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Internal Medicine > Neurology > Flashcards

Neurology Flashcards

1
Q

What are serum prolactin levels used for?

A

Differentiate seizure from pseudoseizure (psychogenic nonepileptic seizure)

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2
Q

Multiple pigments on iris suggests…

A

Lisch nodules - raised hyperpigmented hamartomas
Neurofibromatosis type I

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3
Q

Neurofibromatosis type I findings

A

Cafe-au-lait spots
Skinfold freckling (age 5)
Lisch nodules (age 6)

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4
Q

Neurofibromatosis type I cancer risks

A

Peripheral nerve sheath tumor malignant transformation
Optic pathway glioma
CNS tumors
Pheochromocytoma

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5
Q

Neurofibromatosis type II findings

A

Vestibular schwannoma (acoustic neuroma)
Some cafe-au-lait macules

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6
Q

Retinal hemangioblastomas are associated with…

A

von Hippel Landau (–> clear cell carcinoma)

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7
Q

Renal angiomyolipoma is associated with…

A

Tuberous sclerosis (benign hamartomas in many organs + various skin findings)

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8
Q

Treatment for idiopathic intracranial hypertension

A

Weight loss (including bariatric surgery)
Carbonic anhydrase inhibitor (acetazolamide), topiramate

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9
Q

Triptan MOA

A

Serotonin receptor agonist (5-HT 1B/1D) –> decreases neurogenic inflammation and calcitonin gene-related peptide (CGRP) release

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10
Q

Persistent migraine medications

A

Triptan
Antiemetics (e.g. promethazine)
Dihydroergotamine

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11
Q

Cluster headache treatment

A

100% oxygen via nonrebreathing mask
Triptan

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12
Q

Ophthalmic findings in glaucoma

A

Atrophy of optic nerve head: optic disc rim thinning, increased cup/rim ratio (“cupping”)
Increased IOP
Gradual loss of peripheral vision

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13
Q

Glaucoma medications from first-line downward

A
  1. Topical prostaglandin (latanoprost, carboprost) - increased drainage through uveroscleral pathway
  2. Topical beta-blocker (Timolol) - decrease aqueous humor inflow; use with caution in comorbid asthma
  3. Surgical (laser trabeculoplasty)

Less effective: Alpha agonists and carbonic anhydrase inhibitors (decrease aqueous humor inflow); cholinergic agonists (increase trabecular outflow)

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14
Q

Carbonic anhydrase inhibitors - difference between open and closed-angle glaucoma

A

Open: Topical dorzolamide
Closed: Systemic/oral acetazolamide

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15
Q

Open globe laceration - signs

A

Peaked/teardrop pupil
Anterior chamber depth increased/decreased
Reduced IOP
Absent afferent pupillary response
Acuity decreased

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16
Q

What is signified by acute corneal opacification?

A

Angle closure glaucoma

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17
Q

What is are hypopyon and perilimbic injection?

A

Hypopyon: layering of inflammatory cells in the anterior chamber
Perilimbic injection/ciliary flush: dilation of vasculature at junction of sclera and cornea

Seen in inflammatory and infectious conditions

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18
Q

Orbital compartment syndrome - treatment

A

Orbital decompression by cutting eyelid from lateral canthus to orbital rim (lateral canthotomy) and then dividing inferior limb of lateral canthal tendon (inferior cantholysis)

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19
Q

What causes paradoxical improvement in hearing speech in noisy environments?

A

Conductive hearing loss (e.g. otosclerosis - may also have reddish hue behind tympanic membrane)

Sensorineural hearing loss would result in worse speech understanding with increased background noise

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20
Q

Decreased vision, floaters, and fluffy yellow-white chorioretinal lesions

A

Candida endophthalmitis

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21
Q

Candida endophthalmitis - risk factors

A

Hospitalized patients with central venous catheters
TPN
Immunocompromise

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22
Q

How could cancer metastases to the brain affect vision?

A

Space occupying lesion –> increased intracranial pressure (e.g. bilateral papilledema)

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23
Q

Common drug-induced glaucoma causes

A
  1. Glucocorticoids
  2. Systemic sympathomimetics (e.g. ephedrine)
  3. Systemic anticholinergics
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24
Q

What is xerophthalmia?

A

Excessive dryness of conjunctiva/cornea that causes ridges - seen in vitamin A deficiency

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25
Q

Who has paraneoplastic optic neuritis?

A

Small cell lung cancer
Acute unilateral vision loss, painful
Papillitis on exam

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26
Q

Pain medications for post-traumatic neuroma

A
  1. Local anesthetic (diagnoses and treats)
  2. TCA
  3. Antiepileptic
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27
Q

How do glucocorticoids cause open-angle glaucoma?

