Neurology Flashcards
3 broad pathological causes of AMS
systemic infxn
metabolic dysfxn
vascular events
what tx can be diagnostic and therapeutic for a common drug related cause of AMS
naloxone
general tx for AMS
- ABCs
- BG
- thiamine plus dextrose
- +/- naloxone
abrupt and transient LOC caused by cerebral hypoperfusion
syncope
t/f: all syncope needs full work up
t!
5 causes of syncope
CVD/structural heart dz
arrhythmia
hypovolemia
orthostatic hypotn
sz
general management of syncope
cardiac monitoring
CT
obs
glasgow coma scale
3 causes of numbness/paresthesia
DM
nerve root pathology
CNS pathology
abnormal dermal sensation due to compromised nerve fxn
paresthesia
a pt may describe paresthesia as (5)
prickling
tingling
itching
burning
cold skin
work up for paresthesia in the emergency setting must include
brain CT vs MRI
sudden onset unilateral facial nerve paralysis w. no other focal neuro/systemic findings
bell’s palsy
60% of bells palsy cases involve a _ prodrome,
and symptoms peak in _ hr
viral
48
how do differentiate bells palsy vs CVA
bells palsy does not spare the forehead
if they can raise their eyebrows, so should you
mc cause of bells palsy
HSV
tx for bells palsy
prednisone
artificial tears
eye patch
bilateral bells palsy makes you think of (2)
lyme dz
mono
common presentations of encephalitis (4)
AMS
sz
personality changes
exanthema
encephalitis is differentiated from meningitis by
altered brain functioning
mc cause of encephalitis
HSV
immunocompromised: CMV
rapidly progressive encephalopathy w. hepatic dysfxn that is usually post flu/URI
reye’s syndrome
2 PE findings of reye’s syndrome
positive babinski
hyperreflexia
2 pharm causes of reye’s syndrome
ASA
pepto
lab findings of reye’s syndrome
elevated:
LFTs
PTT
NH3
hypoglycemia
metabolic acidosis
tx for reye’s syndrome
supportive
IV acyclovir asap
+/- abx til meningitis is ruled out
sx of reye’s syndrome
fever
HA
AMS
personality changes
sz
exanthema
what is exanthema
a skin rash accompanying a dz or fever
dx for reye’s syndrome
LP
MRI
PCR
2 types of sz in ED setting
status epilepticus
focal sz
what is status epilepticus
sx >/= 5 min continuous
OR
more than one sz w.o recovery from postictal state
always check _ when pt presents w. sz
finger stick BG
tx if pt on TB meds presents w. sz
B6 for INH toxicity
mc cause of sz in emergency setting
change in meds of someone w. sz d.o
emergent management of sz
-place in lateral decubitus position
-IV benzos/phenytoin/phenobarbital/lacosamide
-correct acidosis
sz lasting > _ min may result in permanent brain damage
60
types of focal sz
-simple partial (retained awareness)
-complex partial (loss of awareness)
tx for focal sz
phenytoin
vs
carbamazepine
types of generalized sz (9)
absence (petit mal)
tonic-clonic (grand mal)
atonic
clonic
tonic
myoclonic
febrile
infantile spasm
psychogenic nonepileptic
-brief mental status change w.o motor activity
-no aura, post ictal state, or loss of postural tone
absence sz
absene sz is mc in what pt pop
5-10 yo
EEG findings of absence sz
brief 3 Hz spike and wave discharge
tx for absence sz
ethosuximide
-convulsive bilaterally symmetric sz w.o focal onset
-begins w. LOC
tonic-clonic sz
describe the phases of tonic clonic sz
tonic: stiff/rigid 10-60 sec
clonic: convulsions
post ictal: confused
drop attack (similar to syncope)
loss of muscle tone
atonic sz
-loss of control of bodily fxn - jerking
+/- LOC
clonic sz
extreme rigidity followed by LOC
tonic sz
muscle jerking, no tonic phase
occurs early in the AM
myoclonic sz
parameters for febrile sz (3)
temp > 38
> 6 mo, < 5 yo
absence of CNS infxn/inflammation
infantile spasm is a type of _ sz
epileptic
what sz is not due to epilepsy but presents similar to an epileptic sz
psychogenic non epileptic
work up for focal/generalized sz
check lytes/BG
pregnancy test
ECG/EEG
adults w. first seizure have bought themselves
CT/MRI
8 common causes of sz
lytes disturbance
infxn
toxic ingestion
trauma
azotemia
hypoxia
hypoglycemia
stroke/bleed
5 meds used for focal sz
phenytoin
phenobarb
valproate
lamotrigine
gabapentin
2 types of hematoma
epidural
subdural
27 yo, mountain bike vs tree, no helmet - admits to LOC but now feels fine - several hr later he decompensates quickly
