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CCFP(EM) Omar > Neurology > Flashcards

Neurology Flashcards

1
Q

What are the triad associated with pseudotumor cerebri?

A

Papilledema<div>Chronic headache</div><div>Blindness</div>

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2
Q

Triad suggestive central vertigo

A

Vertical or rotators nystagmus

<div>Diplopia</div><div>Dysmetria</div>

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3
Q

Triad of Normal pressure hydrocephalus

A

Wet, Wobbly, Wacky<div>Urinary incontinence</div><div>Ataxia</div><div>Altered mental status</div>

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4
Q

“Triad of Wernicke’s encephalopathy”

A

Altered mental status<div>Ophthalmoplegia</div><div>Ataxia</div>

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5
Q

What features of nystagmus suggest central cause?

A

Vertical, rotatory, or horizontal nystagmus that changes directions is a sign of central vertigo

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6
Q

Pt with HA, what are the important elements in Hx to ask?

A

Onset (sudden, severe)<br></br>Duration<br></br>Location of pain (unilateral vs bilateral)<br></br>Character of pain (throbbing vs tension)<br></br>Associated symptoms (n/v, photo/phonophobia)<br></br>Focal Neurologic signs/symptoms<br></br>Fever or other systemic symptoms<br></br>Comorbidities (esp. hx of malignancy)<br></br>History of trauma<br></br>IV drug use, immunocompromised<br></br>Age of patient<br></br>Prior headache history<br></br>Sleep disturbance<br></br>FMHx of intracranial lesions, masses<br></br>Medication history

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7
Q

How much opening pressure to suspect IIH

A

> 250 mm of H2O/CSF

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8
Q

Describe the LP procedure:

A

Obtain informed consent<br></br>Position patient (lateral NOT sitting, given need to measure opening pressures)<br></br>Landmark L3-4 interspace with posterior superior iliac spines<br></br>Sterile prep<br></br>Sterile technique<br></br>Local anesthetic infiltration<br></br>Spinal needle (20-25 G) advanced through anesthetized area through dura<br></br>Collect CSF<br></br>Replace stylet<br></br>Remove spinal needle<br></br>Apply bandage

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9
Q

“<span>What one abnormality would be most consistent with Guillain-Barre Syndrome LP diagnosis?</span>”

A

Elevated protein

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10
Q

Treatment of Guillain-Barre syndrome

A

Intubation<div>IVIG</div><div>Plasmapheresis</div><div>Supportive care</div>

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11
Q

Wallenberg’s syndrome

A

The history of diplopia and dysphagia are concerning for abnormalities of posterior circulation and central vertigo. Wallenberg’s syndrome is also known as lateral medullary infarction, and is associated with <b>acute onset of disequilibrium and vertigo</b>.<div>The classic findings are:</div><div> <i>ipsilateral (to the infarct) horner syndrome (anhydrosis, miosis, and ptosis),</i></div><div><i> ipsilateral limb ataxia, and</i></div><div><i> loss of pain and temperature sensation on the contralateral limb.</i></div><div>Wallenberg’s syndrome typically occurs as a result of either traumatic vertebral artery dissection, or from long-standing atherosclerosis. (PICA)</div>

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12
Q

Bacterial Meningitis causes by age

A

“<img></img>”

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13
Q

Causes of isolated bilateral facial n. palsy

A

“Lyme disease<div>Guillain-Barre synd</div><div>Atypical Bell’s palsy</div><div>Sarcoidosis</div><div>Meningitis</div><div>Encephalitis</div><div>Leukemia</div><div>DM</div><div>HIV</div><div>Syphilis</div><div>EBV</div>”

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14
Q

Best imaging for IIH

A

MR brain with venography to exclude venous sinus thrombosis

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15
Q

<div><div>Which of the following physical exam findings is an indication for CT scan prior to lumbar puncture in a patient with suspected meningitis?</div></div>

<div><div><br></br></div><div><div><br></br></div></div></div>

A

Papilledema

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16
Q

Miller Fisher Syndrome (MFS)

A

“a variant of Guillain-Barre syndrome: <div> ophthalmoplegia,<div> ataxia, and</div><div> areflexia.</div><div>The clinical context of a recent diarrheal illness points to the most common precipitant of this <b>immune-mediated acute neuropathy: Campylobacter jejuni<span>.</span></b></div></div><div><b><span><br></br></span></b></div>”

