Rapid sequence intubation
Cervical fractures may lead to immediate or delayed cervical spinal cord compression and/or phrenic nerve paralysis and subsequent respiratory failure
High doses of dexamethasone in pituitary vs. ectopic source of increased ACTH
dexamethasone sends a negative feedback response to the brain to decrease ACTH production. Since the pituitary is receptive to negative feedback loops but ectopic foci are resistant to negative feedback, cortisol levels will decrease to < 50% of baseline following high doses of dexamethasone if the patient has Cushing disease, but will be relatively unchanged in ectopic ACTH production.
Approx. 25% of patients on lithium develop which neuro sx?
symmetric, nonprogressive, fine (approx. 10 Hz) postural tremor in the distal ends of the upper extremities
Patient with Down syndrome presents with ataxia, quadriparesis, hyperreflexia, and vertebrobasilar symptoms (vertigo, diplopia). These symptoms suggest ??
atlantoaxial instability
tx: Surgical fusion of C1 (atlas) and C2 (axis) stabilizes the upper vertebrae
which drugs increase lithium toxicity?
ACE inhibitors, such as enalapril, cause vasodilation of the efferent arterioles and a subsequent decrease in GFR, which can lead to renal impairment. Lithium has a narrow therapeutic window, and any cause of renal impairment (e.g., chronic kidney disease, NSAID use) or volume depletion (e.g., due to diuretic therapy, cardiovascular disease) can precipitate lithium toxicity.
what are features of lithium toxicity? (4)
myoclonic seizures, altered mental status, coarse tremors, and neuromuscular excitability.
In older patients with MDD, cognitive deficits may resemble ??
dementia (i.e., pseudodementia)
teratogenic effects of valproic acid?
Inhibition of folate absorption in the mother due to valproic acid intake leads to an increased risk of neural tube defects such as spina bifida in the embryo, which may require lower spinal surgery after birth
Critically ill patients with an intact gastrointestinal tract can receive what kind of nutrition??
short-term enteral feeding via nasogastric tube (e.g., less than 3 weeks) if there are no contraindications. Enteral feeding is preferred over parenteral nutrition because it stimulates intestinal motility and prevents atrophy of the GI tract
first-line treatments for all prolactinomas
Dopamine receptor agonists such as cabergoline or bromocriptine
Dopamine agonists usually also induce regression of tumor size, thereby improving symptoms due to mass effect such as headaches or bitemporal hemianopsia.
how does hyperglycemia effevt vision?
. Hyperglycemia with subsequent osmotic diuresis affects visual acuity, most probably due to swelling of the lens.
Diarrhea, Urination, Miosis/Muscle weakness, Bronchospasm, Bradycardia, Emesis, Lacrimation, Lethargy, Salivation, and Sweating should raise concern for ??
cholinergic crisis (DUMBBELLSS)
organophosphate poisoning
tx: atropine; anticholinergic agent that competitively blocks muscarinic acetylcholine receptors
preferred imaging modality for TIA bc it shows even small ischemic changes within 30 minutes after onset (while a CT scan shows changes only after 6–24 hours) and can differentiate acute from chronic lesions
Diffusion-weighted MRI of the brain
neurologic abnormalities (likely TIA or stroke, confusion), fever, impaired renal function (increased BUN and creatinine), microangiopathic hemolytic anemia (decreased hemoglobin, elevated LDH and indirect bilirubin, schistocytes), and thrombocytopenia (platelets < 150,000/mm3)
thrombotic thrombocytopenic purpura (TTP)
A CD4 count < 200 cells/mm3 indicates AIDS. The MRI shows a confluent, hyperintense area of asymmetrical shape that mainly involves the right frontoparietal white matter without any mass effect. In conjunction with the progressive onset of focal neurological deficits, these findings suggest ???
Progressive multifocal leukoencephalopathy
PML is a demyelinating disease of the CNS caused by the reactivation of JC virus and is mainly seen in patients with severe immunosuppression (e.g., AIDS)
Rupture of small penetrating artery vs. saccular aneurysm
A noncontrast CT scan of the head characteristically shows a solitary hyperdense lesion surrounded by hypodense edema (most commonly within the basal ganglia or internal capsule) for small artery
saccular: a noncontrast CT scan of the head would characteristically show focal or diffuse hyperdensity within the subarachnoid space.