epidural hematoma
progression of epidural hematoma
transient LOC -> lucid -> HA -> unilateral/contralateral weakness
cause of epidural hematoma
trauma to skull -> blood between dura and skull
artery mc involved w. epidural hematoma
middle meningeal
imaging for epidural hematoma and hallmark finding
-non contrast CT
-lenticular, unilateral convexity -> lens shape/lemon in temporal region
tx for epidural hematoma (4)
surgical craniotomy
mannitol, steroids
hyperventilate
ventricular shunt
73 yo M w. hx afib on warfarin - presents after fall w. syncope - quickly becomes unconscious
subdural hematoma
mc pt pop affected by subdural hematoma
elderly and alcoholics: fall -> tear bridging veins
classifications of subdural hematoma
acute: 48 hr
subacute: 3-14 days
chronic: > 2 weeks
w. subdural hematomas, blood collects between the _ and _
dura and arachnoid mater
dx for subdural hematoma and hallmark finding
non contrast CT
crescent shaped concave hyperdensity
tx for subdural hematoma, small vs severe
small: obs
severe: surgery -> burr hole vs trephination, craniotomy vs craniectomy
what is this showing
epidural hematoma
epi = pie, lemon pie
what is this showing
subdural hematoma
sub = b = banana
mc causes of spinal cord injury
trauma
disease
classifications of spinal cord injury (4)
anterior cord syndrome
central cord syndrome
complete cord transection
brown-sequard (hemisection)
-loss of pain/temp below the level of the lesion
-preserved position/vibration/touch
anterior cord syndrome
-loss of pain and temp sensation at the level of the lesion
central cord syndrome
-complete loss of movement and sensation below the level of injury
-urinary retention, distended bladder
complete cord transection
-loss of proprioception and vibration on teh same side as the lesion
-loss of pain/temp on the opposite side a few levels below the lesion
brown-sequard (hemisection)
-ascending paralysis beginning in distal limbs/leg weakness -> total paralysis of all 4 limbs, facial muscles, eyes, reflexes
guillain-barre
2 causes of guillain barre
-post immunization
-post infectious
infxn mc associated w. guillain barre
**campylobacter jejuni **
also CMV, EBV, HIV
dx and tx for guillain barre
dx: LP
tx: plasma excange PLUS IVIG
LP findings of guillain barre (2)
elevated protein
normal WBC
2 forms of status epilepticus
convulsive
nonconvulsive
sz characterized by regular pattern of contraction and extension of arms and legs
convulsive status epilepticus
2 types of nonconvulsive status epilepticus
complex partial
absence
tx for status epilepticus
- benzos
- phenytoin
transient, traumatic brain dysfxn
concussion
6 sx of concussion
confusion
memory loss
LOC
HA
dizzy
n/v
concussion and _ are synonymous
mild TBI/mTBI
mTBI definition
-GCS 13-15 30 min post injury
-consciousness loss < 30 min
-post-traumatic amnesia < 24 hr OR other transient neuro abnormality (sz, focal deficits)
t/f: all pediatrics with mTBI need brain imaging
f!
what tool is used to determine who needs CT in peds >/= 2 yo w. mTBI
pecarn
what peds >/= 2 yo w. mTBI probs don’t need imaging
normal mental status
no LOC
no vomiting
non severe MOI
no skull fx
no HA
tx for mTBI
-2-3 days of brain rest followed by gradual reintroduction of activity that does not worsen sx
-monitor for sx
-APAP/ibuprofen
-limit caffeine
when can kiddos return to sport after mTBI
only when full recovery is evident
2 types of stroke
ischemic - mc
hemorrhagic
2 types of ischemic stroke
thrombotic
embolic
-clot develops in the blood vessels inside the brain
-usually preceded by TIA
thrombotic stroke
-clot develops somewhere outside the brain
-occurs abruptly/w.o warning
embolic stroke
2 mc locations for embolic stroke to develop
aortic arch
large cerebral arteries
hemorrhagic strokes are mc due to
HTN
sx of hemorrhagic stroke
hemiparesis
hemisensory deficit
present on one side only
present on side of body opposite stroke
types of hemorrhagic stroke (8)
anterior
posterior
carotid/ophthalmic
MCA
ACA
PCA
basilar
lacunar
what arteries are involved w. anterior stroke
anterior cerebral
middle cerebral
sx of anterior stroke
aphasia
apraxia
hemiparesis
hemisensory loss
visual field defect
