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Neurology Flashcards

1
Q

What are the symptoms of a lateral medularry syndrome (Wallenberg)

A
  1. Ipsilateral ataxia
  2. Ipsilateral horners
  3. Ipsilateral face loss of pain/temp sense
  4. Controlateral body loss of pain/temp sense
  5. Vertigo and nystagmus
  6. Dysphagia and horseness
  7. hiccups
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2
Q

What vessel is involved in Wallnenbergs

A

PICA or vertebral

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3
Q

What are the symptoms of a medial medullary syndrome?

A
  1. Ipsilateral tongue weakness
  2. Controlateral arm and leg weakness
  3. Controlateral body vibration and proprioception loss
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4
Q

What vessel is involved in medial medullary syndrome?

A
  1. Anterior spinal artery
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5
Q

What are the symptoms of a midbrain stroke. (Weber)

A
  1. Ipsilateral cranial nerve 3 palsy
  2. Controlateral hemiplegia
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6
Q

What vessel is involved in weber syndrome

A

PCA

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7
Q

What are the symptoms of an ACA stroke?

A
  1. Contralateral leg weakness
  2. Contralateral leg numbness
  3. Contralateral grasp reflex
    1. Other frontal signs
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8
Q

What are the symptoms of a Left MCA stroke in the superior branch

A
  1. Broca’s aphasia
  2. Right weakness in face & arms > legs
  3. Gaze deviation to the left
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9
Q

What are the symptoms of a left MCA stroke in the inferior branch?

A
  1. Wernicke’s aphasia
  2. Right cortical sensory loss
  3. Right “pie in the sky”
    1. R homonymous superior quandrantonopsia
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10
Q

What are the symptoms of a left MCA stroke in the main branch?

A
  1. Combination of supperior and inferior branch MCA stroke
  2. Global aphasia
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11
Q

What are the symptoms of a right MCA stroke, superior branch?

A
  1. Left weakness: Face + arm
  2. Gaze deviation to right
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12
Q

What are the symptoms of a right MCA stroke in the inferior branch?

A
  1. Left cortical sensory loss
  2. Left hemineglect
  3. Left “pie in the sky”
    1. left homonymous superior quandrantonopsia
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13
Q

What are the symptoms of a right MCA stroke in thee main branch?

A

Combination of supperior and inferiot branch

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14
Q

What are the symptoms of a PCA stroke

A

Controlateral homonymous hemianopsia

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15
Q

What types of stroke can cause pure motor symptoms. What artery is associated with each

A
  1. Lacunar strokes
    1. Posterior limb internal capsule
      1. Anterior choroidal
    2. Corona Radiata
      1. Small MCA branch
    3. Midbrain – cerebral peduncle
      1. Small PCA branch
    4. Ventral pons
      1. Basilar
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16
Q

What stroke causes pure sensory deficits and what artery is involved?

A
  1. Thalamus
    1. thalamoperforators from PCA, MCA
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17
Q

What workup should be done for a non-disabling stroke presenting >24hrs to an outpatient setting?

A
  1. CT or MRI head
  2. Ideally CTA or MRA of aortic arch to vertex
    1. Carotid dopplers are ok but can miss intracranial disease or posterior circulation problems
  3. Basic BW
    1. CBC
    2. lytes
    3. PTT, INR
    4. Cr
    5. Glucose
    6. Lipids
    7. A1C
  4. ECG
  5. Holter ≥24hrs
    1. 2 weeks if suspicion of cardioembolic disease
  6. If suspected embolic stroke or TIA of uncertain cause, ECHO
    1. If <60, bubble study for ?PFO
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18
Q

How should a patient presenting to the ER with stroke symptoms since less that 24hrs be worked up?

A
  1. Immediate evaluation for tPA or EVT
  2. ABCs + NIHSS + evaluate/treat seizures if present
  3. Basic bloodwork
    1. CBC
    2. Lytes/cr
    3. glucose
    4. INR/PTT
  4. Imaging
    1. If Sx <4.5 hrs
      1. CT head. Determine if tPA candidate
    2. If Sx < 6 hrs
      1. CT, CTA arch to vertex, determine if EVT candidate
    3. if Sx 6-14hrs and eligible for late window EVT
      1. CT, CTA, CT Perfusion
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19
Q

What are the tPA inclusion criteria?

A
  1. Ischemic stroke causing disabling neurological deficits in patient > 18 years old
  2. Time from last known well <4.5 hrs
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20
Q

What are the absolute tPA exclusion criteria

A
  1. Any source of active hemorrhage
  2. Any condition that can increase the risk of major hemorrhage with tPA
    1. If on DOAC, cannot give tPA (Can still get EVT)
  3. Any hemorrhage on brain imaging
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21
Q

What are the relative tPA exclusion criteria?

A
  1. Historical
    1. Hx intracranial hemorrhage
    2. Stroke or serious head or spinal trauma in last 3 months
    3. Major surgery, such as cardiac, thoracic, abdominal, orthopedic in last 14 days. risk varies by procedure
    4. Arterial puncture at non-compressible site in last 7 days
  2. Clinical
    1. Sx suggestive of subarachnoid hemorrhage
    2. Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd’s paralysis or focal neuro signs 2/2 severe hypo/hyper glycemia
    3. Hypertension refractory to aggressive hyperacute antihypertensive Tx such that target BP 180/105 cannot be achieved or maintained.
  3. CT MRI findings
    1. early signs of extensive infarction
  4. Lab
    1. BG <2.7 or above 22.2
    2. Elevated APTT
    3. INR>1.7
    4. plt <100
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22
Q

What is considered a dissabling neurological deficit in the context of stroke?

A
  1. Judgement call biu in general:
    1. NIHSS ≥6
    2. Dissabling =
      1. aphasia
      2. hemianopsia
      3. weakness limiting sustained effort against gravity
      4. visual/sensoory extinction
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23
Q

What are the EVT inclusion criteria?

A
  1. >18 years of age
  2. Dissabling stroke AND functionally independent AND life expectancy >3 months
  3. <6hrs from Sx onset or last known well
    1. 6-24hrs in highly selected patients (clinical and imaging criteria)
  4. CT head: small to moderate ischemic core
  5. CTA showing occlusion in the anterior circulation of proximal large vessels (distal MCA or ICA)
    1. No evidence for EVT in proximal posterior circulation stroke but can consider it for basilar thrombus because of the high risk of morbidity/mortality
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24
Q

What are the target blood pressures in acute ischemic stroke

A
  1. tPA: 180/105 for 24hrs
  2. tPA and EVT: 180/105 for 24hrs
  3. no tPA: 220/120
  4. EVT only: Whatever the EVTer wants… ?220/120
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25
Q

When should ASA get started after tPA

A

24hrs post

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26
Q

When should ASA be started in stroke patients not getting tPA

A

Right away

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27
Q

Who should get DAPT following an acute ischemic stroke? For how long?

A
  1. High risk TIA (ABCD2≥4) or minor score (NIHSS≤3) of non-cardioembolic origin
    1. For 21-30 days
  2. Severe intracranial atherosclerosis
    1. TIA or stroke in last 30 days
    2. 70-99% stenosis in major intracranial vessel
    3. Low bleeding risk
    4. DAPT x 3 months

*start ASAP after brain imaging. Ideally 12-24 hours

*ASA + Plavix. Ticagrelor also acceptable now

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28
Q

What can you do if a patient has a stroke while already on an antiplatelet agent

A
  1. If on ASA, consider switch to plavix monotherapy
  2. If on plavix, consider switch to ASA/Dipyridamole

Very little evidence of benefit

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29
Q

When should carotid endarterectomy be considered in patients following acute stroke?

