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Neurology > Neurologic Emergencies > Flashcards

Neurologic Emergencies Flashcards

1
Q

ipsilateral weakness and loss of fine touch/vibration sensation
contralateral loss of pain and temp. below the lesion

A

Brown-sequard syndrome (hemisection)

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2
Q

bilateral loss of pain and temperature and weakness but with preservation of fine touch, proprioception and vibration

A

anterior cord syndrome

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3
Q

bilateral loss of pain and temp in upper extremities as well as weakness but with preservation of fine touch

A

central cord syndrome

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4
Q

best imaging test for visualizing spinal cord

A

MRI

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5
Q

below what age should all children have imaging done with suspect spinal cord injury

A

below age 9

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6
Q

what clinical findings are suggestive of spinal shock?

A
  • loss of autonomic function (hypotension with paradoxical bradycardia if vagal output is intact)
  • complete absence of DTRs, superficial cutaneous reflexes and rectal tone
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7
Q

principal indications for early surgery in traumatic spinal cord injury

A
  • significant compromise of spinal canal

- fixation of very unstable spine

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8
Q

18 yo athlete with a sports-related trauma where he hit his head experienced transient loss of consciousness right after the event followed some time by a seizure. His neuro exam is relatively non-focal and imaging of his brain is normal but his condition continues to worsen with nausea, headache and vomiting - dx?

A

intracerebral bleed - most likely epidural hematoma

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9
Q

next diagnostic step if you suspect intracerebral bleed?

A

non-contrast CT scan of head

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10
Q

findings on CT scan in typical epidural hematoma

A
  • mass that displaces brain from skull
  • extra axial
  • smoothly marginated
  • biconvex (lens) homogenous density
  • high density on CT scan
  • does not cross suture lines
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11
Q

what do focal isodense or hypodense zones within an EDH imply?

A

active bleeding

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12
Q

what does air in acute EDH suggest?

A

fracture of sinuses or mastoid air cells

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13
Q

24 yo women w/o medical illnesses presents with acute alteration in mental status 24 hrs after head trauma with brief LOC. She has attentional deficits, disorganized thinking, altered psychomotor activity, difficulty focusing, memory deficits and disorientation; these symptoms fluctuate. P/E shows generalized hyperreflexia and positive babinski sign bilaterally

A

delirium from subarachnoid hemorrhage

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14
Q

what metabolic derangements can head trauma cause?

A

SIADH –> causes hyponatremia with delirium or altered mental status

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15
Q

presentation of acute mental status change, abnormal attention and fluctuating course should make you think of…

A

delirium

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16
Q

Risk factors for delirium

A 
age ( esp > 80)
pre-existing cognitive impairment
dehydration
electrolyte disturbances
men >> women
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17
Q

concussion

A

traumatic alteration in cognitive function with or without loss of consciousness; aka. mild traumatic brain injury

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18
Q

grade 1 concussion

A

no LOC and all symptoms resolve w/in 15 min

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19
Q

grade 2 concussion

A

no LOC but sx last longer than 15 min

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20
Q

grade 3 concussion

A

LOC for any period of time

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21
Q

New Orleans Criteria

A

indications for head CT in concussion:

  • persistent headache
  • emesis
  • age > 60 yo or children < 16 yo
  • drug or alcohol intoxication
  • persistent anterograde amnesia
  • soft tissue or bony injury above clavicles
  • seizure
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22
Q

observation rules for pt who sustained grade 1 or 2 concussion with normal head CT and neuro exam

A

observe for 2 hours in ER then discharge home

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23
Q

return to play guidelines for grade 1 concussion

A

remove from game for atleast 15 minutes, assessed every 5 minutes; if everything ok at 15 min, can return to play

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24
Q

return to play guidelines for grade 2 concussion

A

removal of game for remainder of day; if neuro exam is normal, athlete can return to play in a week

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25
Q

return to play guidelines for grade 2 concussion

A

must go to ER for neuroimaging and assessment; can return to play between 1-2 weeks

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26
Q

treatment of brief convulsion at time of head injury

A

does not require tx. with anticonvulsants and is not assoc. with increased risk of epilepsy

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27
Q

68 yo woman presents with sudden onset of right hemiparesis (in arm and leg) as well as aphasia (word fluency, naming and repetition; she also has right lower facial droop and left gaze deviation - dx?

