Neurology Flashcards
Migraine
F>M
Q few weeks
1/2 hr onset
Lasts hours to days
Frontal/temporal one or both sides
Throbbing
n/v/aura/photophobia, AM menarch, menses, weahter, stress, worse with movement
Tx: Tylenol/NSAID/ASA -> Sumatriptan->chloropromazine/metochlopramide
Prevention: BB, TCA, Vit B2 (riboflavin), CoQ 10, Topiramate, Botox
Cluster h/a
M>F
1-2/day
onset 2-15min
lasts 1/2 hr-2hrs
Orbital/one side
Excruciating
Rhinorrhea, ipsilateral Horner’s, Unilateral lacrimation
Tx: 100 OXYGEN, intranasal lidocaine, sumatriptan
Prevention: Verapamil, valproate, gabapentin
Tension h/a
F>M How often? Variable Onset Variable how long 1/2hr to 7 days Where: diffuse Non-throbbing Band like Tx: analgesics Prevention: BB, TCA
25yo F p/w chronic h/a x years noticed from puberty, mainly with waking up, several hours every few weeks, throbbing aw nausea and vom no auras - several tylenol and motrin didn’t help - acute pain would respond to….
Sumatriptan
25yo F with FLASHES of light moving across eyes for a few minutes wiht loss of visio nin one eye - left homonymous defect -normal after 45 min
Dx: Migraine
Young woman co wk in R arm and leg - PMHx migraines - feels better after couple hours - carotid US, MRI brain and TEE normal dx?
Migraines
DO NOT USE TRIPTANS with CAD or vasculitides
52yo M p/w moderately severe befrontal throbbing ha - aw nausea - had h/a for past few years - normal temp - BP 150/90, fundoscopy normla neck supple, pupils reactive no focal neur effects histor significant for CAD wtd?
NSAID with prochloroperazine
Acute migrain with nausea and vomiting fastest relief?
SQ Sumitriptan
Severe acute migraine not responding to sumatriptan or lasting >72hrs
IV dopamin antagonist (prochlorperazine.metoclopramide) + IV diphenyhydramine (prevent acute dystonic rxn)
Severe acute migrain x more than 72hrs - last sumatriptan >24hrs ago with little response - >
parental dihydroergotamine
Pregnancy with migraine h/ once a week
tylenol or NSAID
Pregnancy with migraine h/a no response to NSAIDs
Metoclopramide or Chloroproazine or ondeansetron
Migraine ppx for h/a’s how often?
2 times per week
PPX for migraine <15x/month
BB, amitriptyline, topiramate, sodium valproate
PPx for migrai >15/month
Topriamate-> botox
PPX migrains with asthma
amitriptyline, topiramate (no BB)
Prevention of menstrual h/a
mefenamic acid 2 days prior and upto end of menstruation
Migraine with Aura
OCP contraindicated!!
Pt with migrain h/a takes NSAIDs now not working wth h/a daily from morning to evening
Analgesic induced h/a
d/c all analgesics
42yo F chronic non-throbbing h/a worse at end of day - band like around neck
Tension h/a
35yo F c/o excruciating Ice pick like retroorbital h/a - h/o rhinorrhea, lacrimation ipsilateral horner’s
Cluster h/a
Pt with recurrent h/a >5-6/day unilateral and retrooribtal
Chornic paroxysmal hemicrania
Tx: Indomethacin
32yo obese woman BMI>30 with daily h/a - horizontal diplopia - blurring of optic disc margins - spinal tap with inc’d pressure
Pseudotumor cerebri
Tx: Acetazolamide, lumboperitoneal shunt
Etio: obesity, Vit A toxicity, tetracycline, steroids, contraceptives, nitrofurantoin, isotretinoin, minocycline, danazol, tamoxifen, levothyroxine
Comoplications of pseduotumor cerebri
Peripheral visual field loss-> central visual field loss
Pt with known HTN with h/a and ataxia - CT scan large cerebellar bleed wtd?