A
  1. In men with 50-99% stenosis and women with 70-99% stenosis
    1. CEA recommended, do ASAP, ideally within 48hrs
      1. Within 2 weeks if not stable in first 48hrs
  2. In women with 50-69% stenosis
    1. CEA can be considered in those at highest risk of stroke recurrence and upon consideration of other factors
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30
Q

Should CEA be considered in asymptomatic or remotely symptomatic (>6 months) carotid stenosis?

A
  • If stenosis 60-99% and life expectancy >5 years
    • Should be evaluated by stroke expert and CEA can be considered in select patients

* in most cases, max medical management

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31
Q

How should a symptomatic carodid with stenosis <50% be managed?

A

Max medical management

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32
Q

In patients with cardioembolic strokes 2/2 AF, how soon after the stroke should anticoagulation be started?

A
  1. No trial evidence
    1. TIA <1 day
    2. mild/small stroke: 3 days
    3. moderate stroke: 6 days
    4. severe/large stroke: 12 days
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33
Q

What factors would favor delaying initiation of DOACS after cardioembolic stroke and what factors would favor starting them earlier?

A
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34
Q

How should anticoagulation be managed if a patient has a stroke while on anticoagulation?

A
  1. Reasonable to switch to a different OAC or to continue with the same one
  2. Do not add ASA
  3. Identify and address medication non-adherence
  4. ensure correct DOAC dosing or therapeutic iNR if on warfarin
  5. Look and avoid DOAC drug-drug interactions
  6. Investigate for and treat other potential stroke etiologies
  7. Promote general; vascular risk factor modification
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35
Q

List broad steps that should be taken for secondary prevention of stroke

A
  • BP management
  • Lipid management
  • DM management
  • lifestyle management
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36
Q

How is long-term blood pressure managed after a stroke?

A
  1. Target BP <140/90
    1. If small subcortical stroke sBP<130
    2. Diabetic <130/80
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37
Q

How are lipids managed after a stroke?

A
  1. Check lipid profile
  2. Start statin on everyone
  3. LDL target <1.8
    1. If LDL <1.8 despite max statin, start ezetimibe or consider PCSK9 inhibitor if atherosclerotic CV disease
    2. If on statin and TG still>1.5 with atherosclerotic CV disease or DM, consider icosapent ethyl 2g BID
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38
Q

How is DM managed after a stroke?

A
  1. Chek fasting BG, A1C or 75gOGTT
  2. Target A1C ≤ 7
  3. If A1C above target despite standart OHA, consider SGLT2 or GLP-1
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39
Q

What are the lifestyle management recommendations after an acute stroke?

A
  1. Diet
    1. High in fruits and vegetables
    2. Low in fat, dairy, fibre
    3. Protein from plant source
    4. low trans/saturated fats
    5. Low cholesterol
    6. *mediterrenean type diet
  2. Low sodium (<2g/day)
  3. Exercise = moderate dynamic exercise 4-7days/week
  4. BMI 18.5-25
    1. Waist circumference 88cm F 102 cm M
  5. Alcohol
    1. M <15d/week, F<10d/week
  6. Stop smoking
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40
Q

What should be done after a stroke attributed to a PFO?

A
  1. PFO + antiplatelets>antiplatelets alone in carefully selected patients with following characteristics
    1. age 18-60
    2. Stroke that is non-lacunar
    3. Stroke specialist thinks PFO is most likely cause of stroke after thorough evaluation to exclude other causes
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41
Q

What are the risk factors for post-stroke depression?

A
  1. Stroke severity
  2. functional dependence
  3. cognitive impairement
  4. Hx of depression
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42
Q

When should patients be screened for post-stroke depression?

A
  1. in the acute setting and at transition points
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43
Q

How is post-stroke depression treated?

A
  1. For mild depression, watchfull waiting x2-4 weeks is ok
  2. Otherwise:
    1. CBT or IPT
    2. SSRI
    3. If effective treat for 6-12 months
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44
Q

What should be done in patients with a stroke in the context of active malignancy?

A
  1. Stroke may be due to hypercoagulable state
    1. Consider anticoagulation over antiplatelet
    2. LMWH is preferred, role of DOAC under study
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45
Q

How should cerebral artery dissection causing stroke be managed?

A
  1. Antiplatelets or anticoagulants reasonable in extracranial carotid or vertebral dissection – Most experts anticoagulate (3-6 months) if symptomatic, antiplatelets if asymptomatic. If there is a floating thrombus on CTA, anticoagulate 3-6 months
    1. Lack of evidence regarding treatment duration
    2. Lack of evidence regarding DOAC use
  2. Lack of evidence for anticoagulation in intracranial dissection
    1. Most experts use antiplatelets
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46
Q

What is a stroke in the young and what are the 2 most common causes?

A
  1. Stroke in patient <55 years old
  2. Very broad differential
  3. 2 most common causes :
    1. cardioembolic
    2. dissection
  4. Most important RF remain HTN, DLP, smoking
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47
Q

What imaging modality should be used to determine the etiology of an intracranial hemorrhage?

A
  1. CTA (better than MRA)
  2. Consider MRI to look for mayloid angiopathy, mass, AVM, AVF
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48
Q

What are the blood pressure targets in acute ICH?

A
  1. SBP <140-160 for first 24-48 hrs
    1. Favor 140 if onset <6hrs ago, anticoagulation Tx, Markers of ICH expansion, presenting w SBP <220
  2. Long term BP target
    1. <130/80 on home monitoring
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49
Q

When should you call neurosurgery in the case of an ICH?

A
  1. ALWAYS
  2. Consider external ventricular drainage if decreased LOC and hydrocephalus
  3. Noo indication for surgery if stable and no sign of herniation
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50
Q

What causes rest tremors

A
  1. PD
  2. -Other parkinsonism
    1. Drug induced
    2. LBD
    3. vascPD
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51
Q

What causes action tremors?

A
  1. Postural
    1. Enhanced physiologic tremor
    2. Essential tremor
    3. Dystonic tremor
  2. Kinetic/intention
    1. Lithium
    2. Cerebellar disease (MS, Stroke, etc…)
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52
Q

How can a tremor be examined?

A
  1. Check with arms at rest
    1. add cognitively distracting task
  2. Check with arms outstretched
  3. Check with finger-to-nose
  4. Check with water pouring task
  5. Look at the company the tremor keeps
    1. Masked facies, hypophonia, rigidity=PD
    2. +ve fam. history, improved with alcohol = ET
    3. Head tilt and head tremor = Dystonic tremor
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53
Q

Compare PD tremor to ET tremor on the following points:

  • Frequency
  • Symmetry
  • FHx
  • response to levodopa
  • Response to alcohol
  • Level of impairment
  • Association with writing
A
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54
Q

Describe an enhanced physiologic tremor

A
  1. High frequency
  2. small amplitude
  3. symmetrical
  4. postural, not at rest
  5. enhanced by caffeine, anxiety, stress, hyperT4, drugs, ETOH withdrawl
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55
Q

Describe a dystonic tremor

A
  1. Seen in patients with dystonia when they “fight” their dystonic posture
  2. Occurs in head and hands
  3. asymmetrical and irregular
  4. postural, not at rest
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56
Q

Describe a cerebella tumor

A
  1. Intention tremor (can also be postural)
  2. Can be associated with other cerebellar signs
    1. Dysdiadochokinesia
    2. Gait ataxia
  3. If asymmetrical, sudden onset
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57
Q

What is the most likely etiology of cerebellar tremors by age group

A
  1. Young patient
    1. Wilson’s
    2. MS
  2. Old patient with vascular risk factors
    1. Stroke
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58
Q

Describe a psychogenic tremor

A
  1. Rest OR posture OR intention OR a mix of all 3
  2. Irregular
  3. VAriable frequency and amplitude
  4. Distractible
  5. Entrainable
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59
Q

What is parkinsonism ?