A

Decrease aqueous humor drainage –> increased IOP

Rapid increase in IOP leads to:
1. Halos around lights
2. Decreased visual acuity
3. Eye pain
4. Headache
5. Corneal edema

Advanced disease –> peripheral vision loss

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28
Q

Meningioma characteristics on MRI imaging; epidemiology; dx; treatment

A

Extra-axial
Well-circumscribed
Round homogeneously enhancing dural-based mass
Calcification
Hyperdense on non-contrast head CT

These are considered benign - commonly found in middle-age to elderly women

Dx intraoperatively

Tx complete resection

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29
Q

Brain metastasis appearance on imaging

A

Multiple ring-enhancing lesions at grey-white junction (intra-axial)

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30
Q

What can cerebral amyloid angiopathy lead to?

A

Intracerebral hemorrhage

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31
Q

When is urgent surgical decompression and clot evacuation indicated for intracerebral hemorrhage?

A

Cerebellar hemorrhage with area >3 cm, brainstem compression (stupor, coma, death), or obstructive hydrocephalus
Signs of neurologic deterioration (lethargy, obtundation, coma)

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32
Q

Pterion region

A

Junction of frontal, parietal, temporal, and sphenoid bones

Fracture here often occurs with epidural hematoma and tearing of middle meningeal artery

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33
Q

What artery is most associated with epidural hematoma?

A

Middle meningeal artery

34
Q

Acute epidural hematoma - signs, imaging

A

Loss of consciousness followed by lucid interval (however, some may initially remain alert)
Elevated ICP - headache, n/v, altered mental status - within minutes to hours

CT - hyperdense biconvex lesion

35
Q

Intracerebral hemorrhage etiologies

A

Usually older patients:
1. Severe HTN
2. Cerebral amyloid angiopathy
3. Anticoagulant/antiplatelet use

36
Q

Subarachnoid hemorrhage - signs, etiology

A

Sudden, severe “thunderclap” headache
Loss of consciousness
Meningismus

Usually due to rupture of intracranial aneurysm

37
Q

Subdural hematoma - etiology

A

Trauma –> tearing of bridging veins –> venous bleeding

Typically older adults, those on antithrombotic agents

Acute –> coma
Chronic –> insidious onset of confusion, headache, somnolence over days/weeks

38
Q

When does paroxysmal sympathetic hyperactivity occur?

A

10-20% of those with severe traumatic brain injury

Thought to be due to loss of cortical inhibition of lower sympathetic centers (e.g. hypothalamus, brainstem, spinal cord)

Opioids, GABA-agonists, and a2-agonists may help

39
Q

What is the most common cause of focal epilepsy?

A

Mesial temporal (hippocampal) lobe sclerosis

40
Q

Gerstmann syndrome

A

Lesions in dominant (left) parietal lobe - difficulties with:
1. Writing
2. Calculations
3. Distinguishing fingers
4. Left-right disorientation

41
Q

Lesions in dominant (right) hemisphere affect?

A

Nonverbal spatial mapping and orientation:
1. Neglect
2. Distortions in position sense (e.g. feeling of floating)
3. Visual interpretation (e.g. object size)

42
Q

Myopia causes focal point to move in which direction relative to retina?

A

Anterior to retina
Anterior-posterior diameter of eye is increased in myopia
Use diverging (concave) lens

43
Q

What is considered high myopia? What bad things can happen? Treatment?

A

> =6 diopters of correction required

Stretching/thinning of sclera, choroid, retina –> retinal detachment, macular degeneration

Treatment:
1. Antimuscarinic drops (e.g. atropine)
2. Orthokeratology (i.e. rigid contact lens)

44
Q

Who has cotton-wool spots (yellow-white retinal lesions)?

A

Hypertension, diabetes - retinal microinfarctions caused by arteriolar obstruction and ischemia

45
Q

Spinal epidural abscess - treatment

A

Antibiotics + emergency surgical decompression

46
Q

How may antipsychotics contribute to orthostatic syncope?

A

Alpha-1 blocking properties (e.g. haloperidol, risperidone, quetiapine)

47
Q

Brown-Sequard syndrome

A

Hemisection (disruption of half) of spinal cord:
1. Ipsilateral hemiparesis
2. Ipsilateral loss of proprioception, vibration, light touch
3. Contralateral loss of pain and temperature (spinothalamic tract) 1-2 levels distal to cord injury and below - axons move up 1-2 levels before crossing over, saving those at the level of the injury

  1. Ipsilateral Horner syndrome (if cervical)
  2. Spinal shock –> ipsilateral reflexes initially absent –> ipsilateral hyperreflexia and positive Babinski
48
Q

Anterior cord syndrome affects which tracts?

A

Distal paralysis (LCT) and decreased pain/temperature (LST)

49
Q

Cyclopentolate

A

Anticholinergic eye drops

Traumatic iritis (e.g. left perilimbal conjunctival injection)

Treat with physostigmine (cholinesterase inhibitor)

50
Q

Where do brain mets tend to localize on MRI?

A

Multiple well-circumscribed lesions with vasogenic edema at gray-white matter junction

51
Q

Primary CNS lymphoma on MRI

A

Periventricular lesion, irregular and nonhomogeneous

52
Q

Most common intracranial tumor of NF1?

