Neurology Flashcards
possible viral etiology for bells palsy
HSV
common preceding event for bells palsy
URI
hallmark presentation of bells palsy
-sudden onset of unilateral facial weakness/paralysis of upper and lower parts of the face
-unable to wrinke forehad and close one eye
how to differentiate bells palsy from stroke
stroke: pt can wrinkle forehad
bells palsy: forehead paralysis
consider _ dz with bells palsy pt’s
do NOT use _ if you suspect lyme dz
lyme
steroids
consider _ testing if bells palsy does not resolve w/in 10 days
EMG
tx for bells palsy
mc self resolves by 1 month
acute: steroids + acyclovir
nighttime eye patch to prevent corneal abrasion
surgical decompression of CN VII if paralysis progresses
47 yo in ED w. stiff neck, photophobia, severe HA that begin while she was gardening - she is in severe distress
cerebral aneurysm
pathophys of cerebral aneurysm
weak/bulging spot in wall of brain artery
classification of cerebral aneurysm based on diameter
small: <15 mm
large: 15-25 mm
giant: 25-50 mm
supergiant: > 50 mm
types of cerebral aneurysm
saccular (berry) - mc
fusiform
traumatic
mycotic
ruptured (AVM)
2 mc locations for saccular/berry aneurysms
- ACA
- ICA
mcc of SAH
berry aneurysm
dilation of the entire circumference of the BV
fusiform aneurysm
what type of cerebral aneurysm is caused by infected emboli
mycotic
6 rf for ruptured cerebral aneurysm
smoking
HTN
hypercholesterolemia
heavy etoh
polycystic kidney dz
coarctation of aorta
6 sx of ruptured cerebral aneurysm
sudden onset worst HA of life
n/v
sz
AMS
HTN
fever
less severe HA that precedes ruptured cerebral aneurysm
herald bleed
dx for cerebral aneurysm
gs: cerebral angiography
initial: non contrast head CT
LP
2 LP findings of ruptured cerebral aneurysm
elevated opening pressure
bloody fluid (xanthochromia) in all tubes
tx for cerebral aneurysm
surgical clipping vs endovascular coiling
2 types of CVA
ischemic - blockage
hemorrhagic - rupture
mc sx of CVA
contralateral paralysis
occular sx of CVA
amaurosis fugax (monocular blindness)
4 sx of MCA CVA
aphasia
hemiparesis
gaze preference
homonymous hemianopsia
3 sx of ACA CVA
leg paresis
hemiplegia
urinary incontinence
hallmark sx of PCA CVA
homonymous hemianopsia
5 sx of basilar artery CVA
coma
cranial n palsies
apnea
drop attack
vertico
what are lacunar infarcts
CVA in areas supplied by small perforating vessels
3 sx of lacunar infarcts
pure motor or sensory sx
dysarthria/clumsy hand syndrome
ataxic hemiparesis
3 rf for lacunar stroke
atherosclerosis
HTN
DM
initial imaging for CVA
CT w.o contrast
management of occlusive CVA’s
occlusive: IV tPA w.in 3-4.5 hr of sx onset
indication for endarterectomy
carotid a > 70% occluded
absolute contraindications to tPA (9)
-hemorrhagic stroke on CT
-hx of ICH
-sx of SAH
-neurosurgery, head trauma, or stroke in past 3 mos
-uncontrolled HTN (SBP > 185, DBP > 110)
-known AVM, neoplasm, or aneurysm
-active internal bleeding
-known bleeding diathesis (PLT<100,000, heparin w.in past 48 hr, elevated aPTT, current antocoags, INR > 1.7)
-BG < 50
45 yo M w. 4 week hx of recurrent nightly 1 hr HA that wake him up during the night - he describes them as a deep excruciating burning sensation centered behind the left eye; he has associated watery eyes/nasal discharge and a sensation of warmth in his face
cluster HA
tx for cluster HA
100% O2 at 6-12 L/min for 15 min
imitrex
glasgow coma score
glasgow coma score < _ = coma
9
idiopathic pain syndrome that causes continuous pain disproportionate to the any inciting event
complex regional pain syndrome
describe the pain w. complex regional pain syndrome
non dermatomal
disproportionate to the injury
budapest criteria for complex regional pain syndrome
at least 1 sx in 3/4 four categories:
-sensory: hyperalgesia and/or allodynia
-vasomotor: skin, temp, color, asymmetry
-sudomotor/edema: edema, sweating
-motor/trophic: decreased ROM or motor dysfxn and/or hair/skin/nail changes
tx for complex regional pain syndrome
stage 1: gabapentin, amitryptiline, bisphosphonates