Cushing’s triad (hypertension, bradycardia, and irregular respiration) as a result of ??? due to traumatic brain injury (TBI).
increased intracranial pressure (ICP)
response to Cushing’s triad and increased intracranial pressure (ICP)
Elevated ICP leads to a decrease in cerebral perfusion pressure (CPP). The sympathetic nervous system is activated in this situation to increase mean arterial pressure to maintain CPP
spinal shock includes flaccid, areflexic paralysis, bradycardia, and absent ??reflex.
bulbocavernosus
Management of spinal cord injuries in an emergency setting involves obtaining vital signs, airway stabilization, immobilization of the neck and body, a thorough neurological examination, and ???
insertion of a urinary catheter
To prevent bladder distension, acute urinary retention (AUR), and eventual bladder rupture
Although ALS is primarily diagnosed clinically, patients with progressively worsening features of UMN and LMN degeneration should undergo ??? to confirm the diagnosis.
electromyography (EMG)
EMG findings in ALS include spontaneous fasciculation potentials, which reflect the random firing of denervated motor units, and fibrillations and positive sharp wave potentials, which reflect the activity of denervated muscle fibers at rest.
Livedo reticularis and peripheral edema occur as adverse effects in up to 5% of patients who take this medication for Parkinson’s
levido retic = reddish-blue discoloration of the skin in a reticular (net-like) pattern
amantadine
which test first when suspecting acute meningitis??
CT scan of the head before lumbar puncture (LP) is indicated in patients presenting with typical signs of acute meningitis accompanied by signs of increased intracranial pressure or a mass lesion (e.g., altered mental status). The primary goal of obtaining neuroimaging before LP is to mitigate the risk of brain herniation, which can be precipitated by the transient decrease in intracranial pressure caused by LP.
indications for performing a head CT prior to LP in patients with suspected meningitis are summarized in the mnemonic ???
“FAILS:” Focal neurological deficit, Altered mental status, Immunocompromised/ICP elevated, Lesion in the brain or skin near LP site, new-onset Seizures.
Ear pain, otorrhea, hearing loss, and granulation tissue in the external auditory canal are consistent with ??
malignant otitis externa
?? patients are at the greatest risk for developing malignant otitis externa.
Elderly diabetic
??? is a complication of TBI that is thought to be caused by the loss of inhibition of the sympathetic nervous system due to cortical injury.
It usually manifests about one week after the inciting event with recurrent episodes of hypertension, tachycardia, tachypnea, fever, diaphoresis, muscle spasms, and possibly dystonia with posturing.
Paroxysmal sympathetic hyperactivity (PSH)
Nieman Picks vs. Tay-Sachs main sx difference
NP has hePATomegaly
next step for suspected brain abscess (Headache, vomiting, and a focal neurologic deficit (abducens nerve palsy), increased intracranial pressure (ICP)
MRI brain
intraparenchymal lesion with a central hypointense (T1-weighted) or hyperintense (T2-weighted), purulent center and a peripheral ring will be visible
This patient’s presentation with apparent inattentiveness and difficulty following directions when directly spoken to, delayed language development (at 4 years, he should be able to speak in at least 4-word sentences), mispronunciation of words (due to poor speech discrimination), and symptoms of frustration (apparently unprovoked episodes of crying and screaming) warrants a thorough evaluation for ???
hearing impairment: in children can cause delays in speech, language, and cognitive development
Episodes of proximal muscle weakness and hyporeflexia with concomitant ECG findings of hypokalemia are consistent with ??
hypokalemic periodic paralysis (hypoKPP)
ECG: T wave flattening and inversion, prominent U waves, a prolonged PR interval, and ST segment depress
excessive daytime sleepiness, cataplexy (tilting of the head and jaw dropping), hypnagogic hallucinations, and sleep paralysis which condition?
tx?
narcolepsy
modafinil
? is used to differentiate neuropathic (e.g., carpal tunnel syndrome, Guillain-Barré syndrome) from myopathic muscle weakness (e.g., polyomyositis (PM), muscular dystrophy); results are abnormal in approx. 90% of patients with PM. If
Electromyography (EMG)
repeated episodes of painful neck stiffness after administration of haloperidol are suggestive of ??
acute dystonia
tx: benzotropine
focal seizure with impaired awareness is the main presenting feature of which epilepsy?
temporal lobe epilepsy
Focal seizures are caused by structural changes or damage to the brain (e.g., encephalitis, developmental disorders) and originate in the temporal lobe of one brain hemisphere
?? is the strongest predisposing factor for both ischemic and hemorrhagic stroke.
Hypertension
first-line disease-modifying drugs for ??? include glatiramer acetate, dimethyl fumarate, teriflunomide, and fingolimod.
relapsing-remitting MS
*also interferon-beta is one of the drugs
??? has been shown to improve both survival and quality of life in patients with a single brain metastasis.