what arteries are involved w. posterior stroke
posterior cerebral
vertebral
basilar
sx of posterior stroke
coma
drop attack
vertigo
n/v
ataxia
what is drop attack
sudden fall w.o warning
+/- LOC or neuro sx
amaurosis fugax is associated w. aneurysm of what arteries (2)
carotid
ophthalmic
aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia
MCA stroke
leg paresis, hemiplegia, urinary incontinence
ACA stroke
coma, cranial n palsy, apnea, drop attack, vertigo
basilar a stroke
silent stroke
pure memory OR sensory
lacunar stroke
dx for stroke
noncontrast CT
transcranial doppler
ecoh for ischemic
tPA must be administered w.in _ hr of stroke sx onset
3-4.5
management of pt on tPA
-neuro exam:
-q 15 min during infusion
-q 60 min for the next 6 hr
-q 24 hr after tx
-serial BP
tPA exclusion criteria
-SAH
-head trauma
-prior stroke w.in past 3 mo
-MI w.in past 3 mo
-GI ulcer w.in last 3 mo
-major surgery in last 2 weeks
-hx ICH
-SBP > 185, DBP > 110
-active bleeding
-INR > 1.7 w. anticoagulation
-BG < 50
-sz w. postictal state
-multilobar infarct on CT
BP management for stroke pt
-hold antihypertensives until SBP > 220 OR DBP > 120
-goal: lower BP 15% in first 24 hr
for tPA to be administered, BP has to be _
< 185/110
how is BP lowered for stroke pt prior to tPA
IV labetalol 10-20 mg over 1-2 min
3 types of HA
cluster
tension
migraine
-which type of HA is always unilateral but side can vary
-mc in men
cluster
describe the pain w. cluster HA
excruciating
unilateral
sx of cluster HA (besides HA)
autononic:
ptosis
miosis
lacrimation
conjunctival injxn
nasal congestion
tx for cluster HA
100% O2
sumatriptan
prophylaxis: CCB
mc type of HA
tension
describe tension HA pain
bilateral
non pulsating
bandlike - frontal/occipital
neck muscle tenderness
4 common triggers for tension HA
stress
fatigue
glare
noise
tx for tension HA
NSAIDs
smoking cessation
5 common triggers for migraines
menstruation
pregnancy
contraceptives
chocolate/cheese/nitrites
etoh
describe migraine pain
mc unilateral
gradual onset
throbbing/pulsating
2 types of migraine
w. aura
w.o aura - mc
sx of migraine w. vs w.o aura
w. aura: scotoma (blind spot), flashing lights, sound
w.o aura: n.v, photophobia, phonophobia
mc type of migraine aura
visual
migrained follows aura w.in _ min
30
abortive vs prophylactic tx for migraines
abortive: triptans, dihydroergotamines (DHE), antiemetics, NSAIDs
prophylaxis: bb, ccb, TCAs
2 types of brain hemorrhage
“worst HA of my life”
SAH
sx of SAH
sudden, severe HA
LOC - 50% of pt
elevated BP
+/- fever
less severe but atypical HA that precedes SAH in 40% of pt’s
herald bleed
mc type of nontraumatic SAH aneurysm
berry (saccular)
4 rf for SAH
smoking
HTN
hypercholesterolemia
heavy etoh
dx for SAH
non contrast CT
LP
LP findings of SAH
elevated opening pressure/grossly bloody fluid in all 4 tubes
tx for SAH
surgical clipping/wrapping
anticonvulsants
-abrupt focal neuro deficit that worsens steadily over 30-90 min
-HA, LOC, stupor, coma, vomiting
intracerebral hemorrhage
mc cause of ICH
HTN -> sudden increase in BP -> ruptured parenchyma
saccular aneurysms are almost always due to
hereditary malformation/weakness in BV of COW
mc cause of syncope
insufficient cerebral blood flow:
decreased CO or venous return
2 mc cause of syncope
vasovagal
idiopathic
6 red flags w. syncope
during exertion
multiple recurrences in short time
heart murmur
old age
significant injury during event
fam hx sudden/unexpected death
3 causes of acute loss of coordination/ataxia
infarction
edema
hemorrhage
when you see loss of coordination/ataxia, think _ involvement
cerebellar
common cause of chronic/progressive loss of coordination/ataxia
parkinsons
imaging for ataxia
MRI/CT w. AND w.o contrast
causes of ataxia
drugs/toxins
tumor
CVA
genetics
eustachian tube dysfxn
MS
stroke
huntington
fibromyalgia
metabolic disorders
transient episode of neuro dysfxn due to focal brain, retinal, or spinal cord ischemia w.o acute infarction
TIA
TIA lasts _ on average
and must last < _ by definition
-average: 15-30 min
-must last < 60 min, with reversal of sx w.in 24 hr
10% of TIA pt’s will have a stroke w.in _ days
90
imaging for TIA
**CT w.o contrast **
carotid doppler US: looks for stenosis