stage 2: add steroids
stage 3: consult pain management specialist - regional n block/spinal cord stimulators
transient, traumatic brain dysfxn
concussion/mTBI
6 main sx of concussion
confusion
memory loss
LOC
HA
dizzy
n/v
clinical definition of concussion/mTBI
-glasgow coma score 13-15 30 mins after injury
-conscious loss < 30 min
post traumatic amnesia < 24 hr
-other transient neuro abnl’s
what tool is used to determine if peds should get imaging post mTBI
PECARN
management of mTBI
-2-3 days of physical/cognitive rest
-return to school 2-3 days post injury
-gradual reintro of activity that does not worsen sx
-return to regular activities when able to do all activities w.o experiencing any sx
-limit caffeine
acute reversible cognitive dysfxn 2/2 to some underlying medical condition
delirium
mc type of hallucination associated w. delirium
visual
3 rf for delirium
post surgery for heart dz
DM
etoh abuse
main diff btw delirium and dementia
derlirium is usually reversible
mc presentation of AMS in the inpatient setting
delirium
mcc of delirium
etoh abuse
delirium caused by acute hyperthyroidism is called
thyroid storm
underlying conditions associated w. delirium (7)
UTI
PNA
metabolic changes
CVA
MI
TBI
meds
3 meds known to cause delirium
anticholinergics
benzos
opioids
workup for delirium should include
MMSE/MOCA
B12/folate
LP if febrile
pharm management of acute agitation/psychosis in derlirious pt
haldol
long term impaired memory dz that is usually irreversible - represents a marked deterioration from previous level of fxn
neurocognitive d.o
2 mc types of neurocognitive d.o
- alzheimer’s
- vascular dz
pathophys of alzheimers
beta amyloid plaques
neurofibrillary tangles
pharm management of alzheimer’s
anticholinesterase drugs:
tacrine
donepezil
rf for vascular disease
arteriosclerotic small vessel dz
vascular dz is mc associated w. a
CVA
hallmark presentation of vascular dz
-stepwise deterioration w. periods of clinical plateaus
-may involve sudden decline
mainstay of vascular dz management
bp control
neurocognitive d.o characterized by language difficulty, personality changes, and behavioral disturbances
frontotemporal lobar degeneration
neurocognitive d.o associated w. parkinsonian sx, hallucinations, gait difficulties, and falls
lewy body dz
t/f: neurocognitive d.o are rarely associated w. hallucinations
t!
if it is, think lewy body dz
neurocognitive d.o associated w. HIV infxn is characterized by
memory deficit
impaired executive fxn’ing
poor attention/concentration
apathy
imaging findings of HIV cognitive decline
cerebral atrophy
acute inflammation of the brain, often due to bacterial/viral infxn or possibly autoimmune d.o
encephalitis
mcc of encephalitis
HSV
immunocompromised: CMV
5 sx of encephalitis
fever
HA
AMS
sz
exanthema
how is encephalitis differentiated from meningitis
altered brain fxn’ing w. encephalitis
work up for encephalitis
LP
MRI
PCR
shaking that occurs w. simple tastsk like tying shoes, writing, shaving, or holding hands against gravity
essential tremor
2 rf for essential atremor
fam hx - autosomal dominant
elderly
intention/action tremor mc affects the (2)
hands
head
essential tremor is aggravated by (4)
stress
fatigue
caffeine
temp extremes
essential tremor is relieved with
etoh
tx for essential tremor
propranolol
resistant: deep brain stimulation
67 yo F w. severe throbbing HA, visual impairment in left eye - pain is worse w. chewing or combing hair - also feels weak/tired - can’t raise arms to reach cabinets - PE shows left sided scalp tenderness, absent left temporal pulse - ESR is elevated
giant cell arteritis/temporal arteritis
giant cell arteritis causes inflammation of large blood vessels in the (3)
scalp
neck
arms
4 hallmark sx of giant cell arteritis
HA
ttp of scalp
jaw claudication w. chewing
amaurosis fugax
what condition is associated w. giant cell arteritis
polymyalgia rheumatica
gs dx for giant cell arteritis
temporal a bx
hallmark lab finding of giant cell arteritis
ESR > 100
tx for giant cell arteritis
high dose prednisone asap!
