Neurologic System Flashcards
complex regional pain syndrome (CRPS)
autonomic and vasomotor dysfunction in extremities
usually follows trauma to affected limb
- pain or tenderness out of proportion to exam
- swelling, muscle atrophy
- does NOT follow peripheral nerve distribution
- no systemic sxs
Tx:
- NSAIDS, PT/OT
- steroids, anti-depressents, gabapentin, etc.
- early mobilization is key
peripheral neuropathies - sxs, dx
may be motor (guillian-barre), sensory (DM), autonomic (DM), or combo
Dx:
- EMG/NCV (nerve conduction velocity) - primary test
- labs: glucose, BUN/Cr, vit B6 and B12, RPR
diabetic neuropathy - clinical, tx
distal, symmetrical polyneuropathy
- most common peripheral neuropathy in western world
tx: no tx to halt progression
- goal: control sxs and prevent osteomyelitis
- tight glucose control
- foot care
meds:
- gabapentin
- pregabalin (lyrica)
charcot-marie tooth disease (CMT)
child or adult with progressive motor weakness
- foot drop (anterior tibialis weakness), high arches, hammer toes
Dx: genetic testing
Tx: focus on function
bell’s palsy
lower motor neuron facial nerve paresis
- causes: infection, pregnancy, DM
- abrupt onset of facial paralysis (complete 1/2 side)
- 60% recover w/out tx (steroids w/in 5 days benefit)
Note: CVA would be able to move eyebrow
cluster headache - clinical, timing, tx
severe, unilateral periorbital pain
- stabbing
- middle-aged man
- often with nasal congestion, tearing on same side
timing:
- occur in clusters: daily for several wks
- 15 min- 3 hrs
tx:
- abortive: 100% oxygen
- prophylactic: Verapamil
migraine headache - clinical, timing, triggers, tx
HA of neurovascular dysfunction
- often a FH
- onset teens - 30s
- women>men
Sxs:
- throbbing, unilateral, pulsing
- N/V, photophopbia
- WORSE with activity
- last hours to date
- can have “aura” and prodrome
Triggers:
-stress, foods, ETOH, smells, bright lights, menstrual
Tx:
- avoid triggers, dark/quiet room
Abortive:
- NSAIDS (mild),
- triptans (mod/severe): avoid in CVD, PVD, pregnency; combine w/ naproxen for inc. benefit
Preventative (if >3 times/month or interferes w/ life activities):
- antiepileptics: Topiramate, valproic acid
- antihypertensives: propranolol
NOTE: if pt over 60, get ESR to R/O giant cell arteritis
tension headaches - clinical, triggers, tx
generalized, constant, squeezing
- most common primary HA
- DO NOT worse with activity
- no N/V
Tx:
- stress reduction, sleep hygiene
- NSAIDS, acetaminophen
Prophylaxis: TCAs
encephalitis - definition, sxs, dx, tx
inflammation/infection of brain parenchyma
- usually viral
Epidemic: west nile virus
Non-epidemic: HSV-1
s/sx:
- viral prodrome (fever, malaise, myalgia, N/V/D, rash)
- HA, photophobia, altered sensorium, seizures
Dx:
- lumbar puncture (CSF PCR): showing elevated opening pressure, elevated protein and WBC, glucose (normal if viral)
Tx: do not wait for LP results
- Acyclovir (since most common is HSV-1)
viral vs. bacterial etiology of CSF
lumbar puncture (CSF PCR):
- viral will have normal glucose
- bacterial will have low glucose (bacteria eat glucose)
meningitis
inflammation/infection of arachnoid membrane, pia mater, and CFS in between
- bacterial, viral, other
- dec. incidence due to vaccines
bacteria meningitis - clinical, signs
acute onset of fever, HA, vomiting, stiff neck, myalgia, backache, weakness
- rapid progression to confusions, loss of consciousness, sz
- MEDICAL EMERGENCY
Signs:
- Kernig and Brudzinski - flexion of knees in pain
- petechiae or ecchymosis rash: meningococcal
