Neurology Flashcards
What is a subdural hematoma?
blood collection under the dura
what causes a subdural hematoma?
tearing of “bridging” veins that pass through the space between the cortical surface and the dural venous sinuses or injury to the brain surface with resultant bleeding from cortical vessels
What classic findings appear on head CT scan for a subdural hematoma?
curved, crescent-shaped hematoma (think sUbdural = cUrved)
What are three types of subdural hematomas?
- acute - symptoms within 48hours of injury
- subacute - symptoms within 3-14 days
- chronic - symptoms after 2 weeks or longer
what is the treatment of subdural hematomas?
mass effect (pressure) must be reduced - craniotomy with clot evacuation is usually required
what are usual causes of subarachnoid hemorrhage?
most cases are due to trauma; of nontraumatic SAH, the leading casue is ruptured berry aneurysm, followed by arteriovenous malformations
what comprises the workup of subarachnoid hemorrhage?
head CT - first test
LP
arteriogram to look for aneurysms or AVMs
what are s/sx of subarachnoid hemorrhage
classic symptom “the worse headache of my life”
occasionally LOC, Vomiting, nausea and photophobia
what are the possible complications of subarachnoid hemorrhage?
- brain edema leading to increased ICP
- rebleeding
- vasospasm
what is the treatment for vasospasm from subarachnoid hemorrhage?
Nimodipine (CCB)
what is a berry aneurysm?
saccular outpouching of vessels in the circle of Willis, usually at bifurcations
what is the usual location of a berry aneurysm?
ACA (anterior communicating artery)
followed by PCA and MCA
what medical disease increases the risk of berry aneurysms>
Polycystic kidney disease and CT disorders
what is the treatment for aneurysms?
surgical placement of metal clip is the mainstay
may also do balloon occlusion/coil embolization
What is an AVM
arteriovenous malformation
- congenital abnormality of the vasculature with connectinos btwn the arterial and venous virculations w/o interposed capillary network
where do AVMs occur?
75% of AVMs are supratentorial
what is the tx of AVMs
many are on the brain surface and accessible operatively; preop embolization can reduce the size of AVM.
for surgically inaccessible lesions - radiosurgery
what is an epidural hematoma?
collection of blood between the skull and the dura
what causes an epidural hematoma?
usually in association wtih skull fracture as bone fragments lacerate meningeal arteries
what artery is associated with epidural hematomas?
MMA (middle menigeal artery)
what is the most common sign of an epidural hematoma?
> 50% have ipsilateral blown pupil
what is the classic history with epidural hematoma?
LOC followed by a “lucid interval” followed by neurologic deterioration
what are the classic CT scan findings with an epidural hematoma?
Lenticular (lens) shaped hematoma
(Think Epidural = lEnticular)
what is the surgical treatment for an epidural hematoma
surgical evacuation
what are the indications for surgery with an epidrual hematoma?
any symptomatic epidural hematoma; or >1cm
What is aphasia
inability to comprehend or formulate language b/c of damage to specific brain regions
what is the typical cause of aphasia
postop CVA (stroke) or head trauma
what is dysarthria
motor speech disorder resulting from neurologic injury of the motor component of the motor-speech system
what causes dysarthria
toxic, metabolic, degenerative disease, TBI or thrombotic/embolic stroke
what degenerative diseases cause dysarthria
parkinsonism, ALS, MS, huntingtons disease
what procedures have an increased risk of perioperative vision loss
cardiac, spine, head and neck and some ortho procedures
what is the most common cause of postop ocular injury
corneal abrasion
what is the most common cause of POVL
central retinal artery occlusion
ischemic optic neuropathy
cerebral vision loss
what is anterior cord syndrome
loss of pain and temp below level of preserved jt position/vibration sense
what is central cord syndrome
loss of pain and temp sensation at level of the lesion, where spinothalamic fibers cross the cord, with other modalities preserved
what is complete cord transection
rostral zone of spared sensory levels (reduced sensation caudally, no sensations in levels below injury); urinary retention and bladder distention
what is brown-sequard syndrome
HEmisection of the cord
loss of jt position sense and vibration sense on the same side as lesion and pain and temp on opposite site a few levels below the lesion
what is distal sensory polyneuropathy
stocking-glove sensory loss most commonly seen in length-dependent axonal neuropathies
what are the most common cuases of axonal neuropathies
DM, alcohol, Vitamin B12 deficiency, syphillis, HIV, lyme, etc.
what is the treatment of carotid stenosis
antiplatelet therapy (ASA)
if >70% - carotid endarterectomy
what population is commonly affected by subdural hematomas
enderly pts with hx of multiple falls
A 75-year-old white woman who had undergone surgical oophorectomy 8 days earlier suddenly experienced impairment of vision, which started in the right eye (OD), lasted 4 days, and then affected both eyes (OU). In the postoperative period, she experienced a hypotensive crisis (blood pressure approximately 80/50 mm Hg) that lasted for 2 days. She also developed severe edema of the lower extremities 4 days postoperatively, which resolved with diuretic treatment. The fundoscopic exam showed no swelling of the disc. Visual field testing showed an altitudinal loss. What is the diagnosis?