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17
Q

Ddx for ophthalmoplegia/bulbar abnormalities

A

MS<div>Botulism</div><div>M.gravis</div><div>Miller Fisher syndrome</div><div>IC SOL (hge, infarct, tumor, aneurysm)</div>

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18
Q

Stroke by areas of the brain

A

” <strong>Area of the brain</strong> <strong>Artery</strong> <strong>Features</strong> Internal capsule (Lacunar stroke syndrome) Penetrating branchs of MCA or Basilar 5 subtypes Lateral frontoparietal, superior temporal MCA <ul> <li>contralateral hemianesthesia, hemiparesis, hemianopia with gaze preference;</li> <li>If dominant hemisphere: aphasia and apraxia; if nondominant hemisphere: aprosodia, hemineglect</li> </ul> Lateral medulla (Wallenberg syndrome) PICA <ul> <li>ipsilateral facial sensory loss, Horner’s syndrome, palatal weakness, dysphagia and ataxia,</li> <li>contralateral body pain and temperature loss</li> </ul> Medial frontoparietal lobes ACA <ul> <li>contralateral anesthesia, leg > arm hemiparesis, abulia</li> <li>If dominant hemisphere: mutism; if nondominant hemi- sphere: acute confusional state</li> </ul> “

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19
Q

Lacunar stroke:

A

” <strong>Type</strong> <strong>Area</strong> <strong>Features</strong> <p>Pure motor hemiparesis</p> Post limb of internal capsule <ul> <li>contralateral hemiparesis of face, arm, and leg</li> <li>Absence of sensory sympt</li> <li>Mild form of dysarthria</li> <li>Cortical signs like aphasia, cognitive deficit, or visual symptoms are always absent</li> </ul> <p>Pure sensory stroke:</p> Thalamus <ul> <li>absent or abnormal sensation of contralateral of face, arm, and leg</li> <li>The sensations affected are pain, temperature, touch, pressure, vision, hearing, and taste</li> <li>e.g:Dejerine Roussy syndrome</li> </ul> <p>Ataxic hemiparesis:</p> <p>internal capsule, pons, or corona radiata</p> <ul> <li>hemiparesis of the contralateral face and leg and ataxia of the contralateral limb.</li> <li>Ataxia is the prominent feature of this stroke.</li> </ul> <p>Dysarthria-clumsy hand syndrome</p> <p>pons or internal capsule</p> <ul> <li>dysarthria</li> <li>Contralateral clumsiness of the upper extremity with preserved motor strength</li> <li>difficulty with subtle fine movements such as writing or tying a shoelace may be present.</li> </ul> <p>A sensory-motor stroke</p> <p>thalamus, internal capsule, or putamen-capsule-caudate</p> <ul> <li>combination of ipsilateral sensory and motor loss</li> </ul> “

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20
Q

ECG Changes in raised ICP

A

Widespread giant T-wave inversion (cerebral T-wave)<div>OT prolongation</div><div>Bradycardia</div>

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21
Q

Rx of cluster HA

A

1st line:<div> High flow O2</div><div><br></br></div><div>2nd lines:</div><div> DHE</div><div> Sumitriptan</div><div> Intranasal lidocaine</div>

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22
Q

Important historical features for cauda equina syndrome:

A

<ul> <li>Onset/ progression of weakness/ falls</li> <li>Changes to voiding (urinary retention)</li> <li>Fecal incontinence</li> <li>Sensory symptoms (perineal or LE)</li> <li>Any known metastatic lesions</li> <li>Fever, night sweats, weight loss</li> <li>Erectile dysfunction</li> </ul>

<p>–Hx of malignancy, LE weakness, back pain <em>not accepted </em>– given in the stem and asked for “other features”</p>

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23
Q

Finings in examination in cauda equina synd

A

Midline tenderness<div>Motor weakness</div><div>Perianal anesthesia</div><div>Altered reflexes (early==>hypo, late==>hyper + babinski)</div><div>Ataxia</div><div>Decreased rectal tone</div><div>Plapable bladder</div>

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24
Q

<p>What is one bedside test you can order that will help you confirm your suspected diagnosis of Cauda equina synd?</p>