A
  1. Akinesia/Bradykinesia
    1. Slowness, fatigability, decrement in size of repetitive movements
  2. Rigidity
  3. Tremor
    1. Rest tremor
  4. Postural instability
    1. Festinant gait: Short shuffling steps, reduced arm swing, sometimes camptocormic, later freezing (in narrow spaces or doorways)
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60
Q

What is the DDX of parkinsonism?

A
  1. PD
  2. Parkinson plus conditions
    1. LBD
    2. PSP
    3. MSA
    4. CBD (renamed CBS)
  3. Vascular parkinsonism (stroke)
  4. Drug induced parkinsonism
    1. Anti-psychotics
    2. Metoclopramide
  5. Genetic
    1. Wilson’s
  6. Toxins
    1. Manganese
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61
Q

What are the diagnostic criteria for idiopathic parkinsons disease?

A
  1. Parkinsonism
  2. Absence of absolute exclusion criteria
  3. Two supportive criteria
  4. no red flags
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62
Q

What are the absolute exclusion criteria in idiopathic parkinsons disease?

A
  1. Cerebellar abnormalities (Think MSA)
  2. Downward vertical gaze palsy/slowing of vertical sacades (Think PSP)
  3. Diagnosis of FTD
  4. Exclusively lower extremity parkinsonism x3years (think vascular PD)
  5. Treatment with a dopamine receptor blocker (think drug induced PD)
  6. Absence of observable response to levodopa
  7. Cortical sensory loss, apraxia or aphasia (think CBD)
  8. Normal functional neuroimaging of the dopaminergic system
  9. Documentation of an alternative diagnosis that can cause parkinsonism
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63
Q

What are the supportive criteria for a diagnosis of Parkinson’s disease?

A
  1. Clear response to L-Dopa
  2. Presence of L-Dopa induced dyskinesia
  3. Rest tremor of a limb
  4. Documented olfactory loss or cardiac sympathetic denervation on MIBG scintigraphy
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64
Q

List red flags that a person does not have idiopathic PD?

A
  1. Rapid gait impairment requiring wheelchair within 5y of onset.
  2. Complete absence of progression of motor symptoms
  3. Ealy bulbar dysfunction
  4. Stridor
  5. Severe autonomic failure in first 5 years of onset
  6. Recurrent falls within 3 years of onset
  7. Anterocollitis
  8. Absence of common non-motor symptoms despite 5 years of disease
  9. Pyramidal signs
  10. Bilateral symmetric Parkinsonism
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65
Q

How does idiopathic parkinson disease usually progress?

A
  1. Preceding illness
    1. Anosmia
    2. REM-sleep behavior sleep disorder
    3. constipation
  2. Early illness
    1. Asymmetric tremor
    2. asymmetric bradykinesia
    3. asymmetric rigidity
  3. Late illness
    1. Postural instability/falls
    2. non-motor manifestations
      1. Dementia
      2. Visual hallucinations (can also be from meds)
      3. Autonomic dysfunction=postural hypotension (can also be from meds)
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66
Q

What are the medications used to treat PD and what are their indications and mechanisms of action?

A
  1. Levodopa/carbidopa
    1. Indication: PD motor symptoms
    2. Converts to dopamine in CNS
  2. Pramipexole
    1. Indications: PD motor symptoms
    2. Dopamine agonist
  3. Trihexyphenidyl
    1. Indication: Tremor
    2. anticholinergic
  4. Segeline
    1. Indication: PD motor Sx
    2. MAO-B inhibitor
  5. Entacapone
    1. Prolongs action of L-Dopa
    2. COMT inhibitor
  6. Amantadine
    1. Indication: Dyskinesia
    2. Multiple mechanisms
  7. Domperidone
    1. Indication: Orthostatic hypotension
    2. Dopamine antagonist in the gut
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67
Q

What are side effects of Levodopa/carbidopa?

A
  1. Non-motor
    1. N/V
    2. Orthostatic hypotension
    3. Sedation
    4. Confusion
    5. Hallucinations
  2. Motor
    1. Dyskinesias
  3. Special
    1. Dopa dysregulation (addictions)
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68
Q

What are side effects of Pramipexole?

A
  1. Same as L-Dopa
    1. More orthostatic hypotension
    2. More sedation (sleep attacks)
    3. more Hallucinations
    4. More ICD (gambling, sexuality, shopping, eating)
  2. Leg swelling
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69
Q

What are side effects of Trihexyphenidyl?

A
  1. Anticholinergic
    1. Confusion
    2. Dry eyes
    3. blurry vision
    4. dry mouth
    5. constipation
    6. urinary retention
  2. Memory difficulties
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70
Q

What are side effects of Selegeline?

A
  1. Above 10mg
    1. HTN crisis after tyramine rich foods
      1. Aged cheese
      2. sausage
      3. red wine
    2. Theoretical risk of serotonin syndrome
    3. alerting
    4. insomina
    5. hallucinations
    6. dry mouth
    7. hypotension
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71
Q

What are side effects of Entacapone?

A

Same side effects as increasing Levodopa/carbidopa but also orange urine

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72
Q

What are side effects of Amantadine?

A
  1. Anticholinergic
    1. confusion
    2. dry eyes
    3. blurry vision
    4. dry mouth
    5. constipation
    6. urinary retention
  2. Insomnia
  3. Livedo reticularis
  4. hallucinations
  5. contraindicated in patients with seizures
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73
Q

What are side effects of Domperidone?

A

Prolongs QT (if above 10mg TID)

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74
Q

Compare Levodopa, Dopamine agonists and MAO-B inhibitors with regards to their effects on motor symptom improvement, motor complications and other adverse events

A
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75
Q

What treatments can be offered to help the non-motor features of parkinsons?

A
  1. Botox helps with drooling
  2. Midodrine, fludrocortisone and domperidone can help with orthostatic hypotension
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76
Q

When should palliative care be involved in PD?

A

In all stages

MAID can be discussed if patient brings it up

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77
Q

What are the clinical features of drug induced parkinsonism?

A
  1. Symetric parkinsonism
    1. Rigidity/bradykinesia
  2. Tremor usually postural > rest
  3. Commonly within weeks to months of onset of drugs
  4. reversible over months
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78
Q

What are the clinical features of vascular parkinsonism?

A
  1. Patient with vascular risk factors, multiple small strokes and stepwise worsening
  2. Symmetrical parkinsonism
  3. “Lower body parkinsonism”
  4. Falls common
  5. Pyramidal signs
  6. Many have dementia and incontinence (looks like NPH)
  7. Tremor not common
  8. Poor response to levodopa
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79
Q

What are the clinical features of multi-system atrophy?

A
  1. Symmetric parkinsonism
  2. No tremor
  3. Early falls
  4. Dysautonomia
    1. orthostasis
    2. erectile dysfunction
    3. incontinence
  5. Ataxia (in MSA-C)
  6. Pyramidal signs
  7. Stridor
  8. Distal myoclonus
  9. No response to levodopa (produces orofacial dyskinesia)
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80
Q

What are the clinical features of progressive supranuclear palsy?

A
  1. Symmetrical parkinsonism
  2. Axial rigidity more than limb
  3. No tremor
  4. Early falls
  5. Vertical supranuclear gaze paresis
  6. Hyperfrontalis (wide-eyed stare)
  7. Severe dysarthria
  8. Mild dementia (frontal lobe dysfunction)
  9. Poor response to levodopa
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81
Q

What are the clinical features of Cortico-Basal degeneration (CBD, now CBS)?

A
  1. Markedly asymmetric parkinsonism
  2. Dystonia
  3. Myoclonus (action or tactile stimulated)
  4. Apraxia
  5. Aphasia
  6. Cortical sensory loss
  7. Alien limb phenomenon
  8. No response to levodopa
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82
Q

What are the clinical features of lewy body dementia?

