Neurology Flashcards
Headache + high ESR
Giant cell arteritis
Headache + extra ocular muscle palsies
CVT
Worst headache in my life
SAH
Frontal headache made worse by bending over
Sinus headache
Women with migrain aura should avoid
OCP due to high risk of stroke
all triptans are contraindicated in the presence
- coronary, cerebral, or peripheral vascular disease
2.uncontrolled hypertension
3.migraine with brainstem or hemiplegic auras.
indications use of triptans
in patients with moderate to severe migraine who have not responded to NSAID therapy
triptans
Almo-
Ele-
Nara-
Riza-
Suma-
Zolmi-
Ditans
Lasmiditan
gepants
Ubrogepant
Rimegepant
status migrainosus
Migraine with a duration lasting longer than 72 hours
status migrainosus can be treated with
several days of glucocorticoids
chronic migraine
> 15 days per month
episodic migraine prevention.
Venlafaxine, propranolol, timolol, metoprolol,
amitriptyline, topiramate, sodium valproate,
erenumab, fremanezumab, eptinezumab and galcanezumab
Neuroimaging is recommended for all patients with a first seizure.
CT of the head is adequate initially to rapidly exclude emergent pathology, including hemorrhage,
but MRI is recommended in most patients.
*The use of contrast may be deferred unless infection, tumor, or vascular lesions are suspected
lumbar puncture is recommended in seizure only if
an infectious cause, such as meningitis or encephalitis, is suspected.
First-line treatment of convulsive status epilepticus
IV benzodiazepines, then IV fosphenytoin
Epilepsy drug therapy for reproductive-age women
Levetiracetam or lamotrigine
First-line treatments for epilepsy in older patients
Gabapentin, lamotrigine, levetiracetam
Test to determine candidacy for epilepsy surgery
Video EEG monitoring
Seizure type requiring lifelong treatment
Juvenile myoclonic epilepsy
Unprovoked seizure treatment indications
2 unprovoked seizures or 1 unprovoked seizure with EEG or MRI abnormalities
Temporal lobe epilepsy symptoms
Aura, loss of awareness, staring, behavior arrest, amnesia
the only thrombolytic agent approved for use in acute ischemic stroke
alteplase
1.BP should be ……… before alteplase.
2.if higher, should start ……..
- BP < 185/110 mm Hg.
- IV labetalol or nicardipine
both antiplatelet and anticoagulant agents should be held for the first ………. after alteplase administration
24 hours
treatment with dual antiplatelet therapy, who did not receive IV alteplase ?
minor noncardioembolic ischemic stroke (NIHSS score ≤3)
Intracerebral Hemorrhage Treatment
1.acutely treating the SBP in ICU 130-140 TARGET
2.antiepileptic medications, IF there are definitive clinical or EEG seizures.
3.Elevated intracranial pressure is a major determinant of morbidity and mortality in ICH. Short-term bolus osmotherapy with mannitol or hypertonic saline may temporarily reduce intracranial pressure in ICH
Ventricular drainage is preferred over medical therapy when elevated intracranial pressure and hydrocephalus result in decreased level of consciousness.
Surgical procedures may be considered in patients with moderate to severe ICH and intraventricular hemorrhage, hydrocephalus, and infratentorial hematoma location.
4.With cerebellar hemorrhages > 3 cm in diameter or volume > 15 mL, early surgical evacuation is necessary to prevent hydrocephalus, brainstem compression, and neurologic deterioration.
- low risk of Aneurysm rupture?
-how to manage ?
if Aneurysms
1. < 7 mm in the posterior circulation
- < 12 mm in the anterior circulation
can be managed conservatively with annual noninvasive neuroimaging.
DVT prophylaxis initiation in patients with hemorrhagic stroke?
intermittent pneumatic compression beginning the day of hospital admission.
After 24 hours, if there is no evidence of hematoma expansion, then LMWH is recommended for VTE prophylaxis.
essential tremor presents with mild additional neurologic signs, such as mild ataxia or isolated tremor at rest without bradykinesia, it would be classified as “
essential tremor plus.