Surgical resection
delayed development, autistic behavior, long and narrow face with a prominent chin, protruding ears, and above average head circumference indicate
fragile X syndrome
*commonly have mitral valve prolapse
Chest pain, diaphoresis, agitation, elevated temperature, tachycardia, hypertension, and mydriasis suggest the use of stimulants (e.g., amphetamine, cocaine)
tx ??
benzodiazepines such as lorazepam
Neuroleptic malignant syndrome (NMS) is a condition most commonly associated with which drug use??
It presents with altered mental status, fever (often > 39°C/102.2°F), diaphoresis, muscle rigidity, and tachycardia
antipsychotics like haloperidol
first line therapy for restless leg syndrome
gabapentin: alpha-2-delta calcium channel ligands (e.g., gabapentin) are considered first-line pharmacotherapy for RLS
Pharmacotherapy is reserved for severe cases of primary RLS (i.e., symptoms result in functional impairment and sleep disturbance) and patients who do not respond to behavioral interventions (e.g., sleep hygiene, leg massage) or the attempted correction of any iron deficiency (in the case of secondary RLS)
??? and ??? are used as a first-line treatment for painful diabetic neuropathy. The SNRIs duloxetine and venlafaxine can also be used as first-line treatment but are relatively contraindicated for patients already taking a serotonergic agent, such as tramadol, because of the associated risk of serotonin syndrome.
gabapentin and pregabalin
?? is the first-line treatment for the acute management of severe migraine in pregnant patients
Acetaminophen
triptans have vasoconstrictive effect on uteroplacental vessels and increased uterotonic activity, both of which can contribute to fetal growth retardation and intrauterine fetal demise.
Lateral cerebral ventricle enlargement (in addition to decreased cortical volume) is one of the most consistent MRI findings in which patients???
schizophrenic patients
The specific reason for ventricular enlargement is not known, but it seems to stem from diffusely decreased cortical volume and shrinkage of the thalamus and putamen. Frequent use of cannabis is a risk factor for psychosis.
The combination of vertical gaze palsy, nystagmus, eyelid retraction on looking upwards, and pupils that do not react to light, but do accommodate, suggests Parinaud syndrome which raises concern for???
Pinealoma, a tumor of the pineal gland
most common type of pinealoma in children is a germinoma = precocious puberty
Brain dead = cause + demonstrate via examination that the patient is comatose, does not have brain-mediated motor responses (e.g., decorticate or decerebrate posturing, facial grimacing) to noxious stimuli applied above and below the neck, has brainstem areflexia, and has a positive ?? test.
apnea test
After preoxygenation with 100% oxygen, the patient is disconnected from the ventilator and observed for evidence of respiratory drive (such as gasps or chest movement). After 8–10 minutes, an arterial blood gas reading is obtained. If the PCO2 is elevated above normal levels, this signifies an absence of respiratory drive, and the apnea test is considered positive.
A history of palpable purpura, increased fatigue, progressive sensorimotor neuropathy, mildly decreased C3 levels, and nearly undetectable C4 levels in a patient with hepatitis C (hepatitis C antibody and HCV RNA positive) is suggestive of ???
mixed cryoglobulinemia
??? should be the initial step in the treatment of patients with severe HCV-associated mixed cryoglobulinemia to reduce inflammation and prevent organ damage.
Immunosuppressive therapy (e.g., rituximab and high-dose prednisone)
Pneumocystis pneumonia prophylaxis (trimethoprim-sulfamethoxazole) is also recommended in all patients with mixed cryoglobulinemia who receive immunosuppression
n a child with a recent history of a sore throat, rapid onset of involuntary purposeless movements, emotional lability, hypotonia, inability to sustain contraction (“milkmaid grip”), and flexion of the wrist and extension of the digits when the arms are extended most likely indicate
Sydenham chorea
****feature of rheumatic fever
inflammation within the basal ganglia and cortical structures leads to Sydenham chorea
Treatment with penicillin V is indicated to completely eradicate S. pyogenes and address the underlying cause of this cross-reaction.
??? is the most common brain tumor in children and is usually located within the posterior fossa.
Imaging typically shows a well-circumscribed, enhancing cystic mass within one of the cerebellar hemispheres, but it can also occur in the cerebral hemispheres.