A

<p>–Post-void residual bladder scan/ POCUS</p>

<p>–>100-200mL – urinary retention</p>

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25
Q

<p>Name 3 other (non-malignant) causes of cauda equina/SCC</p>

A

<p>–Spinal epidural abscess</p>

<p>–Post operative hematoma/ iatrogenic</p>

<p>–Lumbar disk herniation</p>

<p>–Fracture/trauma</p>

<p>–Spinal stenosis</p>

<p>Ankylosing spondylitis</p>

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26
Q

TIA/Stroke mimics

A

“Migraine with aura<div>Seizures (Todd’s paralysis)</div><div>MS</div><div>Anxiety</div><div>Metabolic (hypoglycemia)</div><div>Htn encephalopathy</div><div>Structural brain lesions (malignancy)</div><div>Medication SE</div>”

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27
Q

Think outside the box, TIA and other features:

A

Check for chest pain, palpitation==>A.Fib<div>Neck pain==> carotid a dissection</div><div>Fever, new murmur==> endocarditis</div>

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28
Q

Mimics of post circulation

A

“Peripheral vestibular disturbance (BPPV, labrynthitis)<div>Vert a dissection</div><div>ETOH intoxication, Wernicke’s enceph</div><div>Hypoglycemia</div><div>Htn enceph</div><div>Malignancy</div><div>Transient global amnesia</div>”

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29
Q

What are the features of TIA that would increase the risk of later stroke?

A

<p>–Think: ABCD2 Score <em>– (still in Key Features)</em></p>

<ul> <li><strong>A</strong>ge: >60</li> <li>Initial <strong>B</strong>P: >140/90</li> <li><strong>*C</strong>linical: speech disturbance +/- unilateral weakness*</li> <li><strong>D</strong>uration: >10min vs >60 mins</li> <li><strong>D</strong>iabetic</li> </ul>

<p>–Very high risk:</p>

<ul> <li><strong>*</strong>Speech disturbance +/- unilateral weakness*</li> <li>Recurrent/ fluctuating symptoms</li> <li>Early presentation (within 48hrs)</li> <li>Previous CVA</li> </ul>

<div></div>

30
Q

What is the dose of tPA

A

0.9 mg/kg to a max of 90 mg<div>give 10% as bolus and the rest as infusion over 60 min</div>

31
Q

Reversal of anticoagulants:

A

Warfarin:<div> vit k 10 mg iv</div><div> FFP 2-4 units</div><div> prothrombin complex concentrate</div><div><br></br></div><div>Dabigatran:</div><div> Idarucizumab</div><div><br></br></div><div>Apixaban, rivaroxaban:</div><div> PCC</div><div><br></br></div><div>ASA, clopidogrel:</div><div> Plt transfusion if ongoing bleeding with plt <30,000</div>

32
Q

What are the early CT findings consistent with stroke?

A

“Hyperdense artery sign (acute thrombus in the vessel)<div>Sulcal effacement due to edema</div><div>Loss of insular ribbon</div><div>Loss of grey-white interface</div><div>Mass effect</div><div>Acute hypodensity</div><div><img></img><br></br></div>”

33
Q

Contraindications of tPA:

A

“<p><span><strong><span>ABSOLUTE</span>:</strong></span></p> <p><strong><span><em> History</em></span></strong></p> <p style="">a. Ever<br></br> i. ICH<br></br> ii. Brain neoplasm, AVM, aneurysm<br></br>b. Recent<br></br> i. Head trauma / prior stroke in last 3 months<br></br> ii. Intracranial or intraspinal surgery<br></br>c. Today<br></br> i. Use of warfarin, DOAC AND evidence of its bleeding diathesis effect</p> <p><strong><span><em>Exam</em></span></strong></p> <p style="">a. Symptoms suggest SAH<br></br>b. BP > 185/110<br></br>c. Active internal bleeding<br></br>d. Bleeding diathesis</p> <p><strong><span><em>Investigations</em></span></strong></p> <p style="">a. Blood glucose < 2.7 mmol/L<br></br>b. Plt count <100,000<br></br>c. Elevated aPTT<br></br>d. INR > 1.7 or PT > 15 sec<br></br>e. CT showing multilobar infarction<br></br></p> <p><span><strong>Relative (for the 3 and 3-4.5 hr window)</strong></span></p> <p><strong><span><em>History</em></span></strong></p> <p style="">a. Any oral anticoagulant<br></br>b. Older > 80<br></br>c. Hx of DB and prior ischemic stroke<br></br>d. Major surgery or serious trauma within 14 days<br></br>e. GI or GU hemorrhage in the past 21 days<br></br>f. MI in the last 3 months</p> <p><strong><span><em>Exam</em></span></strong></p> <p style="">a. Severe stroke (NIHSS > 25)<br></br>b. Minor or rapidly improving stroke symptoms</p> <p><strong><span><em>Labs</em></span></strong></p>”

34
Q

What is MCA sign?