A
  1. Worstening with antipsychotic medications
  2. Symmetric parkinsonism
  3. Temors
  4. Early dementia (frontal and visuospatial)
  5. Fluctuating attention (good days and bad days)
  6. Visual hallucinations
  7. Some response to levodopa (but can worsten visual hallucinations)
  8. REM behavior sleep disorder
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83
Q

What is associated with a cherry-red spot on ophthalmoscopy?

A

Central retinal artery occlusion

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84
Q

What is associated with bilateral disc edema on ophthalmoscopy?

A

Likely papilledema

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85
Q

What is associated with unilateral disc enema and pain on ophthalmoscopy?

A

Acute optic neuritis

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86
Q

What is associated with a pale disc on ophthalmoscopy?

A

Prior optic neuritis

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87
Q

What is associated with a large cup-disc ratio and pale disc on ophthalmoscopy?

A

Glaucoma

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88
Q

What do you expect to see on ophthalmoscopy in diabetic retinopathy?

A
  1. Cotton wool spots
  2. microaneurysms
  3. Hard exudates
  4. Neovascularisation
  5. flame hemorrhages
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89
Q

What do you expect to see on ophthalmoscopy in hypertensive retinopathy?

A
  1. Cotton wool spots
  2. hard exudates
  3. flame heomrrhages
  4. AV nicking
  5. copper wiring
  6. disc edema
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90
Q

What do you expect to see on ophthalmoscopy in infective endocarditis?

A

Roth spots

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91
Q

What cranial nerves traverse the cavernous sinus?

A
  1. CN III
  2. CN IV
  3. CN V1, V2
  4. CN VI
  5. Sympathetics
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92
Q

What 5 questions should you ask to better caracterise diplopia

A
  1. Monocular or binocular
    1. Mono=Psych or ophtalmo
    2. Binocular=neurology
  2. Images horizontal, vertical or oblique to each other
    1. Horizontal: 6th nerve palsy
    2. Vertical: 4th nerve palsy
    3. Oblique: 3rd nerve palsy
  3. Diplopia worst when looking near or far
    1. Near; 3rd o 4th nerve palsy
    2. Far: 6th nerve palsy
  4. Diplopia worst when looking up, down, left or right
    1. Left or right: 6th nerve palsy
    2. Up and down: 3rd or 4th nerve palsy
  5. Associated symptoms
    1. ptosis
    2. Eye pain
    3. headache
    4. vision loss
    5. recent trauma
    6. other CN involvements
    7. fluctuations
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93
Q

Differentiate 3rd nerve palsy from horner’s syndrome

A
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94
Q

What are the possible localisations and etiologies of binocular diplopia?

A
  1. Extraoccular muscle (thyroid eye disease)
  2. NMJ (MG)
  3. CN 3, 4, 6 anywhere including cavernous sinus
    1. Ischemic, compressive, infectious, inflammatory, infiltrative…
  4. Nucleus of CN 3, 4, 6
  5. Internuclear pathways in brainstem
    1. Stroke, MS causing INO
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95
Q

Differentiate ischemic from compressive 3rd nerve palsy.

Who needs a CTA?

A

Complete 3rd nerve palsy with spared pupil= no CTA

partial 3rd nerve palsy with spared pupil=do CTA

Pupil involved=CTA

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96
Q

What triad is associated with Horner’s syndrome?

A
  1. Ptosis
  2. Miosis
  3. Anhidrosis (if 1st or 2nd order neuron damaged)
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97
Q

What is the DDx of Horner’s syndrome?

A
  1. 1st order neuron
    1. Stroke
    2. Demyelination
    3. tumor
  2. 2nd order neuron
    1. T1 radiculopathy
    2. Pancoast tumor
  3. 3rd order neuron
    1. Carotid dissection/aneurysm
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98
Q

How should horner syndrome be investigated?

A
  1. 1st order neuron
    1. MRI brain
  2. 2nd order neuron
    1. MRI c-spine
    2. CT chest
  3. 3rd order neuron
    1. CTA neck + brain
99
Q

What are the possible locations and ethiologies for 6th nerve palsy?

A
  1. Brainstem
    1. Stroke
    2. Demyelination
    3. tumor
  2. Cavernous sinus
    1. Fistula
    2. aneurysm
    3. dissection
    4. pituitary tumor
    5. inflammation
    6. infection
  3. False localizing
    1. ICP from tumor
    2. IIH
    3. VST
    4. Trauma
  4. Anywhere else along the course of the nerve
    1. Ischemia
100
Q

What investigations should be sent in 6th nerve palsy?

A
  1. CT/CTA intracranial vessels
    1. cavernous sinus pathology
  2. MRI brain with GAD
    1. Tumor/inflammation/infection
  3. MRI brain with MRV or CTV (for VST) then LP (IIH)
101
Q

What are red flags that something is NOT a peripheral neuropathy?

A
  1. Pure motor syndrome
    1. Usually myopathy, NMJ, AHC
102
Q

What are the symptoms of a usual common polyneuropathy

A
  1. Chronic
  2. Distal/lenght-dependant
  3. symmetric
  4. sensory and motor
  5. sendory>motor
  6. Large fiber sensory>small fiber sensory
  7. Tingling precedes numbness
  8. Cramps precede weakness
  9. axonal (can determine by EMG/NCS)
103
Q

What is the differential for usual common polyneuropathy?

A
  1. Idiopathic sensory neuropathy of the elderly (ISNE)
    1. >60
  2. Metabolic/endocrine
    1. DM
    2. B12
    3. Thyroid
    4. kidney/liver disease
  3. Toxic
    1. ETOH
    2. Chemotherapy
    3. Heavy metals
  4. Genetic
    1. charcot-marie-tooth type 2
  5. Rarely (more monooneuritis multiplex)
    1. Inflamatory
      1. SLE
      2. Sjogrens
      3. RA
      4. Sarcoidosis
    2. Vasculitis
      1. GPA
      2. eGPA
      3. PAN
    3. Infectious
      1. HIV
    4. Neoplastic
      1. Lymphoma
      2. Leukemia
    5. Paraprotein
      1. AMyloidosis
      2. MM
104
Q

What investigations should be performed in the usual common polyneuropathy?

A
  1. EMG/NCS
  2. Bloodwork
    1. CBC
    2. Cr
    3. A1C
    4. HbA1C
    5. B12
    6. TSH
    7. Not as usefull in patients>60 but can consider
      1. Inflamatory markers
        1. ANA, RF, ESR, CRP
      2. SPEP with immunofixation
105
Q

How is the usual common polyneuropathy treated?

A
  1. Treat the cause
  2. Try pregabalin, gabapentin, venlafaxine, duloxetine for pain
  3. No treatment for numbness
106
Q

Describe the muscles of the arm with their associated nerve root and nerve

107
Q

Describe the muscles of the leg with their associated nerve root and nerve

108
Q

Describe the reflexes and their associated nerve and nerve root

109
Q

Describe the dermatomes of the arm and the peripheral sensory nerve distribution

110
Q

Describe the dermatomes of the leg and the peripheral sensory nerve distribution

111
Q

Differentiate an L5 lesion from a peroneal neuropathy

112
Q

Differentiate a C7 and a radial neuropathy

113
Q

Differentiat a C8/T1 vs ulnar neuropathy

114
Q

Where do you landmark for an LP

A

At tuffier’s line (imaginary line between iliac crests) at L4

115
Q

What must be done to be able to measure the opening pressure when doing an LP/

A
  1. Place the patient in lateral decubitus
  2. cannot measure opening pressure if LP done sitting
116
Q

What are the contraindications to performing an LP?