CTA/MRA
carotid endarterectomy is indicated if common carotid artery stenosis is _
> 70%
pharm for for TIA
ASA + dipyridamole
OR
clopidogrel
_ criteria predicts likelihood of stroke w.in 2 days
ABCD2:
when is risk for CVA greatest after a TIA
24 hr after initial event
3 causes of memory loss
dementia
delirium
amnesia
mc cause of dementia after age 65
alzheimers
sudden, reversible change in mental status
delirium
3 common causes of delirium
medical conditions:
withdrawal from etoh/drugs/medicines
infxn/sepsis
sunstroke
4 common causes of amnesia
head injury
CVA
substance use
emotional event
criteria for delirium
-disturbed level of consciousness (attention/awareness)
-cognitive change (memory, disorientation, language, hallucinations)
-rapid onset (days-hr)
-evidence of a causal physical condition
sx of alzheimer’s
-progresive memory loss
-difficulty word finding
-concentration problems
-emotional lability
-personality changes
-social withdrawal
-difficulty w. ADLs
2 mc types of dementia
alzheimer
vascular
lewy body
frontotemporal
neurodgenerative conditions
dx tool for dementia
folstein MMSE
memory impairment screen
2 early signs of alzheimers
language deficits
visuospatial deficits
5 rf for vascular dementia
HTN
dyslipidemia
DM
smoking
old age
what dementia is characterized by cognitive fluctuations, visual hallucinations, and parkinsonism
lewy body
what dementia is characterized by personality/social behavior changes and non-fluent speech
frontotemporal dementia
what neurodegenerative condition can cause dementia
huntington
6 reversible causes of dementia
B12 deficiency
syphilis
hypothyroidism
NPH
drugs
intracranial mass
2 drugs that may slow the progression of dementia
donepezil - cholinesterase inhibitor
memantine - NMDA agonist
sensation of movement in the absence of movement
vertigo
2 types of vertigo
peripheral
central
peripheral vertigo is _ dysfxn
central vertigo is _ dysfxn
peripheral: inner ear
central: brainstem
5 causes of peripheral vertigo
labyrinthitis
BPPV
meniere
vestibular neuritis
head injury
peripheral vertigo is characterized by (5)
sudden onset
n/v
tinnitus
hearing loss
horizontal nystagmus
5 causes of central vertigo
brainstem vascular dz
AVM
tumor
MS
vertebrobasilar migraine
central vertigo is characterized by (3)
gradual onset
vertical nystagmus
no auditory sx
vertigo + syncope =
vertebrobasilar insufficiency
positional vertigo w. no hearing loss, tinnitus, or ataxia
BPPV
dx and tx for BPPV
dx: dix hallpike
tx: epley, meclizine
non positional vertigo w.o hearing loss/tinnitus
vestibular neuritis
tx for vestibular neuritis
meclizine
acute, self resolving vertigo w. hearing loss
labyrinthitis
tx for labyrinthitis
meclizine
+
steroids
chronic, progressive, relapsing vertigo w. hearing loss/tinnitus
meniere’s dz
tx for meniere’s
diuretics
salt restriction
severe: CN VIII ablation
vertigo from trauma
perilymph fistula
tx for perilymph fistula
surgery
vertigo w. ataxia, hearing loss, tinnitus
neurofibromatosis type II
acoustic neuroma
meningitis triad
fever > 38
nuchal rigidity
HA
how is meningitis differentiated from encephalopathy
no AMS w. meningitis
kernig:
brudzinski:
kernig: neck pain w. knee extension
brudzinski: leg raise to compensate for pain w. neck bending
2 types of meningitis
aseptic: mc viral
bacterial
mc cause of bacterial meningitis
strep pneumo
gram positive cocci
meningitis w. a rash should make you think
n. meningitidis
gram negative diplococci
2 pathogens associated w. meningitis in neonates
e.coli
s.agalactiae
2 pathogens associated w. meningitis in pt’s >50-60 yo
listeria
cryptococcus neoformans
pathogen associated w. HAP meningitis
staph
dx for meningitis
- check for ICP/papilledema (CT if unsure)
- LP
LP findings of bacterial vs aseptic meningitis
aseptic: normal pressure, lymphocytosis
bacterial: increased opening pressure and protein, decreased glucose
think bacteria like to eat glucose
tx for meningitis: aseptic vs bacterial vs household contacts
aseptic: symptomatic vs IV acyclovir if HSV
bacterial: dexamethasone, empiric IV abx
household contacts: rifampin, cipro, levaquin, azithromycin, ceftriaxone
abx for step pneumo meningitis
ceftriaxone
cefotaxime
vanco
pen g