A

Clot in M1 seg of MCA, may benefit from endovascular therapy

35
Q

“What is ““hypodensity > 50%”” of MCA?”

A

Means area of ischemia >1/3 of hemisphere<div>Increases the risk of bleeding with lysis</div><div>CI for tPA</div>

36
Q

<p>What physical features are more suggestive of a large vessel occlusion that may be amenable to intravascular thrombectomy?</p>

A

<p>–Motor weakness</p>

<p>–Visual defect</p>

<p>–Aphasia</p>

<p>–Neglect</p>

<p>(VAN or FAST-ED scores)</p>

37
Q

<p>What are 4 means to prevent elevations in ICP prior to impending herniation?</p>

A

<p>–Elevate HOB</p>

<p>–Remove constriction around neck</p>

<p>–Treat anxiety/pain/nausea</p>

<p>–Normoglycemia (insulin)</p>

<p>–Prevent hyperthermia/ cooling</p>

<p>–Paralysis</p>

38
Q

<p>What is a temporizing measure when there is concern for impending herniation?</p>

<p>–How does it work?</p>

<p>What negative effects could it have?</p>

A

” <strong>Temporizing agent</strong> <strong>Mech of action</strong> <strong>Disadvantage</strong> Hyperventilation to CO2 of 30 Cerebral vasoconstriction leading to decrease blood vol Brain ischemia Hypertonic Saline Osmotic diuresis Central pontine demyelination Mannitol 1g/kg iv (max 150g) Osmotic diuresis <p>Hypotension leading to decrease CPP</p> “

39
Q

Routes of Benzo other than iv:

A

Lorazepam 4 mg IO<div>Lorazepam 4 mg IN</div><div>Midazolam 10 mg IN/IM/buccal</div><div>Diazepam 10-20 mg PR</div>

40
Q

Dose of lorazepam iv in seizure:

A

2-4 mg iv q1-2 min up to 10 mg

41
Q

Seizures amenable to Rx

A

” <strong>Vital signs extremes</strong> Hypertensive emergencies Labetolol Hyperthermia Cooling Hypozia O2, intubation <strong>Metabolic</strong> HypoNa Hypertonic saline hypoglycemia dextrose HypoCa/Mg replace <strong>Toxicology</strong> TCA bicarbonate ETOH withdrawal Bnzo Digoxin digibind Anticholinergics bicarbonate INH pyridoxine <strong>Intracranial</strong> ICH neurosurgery SOL steroids <strong>Others</strong> Infection AB Eclampsia Mg sulfate, delivery “

42
Q

When would you avoid using phenytoin/fosphenytoin?

A

Unknown OD (Na channel blockade) may lead to torsade, VT, arrest<div>ETOH withdrawal</div>

43
Q

What are the benefits of fosphenytoin over phenytoin?

A

Can be infused at faster rate<div>Less hypotension/cardia arrh</div><div>Can be given IV</div>

44
Q

<p>In a patient with a first presentation seizure, what high-risk activities must be addressed?</p>

A

<ul> <li>Driving, including documentation to appropriate authorities</li> <li>Occupational: climbing, heavy equipment, factory equipment, etc</li> <li>Sports: swimming</li> </ul>

45
Q

<p>What clues can prompt you to add seizure to your Ddx in an unwitnessed event?</p>

A

<p>–Confusion/ altered mental status (post-ictal)</p>

<p>–Incontinence</p>

<p>–Tongue biting</p>

<p>–Falls/accidents/other injury patterns</p>

<p>–Amnesia of event</p>

46
Q

Forgotten causes of Headache

A

<ul> <li>Cavernous sinus thrombosis</li> <li>Vasculitis/autoimmune</li> <li>Internal carotid or vert a dissection</li> <li>Angle closure glaucoma</li> <li>Iritis/scleritis/uveitis</li> <li>HZV inf</li> <li>CO poisoning</li> <li>Pre-eclampsia</li> </ul>