A
  1. INR > 1.7
  2. plt < 50
  3. papilledema/ raised ICP secondary to intracranial mass
  4. Patient can’t safely tolerate the procedure
117
Q

What are pre-imaging contraindications for LP

A
  1. Focal neurological deficits
  2. new seizure
  3. GCS<10 or alt LOC that impairs neuro exam
  4. immunocompromised patient
  5. Anatomical issues – spine instrumentation, tethered cord
  6. Chiari malformation
  7. local skin infection
118
Q

What are the risks of an LP?

A
  1. Local dyscomfort
  2. Infection <1%
  3. hemorrhage <1%
  4. Nerve injury <0.01%
  5. Post-LP headache
    1. 10-20% risk but vast majority recover within 48hrs
    2. 4% will have a blood patch
119
Q

What analysis happens in each of the 5 tubes taken from an LP

A
  1. Cell count and differential
  2. glucose and protein, ACE levels
  3. Cultures
  4. Cytology + flow cytometry
  5. cell count and differential
120
Q

What are the clinical manifestations of ALS

A
  1. Progressive symptoms
    1. Asymmetric limb weakness, bulbar symptoms
    2. CN dysfunction above C-Spine
    3. Frontotemporal degeneration- cog/behavioral decline in up to 50%
    4. family history of motor neuron disease
  2. Physical exam
    1. Pseudobulbar affect
    2. Cranial nerve findings
      1. Tongue wasting
      2. fasciculations
      3. weakness
      4. brisk jaw jerk
    3. Upper motor neuron symptoms bellow the lesion, lower motor neuron symptoms at the level of the lesion
121
Q

What investigations should be done to help confirm a diagnosis of ALS?

A
  1. MR cervical spine, exclude structural lesion
  2. NCS/EMG

*Refer to expert clinic within 4 weeks

122
Q

How is ALS managed?

A
  • Disease modifying therapies
    1. Multidisciplinary clinics
    2. Riluzole
    3. Edaravone
  • Symptom relief
    1. Sialorrhea
      1. Anticholinergics
      2. oral suctioning
      3. botox
    2. Spasticity
      1. physio, streaching
      2. baclofen
      3. tizanidine
      4. botox
      5. benzo
      6. Consider CBD
    3. Cramps
      1. Tonic water
      2. gabapentin
      3. Baclofen
    4. Depression/anxiety
      1. SSRI or SNRI first line along with non-pharm support
      2. Benzos will exacerbate breathing difficulties
123
Q

What are the side effects of riluzole?

124
Q

What are the non-pharmacological management strategies in ALS?

A
  1. Respiratory care
    1. Get FVC @ baseline then q 3 months + one of SNIP, supine FVC or MIP
      1. Home NIV if
        1. Symptoms – orthopnea
        2. SNIP <40 or MIP <40
        3. upright FVC <65
        4. FVC sitting or suppine <80 with symptoms or signs of resp insufficiency
        5. Daytime hypercapnea
        6. Abnormal nocturnal oximetry or symptomatic sleep breathing disorder
  2. VTE risk
    1. Higher in these patients but Px has not been studied
  3. Nutritional considerations​
    1. Get baseline BMI and q3 months
    2. High calory, carbs diet
    3. Consider early enteral feeding if
      1. Aspiration risk/bulbar symptoms/dysphagia
      2. 5-10% weight reduction, over 1 point reduction in BMI or BMI < 18.5
      3. FVC approaching 50% even in the absence of dysphagia
  4. Refer to palliative care. Can discuss MAID, organ donation, caregiver support
125
Q

What is the definition of status epilepticus?

A

>5 minutes of clinical or electrographic seizure activity OR ≥ 2 seizures without recovery between them

126
Q

What is the definition of refractory status epilepticus?

A

Failure of Benzos + 1 AED

*Occurs in 30% of status epilepticus patients. 30% die

127
Q

What is the rapid management of status epilepticus?

A
  1. Airway: Oral airway, lateral decubitus, succion, rapid sequence intubation
  2. Breathing: Bag mask, O2, Sat probe, RT
  3. Circulation: Cardiac monitor, IV access
  4. Fever: antipyretics, cooling, ABx
  5. CHECK glucose
    1. If low, thiamine + D50
128
Q

What can be used as abortive therapy for status epilepticus

A
  1. Lorazepam 0.1mg/kg OR 4mg IV over 2 min, repeat 4mg after 4 min
  2. Midazolam 10mg IM, buccal, IN
  3. Diazepam 0.2mg/kg PR up to 20 mg
129
Q

What can be used for maintenance therapy in status epilepticus

A
  1. Phenytoin
  2. Fosphenytoin
  3. Valproic acid
  4. Levetriacetam
  5. Lacosamide
  6. Phenobarbital
130
Q

How is refractory status epilepticus managed?

A
  1. ICU monitoring
  2. Midaz
  3. Propofol
    1. Aim for burst suppression before tapering
  4. Monitor for non-convulsive status with continuous EEG
    1. Especially important if paralytics are used!
131
Q

What investigations should be sent in status epilepticus

A
  1. Glucose
  2. ABG/VBG
  3. Lactate
  4. CBC
  5. lytes
  6. Extended lytes
  7. Cr
  8. Ammonia??
  9. Tox screen
  10. Liver enzymes
  11. Antiepileptic drug levels
  12. Prolactin
  13. Beta-HCG
  14. Imaging
    1. CT brain (tumor, pus, blood)
    2. MRI brain (cortical lesion)
    3. EEG (intericteral epileptiform discharges)
132
Q

List causes of status epilepticus

A
  1. Metabolic
    1. Hypoglycemia
    2. Missed antiepileptics
    3. ETOH withdrawl
    4. Drug toxicity
    5. Hyponatremia
    6. Hypocalcemia
    7. Hypomagnesemia
    8. Eclampsia
    9. Renal/hepatic dysfunction
  2. Structural
    1. Meningitis
    2. Encephalitis (HSV 1>2)
    3. Stroke: ischemic or hemorrhagic (epidural, subarachnoid, intraparenchymal)
    4. Cerebral venous thrombosis
    5. Hypoxic, ischemic encephalopathy
    6. Hypertensive encephalopathy (PRESS)
    7. Auto-immune (lymbic encephalitis, NMDA, LGI-1, GABA-B)
133
Q

What is the definition of epilepsy?

A

≥2 unprovoked seizures > 24hrs apart

OR

1 unprovoked seizure with > 60% recurrence risk

OR

Epilepsy syndrome

134
Q

What are the subclassifications, EEG findings and treatments of focal, generalized and unknown Epilepsy?

135
Q

How can seizures be differentiated from syncope, TIA and Migraine with aura?

136
Q

What is the riks of recurrence after a first seizure?

A
  • 12-45%, greatest in first 2 years
  • ≥60% if abnormal EEG or MRI
137
Q

Was is the diagnostic yield of an EEG for the prediction of further seizures?

A
  1. ROutine EEG is low yield (approx 30%), 50% if within 24hrs of event
  2. Serial EEGs 70%
  3. Sleep deprived EEG 50%
138
Q

What are good antiepileptics for generalized seizures?

A
  1. Valproate
  2. Lamotrigine
  3. Levetriacetam
  4. Clonazepam
  5. CLobazam
  6. Topiramate
  7. Perampanel
  8. Rufinamide
139
Q

What are good antiepileptics for focal seizures?

A
  1. Carbamazepine
  2. Oxcarbazepine
  3. Phenytoin
  4. Lacosamide
  5. Phenobarbital
  6. Eslicarbazepine
  7. Gabapentin
  8. Pregabalin
140
Q

What are good antiepileptics for absence seizures?

A
  1. Ethosuximide
  2. Valproate
141
Q

What are good antiepileptics for myoclonic epilepsy?

A
  1. Levetriacetam
  2. Valproate
142
Q

What are side effects of anti-epileptics?