surgery - brainstem compression
65yo h/a ESR 75
Temporal arteritis
H/a with rhinorrhea
Cluster h/a
100% O2
Cluster h/a
H/a with zigzag wavy lines photophobia and aura
Migraine
Sumatriptan
Migraine, Cluster h/a
Thunderslap h/a, CT head neg, CSF xanthochromia
Subarachnoid hemorrhage
Chronic h/a inc’d with lying down
brain tumor
Young obese pt with headache and horizontal nysstagmus
Pseudotumor cerebri
Acetazolamide
Pseudotumor cerebri
50yo F seizure or focal weakness, h/a worse on coughing/lying down CT 4cm large edema/mass effect NO CA+
Glioblastoma/astrocytoma
most common and aggressive primary brain tumor
Surgery primary therapy with chemo/radiation
dexamethasone
50yo h/a worse on coughing, lying down, CT INTRAVENTRICULAR tumor
Choroid plexius papilloma
slow growing benign tumor of ventricular system in choroid plexus - inc’d CSF production - inc’d OCP -> hydrocephalus
Tx: Surgery
50yo F h/o seizure d/o for 4 years - CTH 3cm tumor in sylvian fissure - diffuse enhancement with contrast
Meningioma Usually benign Arise from meninges Seizures or weakness Syvian fissure Inc'd ICP
Following tumors metastasize to brain
Breast, lung melanoma, lymphoma, renal
NOT prostate
45yo F lighting pain jabs in gums, cheek, chin, several times per day and last few seconds at a time - no focal neurolgical signs, oral exam normal
Carbamazepine
Facial Palsy
Supranuclear (CVA) - Upper face spared
Infranuclear - both UPPER AND LOWER face Bell's palsy Accoustic Neuroma Ramsay Hunt syndrome Guillain-barre Lyme Dz Sarcoidosis
Motor Neuron Disease
Lower motor neuron (Infra-nuclear) - dec’d reflexes, dec’d muscle tone, +Fasciculations
Upper motor neurons (Supra-nuclear) - inc’d reflexes, inc’d muscle tone, NO fasciculations
30yo with erythema chronicum migrans 4 weeks ago now with left sided upper and lower face paralysis preceded by ha
Infranuclear lesion
55yo vesicular lesions on R side face with pain involving ear
Supra-nuclear lesion
65yo M with slurred speech and lower face paralysis
Suprnuclear lesion
55yo pw R sided facial paralysis of unknown etio
infranuclear lesion
60yo M sudden onlset R facial weakness, drooling of saliva inability to close R eye - mouth deviating to left side, unable to raise eyebrows - rest of neuro exam normal
Artificial tears, patch R eye at night, start PREDNISONE
Young woman co diplpia - closing one eye - diplpia persists dx?
Monocular psychogenic diplopia
CN III palsy
can’t look up, down or inward
Where is lesion?
posterior commuicating artery
Dx: MRA brain
Pt in MVA brought to ER with h/a - PE shows R pupil 2mm, left pupil 4mm - ptosis of R eye - wtd?
CT angio neck
dx: Carotid artery dissection
Pt with acute onset diplopia h/o DM, Ptosis
Acute cranial mononeuropathy
Pt with hyperthyroid and exopthalmos - unable to completely abduct and has double vision - cause?
Thyroid opthalmopathy
Tx: steroids
R optic neuritis
MS with blindness in right eye
Tumor pressing on optic chiasma (acromegaly)
Bitemporal hemianopia
Left Optic tract
Right dense homonymous hemianopia
Left optic radiation (occipital lobe)
Right homonymous quadrantanopia
Stroke
Days
Throbotic - 50% preceeded by TIA
Embolic - more rapid onset
Hemorrhagic - HTN, amyloi angiopathy
Minutes
TIA -
Carotid artery syndrome -
Ipsillateral visual loss (amaurosis fugax)
Shadow in front of eye - contralateral motor or sensory changes
Vertebrobasilar syndrome DDD Dizziness, Diplopia, Dysarthria Sudden wk of legs -> dorp attacks B/l Wk Tx: ASA
Pt with TIA higher risk of stroke if…
Duration >10min
Speech disturbance
Age>60
DM
Most important risk factor for stroke?