Pilocytic astrocytoma
typical (fluphenazine) vs atypical antipsychotics (risperidone)
atypical antipsychotics have weaker interactions with D2 dopamine receptors, resulting in less dopamine antagonism and lower rates of extrapyramidal symptoms than typical antipsychotics.
infant c. botulinum vs c. tetani
tetani: muscle spasms, myoclonus, irritability, and poor feeding
botulism: hypotony, weakness, poor feeding, and irritability
what is hypercalcemia of malignancy?
metastatic lytic bone lesions cause hypercalcemia
Patients with mild to moderate hypercalcemia are typically asymptomatic or develop symptoms such as constipation, fatigue, and polyuria. Severe hypercalcemia (hypercalcemic crisis), which is seen here, is a life-threatening condition that manifests with oliguria/anuria, dehydration, gastrointestinal symptoms, and an altered level of consciousness
?? antibodies are specific to both dermatomyositis and polymyositis.
Anti-Jo-1
The presence of anti-Jo-1 antibodies is associated with a more aggressive disease course and an increased risk for interstitial lung disease.
?? antibodies may be present with dermatomyositis or polymyositis and are typically associated with a more favorable prognosis
Anti-Mi-2
patients with meningiomas at the ?? present with sensory and motor deficits typically start in one extremity and spread to the others. Late presentation is characterized by spastic quadriparesis (hyperreflexia, positive Babinski’s sign), gait disturbances, and lower cranial nerve palsies (CN IX–XII)
foramen magnum
Hypotonia (floppy infant syndrome), bulbar palsy symptoms (e.g., tongue fasciculations, difficulty feeding), and hyporeflexia are characteristic of ????
Children can also present with recurrent hip dislocation (differences in leg length with external rotation of the affected leg)
Spinal muscular atrophy (SMA) is an autosomal recessive condition caused by apoptosis of lower motor neurons
Leg pain associated with sensory, motor, and vasomotor symptoms following a femur fracture is consistent with
usually develop within 4–6 weeks of the event
complex regional pain syndrome (CRPS)
Physical and occupational therapy is the recommended first-line therapy for CRPS
corneal haziness with neovascularization is called pannus and is a classic presentation of active ???
initially manifests as follicular conjunctivitis and then progresses to a mixed papillary and follicular conjunctivitis
Trachoma is caused by Chlamydia trachomatis serotypes A–C.
exposure to what??
distal sensorimotor polyneuropathy, white bands across the nails (Mees lines), and hyperkeratosis. Workers in battery factories have an increased risk of being exposed
arsenic
New-onset seizure and CT scan results showing ring-enhancing lesions in a patient with HIV infection are highly suggestive of a diagnosis of ???
cerebral toxoplasmosis
occupations that involve hammering and lifting heavy objects, such as carpentry, the ulnar nerve can be compressed proximally within the ???? as a result of repetitive elbow flexion, which decreases the volume of the cubital tunnel. Decreased pinch strength occurs as a result of weakness of the adductor pollicis muscle, which appears as the Froment sign.
cubital tunnel (cubital tunnel syndrome)
simple febrile seizure (a generalized seizure lasting < 15 minutes) due to herpangina
what is the treatment?
Antipyretic therapy (NSAIDs such as ibuprofen, or acetaminophen)
sudden, monocular loss of vision; does not resolve spontaneously
manifests with massive retinal hemorrhages, dilated tortuous retinal veins, macular edema, and papilledema on fundoscopic examination
Thrombotic occlusion of the retinal vein
***flame shaped hemorrhages
Where does blood pool on CT for a subarachnoid hemorrhage?
brainstem and basal cisterns
subependymal nodules, periungual fibromas
which disease?
tuberous sclerosis
?? poisoning can cause permanent hypoxic brain injury, as evidenced in this patient’s MRI showing bilateral hyperintensity of the globus pallidus, an area highly sensitive to hypoxic conditions.
carbon monoxide
patient with confusion and fever has multiloculated, rim-enhancing fluid lesions in the temporal lobe, indicating likely
Brain abscess usually occurs due to direct spread from adjacent infection (eg, sinusitis) or hematogenous spread from distant infection. In this case, the presence of subacute nonspecific symptoms, subconjunctival hemorrhage (petechiae), and signs of mitral valve insufficiency (holosystolic murmur at cardiac apex) raises suspicion for left-sided infective endocarditis (IE) with septic emboli to the eye and brain.
Examination findings include ciliary flush, pupillary constriction, a hazy “flare” in the aqueous humor, and hypopyon.
anterior uveitis
this imaging finding and difficulty swallowing means ??
Myasthenia gravis is caused by autoantibody-mediated degradation of acetylcholine receptors at the neuromuscular junction, which often leads to fatigable ocular and bulbar muscle weakness. Most patients with acetylcholine receptor antibodies have thymic abnormalities (eg, thymoma), which appear as an anterior mediastinal mass on chest imaging.