don’t wait for bx results
major complication of giant cell arteritis
blindness
ascending paralysis beginnign in distal limbs and progressing to total paralysis of all 4 limbs, facial muscles, and loss of reflexes
guillain barre
5 rf for guillain barre
post immunization
campylobacter jejuni infxn
CMV
EBV
HIV
mcc of guillain barre
campylobacter infxn
dx for gullain barre
LP:
elevated CSF protein
WBC wnl
tx for guillain barre
plasma exchange
IVIG
PFTs to monitor resp fxn
huntington dz is autosomal _
dominant
hallmark presentation of huntington (4)
dementia
mutism
dysphagia
chorea
what is chorea
nonrepeating, complex, involuntary rhythmic movements that may appear purposeful
genetic testing for huntington shows
40+ CAG repeats
MRI findings of huntington
atrophy of cerebrum and caudate nucleus
managment of huntington’s
chorea: tetrabenzine vs risperidone vs haldol
speech therapy
types of intracranial tumors
glial
meningioma
vestibular
schwannoma
pituitary adenoma
neurofibroma
CNS lymphoma
most _ intracranial tumors are malignant
glial
3 types of glial intracranial tumors, mc -> lc
astrocytoma
ependymoma
medulloblastoma
mc type of glial tumor in peds
medulloblastoma
4 mc sources of intracranial metastasis
lung
breast
kidney
GI
inflammation of membranes surrounding the brain/spinal cord
meningitis
meningitis triad
HA
fever
nuchal rigidity
if meningitis is associated w. a petechial rash, think
n. meningitidis
mcc of meningitis
enteroviruses
bacterial causes of meningitis based on pt pop
neonate: e.coli, GBS (s.agalactiae)
most people: s. pneumo
immunocompromised: cruptococcus neoformans
which type of bacterial meningitis is dx’ed w. india ink stain
cryptococcus neoformans
cryptococcal meningitis makes you think
HIV/immunecompromised
LP findings of bacterial vs viral meningitis
bacterial: increased pro, decreased glucose
viral: no specific, +/- lymphocytes
before performing LP for meningitis, you must
CT to check for papilledema
tx for meningitis
dexamethasone
empirc abx: cephalosporin vs vanco vs pcn
viral: IV acyclovir
household contacts: rifampin vs cipro vs azithromycin vs ceftriaxone
hallmark presentation of migraines
unilateral, pulsating
nausea
photophobia
phonophobia
typical duration of migraine
4-72 hr
is migraine w. or w.o aura mc
w.o aura
tx for migraines: abortive vs prophylactic
abortive: triptans, ergots
prophylaxis: atenolol/propranolol, verapamil, TCAs
contraindication for triptans and ergots
triptans: ischemic heart dz
ergots: pregnant
21 yo F w. acute onset of double vision in left eye - 2 months ago she had loss of central vision and pupillary light reflex that resolved spontaneously - PE shows delay in adduction of left eye w. nystagmus of right eye on lateral gaze
MS
AI dz that that causes demyelination and scarring of white matter in brain and spinal cord
MS
hallmark sx of MS
visual disturbances over many years
4 mc sx of MS
sensory loss
optic neuritis
weakness
paresthesias
electrical shock sensation in limbs/torso brought on by flexion of the neck
lhermitte’s sign -> MS
mc type of MS
relapsing-remitting: episodic flare ups over days/weeks btw periods of neuro stability
4 types of MS
relapsing-remitting
secondary progressive
primary progressive
progressive relapsing
MS that relapses, remits, and then progresses to steady decline
secondary progressive
MS with no episodes of remission - steady decline from onset
primary progressive
MS that gets worse over time with acute relapses
progressive relapsing
gs dx for MS
MRI showing dawson fingers (white matter lesions)
what is this showing
dawson fingers -> MS
diagnostic criteria for MS
2 episodes/attacks
2 different areas of CNS involved
CSF findings of MS
elevated IgG
oligoclonal bands
pharm tx for MS
acute: steroids
prevention: interferon betas (avonex)
AI attack of Ach receptors at the neuromuscular junction that results in motor problems
myasthenia gravis
hallmark presentation of MG
-fatigability
-weakness in every day activities like brushing hair
-ptosis and diplopia that improves w. rest
MG is associated w. _ hyperplasia and _
thymic
thymoma
dx for MG: initial/mc vs gs
initial/mc: tensilon test
gs: SFEMG (single fiber electromyography)
chest CT to r.o thymoma
what is the tensilon test
injection w. tensilon results in improved muscle strength
moa for tensilon
prevents breakdown of Ach
SFEMG findings of MG
decremental response to repetitive stimulation of motor nerves
tx for MG
-first line: Achase inhibitor: pyridostigmine/neostigmine
-steroids
-thymectomy
-crisis: plasma exchange/IVIG
sx of MG crisis
neuromuscular respiratory failure
dysphagia/aspiration
