Neurology Flashcards
Dose of rtPA
0.9mg/kg IV
max 90mg
Indications for rtPA
Contraindications for rtPA
ABCD2 score for TIA that requires admission
> 3
most common site for a hypertensive hemorrhage?
Putamen
other common sites: thalamus, cerebellum, pons
What is the cut-off diameter for the intracranial bleed that will warrant surgical intervention?
> 3cm
most common cause of sporadic acute encephalitis in immunocompetent adults?
Herpes virus
What malignancy is the most common cause of brain metastases?
lung
But MELANOMAS have the greatest propensity to
metastasize to the brain
All patients with unexplained new onset seizures should undergo ____
brain imaging eg MRI or CT to search for an underlying structural abnormality
First line medications for generalized onset tonic clonic
Lamotrigine and Valproic acid
First line medications for focal seizures
Lamotrigine
Carbamazepine
Oxcarbazepine
Phenytoin
Levetiracetam
First line medications for typical absence
Valproic acid
Ethosuximide
Lamotrigine
First line medications for atypical absence and myoclonic,atonic
Valproic acid
Lamotrigine
Topiramate
Type of dementia suggested by early presence of visual hallucinations and tendency to have delirium
Dementia with Lewy bodies
Most common cause of dementia
Alzheimer’s dmentia
Rapidly progressive dementia with myoclonus
CJD
Characteristic imaging of Alzheimer’s disease
Entorhinal cortex and hippocampal atrophy
Characteristic imaging of CJD
Cortical ribboning, and basal gannglia or thalamus hyperintensity on DWI/FLAIR/MRi
First clinical manifestation of Alzheimer’s disease
memory impairment
Histopath findings in Alzheimer’s disease
Neuritic plaques composed of AB amyloid neurofibrillary tangles composed of phosphorylated tau
Acetylcholinesterase inhibitors that may be used for Alzheimer’s disease
Donepezil, Rivastigmine, Galantamine
NMDA inhibitor that may be used for Alzheimer’s disease
Memantine
Most common FTD syndrome
Behavioral variant
social and emotional systems dysfunction manifests as apathy, disinhibitrion, compulsivity, loss of empathy and oveeating
Cardinal features of Parkinson’s disease
Bradykinesia
Rigidity
Resting Tremor
Postural instability
Most common mutations associated with PD
Glucocerebrosidase
Why is levodopa routinely combined with decarboxylase inhibitor for PD?
prevents peripheral metabolism to dopamine and the development of nausea/vomiting
Levodopa remains the most effective symptomatic tx for PD
What do you call the decreasing duration of benefit of Levodopa ?
weaing off effect
Deep brain timulation of the _____ or ____ has largely replaced ablation surgery
Subthalamic nucleus or Globus pallidus interna
In which cases should patients undergo a neuroimaging study prior to LP?
Head trauma
Immunocompromised
Malignancies
Focal neurologic findings
In contrast, if bacterial meningitis is suspected, give antibiotics PRIOR to neuroimaging and LP
Most common pathogen causing acute bacterial meningitis in immunocompetent adults
S. pneumoniae
Pathogens that are implicated in acute bacterial meningitis following neurosurgical procedures especially shunting
S. aureus
CONS
Classic triad of meningitis
Fever
Headache
Nuchal rigidity
Empiric therapy for acute bacterial meningitis for chilcren >3 months and adults < 55
Cefotaxime/ Ceftriaxone/Cefepime + Vanco
Empiric therapy for acute bacterial meningitis for adults > 55 and adults of any age with alcoholism or debilitating illnesses
Ampicillin + cefotaxime/Ceftri/Cefepime + Vancomycin
Empiric therapy for acute bacterial meningitis for hospital acquired meningitis, posttraumatic or postneurosurgery meningitis, neutropenic patients or patients with impaired cell mediated imunity
Ampicillin + ceftazidime/meropenem + vanco
so dapat may coverage for P. aeuruginosa
Empiric treatment for L. monocytogenes
Ampi + Genta
Treatment course for the following pathogens for acute bacterial meningitis
Meningococcus
Pneumococcus
Gram neg
L. monocytogenes
Meningococcus - 7 days
Pneumococcus - 14 days
Gram neg - 21 days
L. monocytogenes -21 days