bacteria meningitis - dx, tx
lumbar puncture:
- elevated opening pressure
- CFS: elevated protein, dec. glucose, elevated cell count (PMN)
- positive gram stain
Blood cultures
CT/MRI of brain and spine
CXR, sinus, mastoid
tx:
- IV ABX and dexamethasone
- empiric tx by demographic (1st)
- pathogen specific tx
viral meningitis - clinical, dx, tx
acute onset of fever, HA, vomiting, stiff neck, myalgia, backache, weakness, rash
- 60% are enteroviruses (fecal-oral transmission)
lumbar puncture:
- slightly elevated opening pressure
- CFS: elevated WBC, normal or slightly elevated protein, normal glucose
- negative gram stain
Tx: supportive
- NSAIDS, analgesics, antiemetics
- acyclovir if HSV
- out-patient recovery 1-3 wks
NOTE: prevention key (mumps was #1 cause prior to vaccine)
essential tremor
postural tremor of hands, head, of voice
- genetic
- may begin at any age
- worse with stress; less with ETOH
Tx:
- nothing if not disabling
- propranolol if disabling
huntington disease
progressive disease resulting in death of nerve cells (including brain cells)
- genetic
- onset b/t 30-50 (fatal 15-20 yrs)
s/sx: gradual onset chorea (jerky, involuntary mov’t), dementia, behavioral changes
dx:
- CT or MRI: cerebral atrophy
- genetic tests for definitive dx
tx: symptomatic
- genetic counseling
Parkinson Disease
disease of imbalance of dopamine and acetylcholine in corpus striatum
- PROGRESSIVE dz
- usually sporadic (NOT inherited)
- onset 45-65 y/o
- lies on spectrum - parkinsonism
s/sx:
- pill rolling tremor at rest, cogwheel rigidity
- bradykinesia (trouble initiating mov’t), gait impairment/shuffle
Dx: clinical
tx:
- early (prevents progression): amantadine, anticholinergics, dopamine agonists, brains stimulation
- Levodopa (converted in body to dopamine) / carbidopa (inhibits enzyme that breaks down levodopa) is MAINSTAY of treatment
cerebral aneurysm: definition, risks, complication, dx, tx
“berry aneurysm” that occur at arterial bifurcations
- asymptomatic until rupture
- most in Circle of Willis
Risks: smoking, HTN, hyperlipidemia
complication: subarachnoid hemorrhage
dx: angiography (gold standard)
tx:
- surgery, endovascular intervention
- monitor if <10mm
stroke - two types
brain infarction
very common - 2nd leading cause of death world-wide
ischemic (85%)
- thrombotic (arthrosclerosis), embolic (a-fib), small vessel dz
hemorrhagic (15%)
- intracerebral
- subarachnoid
stroke - risk factors
HTN
DM
Smoking
also:
- atrial fibrillation
- carotid stenosis
- black/hispanic
- men
- obesity
- ETOH
- OCP
transient ischemic attack - definition, cause, W/U
acute onset of focal neurologic deficit lasting
- sxs < 24 hrs
- no infarction
Cause: emboli from heart or extra cranial artery
W/U: CT or MRI w/in 24 hrs
- also carotid U/S, MRA, CTA
Note: if sxs >1-2 hrs, possibly infarction and generally worse outcome
transient ischemic attack - treatment
assess ABCD2 score
- age (>60)
- BP>140/90
- focal weakness on exam
- duration of sxs > 60 min
- DM
Tx: Statin, ASA, anti-platelet meds (clopidogrel), carotid surgery of severe stenosis
ischemic stroke -s/sx, dx
s/sx:
- focal neurological deficit (mental status, speech, CNs, strength, reflexes)
- painless, abrupt onset
- NIH stroke scale
NOTE: presentation depends on artery occluded
- Middle cerebral artery is MOST COMMON and presents w/ contralateral hemiparesis, arm/face sensory loss, expressive aphasia (Broca’s - partial loss of ability to produce language)
dx:
- non-contrast
CT brain (r/o hemorragic)!!!