A
  1. Sedation
  2. Cognitive impairement
  3. Ataxia
  4. Rash
  5. Emesis/GI upset
  6. Diplopia/visual disturbance
  7. Pregnancy – Consider risk of pregnancy when choosing
143
Q

Which antiepileptics are also mood stabilizers?

A
  1. Valproate
  2. Lamotrigine
  3. Carbamazepine
144
Q

Which are the 2 prefered antiepileptics in pregnancy?

A
  1. Lamotrigine
  2. Levetriacetam
145
Q

How should patients with epilepsy be councilled with regards to safety?

A
  1. Avoid climbing, swimming, driving
    1. Driving restrictions:
      1. 3 months after 1st unprovoked seizure
      2. Epilepsy: 6 months free of seizures on medication
      3. 3 months after medication change
  2. Spouse, parent should be encouraged to take a first aid course
  3. Medicalert bracelet
  4. Council regarding sudden unexpected death in epilepsy
146
Q

What are non-pharmacological methods that can be used in epilepsy?

A
  1. Alcohol, recreational drug cessation
  2. Sleep Hygene
  3. Trigger avoidance (i.e. photosensitivity)
  4. Screen for anxiety, depression, SI
147
Q

List risk factors for GBS

A
  1. Antecedant infection
    1. C. Jejuni (30%)
    2. influenza >>> flu vaccine
    3. HIV
    4. Zika
148
Q

How is GBS managed acutely?

A
  1. Non-ambulating patients within 4 weeks of symptom onset
    1. IVIG or PLEX
  2. Elective intubation based on 20-30-40 rule:
    1. FVC<20
    2. MIP 0 to -30
    3. MEP <40
  3. Telemetry, BP, FVC q4h
149
Q

List predictors of respiratory failure in patients with GBS

A
  1. Onset to admission <7days
  2. FVC < 60% of predicted
  3. Facial weakness
  4. Inability to cough
  5. inability to lift head
  6. inability to lift arms
  7. inability to stand
150
Q

What percentage of GBS patients have dysautonomia and what symptoms do they typically exhibit?

A
  1. 70%
    1. Paroxysmal hypertension
    2. Orthostatic hypotension
    3. Sinus tachycardia
    4. Bradycardia, AV block
    5. Urinary retention
    6. Ileus
151
Q

What investigations should be done in GBS?

A
  1. FVC
  2. Post-void residual
  3. MRI whole spine with GAD
    1. R/O acute myelopathy
    2. Nerve roots and cauda equina may enhance
  4. Basic BW, CBC, LBC, coags
  5. LP for albuminocytologic dissociation
  6. EMG/NCS
    1. Look for absent F waves, conduction blocks
    2. Most sensitive 2 weeks post Sx onset
  7. +/-Anti-Gq1b antibodies (Miller-fisher syndrome)
152
Q

What is the natural history of GBS?

A
  1. Mostly monophasic
  2. 85% walking by year 1
  3. 5% progress to CIDP
153
Q

What are the clinical features of CIDP?

A
  1. Progressive proximal and distal symmetric weakness
  2. Large fiber sensory loss
  3. Areflexia
  4. Fatigue > 2 months
  5. Usually spares cranial nerves, autonomic nerves and respiratory muscles
154
Q

What is the diagnostic evaluation for CIDP?

A
  1. EMG/NCS: demyelination
  2. Basic BW
    1. CBC
    2. LBC
    3. liver function
    4. TSH
    5. B12, MMA
    6. SPEP, UPEP, FLC
    7. HbA1C
  3. +/- LP: albuminocytologic dissociation
  4. +/- MRI spine w GAD: Enhancing nerve roots, plexus, peripheral nerves
  5. +/- nerve U/S: focal enlargement
155
Q

How is CIDP treated?

A
  1. Maintenance IVIG x 3 weeks
  2. prednisone 1mg/kg
156
Q

What is the prognosis of CIDP?

A

25% complete remission

50% assistive gait devices

10% permanently disabled

157
Q

What are the typical symptoms in peripheral neuropathy that suggest CIDP and which symptoms are red flags for another etiology?

A
  1. Typical pattern
    1. Distal symmetric polyneuropathy
    2. Paresthesias migrate from feet to leg leaving wake of numbness
    3. loss of ankle reflexes
    4. Decreased feet sweating
    5. Atrophy of extensor digitorum brevis
    6. Toe flexor/extensor weakness
    7. Paresthesia at knees → fingertips
  2. Red flags
    1. Significant asymetry
    2. Acute onset
    3. early motor involvement
    4. significant motor involvement
158
Q

What is the age of onset of MG?

A

Bimodal: Women in their 20s, men in their 60s

159
Q

What are the symptoms of MG?

A
  1. Fatigeable weakness, especially of:
    1. Occular: Ptosis, binocular diplopia, pupil-sparing
    2. Bulbar: Dysarthria, dysphagia, Chewing fatigue, head drop
    3. Respiratory: Orthopnea
    4. Extremities: proximal>distal weakness, intense fatigue
160
Q

How should MG be investigated?

A
  1. FVC/PFTs
  2. Serum AChR Ab (+/- MuSK, LRP4)
      • in 80% generalized MG, 50% occular
  3. EMG/NCS
    1. Single fibre EMG of frontalis, orbicularis oculi for enhanced jitter
    2. RNS: repetitive nerve stimulation for decrement
  4. CT Chest: R/O Thymoma
  5. CBC, LBC
  6. TSH, CK
161
Q

When should elective intubation be considered in MG crisis?

A

Elective intubation based on 20-30-40 rule:

FVC<20

MIP 0 to -30

MEP <40

Same as GBS

162
Q

How is an MG crisis treated?

A

PLEX (works faster)

OR

IVIG 2-5d

*Hold pyridostigmine when intubated

**CAUTION with high dose prednisone, can temporarily worsten respiratory status

163
Q

What are the side effects of Pyridostigmine

A
  1. Gi upset
  2. bronchorrhea
  3. cholinergic crisis
164
Q

What are the options for maintenance treatment of MG and what are their side effects?

165
Q

Who should be considered for thymectomy in the context of MG?

A
  1. Thymoma +:
    1. Refer all to surgery
  2. Thymoma -: Elective thymectomy if all 3 present:
    1. <60 years
    2. ACHRAb +
    3. Disease duration < 5 years
166
Q

What medications should be avoided in MG?

A
  1. Anesthetic agents
    1. Neuromuscular blockade
  2. Botox
  3. Antibiotics
    1. FQ
    2. macrolides
    3. Aminoglycosides
  4. Cardiovascular drugs
    1. BB
    2. procainamide
    3. quinidine
  5. Anti-PD1 monoclonal Ab
    1. Nivolumab
    2. Pembrolizumab
  6. Chloroquine, hydroxychloroquine
  7. Mg, Li
  8. CAUTION with glucocorticoids in MG crisis
167
Q

List a DDx for headaches

A
  1. Primary
    1. Migraine
    2. Tension headache
    3. Trigeminal autonomic cephalalgia
      1. Cluster headache
      2. Paroxysmal hemicrania
      3. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing or cranial autonomic symptoms (SUNCT/SUNA)
      4. Hemicrania continua
  2. Secondary (dangerous)
    1. Vascular
      1. Ischemic stroke/ venous thrombus
      2. Hemorrhage (ICH, SAH, SDH, EDH)
      3. Dissection (Carotid or vertebral)
      4. GCA
      5. Reversible cerebral vasoconstriction syndrome (RCVS)
      6. Posterior reversible encephalopathy syndrome (PRES)
      7. Pituitary apoplexy
      8. A-V malformation
    2. Space-occupying
      1. Tumors
      2. Hydrocephalus
      3. IIH
    3. Infectious
      1. Meningitis
      2. Encephalitis
      3. Abcess
      4. Sinusitis/otitis
    4. Ophtalmologic
      1. Acute Glaucoma
      2. Iritis
      3. Optic neuritis
168
Q

What are the red flags in headaches?