parkinson’s is caused by degeneration of the _ in the _,
which leads to loss of _ containing neurons
degeneration of the basal ganglia
in the substantia nigra
leading to loss of dopamine containing neurons
class of meds that causes parkinsonism
neuroleptics:
chlorpromazine
metoclopramide
reserpine
parkinsinons’ is caused by a _ imbalance
Ach/dopamine
triad of parkinsons
resting/pill rolling tremor
cogwheel rigidity
bradykinesia
clinical features of parkinson’s (other than triad)
mask facies
loss of postural reflexes
shuffling gait
hypophonia
micrographia
gait arrest
backward falling
parkinson’s dx is usually clinical, but what is considered gs
neuropathologic exam
pharm management of parkinsons
<65 yo: dopamine agonists: bromocriptine, pramipexole, ropinirole
> 65 yo: sinemet (levodopa/carbidopa)
4 common s.e of sinemet
GI upset, n/v
vivid dreams/nightmares
psychosis
dyskinesias
typical presentation of peripheral neuropathy
symmetrical
stocking and glove distribution
pharm managment of peripheral neuropathies
gabapentin
amitriptyline
topiramate
tramadol
NSAIDs
complication of peripheral neuropathies
charcot’s joints
2 types of focal sz’s
consciousness maintained: simple partial
consciousness impaired
presentation of consciousness impaired focal sz (aka complex partial sz)
altered consciousness
lip smacking
postictal state: confusion/memory loss
how are consciousness impaired partial sz differentiated from abscence sz
no postictal state w. absence sz
tx for focal sz
phenytoin
carbamazepine
widespread sz activity in the left and right hemispheres of the brain - start midbrain and spread to both cortices
generalized sz
6 types of generalized sz
absence
tonic-clonic
atonic
clonic
tonic
myoclonic
brief impairment in consciousness w. abrupt beginning and end - rarely involve involuntary movements - pt has no recollection
absence sz
bilat symmetric convulsive sz beginnign w. LOC that involves a post ictal state
tonic-clonic
3 phases of tonic-clonic sz
tonic: stiff/rigid x 10-60 sec
clonic: generalized convulsions/limb jerking
post ictal state: confusion/AMS
sz that mimics syncope and involves sudden loss of muscle tone
atonic (drop attack)
sz characterized by loss of control of bodily fxn, jerking, and post ictal state
clonic sz
sz characterized by extreme rigidity, immediate LOC, and NO involuntary movements
tonic sz
sz characterized by muscle jerking, but no loss of muscle tone - mc occurs in the morning
myoclonic sz
3 types of sz NOS
febrile
infantile spasm
psychogenic non-epileptic sz (PNES)
3 criteria for febrile sz
temp > 38
> 6 mos old, < 5 yo
absence of CNS infxn/inflammation
type of epilepsy sz that does not fit into focal or generalized sz
infantile spasm
PNES sz may mimic
epilepsy
single epileptic sz lasting > 5 min OR >/= 2 or more sz w.in a 5 min period w.o return to normal in between
status epilepticus
2 types of status epilepticus
convulsive
nonconvulsive
convulsive status epilepticus is characterized by
regualr pattern of contraction/extension of the arms/legs
nonconvulsive status epilepticus includes (2)
complex partial status epilepticus
absence status epilepticus
pharm for generalized sz, initial vs maintenance
initial: lorazepam
maintenance: phenytoin
transient LOC/postural tone 2/2 to acute decrease in cerebral blood flow w. rapid recovery of consciousness w.o resuscitation
syncope
5 types of syncope
cardiac
vasovagal
orthostatic
cerebral vascular dz
other noncardiogenic
3 causes of cardiac syncope
arrhythmias
obstruction of blood flow
massive MI
mc type of syncope
vasovagal
3 rf for orthostatic syncope
elderly
DM
meds
5 classes of meds that cause orthostatic syncope
diuretics
vasodilating ccb
bb
nitrates
antiarrhythmics
hallmark presentation of tension HA
bilat band like distribution
mild-mod, dull/squeezing pain
tension HA pain is:
migraine pain is:
tension: bilat, squeezing/dull
migraine: unilateral, pulsating
tx for tension HA
NSAIDs
muscle relaxants
transient episode of neuro dysfxn due to focal brain, retinal, or spinal cord ischemia w.o acute infarction
TIA
presentation of TIA
sudden onset
<60 min (15-30 min avg)
reversal of sx w.in 24 hr
4 clinical manifestations of TIA
ICA
ICA/MCA/ACA
PCA
vertebrobasilar
typical presentation of ICA TIA
amaurosis fugax - lampshade down on one eye
weakness of contralateral hand
typical presentation of ICA/MCA/ACA TIA
sudden HA
speech changes
confusion
typical presentation of PCA TIA
somatosensory deficit
typical presenatation of vertebrobasilar TIA
brainstem/cerebral sx -> gait/proprioception deficits
pharm management of TIA
- ASA w.in 24 hr
- clopidogrel
- high risk: warfarin