47
Q

HA red flags:

A

Onset: sudden, worst<div>Course: progressive</div><div>Duration: variable</div><div>Timing: early morning, during strenous activity<br></br></div><div>Affecting factors: positional<br></br></div><div>Associated symptoms: fever, dizziness, focal weakness, ataxia, meningeal signs, neck/facia pain, ehe pain, vision changes, jaw claudication</div><div>Associated conditions: pregnancy, imm compr, IVDU, clotting dis, anticoagulation, trauma, multiple patients<br></br></div>

48
Q

HA PE red flags

A

Abn VS<div>ALOC</div><div>Focal neurological findings</div><div>Papilledema</div><div>Meningismus</div><div>Rash</div><div>Temporal area tenderness</div><div>Signs of trauma</div><div>Vertical or torsional nystagmus</div>

49
Q

CI to LP

A

Known SOL<div>Increased ICP</div><div>low plt/bleeding disorders/anticoagulation</div><div>Infection over the skin/epidural abscess</div>

50
Q

“Suspected features of Wenicke’s encep”

A

Hx of ETOH abuse<div>Ataxia</div><div>Horizontal nystagmus</div><div>Lateral rectus palsy</div><div><br></br></div>

51
Q

“What are the features of Korsakoff’s synd?”

A

Amnesia with confabulation<div>Intact sensorium</div><div>Intact long term memory</div><div>Usually permanent</div>

52
Q

Stroke by teritorry:

A

“<img></img>”

53
Q

ABCD2 Score

A

“<img></img>”

54
Q

Criteria for simple febrile seizure

A

<ul> <li>Age 6 months to 5 years,</li> <li>seizure must be generalized (non-focal),</li> <li>single seizure in 24 hours,</li> <li>seizure must last less than 15 minutes,</li> <li>normal neuro exam and with a return to baseline after a postictal state</li> </ul>

55
Q

CSF analysis

A

“<img></img>”

56
Q

Whatinterventions shows the most significant reduction in morbidity and mortality after a transient ischemic attack?

A

Carotid endartarectomy for stenosis >70%

57
Q

Organisms most causing Guillain-Barre syndrome

A

Campylobacter<div>Mycoplasma pneumonia</div>

58
Q

Central vs Peripheral vertigo

A

“<img></img>”

59
Q

Emergency reduction or raised ICP in case of IIH

A

Acetazolamide<br></br>Loop diuretics<br></br>Corticosteroids<br></br>Serial LPs to draine CSF

60
Q

“<span>What other physical exam findings would be considered red flags for headache?</span>”

A

-Abnormal vital signs (fever, HTN, etc)<br></br>-Altered mental status<br></br>-Cachexia<br></br>-Focal neurological findings<br></br>-Papilledema<br></br>-Meningismus<br></br>-Rash<br></br>-Temporal artery tenderness<br></br>-Signs of trauma<br></br>-Vertical or torsional nystagmus

61
Q

<p>Provide a differential diagnosis for delerium</p>

A

<p><strong>I</strong>nfection (sepsis, meningitis, encephalitis, neurosyphilis)</p>

<p><strong>W</strong>ithdrawal (EtOH)</p>

<p><strong>A</strong>cute metabolic (high Ca, Mg, Glu, Acidosis, hepatic or renal failure</p>

<p><strong>T</strong>rauma (head injury, burn)</p>

<p><strong>C</strong>NS pathology (abscess, hemorrhage, hydrocephalus, SDH, Infection, seizures, stroke, tumor, metastases, vasculitis)</p>

<p><strong>H</strong>ypoxia (acute or chronic lung disease or <strong>H</strong>ypotension</p>

<p><strong>D</strong>eficiencies (B12, Niacin, Thiamine)</p>

<p><strong>E</strong>nvironmental (hypo or hyperthermia) or <strong>E</strong>ndocrinopathies (DM, adrenal, thyroid)</p>

<p><strong>A</strong>cute Vascular (CVA, HTN emerg, SAH)</p>

<p><strong>T</strong>oxins (meds, EtOH, street drugs, pesticides, industrial poisons, CO, CN, solvents)</p>