A
  1. Systemic: Fever, weight loss, immunosupression (HIV, steroids, cancer, pregnancy)
  2. Neurological (focal) signs/Sx: Meningismus, encephalopathy, papilledema
  3. Onset (thunderclasp)
  4. Older: >50
  5. P4: Positional, pulsatile tinitus, pattern change, precipitated by cough or valsalva
169
Q

What investigations should be sent when suspecting a secondary headache?

A
  1. CT/CTA/CTV head and neck
  2. +/-MRI brain

“Don’t order neuroimaging or sinus imaging in patients who have a normal clinical examination, who meet criteria for episodic migraine and have no “red flags” for a secondary headache disorder”

  1. Bloodwork
    1. CBC, LBC
    2. +/-ESR/CRP is suspecting GCA
    3. +/- D- Dimer if suspecting CVT
    4. +/- Blood cultures if suspecting IE
    5. +/- LP: SAH, meningitis
170
Q

What should be suspected if a patient has a headache + Transient visual obscurations + pulsatile tinitus + weight gain

171
Q

What should be suspected if a patient has a headache + Worst standing

A

Spontaneous intacranial hypotension

172
Q

What should be suspected if a patient has a headache + Fever, photophobia and neck stiffness

A

Meningitis (infectious or SAH)

173
Q

What should be suspected if a patient has a headache + fever + encephalopathy

A

HSV encephalitis

174
Q

What should be suspected if a patient has a headache + fever + Weight loss + scalp tenderness + jaw claudication + transient monocular vision loss + proximal myalgias + anemia

175
Q

What should be suspected if a patient has a headache + Recurrent thunderclasp + pregnant + canabis/decongestionant use

A

Reversible cerebral vasoconstriction syndrome (RCVS)

176
Q

What should be suspected if a patient has a headache + HTN + cyclosporine/tacrolimus use

A

Posterior reversible encephalopathy syndrome (PRES)

177
Q

What should be suspected if a patient has a headache + seizures + hypercoagulable state

A

Cerebral venous sinus thrombosis

178
Q

What should be suspected if a patient has a headache + Neck pain + horner syndrome

A

Internal carotid/vertebral artery dissection

179
Q

What should be suspected if a patient has a headache + vision loss+ diplopia + hypotension + pregnancy

A

Pituitary apoplexy

180
Q

What are the diagnostic criteria for migraine?

A

≥5 headache attacks lasting 4-72hrs with no better explanations

  • 2 of:
    1. Unilateral location
    2. Pulsating quality
    3. Moderate or severe pain intensity
    4. Agravation by or causing avoidance of routine physical activity (i.e. climbing stairs, walking)

AND

  • 1 of:
    1. N/V
    2. Photophobia and phonophobia
181
Q

How is status migrainous treated?

A
  1. Oral
    1. NSAIDS
      1. ASA
      2. Dicophenac
      3. Ibuprofen
      4. Naproxen
    2. Acetaminophen
    3. Triptans
      1. Sumatriptans
      2. Rizatriptans
      3. Zolmitriptans
  2. Parenteral
    1. Ketorolac
    2. IVF
    3. Metoclopramide
    4. Domperidone
    5. MgSO4
    6. Dexamethasone
    7. Consider Dihydroergotamine
  3. Peripheral nerve block
  4. Neurostimulation
182
Q

What lifestyle modifications should be suggested in migraines?

A
  1. Regular meals
  2. Sleep
  3. Trigger avoidance
  4. stress reduction
183
Q

How mant triptans or NSAIDs must you take to be considered as medication overuse headache?

A
  1. NSAIDS≥15 days/month
  2. Triptans ≥ 10 days/month
184
Q

What are the different spinal cord syndromes?

185
Q

Give a DDx for Complete spinal cord syndrome

A
  1. Severed cord
  2. Transverse myelitis
186
Q

Give a DDx for hemicord syndrome

187
Q

Give a DDx for central cord syndrome

A

Syringomyelia

188
Q

Give a DDx for anterior cord syndrome

189
Q

Give a DDx for posterior cord syndrome

A
  1. Syphilis
  2. B12
190
Q

Give a DDx for Pure motor cord syndrome

A
  1. West nile virus
  2. ALS
191
Q

What is the epidemiology of MS?

A
  1. 3F:1M
  2. 60% between 20-49
  3. Higher risk in northern europeans
  4. 3% risk in 1st degree relative
192
Q

What are the 3 subtypes of MS?

A
  1. Relapsing remitting
  2. Primary progressive
  3. Secondary progressive
193
Q

Define a clinically isolated syndrome (CIS)

A

A monophasic clinical episode of acute or subacute onset with patient-reported symptoms and objective findings typical of MF reflecting a focal or multifocal inflammatory demyelinating event in the CNS with or without recovery and in the absence of fever or infection

194
Q

What are the typical syndromes associated with MS

A
  1. Optic neuritis: Painfull eye movements, monocular vision and colour loss or scotoma, RAPD, 1/3 mild disc swelling
  2. Brainstem/cerebellar syndrome: Bilateral INO, diplopia, dysarthria, ataxia, gaze-evoked nystagmus, vertigo, facial numbness, 6th nerve palsy
  3. Incomplete 6th nerve palsy: Sensory loss, asymmetric limb weakness, urge incontinence, erectile dysfunction, Lhermitte (spinal electric shock sensation on neck flexion), Uhtoff (heat exacerbation)
195
Q

List a DDx for MS

A
  1. Demyelinating
    1. ADEM
    2. NMO/MOG
  2. Inflamatory
    1. Neurosarcoidosis
    2. SLE
    3. Sjogren
    4. GPA
    5. Bechet
  3. Infectious
    1. Post-infectious demyelination
    2. HIV
    3. PML
    4. HTLV
    5. Syphilis
    6. Lyme
    7. Bartonella
    8. TB
  4. Metabolic
    1. Cu or B12 deficiency
  5. Neoplastic
    1. Lymphoma
  6. Psychiatric
    1. Somatisation
  7. Vascular
    1. Vasculitis
    2. Vascular malformation
    3. migraine
196
Q

What are the revised MacDonald criteria for relapsing-remitting MS

A
  1. MS is the most likely Dx AND
  2. 1 clinical attack AND
  3. Dissemination in time and space
    1. DIS
      1. ≥ 2 clinical attacks OR
      2. ≥ 2 lesions in ≥ 2 of cortical/juxtacortical, periventricular, infratentorial or spinal cord
    2. DIT
      1. ≥ 2 clinical attacks OR
      2. 1 MRI: GAD enhancing and non-gad enhancing lesion OR
      3. 2 MRI: new T2 or gad lesion on follow-up scan OR
      4. CSF specific oligoclonal bands
197
Q

What investigations should be done when suspecting MS?

A
  1. MRI brain and cervicothoracic spine with gad
  2. +/- LP looking for oligoclonal bands, IgG index
  3. Bloodwork
    1. CBC, LBC, liver enzymes, SPEP
    2. B12, TSH
    3. +/- visual evoked potentials
    4. +/- NMO/MOG antibodies
    5. +/- ANA, ESR, CRP, ENA, ACE, ANCA
    6. +/- VDRL, Lyme, HIV, HTLV
198
Q

How is an MS attack treated?

A
  1. Methylprednisolone 1g daily for 3-7 days then taper
    1. Can speed up recovery if functionally disabling
      1. Used in optic neuritis, motor weakness, not in mild sensory Sx
    2. Does not alter the degree of recovery
    3. Does not reduce future attack risk
  2. If no response, PLEX
199
Q

What lifestyle modifications can be considered as disease modifying in relapsing-remitting MS?