The treatment of essential tremor is symptomatic.
Weighted utensils and wrist weights can help reduce tremor amplitude during feeding.
pharmacologic treatments: propranolol, primidone, and topiramate.
second-line options include atenolol, sotalol, clonazepam, gabapentin, and nimodipine.
Botulinum toxin injection can help with some tremors, especially those involving the neck and voice, but its benefit for limb tremor is limited by local weakness.
Dystonia treatment
anticholinergic agents, benzodiazepines, baclofen, levodopa,
injection with botulinum toxin
in refractory cases, DBS therapy.
Symptomatic treatments of chorea
dopamine depleters valbenazine, deutetrabenazine, and tetrabenazine;
antipsychotic agents; clonazepam; and antiepileptic drugs.
Management of myoclonus
addressing the underlying systemic or toxic causes and
administering antimyoclonic agents, such as clonazepam or valproic acid.
Tic Treatment
reassurance (in mild disease), cognitive behavioral therapy, and addressing psychiatric comorbidities.
Anti-tic medications are indicated when tics interfere with daily functioning, education, or work.
First-line treatments include aripiprazole, clonidine, guanfacine, topiramate, levetiracetam, and tetrabenazine.
Aripiprazole is the preferred agent in severe cases.
In refractory disease, antipsychotic agents, injections with botulinum toxin, and DBS therapy may be considered.
Corticobasal degeneration
is a Parkinson-plus syndrome characterized by severely asymmetric parkinsonism, fixed dystonia, myoclonus, cortical sensory deficits, apraxia, and cognitive deficits.
In Epidural hematoma, Urgent surgical evacuation is recommended for
- GCS score < 9
- anisocoria
- hematoma > 30 mL in volume.
acute subdural hematomas, indications for immediate surgical treatment.
- a hematoma thickness > 10 mm,
- GCS < 9
- the presence of pupillary asymmetry or fixation
In chronic hematomas, indications for neurosurgical drainage.
- a hematoma thickness > 10 mm,
- midline shift > 5 mm, and
- significant neurologic compromise
First-line treatment of relapsing-remitting MS
Glatiramer acetate or interferon beta
Primary progressive MS treatment
Ocrelizumab
Secondary progressive MS treatment
Mitoxantrone
Neurologic complication of natalizumab therapy
Multifocal leukoencephalopathy
MS fatigue drug treatment
Modafinil, armodafinil, amantadine
MS medication for impaired mobility (gait speed and endurance)
Dalfampridine
Required monitoring with fingolimod therapy
Ophthalmic examinations (macular edema)
myasthenic crisis can be triggered by
1.infection
2.surgery
- medications (especially aminoglycosides, quinolones, magnesium, β-blockers, and hydroxychloroquine).
Symptomatic treatment of ocular and mild generalized myasthenia
cholinesterase inhibitor pyridostigmine
advanced disease of MG treatment
immunosuppressive therapy
Oral glucocorticoids often are used as first-line treatment
prominent bulbar or generalized weakness and in myasthenic crisis, treatment with
IVIG or plasmapheresis
treatment of MG in patients with thymoma
Thymectomy
MuSK-positive myasthenia responds well to
plasmapheresis and glucocorticoids
but requires aggressive maintenance immunosuppression.
serology of Diagnosis of MG
1.acetylcholine receptor antibodies
2.anti–muscle-specific kinase (MuSK)
3.anti–lipoprotein receptor-related protein 4 (LRP4) antibodies.
Indications for thymectomy in myasthenia gravis include
- presence of thymoma
or
- to minimize immunotherapy requirements in patients without thymoma who have active disease and positivity for acetylcholine receptor antibodies, younger < 65 years, and are within 3 years of diagnosis.
Lambert-Eaton Myasthenic Syndrome presents similarly to MG, except
that weakness improves with exercise, and hyporeflexia and dysautonomia are present
Lambert-Eaton Myasthenic Syndrome associated with antibodies
against the voltage-gated calcium channel
Treatment of Lambert-Eaton Myasthenic Syndrome
- treating any underlying malignancy or,
- in nonparaneoplastic disease, immunosuppression, IVIG, or plasmapheresis.