A

acute cerebral infarct - Left hemisphere, anterior circulation

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28
Q

Todd’s paralysis

A

brief period of transient (temporary) paralysis following a seizure

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29
Q

carotid arteries are vascular supply for…

A

frontal lobes
parietal lobes
most of temporal lobes
basal ganglia

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30
Q

vertebrobasilar blood supply

A

encompasses brainstem, cerebellum, occipital lobes and thalamus

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31
Q

next step in diagnosis of suspected subarachnoid hemorrhage

A

non contrast CT scan of head

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32
Q

next step in therapy for suspected subarachnoid hemorrhage

A

cerebral angiography

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33
Q

risk factors assoc. with aneurysms

A
  • fibromuscular dysplasia
  • polycystic kidney disease
  • chronic severe HTN with DBP > 110
  • liver dz
  • tobacco/alcohol use
  • vasculitides
  • collagen vascular disorders
  • infections
  • oral contraception
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34
Q

non-aneurysmal causes of subarachnoid hemorrhage

A

trauma
AV malformation
cocaine/amphetamine abuse

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35
Q

how do you manage grade 1 or 2 subarachnoid hemorrhage?

A

observe

36
Q

when should you consider cerebral angiography in pt with subarachnoid hemorrhage?

A

if rupture is suspected and neurosurgical intervention will be required

37
Q

indication for endovascular coiling

A

to reduce rebleeding in low grade cases of subarachnoid hemorrhage; superior to clipping

38
Q

when should clipping be done for SAH?

A

in first 48 hours after onset OR delay for 2 weeks to avoid window of greatest risk for vasospasm

39
Q

mainstay of medical management of SAH

A
  1. triple H therapy (hypertensive hypervolemic hemodilution) to reduce vasospasm and maintain cerebral perfusion
  2. nimodipine (CCB)
40
Q

carotid dissection

A

tear in carotid arterial wall that can result in luminal obstruction, thromboembolic complications and/or pseudoaneurysm formation

41
Q

AV malformation

A

congenital, high pressure, high flow cerebral vascular malformations characterized by direct AV shunting

42
Q

what can cause craniocervical dissection?

A

usually preceded by head or neck trauma such as MVA, chiropractic neck manipulation or thromboembolic CV events

43
Q

what symptoms is carotid dissection frequently assoc with?

A

Horner syndrome - ipsilateral ptosis and miosis

44
Q

what factors predispose to spontaneous craniocervical dissection?

A

Fibromuscular dysplasia
Ehler’s Danlos syndrome
Marfan syndrome

45
Q

moyamoya disease

A

idiopathic noninflammatory cerebral vasculopathy with progressive occlusion of the large arteries at the circle of willis; moyamoya vessels refer to the small penetrating arteries that hypertrophy in response to chronic cerebral ischemia

46
Q

horner syndrome in a pt with headache and recent head/neck injury is suspicious for..

A

carotid dissection

47
Q

etiology most often discovered in young pt with cryptogenic stroke is…

A

patent foramen ovale

48
Q

23 yo man lost consciousness and when he awoke, he was confused, incontinent of his urine and had muscle soreness; his neuro examination was normal the following day - dx?

A

seizure disorder

49
Q

next diagnostic step of new onset seizure in an adult

A

MRI of brain and EEG

50
Q

what stage of sleep has high likelihood of seizures?

A

stage 2 sleep

51
Q

adult onset seizure is caused by (1) or (2) unless proven otherwise

A
  1. tumor

2. stroke

52
Q

difference between partial/focal seizure and generalized seizures

A

partial/focal seizures relate to only one of the cerebral hemispheres whereas generalized seizures involve both hemispheres of the brain

53
Q

juvenile myoclonic epilepsy

A

myoclonic seizures (quick little jerks of arms, shoulders or legs) usually early in the morning. The jerks are sometimes followed by tonic-clonic seizure in context of sleep deprivation or alcohol ingestion

54
Q

23 yo old man suddenly began smacking his lips, stared into space, seemed confused and kept mumbling the same word repeatedly; within a few seconds, he became totally asymptomatic - dx?