ischemic stroke - tx
ABCs
Correct glucose
Thrombolytic therapy: rtPA (w/in 4.5 hrs of onset)
Lower BP (so can receive rTPA) : Labetalol, nicardipine
Aspirin (if rtPA contraindicated)
Mannitol: lowers ICP
PT/OT
thrombolytic therapy (rtPA) contraindications
BP>185/110 head trauma or stroke in previous 3 mo recent CNA surgery GI bled Hx of ICH Recent anti-coag/bleeding diathesis Glucose < 50
Note: no anticoagulants of platelet-inhibitors for 24 hrs after admin of t-PA
ischemic stroke - prevention
anti-platelet therapy: ASA, Plavix
control lipids: statins
control BP: ACE-I in DM
smoking cessation
anti-coagulation for A-fib patients (Warfarin, DOAC)
carotid endarterectomy or stenting
intracranial hemorrhage (ICH) - definition, causes, dx
bleeding into brain
causes:
- HTN (very abrupt), trauma, drugs (anti-coagulants, 1-2 day onset)
- Asian and AA
dx:
- CT brain (differentiate from ischemic stroke so DO NOT give tPA)
- investigate for coagulopathy: PT/PTT/INR
- CTA to find site of bleed
intracranial hemorrhage (ICH) - tx
manage HTN: nicardipine
control ICP: mannitol, fluid restrict
seizure ppx: fosphenytoin
reverse coagulopathy: FFP (fresh frozen plasma), vit K
surgical evacuation of hemotoma
subarachnoid hemorrhage (SAH) - definition, cause, s/sx, dx
ruptured vessel in subarachnoid space
- high mortality
cause: trauma follow by ruptured aneurysm
s/sx:
- rapid onset, severe HA (thunderclap; worst of life)
- N/V, AMS, neck stiffness
dx:
- non-contrast CT
- LPL blood in CSF
- cerebral angiography: finds source of bleed
- CBC, coag studies, electrolytes
subarachnoid hemorrhage (SAH) - tx
BP control: beta-blockers
Sz ppx: fosphenytoin
Nimodipine: CCB to reduce vascular spasm
surgery: clipping, coiling
reduce ICP: Mannitol, diuretics
Support: ventilation, nutrition
subdural hematoma (SDH) - definition, causes, common population, s/sx
hemorrhage beneath dura
-venous bleed = slower
causes:
- trauma (may be minor)
- anticoagulation
- ETOH
- frequent falls
common: very young and very old
s/sx:
- unilateral HA and ipsilateral enlarged pupil
- subacute many progress over 3-7 days
subdural hematoma (SDH) - dx, tx
CT brain: crescent-shaped collection over 1 or both hemispheres
- crosses sutures, not midline
- concave
epidural hematoma (EDH)
blood accumulates below skull but above dura
- arterial bleed = faster
s/sx:
- lucid interval of min to hrs b/f alter mental status
dx: CT brain
- bi-convex-shaped
- does not cross suture lines
altered level of consciousness - causes and definitions
result from a serious insult to CNS
- seizure, structural lesion, hypothermia, metabolic d/o, toxic/drug induced
stupor: transient arousa by vigorous stimuli
coma: non-arousable, no response to external events
vegetative: wakefulness present but awareness absent
altered level of consciousness - dx
Glasgow coma scale
- mild head injury: 13-15
- moderate head injury: 9-12
- severe head injury: 8 or less
finger-stick glucose STAT
EKG: did MI occur
Labs: serum glucose, electrolytes, calcium, LFTs, BUN/Cr, tox studies, ABG
EG, brain CT/MRI, LP
altered level of consciousness - tx
tx depends on etiology
- correct underlying d/o
supportive tx:
- stabilize c-spine, ABCs
- control sz
- empiric ABX if meningitis
- lower ICP: mannitol, surgical decompression
- coma cocktail: dextrose, naloxone (in case opioid OD), thiamine IV (correct deficiency in ETOH)