A Malignant hypertension with disc edema
B Retinal vascular occlusion
C Compressive optic neuropathy
D Anterior ischemic optic neuropathy
D. anterior ischemic optic neuropathy
The correct diagnosis is anterior ischemic optic neuropathy (AION). The mechanism for ischemia to the optic nerve is hypoperfusion as a result of the hypotensive crisis after oophorectomy surgery, along with these risk factors: systemic low blood pressure, anemia, small cup-to-disc ratio, and atherosclerosis. AION is caused by ischemia or poor circulation to the short posterior ciliary blood vessels that supply the front, or anterior, portion of the optic nerve. This results in a painless abrupt reduction in vision and optic disc pallor and swelling. An immediate work-up that includes laboratory tests must be performed to rule out giant cell arteritis and other autoimmune diseases.
A 60-year-old man presents with a sudden change in speech following a thyroidectomy performed 2 days ago. He describes his voice as hoarse and weak. He denies any respiratory distress, difficulty swallowing, or neck pain. On examination, his voice is noticeably hoarse, but there are no signs of stridor or respiratory distress. Which of the following is the most likely cause of his symptoms?
A Recurrent laryngeal nerve injury
B Postoperative hematoma
C Thyroid storm
D Laryngeal edema
E Esophageal injury
a. recurrent laryngeal nerve injury
A 45-year-old woman presents with sudden onset of motor and sensory loss in her right leg following a prolonged surgical procedure for pelvic cancer. She reports an inability to dorsiflex her foot and numbness over the lateral aspect of her leg and dorsum of her foot. She has no history of diabetes or peripheral neuropathy. Which of the following is the most likely cause of her symptoms?
A Sciatic nerve injury
B Femoral nerve injury
C Peroneal nerve injury
D Tibial nerve injury
E Lumbosacral plexopathy
c. peroneal nerve injury
The patient’s symptoms of foot drop (inability to dorsiflex the foot) and sensory loss over the lateral aspect of the leg and dorsum of the foot are characteristic of peroneal nerve injury. The peroneal nerve is susceptible to injury during surgical procedures, especially those involving the pelvis, due to its superficial course around the fibular head. Prolonged pressure or stretch during surgery can lead to this type of nerve injury.
A 47-year-old male presents to the emergency department with headache. He reports that he suddenly developed a throbbing, bitemporal headache about five hours ago “out of nowhere.” He has a history of migraine headaches, but he feels that this headache is significantly more painful than his typical migraines. The patient took his prescribed sumatriptan with no relief in his symptoms. The patient reports nausea and he vomited once before arrival in the ED. The patient denies any recent trauma to the head. His past medical history is significant for migraines and hypertension. He has a 20 pack-year smoking history and a history of cocaine use. He drinks 5-6 beers per week. On physical exam, he appears to be in moderate distress and has pain with neck flexion. He has no focal neurologic deficits. A head CT is performed and can be seen here.
A Between periosteum and skull
B Between periosteum and galea aponeurosis
C Between skull and dura mater
D Between dura and arachnoid mater
E Between arachnoid and pia mater
e. between arachnoid and pia mater
Which of the following patient profiles would be most likely to present with a chronic subdural hematoma?
A 12-year-old male gymnast with hemophilia A
B 20-year-old male suffering a head injury 2 hours ago
C 36-year-old female with head injury 30 minutes ago
D 55-year-old female with a cerebral aneurysm
E 78-year-old male with long-standing alcoholism
e. 78yo with long standing alcoholism
A 68-year-old man with a history of hypertension and smoking presents with a transient episode of right-sided weakness and difficulty speaking that resolved within an hour. He has no history of diabetes or coronary artery disease. On examination, his blood pressure is 150/90 mmHg, and a bruit is heard over the left carotid artery. Which of the following is the most appropriate next step in management?
A Immediate carotid endarterectomy
B Magnetic resonance angiography (MRA) of the carotid arteries
C Start a beta-blocker for blood pressure control
D Prescribe a statin and antiplatelet therapy
E Schedule for a coronary artery bypass graft surgery
b. MRA of carotid
what is amaurosis fugax
temporary monocular blindness (“curtain coming down”): seen with microemboli to retina (TIA)
what is the gold standard invasive method of evaluating carotid disease
a-gram
A 25-year-old man is brought to the emergency department after a motor vehicle accident. He was initially alert and oriented but became progressively drowsy over the next few hours. His Glasgow Coma Scale score is now 12. A head CT scan shows a biconvex, lens-shaped hyperdense collection over the right parietal region without significant midline shift. Which of the following is the most appropriate next step in management?
A Observation and serial neurological examinations
B Immediate administration of mannitol
C Surgical evacuation of the hematoma
D Lumbar puncture for cerebrospinal fluid analysis
E High-dose corticosteroids
c. ssurgical evacuation of hematoma