A

complex partial seizure

55
Q

MC aura for any focal onset seizure

A

sensation of abdominal discomfort

56
Q

complex partial seizure

A

impaired consciousness and assoc. with bilateral spread of seizure discharge, involving at minimum the basal forebrain and limbic structures

57
Q

absence seizures

A

present with momentary lapses in awareness characterized by motionless staring and stoppage of ongoing activity; begin and end abruptly, occur w/o aura and are not assoc. with post-ictal confusion –> can occur many times a day and last 10-15 sec

58
Q

atypical absence seizures

A

if beginning and end of absence spell is not distinct, or if tonic or autonomic components are present; usually occur in cognitively challenged children with epilepsy or in pts with epileptic encephalopathy

59
Q

unilateral manual automastisms with contralateral arm dystonia indicate

A

seizure onset from the cerebral hemisphere ipsilateral to the manual automatisms

60
Q

aside from complex partial seizures, when can automatisms happen?

A
  • nonepileptic states of confusion
  • after ictus
  • during absence seizures
61
Q

automatisms in absence seizures

A

are duration dependent – usually only after 10-15 seconds of absence seizure

62
Q

complex partial seizures of temporal lobe - how do they look?

A

begin with motionless stare followed by simple oral or motor automatisms

63
Q

complex partial seizures of frontal lobe usually look like…

A

begin with vigorous motor automatisms or stereotyped clonic or tonic activity (i.e. tonic or dystonic arm posturing in arm contralateral to seizure focus)

64
Q

partial seizures are more common in countries where..

A

cysticercosis is prevalent

65
Q

mortality rate of pts with epilepsy

A

2-3x greater mortality than general population

66
Q

characteristic pathologic changes on brain imaging seen in complex partial seizures

A
  • mesial temporal sclerosis
  • reduced hippocampal volume
  • increased signal on FLAIR
67
Q

DOC for absence seizures

A

ethosuximide

68
Q

what types of seizures can valproate be used for?

A

absence seizures
myoclonic seizures
tonic-clonic seizures
partial seizures

69
Q

which anticonvulsant is most likely to cause congenital birth defects in pregnancy?

A

valproate

70
Q

what should women of child-bearing age who take anticonvulsants be instructed to do?

A
  • effective birth control

- up to 4 mg of folic acid daily

71
Q

surgical intervention for epilepsy?

A

indicated if pt has frequent, disabling seizures despite trails of two or more anticonvulsants

72
Q

MC form of seizure disorder in adults

A

complex partial seizures

73
Q

catamenial epilepsy

A

in approx 1/3 of women with seizures, there is a relationship between menstrual cycle and seizures, with the seizure frequency doubling

74
Q

pathophysiology of cardiogenic syncope

A

decreased cerebral blood flow with resultant cerebral hypoxia, which prompts immediate and forceful rearrangement of posture to ensure adequate flow of blood to CNS; MC caused by decreased CO and arrhythmias

75
Q

MC non-cardiac related causes of syncope

A

peripheral vasodilation
decreased VR to heart
hypovolemia

76
Q

clinical features of cardiac syncope

A

occurs suddenly and ends abruptly w/o warning or post-event confusion; pt usually falls down

77
Q

first diagnostic test in exertional syncope

A

echocardiogram

- bc usually due to cardiac outflow obstruction such as aortic stenosis

78
Q

syncope during cough, micturition or valsalva maneuvre

A

implicates decreased VR and can occur in healthy individuals

79
Q

clinical features of vasovagal syncope

A

pt is usually in upright position and describes a sensation of lightheadedness, dimmed vision/hearing, depersonalization, sweating, nausea and increased HR; pt usually wakes up immediately after the event

80
Q

can incontinence happen in any form of syncope?

A

yes! if the pt has a full bladder prior to event it can happen in any form of syncope

81
Q

how can you ddx. syncope from syncope caused by epileptic seizure

A

in epileptic syncope, the pt experiences at least brief postictal confusion

82
Q

orthostatic syncope

A

occurs with sudden changes of posture from lying or sitting to standing or after prolonged standing w/o moving

83
Q

next test if you suspect orthostatic syncope?

A

tilt-table test

84
Q

causes of orthostatic syncope in elderly

A

hypovolemia or increased venous pooling

polypharmacy with BB, diuretics and nitrates

85
Q

mechanism of orthostatic syncope in diabetics

A

dysautonomia - interruption of sympathetic reflex arc inhibits adequate adrenergic response to standing

86
Q

23 yo man suddenly seized in all 4 extremities, remained conscious, complaining about pain and querying his surroundings - dx?

A

pseudoseizure

87
Q

best method to diagnose pseudoseizures

A

video EEG monitoring

Neurology (15 decks)

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