concussion - definition, s/sx, W/U, tx
transient trauma-induced change in mental status
- may or may not involve LOC
- simple: resolves w/in 3 wks
- complex: does not resolve
s/sx:
- HA, N/V, disorientation, irritability, visual disturbance, neurological deficits
W/U:
- Head CT: use Canadian CT Head rules to determine risk (GCS<15, possible skull fx, vomit >2x, age<65, mechanism)
- ADMIT: age >65, intoxication, soft tissue injury above clavicle
- MRI if sxs persist > 14 days or worsen
Tx: MUST be cleared by trained provider
- cognitive and physical rest key
post-concussive syndrome
sxs lasting weeks to > 1 year
s/sx:
- HA, trouble concentrating, fatigue, dizziness, irritability
cerebral palsy - clinical, s/sx
chronic, static impairment of muscle tone, strength, coordination, and movement (does not progress)
- results from insult to neonatal nervous system / brain
- possibly hypoxia, infection
s/sx: spasticity, ataxia
- can have associated developmental delay or sz d/o
cerebral palsy - dx, tx
dx: clinical
tx: maintain maximal physical fx
- PT/OT, speech
- counseling, education
meds: for spasticity (Baclofen, botox)
prognosis depends on severity of deficits
dementia - definition, risk factors
progressive decline in intellectual and cognitive fx
- compromises social and occupational fx
- leads to loss of independence
- age > 60 typical
Loss of ST memory and 1+ cognitive deficit:
- aphasia: impaired word-finding
- apraxia: impaired motor tasks
- agnosia: impaired recognition of objects
- impaired executive fx (planning)
Risk factors:
- age, stroke, FH, DM, head injury
alzheimer disease - cause, s/sx
loss of ST memory (anterograde amnesia)
- most common type of dementia
cause: accumulation of B-amyloid plaques in brain
s/sx:
- early: difficulty w. finances, independent travel meal prep
- late: difficulty with ADLs
usually no motor deficits
alzheimer disease - tx
aerobic exercise, mental stimulation
1st line: acetylcholinesterase inhibitors
- donepezil (Aricept)
- rivastigmine (Exelon)
Types of dementia (in addition to alzheimer disease)
- Vascular
- Lewy body
- Frontotemporal lobar degeneration
Vascular: due to multiple infarcts to brain (stroke)
- motor slowing, gait d/o
Lewy body: dementia with parkinsonism, visual hallucinations,
- antipsychotics worsen
Frontotemporal lobar degeneration: d/o of behavior and personal relationships
- rude, sexually explicit, poor judgment, poor hygiene
delirium - definition, causes
global impairment in cognitive functioning that is sudden in onset
- presents with diminished level of consciousness, inattention, visual hallucinations, autonomic changes (tachycardia, sweating)
- usually reversible
- lasts <1 wk
Causes:
- Hypoxia
- Hypoglycemia
- Acute intoxication or withdrawal
- Meningitis/ encephalitis
- Intracranial injury
- Hypo/hypernatremia
- Drug side effects
- Medications!!
guillain-barre syndrome - definition, causes, s/sx, dx tx, prognosis
acute, inflammatory demyelinating polyneuropathy
causes: infection, vaccine surgery
- Caplylobacter jejuni (?)
s/sx:
- weakness>sensory disturbance (“rubbery legs”)
- begins distal and spreads proximal
- motor paralysis
- autonomic disturbance: cardiopulmonary (may need intubation)
dx:
- CSF: inc. protein
- R/O other neuropathies
tx:
- plasmapheresis, IVIG
- steroids are INEFFECTIVE
Prognosis:
- recovery takes months!