A
  1. Physical activity
  2. Smoking cessation
  3. Vitamin D 4000 UI daily
200
Q

What are the disease-modifying medications in RRMS?

A
  1. Injectibles
    1. Beta-interferon
    2. Glatiramer-acetate
  2. Oral agents
    1. Dimethyl fumarate
    2. Teriflunomide
    3. Fingolimod
    4. siponimod
    5. cladribine
  3. Infusions
    1. Natalizumab
    2. Alemtuzumab
    3. Ocrelizumab
  4. HSCT
201
Q

List the neurological manifestations of COVID-19

A
  1. Anosmia
  2. Ageusia
  3. Acute ischemic stroke (2-6%)
  4. Encephalopathy
  5. Encephalomyelitis
  6. Headache (8%)
  7. Myalgia, rhabdo
  8. ICH
  9. GBS
  10. Bell’s palsy
  11. Special populations
    1. 40% crisis in MG
202
Q

What should be assessed on history for a patient in encephalopathy/coma?

A
  1. Onset (acute or gradual)
  2. Complaints
    1. Headache
    2. Depression
    3. focal weakness
    4. vertigo
  3. Trauma
  4. Medical illnesses
    1. DM
    2. renal failure
    3. heart disease
  5. Psych history
  6. Access to drugs
203
Q

What should be part of the physical exam of a patient with encephalopathy/coma?

A
  1. Vitals,ABC, breathing pattern, glucose
  2. Periorbital/mastoid bruises, lateral tongue biting, skin/nail embolic phenomenon, needle marks, breath odor
  3. MSE: meningismus, attention, memory
  4. CN: Brainstem reflexes: fundi, pupils, eye opening, corneals, eye movement, vestibulo-occular, gag/cough
  5. Motor/sensory: Tone, Motor response (eg nailbed pressure), reflexes
204
Q

What emergent management should be provided to patients in encephalopathy/coma?

A
  1. Stabilize ABCs
  2. Thiamine, dextrose, +/- naloxone
  3. If hyperthermic: Cooling blankets, antipyretics
  4. COnsider antibiotics/antivirals: CTx, vanco, amp, acyclovir
205
Q

What rapid investigations should be performed in patients presenting in encephalopathy?

A
  1. Bloodwork
    1. CBC, LBC, Glucose
    2. ABG
    3. Osm
    4. LFT
    5. ?ammonia
    6. bili
    7. albumin
    8. INR, PTT
    9. tox screen
    10. TSH, B12
  2. CT/CTA head+neck
  3. MRI brain
  4. EEG
  5. LP
206
Q

How does herpetic encephalitis present?

A
  1. <1 week altered mentation
  2. aphasia
  3. ataxia
  4. memory impairment
  5. focal seizures
207
Q

What investigations should be sent for suspected herpetic encephalitis?

A
  1. MRI brain
  2. LP: increased RBC, Lymphocytes, glucose normal
  3. EEG: High amplitude slow waves, occasionally lateralized periodic discharges
  4. HSV CSF PCR
208
Q

What is the prognosis of HSV encephalitis?

A
  1. If untreated, mortality 70%
  2. Survivors are usually disabled: 67% have residual defects
  3. Associated with later development of anti-NMDAR encephalitis
    1. Psych changes
    2. dyskinesias
    3. autonomic instability
209
Q

Compare otologic, neurologic, medical and psychogenic vertigo based on symptoms, signs and ancillary test results

210
Q

Describe the HINTS exam and what you would find in central vs peripheral vertigo

211
Q

What are the risk factors for PRES?

A
  1. Rapid fluctuations in BP
  2. AKI/CKD
  3. HUS
  4. TTP
  5. SCD
  6. Eclampsia
  7. VAsculitis
  8. Porphyrias
  9. HyperCa, hypoMg
  10. Iodine contrast media exposure
  11. Sepsis
  12. Transplant
212
Q

What medications can predispose to PRES?

A
  1. Bevacizumab and other VEGF inhibitors
  2. Cisplatin and other platinum based agents
  3. Combination chemo
  4. Cyclosporine A
  5. Cytarabine
  6. Gemcytabine
  7. Interferon alpha
  8. IVIG
  9. Ipilimumab
  10. MTx
  11. Rituximab
  12. Tacrolimus, Sirolimus
  13. TKIs
  14. Vincristine
213
Q

List side effects of most anti-epileptic drugs

A
  1. Cytopenias
  2. Reduced BMD
  3. ataxia
  4. SJS
214
Q

List side effects of carbamazepine

A
  1. Hyponatremia
  2. Mild leukopania
  3. Lupus-like syndrome
  4. AA
215
Q

List side effects of phenytoin

A
  1. IV phlebitis
  2. purple glove syndrome
  3. eosinophilia
  4. hirsutism
  5. gingival hyperplasia
216
Q

List side effects of valproic acid

A
  1. PCOS
  2. Hyperandrogenism
  3. insulin resistance
  4. weight gain
  5. tremor
  6. hair loss
  7. pancreatitis
  8. Rarely hepatotoxicity
217
Q

List side effects of levetriacetam

A
  1. Neuropsychiatric effects
  2. irritability
218
Q

List side effects of lacosamide

A

Increased PR interval

219
Q

List side effects of gabapentin and pregabalin

A

Peripheral edema

220
Q

List side effects of Topiramate

A
  1. Acute angle closure glaucoma
  2. Nephrolithiasis
  3. Weight loss
221
Q

List side effects of most MS drugs

A
  1. Lymphopenia
  2. Hepatotoxicity
222
Q

List side effects of interferon

A
  1. Flu-like symptoms
  2. thyroiditis
223
Q

List side effects of Fingolimod

A
  1. Macular edema
  2. shingles
224
Q

List side effects of Alemtuzumab

A
  1. ITP
  2. AI thyroiditis
  3. Anti-GBM
225
Q

List side effects of IVIG

A
  1. ACS
  2. Hemolytic anemia
  3. aseptic meningitis
  4. AKI
226
Q

List side effects of pyridostigmine

A
  1. GI upset
  2. Bradycardia
  3. Bronghorrhea
227
Q

List neurological side effects of PD-1/CLTA-4 inhibitors

A
  1. MG
  2. Myositis
  3. hypophystis
228
Q

List neurological side effects of CAR-T cell therapy

229
Q

List neurological side effects of antimicrotubules (vincristine, paclitaxel), platinum based chemo and bortezomib

A
  1. Polyneuropathy
230
Q

List neurological side effects of ATRA

231
Q

List neurological side effects of anti-TNFs

A

Demyelination

232
Q

List neurological side effects of antimetabolites (MTx)

A

Demyelination

233
Q

List neurological side effects of Metronidazole

A

Corpus callosum demyelination

234
Q

List neurological side effects of ethambutol

A

optic neuropathy

235
Q

List neurological side effects of isoniazid

A

Dorsal root ganglionopathy

236
Q

List neurological side effects of imipenem, PNC and cephalosporins

237
Q

List neurological side effects of statins

238
Q

List neurological side effects of NS

239
Q

List neurological side effects of opioids

A
  1. Migraine
  2. Medication overuse headache
240
Q

List neurological side effects of MEtoclopramide, prochloperazine

A

EPS (parkinsonism, acute dystonic reaction)

241
Q

List neurological side effects of haldol

A

NMS, Parkinsonism

242
Q

What are the most common secondary causes of headache in pregnancy?

A
  1. Pre-eclampsia
  2. RCVS
  3. SAH
  4. PRES
  5. CVT
  6. pituitary apoplexy
  7. dissection
  8. post-LP
243
Q

What can be used to treat migraines in pregnancy?

A
  1. Acetaminophen
  2. Sumatriptans
  3. Nerve blocks
  4. Neurostimulation

RCPSC (14 decks)

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