<p><strong>H</strong>eavy metals (Lead, mercury)</p>

62
Q

<p>Describe Transverse Cord Syndrome</p>

A

“<p><img></img></p> <ul> <li>Sensory: Below Lesion</li> <li>Motor : Below lesion</li> <li>Loss of Sphincter control</li> </ul>”

63
Q

<p>Describe Brown-Sequard Syndrome</p>

A

“<p><img></img></p> <ul> <li><strong>Sensory</strong>:</li> </ul> <p>–<em>Ipsilateral position & vibration</em></p> <p><em>–Contralateral pain & temp</em></p> <ul> <li><strong>Motor</strong>:</li> </ul> <p>–<em>Ipsilateral motor loss</em></p> <ul> <li><strong>Sphincter</strong>:</li> </ul> <p><em>Variable</em></p>”

64
Q

<p>Describe Central Cord Syndrome</p>

A

“<p><img></img></p> <ul> <li>Hyper extension of the C-spine (MVC, Diving)</li> <li>Sensory:</li> </ul> <p>–Variable</p> <ul> <li>Motor:</li> </ul> <p>–Upper Extremity > Lower</p> <p>–Distal> Proximal</p> <ul> <li>Sphincter:</li> </ul> <p>–Variable</p> <ul> <li>PEARL: (<strong>MUD)</strong></li> </ul> <p>–<strong>M </strong><strong>otor</strong><strong> > Sensory</strong></p> <p>–<strong>U </strong><strong>pper</strong><strong> > Lower</strong></p> <p><strong>D </strong><strong>istal</strong><strong> > Proximal</strong></p>”

65
Q

<p>Describe Anterior Cord Syndrome</p>

A

“<p><img></img></p> <ul> <li>Sensory:</li> </ul> <p>–Loss of pain & temperature</p> <p>–Vibration and position preserved</p> <ul> <li>Motor:</li> </ul> <p>–Loss or weakness below level</p> <ul> <li>Sphincter:</li> </ul> <p>Variable</p>”

66
Q

<p>dDx of flaccid paralysis</p>

A

<ul> <li><strong>Ascending</strong></li> </ul>

<p><em>Guillane Barre</em></p>

<p><em>Tick Paralysis</em></p>

<p></p>

<ul> <li><strong>Descending</strong></li> </ul>

<p><em>Myasthenia Gravis</em></p>

<p><em>Botulism</em></p>

<p><em>Multiple Sclerosis</em></p>

67
Q

What are the CNS complications commonly seen in pts surviving SAH

A

Rebleeding<br></br>Vasospasm<br></br>Acute hydrocephalus

68
Q

Very High Risk for Recurrent Stroke (Symptom onset within last 48 Hours):

A

<ol> <li>Transient, fluctuating or persistent unilateral weakness (face, arm and/or leg);</li> <li>Transient, fluctuating or persistent language/speech disturbance;</li> <li>And/or fluctuating or persistent symptoms without motor weakness or language/speech disturbance (e.g. hemibody sensory symptoms, monocular vision loss, hemifield vision loss, +/- other symptoms suggestive of posterior circulation stroke such as binocular diplopia, dysarthria, dysphagia, ataxia).”</li></ol>

69
Q

“<div><b><span>Which TIA patients need an urgent echocardiogramand/or holter monitor?</span></b><b></b></div>”

A

<div>1. Patients with known heart disease including rheumatic heart disease, heart failure, severe valvular disease, severe CAD or history of MI.</div>

<div>2. Patients with no obvious cause of their TIA and no classic risk factors to identify an underlying cause of their TIA such as paroxysmal atrial fibrillation, severe valvular disease including endocarditis, PFO etc.</div>

70
Q

What conditions are associated with an increased incidence of berry aneurysms?

A

Family history, <br></br>coarctation of the aorta, <br></br>polycystic kidney disease, <br></br>Marfan syndrome, and <br></br>Ehlers-Danlos syndrome

71
Q

<div><b><u>Carotid Artery Dissection</u></b></div>

A

“<img></img>”

72
Q

<div>What is the pathognomonic finding for subarachnoid hemorrhage on funduscopic exam?</div>

A

“<span>Retinal subhyaloid hemorrhage</span> is seen in 11–33% of cases”

CCFP(EM) Omar (27 decks)

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