- 15-20% w/ lasting disability
multiple sclerosis - definition, causes, s/sx, dx tx, prognosis
focal areas of demyelination
- scattered white matter changes in CNS (periventricular, spinal cord)
- likely autoimmune
- progressive dz
- women>men (white)
- can occur postpartum
s/sx:
- weakness, numbness, optic neuritis, diplopia
- nystagmus, UMN findings (hyper-reflexia)
types:
- relapsing-remitting
- secondary progressive
- primary progressive
Dx:
- s/sx must be disseminated in time and space
- s/sx last at least 24 hrs at least 1 mo apart
- pathology in anatomically noncontiguous white matter tracts of CNS
- MRI: brain and spinal cord (“black holes”, “dawson’s fingers” in brain)
- LP: oligoclonal bands (IgG)
tx:
- acute attacks: corticosteroids (do not prevent progressive)
- progressive dz: B-interferon or glatiramer
myasthenia gravis
autoantibodies to acetylcholine receptors
- autoimmune dz
- slow, progressive
- women>men
- may be associated with thymus d/o
s/sx:
- fluctuating weakness of voluntary muscles
- weakness worsens with repetitive activity
- insidious onset: illness, pregnancy, menstruation
- ptosis, diplopia, difficult chewing/swallowing
- limb weakness
dx:
- weakness on exam
- serum acetylcholine receptor antibodies
Tx:
- acetylcholinsterase inhibitors: pyridostigmine, neostigmine
epilepsy
recurrent, unprovoked seizures
seizure - definition, causes, types
transient disturbance of cerebral function due to neuronal hyper excitability
causes:
- genetic
- strutural
- metabolic
- unknown
focal:
- simple partial: w/out impaired consciousness
- complex partial: with impaired consciousness
general:
- tonic-clonic
- absence (petit mal)
focal seizure - types, s/sx, tx
simple partial: w/out impaired consciousness
complex partial: with impaired consciousness
s/sx:
- motor jerking or paresthesias along limb or part of body
tx: anti-convulsants
- lamotrigine, carbamazepine, oxcarbazepine
- phenytoin
- Levetiracetam (Keppra)
absence (petit mal) seizure - s/sx, tx
type of generalized seizures
brief impairment of consciousness
- pt often no aware
- may include tonic/clonic movements
- enuresis possible
- EXCLUSIVELY in childhood (< 20 y/o)
Tx: anti-convulsants
- valproic acid
- ethosuximide
tonic-clonic (grand mal) seizure - s/sx, tx
type of generalized seizures
- sudden loss of consciousness with rigidity (tonic)
- jerking, convulsive mov’t (clonic) - 2-3min
- urinary/fecal incontinence, tongue biting, aspiration
followed by:
- flaccid coma
- postictal state of confusion
tx:
- valproic acid
- ethosuximide
seizure evaluation/dx
EEG: mainstay of dx
- paroxysmal spikes, sharp waves
MRI of brain (CT if MRI contraindicated)
Labs: CBC, glucose, electrolytes, calcium, Mg, LFTs
LP: r/o infection
seizure - tx
meds:
- Valproic acid, phenytoin, carbamazepine, phenobarbital, topiramate, lamotigine
- ETOH w/drawal: benzodiazepine
lifestyle:
- avoid triggers
- avoid dangerous situations (driving, operating machinery)
- comply w/ state laws
Note: tx until >2 yrs sxs free
seizure - medication considerations
many sz meds are teratogens:
- avoid in pregnancy: valproic acid
- cat D: carbamazepine, phenobarbital, topiramate
Many have side effects and interactions
Must monitor serum levels for most drugs
- except Keppra (levetiracetam)
Wait at least 2 yrs sz-free to d/c meds
status epilepticus - definition, cause, tx
repeated seizure, without recovery, lasting > 30 minutes
- MEDICAL EMERGENCY
cause: poor medication adherence
tx:
- ABC: maintain airway
- dextrose IV (potential hypoglycemia)
- benzos to break seizure
syncope - definition, 3 types
transient loss of consciousness
- due to global impairment of cerebral blood flow
- often impairment of vasoconstriction
3 types:
- cardiogenic: arrhythmias, aortic stenosis
- orthostatic hypotension
- autonomic neuropathy (DM) common cause - neurally mediated/vasovagal: provoked by fear, pain
- preceded by sweating, dizziness
syncope - manage / tx
vasovagal:
-avoid triggers
All:
- eval for head injury from fall
- cardiac W/U
- carotid imaging
- tx cardiac abnormalities
Meds:
- midodrine: vasoconstrictor
tourette syndrome
frequent motor and/or phonic tics lasting at least 1 year
- sxs must begin b/f age 21
- cause is not known (possibly chromosomal)
- chronic course; may be relapsing/remitting
- often associated with OCD
- motor tics and phonic tics
tx: symptomatic
- CBT 1st line
- FDA-approved: antipsychotics (Haloperidol)