HTN
Pt with TIA
Hopsital w/u - carotid dopper, EKG, CT brain, Coags, TEE r/o PFO
If carotid shows >70% wtd?
Carotid endarectomy + ASA
If TIA and carotid 90% inoperable wtd?
Stent
Pt with TIA and cardid US with <50% wtd?
ASA + dipyrimadamole OR plavix
Pt h/o TIA no PAD - best management
ASA - can add ACE+- indapamide to decrease recurrence
Pt has TIA on ACEi, ASA and statin
d/c ASA and start Plavix
don’t use both unless has CAD with stent also
Endartectomy vs stent
Endartectomy better mortality, less stroke,
Stent better with high carotid bifurcation
Pt with TIA found to have afib
start warfarin
Pt with CA going for CABG - what other w/u needed?
Carotid US
If significant stenosis - carotid endarectomy FIRST
Pt with diplopia, dyarthria, dizziness - dx with verebrobasilar ischemia wtd?
ASA
Establish dx of vertebrobasilar ischemia with MRA posterior cranial vessels
Pt has occasional epistaxis esp when sneezing dx?
vWF dz
TPA criteria
Ischemic stroke with clearly defined sx onset
No IC bleed on HCT
<270 minutes sx onset to TPA
Exclusion crtieria for TPA
Rapidl improving sx Stroke or head trauna/major 3 months Major surgery w/in 14 days Suspected SAH despite normal CT head SBP>185/>110 on A/C PT>15, plt400
65yo M woke up in AM and THEN had stroke CT neg for bleed - presents within 3 to 4.5 hrs
TPA
70yo M h/o afib pw sudden onset wk one side CT neg wtd?
TPA
ASA 24-48 hrs later
65yo M found in AM in bed with stroke
NO TPA since duration unknown
Pt with ischemic stroke, time onset 60 min CT no bleed, BP 200/120 wtd?
Labetoll iV when BP <185.110 then TPA
Pt not taking HTN meds x 1 week - BP in office 240/130, h/a visual distrubances with hemianopsia, aura, cortical blindness MRI shows white matter edema in parieto-occiptal regions
Posterior Reversible Encephalopathy syndrome (PRES)
Started on nitroprusside - BP 140/90
-> taper nitroprusside
Pt with hemorrhagic stroke when should anti-HTN be started
BP>190/100
Pt with uncomplicated ischemic stroke not eligible for TPA when to start antiHTN
BP>220/120
Pt with ischemic stroke post tPA when to start anti-HTN
BP>170/100
ACA stroke
wk leg/foot WITH sensory loss
urinary incontinence
Primitive reflexes
MCA stroke
Parietal lboe (dominant) acalculia, agraphia, Lt/Rt disorientation, finger agnosia, tactile agnosia, paresthesia Temporal Lobe - aphasia Pariet laobe Right (non-dominant) -spatial neglect Unable to dress
PCA stroke
U/L homonymous hemianopia
I/L 3rd N palsy - webers’ syndrome
contralateral sensory abn
Lateral Medullary Syndrome (wallengberg)
I/L loss pain/temp from face I/L palsy upper and lower face I/L loss of lacrimationa nd salivation I/L loss of taste anti 2/3 tongue Vertigo, nystagmus, nausea, vomiting Tending to fall to same side, wavy images Hoarseness, dysphagia
Medial Medullary syndrome
Contralateral hemoparesis adn parastesia
affected eye looks down and toward nose
I/L tongue palsy
Basilar artery stroke
Hemiparesis, involutary shaking movement
Bulbar muscles invovlement with loss of fxn in throat - unable to move tongue - only eye movements present and called LCOKED IN SYDROME
Quadriplegia
Pt with right sided hemiplegia and sensory defeits - r hemianopsia and aphasia
L MCA
Pt with L foot and leg wk, urinary incontinence
R ACA
Pt with R side sensory abn, ptosis L eye, pupillary dilation
L PCA
Pt with diplopia, dysartria one sided wk with priorbital numbness and shakign/shivery moveemnts of affected limbs
Basilar artery
Pt with quadriplegia, cnat speak can’t put tongue out, eye movements ok
Basilar artery
Pt with dizziness, n/v, loss of pain/tmep sensation L half of face adn R side body, wavy lines, tends to fall to left while trying to sit up, hoarsemneess, dysphagia
Left Lateral Meduallary syndrome
32yo F no Pmhx p/w stroke - exam pain and tenderness over calk - etio?