A

Optic pathway glioma in toddlerhood

Then astrocytomas, brainstem gliomas into adulthood

53
Q

Trochlear nerve innervates which muscle?

A

Superior oblique - eye downward and intorsion

Palsy leads to hypertropia and extorsion; chin tuck head tilt to compensate

54
Q

Meningioma appearance

A

Dural based, calcified, homogeneously enhancing lesion

Arise from meningothelial cells of arachnoid mater

55
Q

Anti-GQ1b antibodies

A

GQ1b ganglioside is found in peripheral nerves; antibody can contribute to rapid-onset ophthalmoplegia

Sensitive for Miller Fisher syndrome (MFS) variant of Guillain-Barre but may be present in other variants with predominant ophthalmoplegia

56
Q

Miller Fisher Syndrome variant of Guillain-Barre

A
  1. Ophthalmoplegia
  2. Ataxia
  3. Areflexia

Strength often preserved vs classic GBS

Associated with anti-GQ1b antibody

57
Q

What labs should be obtained in anyone with clinical diagnosis of restless legs syndrome?

A

Serum iron studies

Those with iron deficiency or even low-normal ferritin (<=75) should take supplemental iron

58
Q

How does pupillary involvement of CN III palsy help distinguish etiology?

A

Parasympathetic component (pupil constriction) is on outside of fascicle and less susceptible to ischemia - if non-pupil sparing, consider mass effect and intracranial aneurysm

Motor component runs within nerve and can be damaged by compression or microvascular ischemia - if pupil-sparing, consider microvascular ischemia from diabetes, HTN, HLD, or age

59
Q

Progressive, painless, symmetric loss of visual acuity and color vision

A

Toxic optic neuropathy

60
Q

Complex regional pain syndrome

A

Pain does not follow specific peripheral nerve

Typically follows trauma or surgery
Associated with edema, vasomotor signs, and trophic changes in skin and hair

61
Q

Spinal epidural hematoma

A

Can lead to cauda equina syndrome
Slowly progressive
Management includes MRI and is a surgical emergency, typically requiring urgent decompression (e.g. laminectomy)

62
Q

What makes essential tremors better?

A

Alcohol

63
Q

What is myoclonus status epilepticus?

A

Symmetric irregular muscle contractions, within 72 hours of hypoxic brain injury

Manage with antiepileptic meds, supportive care

64
Q

Folate vs B12 deficiency

A

Folate deficiency does not cause neuro issues
Folate deficiency has normal methylmalonic acid

65
Q

Opaque conjunctival plaques

A

Bitot spots - specific for vitamin A deficiency
Would also see xerophthalmia, follicular hyperkeratosis

66
Q

Small vs large nerve fibers convey…

A

Small: pain, allodynia, paresthesia
Large: numbness, vibration proprioception, reflexes

67
Q

CNS hamartomas are associated with…

A

Tuberous sclerosis

68
Q

AVM appearance on MRI

A

Dark flow voids and little surroundong edema

69
Q

Triptan mechanism

A

Serotonin receptor agonist
Decrease CGRP release, but also has vasoconstrictive effects

Ergots work similarly, but higher potency and less selectivity

70
Q

What should be done to prevent falls in elderly with delirium inpatient?

A

Direct line of sight of nursing staff

Rails, restraints, and bed alarms bad

71
Q
A
72
Q

What diabetes med can cause B12 deficiency despite no changes in CBC?

A

Metformin - effect on absorption in ileum

73
Q

Head tremor is associated with…

A

Cervical dystonia

Tremor is more jerky, less rhythmic than essential tremor

74
Q

Essential vs intention tremor

A

Essential can occur with and without intentional movement

Both are action tremors, essential is kinetic whereas intention is a subtype of kinetic that worsens as it approaches

Intention often caused by cerebellar pathology

75
Q

What causes most cases of mononeuritis multiplex?

A

Vasculitis, particularly polyarteritis nodosa

76
Q

Only homocysteine or only MMA elevation is associated with folate deficiency?

A

Homocysteine elevation only

If both elevated, then B12 deficiency

77
Q

Salt wasting syndrome

A

Polyuria, hyponatremia and hypovolemia after brain injury - urinary sodium losses due to BNP secretion

78
Q

Lambert-Eaton - treatment

A

Amifampridine or guanidine - decrease K efflux from presynaptic neurons -> prolonged depolarization and ACh release
Pyridostigmine
IVIG followed by oral immunosuppressive agents if persistent disease

79
Q

Myasthenia gravis - treatment

A

Plasmapheresis or IVIG +/- steroids
Pyridostigmine +/- glycopyrrolate (antimuscarinic to counter pyridostigmine) for symptoms
Steroids may transition to nonsteroidal immunosuppressants (e.g. azathioprine)

80
Q

Botulism treatment depending on source

A

Infant: human botulism Ig - due to ingestion of spores, maybe from honey
Foodborne or wound: equine botulinum antitoxin

81
Q

Lyme ascending paralysis vs GBS

A

Lyme doesn’t have autonomic dysfunction

Internal Medicine (23 decks)

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