- Amifampridine can provide symptomatic benefit.
Treatment of ALS
- Riluzole and edaravone
- Noninvasive ventilation
- nutritional support (including percutaneous endoscopic gastrostomy)
- treatment of pseudobulbar affect by dextromethorphan-quinidine also have shown some benefit
Sodium phenylbutyrate–taurursodiol has been shown to slow functional decline, delay first hospitalization, and prolong tracheostomy-free and ventilation-free survival
ALS Diagnosis is based on clinical evidence of
both upper and lower motor neuron signs on examination and EMG evidence of lower motor neuron signs in at least two (probable ALS) or more (definite ALS) regions.
Upper and lower motor neuron signs without sensory involvement
ALS
Peripheral neuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes
POEMS syndrome
Test for Miller-Fisher variant of GBS
Antibodies to GQ1b ganglioside protein
Evaluate dementia with neuroimaging
Either a brain MRI or a head CT without contras
Acetylcholinesterase inhibitors should be avoided in patients with
pre-existing bradycardia or documented conduction disease.
treatment of Alzheimer disease
The acetylcholinesterase inhibitors
1.donepezil
2.rivastigmine
3.galantamine
The N-methyl-D-aspartate receptor antagonist memantine is approved for moderate to severe dementia
The antiamyloid therapies aducanumab and lecanemab for symptomatic Alzheimer disease
Cholinesterase inhibitor contraindications
Bradycardia, sick sinus syndrome, LBBB
Medication to prevent progression of Mild Cognitive Impairment
(MCI) to dementia
none
Treatment
Traumatic Encephalopathy Syndrome
- acetylcholinesterase inhibitors
As in behavioral-variant FTD, treatment is often symptom directed and includes antidepressants, mood stabilizers, and (occasionally) stimulants for severe apathy.
neuroimaging finding in Traumatic Encephalopathy Syndrome
-global Brain atrophy
which can help differentiate TES from FTD (which is associated with frontal lobe atrophy).
Cognitive slowing, disorganized thought processing, parkinsonism after head trauma
Traumatic encephalopathy syndrome
Which AED can cause or worse depression and anxiety and suicidal thoughts
Levetiracetam
Treatment of levodopa induced dyskinesia
Amantadine
Treatment of Tardive dyskinesia
Valbenazine
Treatment of asymptomatic carotid stenosis < 80 %
No intervention
Atypical facial palsy evaluation
MRI Brain
Anticoagulant Contraindications in brain tumor
- Hx of previous ICH
- Plt < 50
Treatment of brain edema & herniation
- Elevation of the head of the bed to 30 degree
- Hyperventilation ( usually MV)
- Infusion hypertonic saline or mannitol
- Glucocorticoids
AED in tumors
Prophylaxis is not recommended
If there is seizures
Preferred to give Levetiracetam or lacosamide
Glioblastoma treatment
Resection if possible followed by radiation and chemotherapy
Meningioma treatment
Resection for symptomatic or large meningiomas
Observation for asymptomatic or small meningiomas
CNS lymphoma
Biopsy
Pan CT or PET scan
Iv methotrexate with rituximab, followed by radiation
Metastatic brain tumors
MRI
Biopsy is not indicated, if pt with active, biopsy proven systemic malignancy
Glucocorticoids are first line for parenchymal tumor
Pt with symptomatic brain metas > surgery or radiation
Isolated exercise induced weakness, cramps and myoglobinuria
McArdle disease
X linked disease, progressive weakness and cardiomyopathy
Becker muscular dystrophy
Autosomal recessive, progressive weakness in proximal and respiratory muscles
Acid Maltese deficiency
Fluctuating weakness and ophthalmoplegia and multiorgan symptoms and maternal inheritance
Mitochondrial myopathy
Postural headache is the most common manifestation of
Intracranial hypotension
Acute asymmetric pain, followed by proximal weakness and muscle loss
Diabetic amyotrophy
* can occur in well controlled DM
Post stroke fatigue, should be evaluated by
Polysomnography