PFO
45yo F lupus and Antiphospholipid syndrome with h/o DVT in past on warfarin PT 3.4 with TIA with R eye blury vision whic resolves in 10 min wtd?
Echo with bubble study
82yo M brought in with h/a and R wkness - CT hyperdense lesion in pareital area suggestive of subarachnoid hematoma BP 135/76 - no h/o trauma cause?
Amyloid angiopathy
Hepatopul syndrome
see bubbles q4 beats
Broca’s aphasia
non-fluent speech
CAN comprehend
Frontal lobe
MCA
Wernicke’s aphasia
fluent speech but non-sensical
Can’t comprehend
Temporal lobe
MCA
Conductive Aphasia
Can’t repeat
CAN comprehend and read
Global Aphasia
Sensory and motor aphasia
Branch of middle cerebral or internal carotid artery
Pure word blindness
can’t read - occipital lobe - PCA
Subarachnoid hemorrhage
Thunderclap headache, hit by hammer headache, worst h/a of life
nausea, vomiting, alter conciousness, neck stiffness, seizure, CNIII palsy wtd?
CTH -
If neg -> LP check for xanthochormia
LP neg? - MRA r/o reversible cerebral vasocontriction syndrome (tx’d with CCB)
Tx: Amlodipine
Best test to confirm prior to surgery: Cerebral angiogram
Complications of SAH
Rebleed 24hrs - 1 month
Vsaospasm 4 to 10 days
Hydrocephalus - late
Best drug to tx vasospam
Nifedipine
Best time to do surgery
ASAP - clipping or coiling for causative aneursym
1 week after aneurysm surgery stroke develops - cuase?
vasospasm induced infarct
Vertigo - Central
Cause - brainstem/cerebellar dz, MS, cerebellar atrophy, basilar infarct, arnold chiari malformation
Nystagmus - Horizontal OR vertical
Visual fixation - NO inhibition of nystagmus
Hearing loss/tinnitis +-
N/V - Pos
Severity - severe
Vertigo - peripheral
Cause - vestibular neuritis, labrythnthitis, Menier’s dz, benign positional vertigo
Nystagmus - ONLY horizontal
Visual fixation - inhibition of nystagmus
Hearing loss/tinnitus - labyrinthitis (vestibular nerutis - ), Menier’s dz +
N/V - very bad
Severity - very bad
Pt with vertigo and horizontal nystagmus - on visual fixation nystagmus dissappears - dx?
peripheral vertigo
Pt with vertigo/horizontal nytagmus - visual fixation negates nystagmus - - inovlvmenet of vestbular portion of 8th nerve with diziness lasting hours to days - no deafness - URI 1 week ago dx?
Vestibular neuritis (Labyrinthitis) Tx: Meclizine
35yo recurrent dizzziness and tinnitius and sensation fullness in ear for months aw n/v - exam horizontal nystagmus disappears with visual fixation - audiogram with hearing loss dx?
Meniere’s dz (tinnitus, hearing loss, vertigo)
Tx: Salt restriction, diuretics, surgical ablation
70yo M with new onset dizziness x 2 hours, BP high wtd?
MRA posterior vessels r/o brainstem stroke
Dx of benign positiional vertigo?
Dix halpike maneurver