Adjunctive therapy with dexamethasone improves outcome from bacterial meningitis particularly if due to this pathogen
Pneumococcal
Prophylaxis for close contacts of acute meningitis
Rifampin 600 mg q12
- not for pregnant women
Alternative: Azithromycin x1 dose or
IM ceftriaxone (250 mg) x 1 dose
Procedure of choice that is rapid , sensitive, specific identification of viral meningitis
CSF PCR
Treatment for meningitis due to HSV, EBV and VZV
IV acyclovir followed by an oral drug for 7-14d
Most common etiologic agent for Viral meningitis
Enteroviruses
Most common etiologic agent for Viral encephalitis in immunocompetent adults
Herpesviruses
Causative agent that should be considered when focal findings are present and when involvement of the inferomedial frontotemporal regions of the brain is likely
HSV
Neuroimaging procedure of choice for viral encephalitis
MRI
Treatment for CMV encephalitis
Ganciclovi/ Foscarnet
Cidofovir
Classic triad of brain abscess
Headache
Fever
Focal neurologic deficit
Empiric tx for brain abscess in immunocompetent patients
Third or 4th gen + Metronidazole
Most common cause of chronic meningitis
TB
Myasthenia gravis is due to autoantibodies against
Acetylcholine receptors
however levels do NOT correlate with severity
Organ that must me checked when patient is diagnosed to have MG
Thymus
Thymus is abnormal in 75% of px (65% hyperplasia, 10% thymoma)
Chest CT/MRI may be used
Lambert Eaton is due to autoantibodies against
presynaptic calcium channels
Autoantibodies that are present in 40% of AcH receptor antibody negative patients with generalized MG
Muscle specific kinase
Diagnostic test for MG
Tensilon (Edrophonium)
Treatment of choice for MG
Anticholinesterase drug pyridostigmine (Mestinon)
Muscarinic side effects of pyridostigmine may be treated by
Atropine/ Diphenoxylate/ Loperamide
Mainstay of chronic immunosuppresive tx for MG
Glucocorticoids
Most common cause of hereditary neuropathy
Charcot Marie Tooth disease
Neuropathic disorders that may be considered if with symmetric proximal and distal weakness with sensory loss
GBS and CIDP
First line tx for painful sensory neuropathies
Lidoderm
TCA (amitriptyline, nortriptyline)
Gabapentin, Pregabalin
Duloxetine
in GBS, maximum weakness is usually reached within ____ week/s
2
Variant of GBS that presents with ophthalmopareis, facial diplegia, ataxia, areflexia
Fisher syndrome
Assoc with antibody to GQ1b
Most common neuropathies (what nerve/s)
Ulnar/Median nerve in the arm
Peroneal/Fibular in the leg
Involved nerve in Saturday night palsy
Radial nerve
Presents with wrist drop
What can be given to px with Duchenne’s muscular dystrophy to slow progression of disease
Glucocorticoids may slow progression of dse for up to 3 yrs
Type of dystrophy with scapular winging
Fascioscapularhumeral dystrophy
Vascular lesion seen in Osler Weber Rendu
Capillary telangiectasia
Window period (in hours) for giving thrombolytics for stroke
May be extended up to 4.5 hours
Head injury that shows lenticular shaped collection the frontal convexity
Epidural
l-E-mon shaped = Epidural
Vessels involved in epidural hematoma
middle meningeal arteries
Vessels involved in subdural hematoma
bridging veins
Triad of Wernicke’s disease
Ophthalmoplegia, ataxia and confusion
Duration of tonic clonic movements that would differentiate syncope vs seizure
Classic EEG finding in absence seizure
generalized symmetric 3hz spike and slow wave pattern
What antiseizure medication is associated with formation of renal stones
Topiramate
since it is a weak carbonic anhydrase inhibitor
The only drug that prevents paroxysmal hemicrania
Indomethacin
Type of headache that may be aborted by oxygen supplementation
Cluster
Prophylactic tx for cluster headache
Verapamil, Topiramate, Melatonin, Lithium
Abortive tx for SUNCT/SUNA
Lidocaine
Prophylactic tx for SUNCT/SUNA
Lamotrigine
Topiramate
Gabapentin
Only proven treatment for chronic tension type headache is
TCA eg. amitriptyline
Most common pattern of nerve injury in HIV neuropathy
distal symmetric polyneuropathy
Gold standard for examining CSF in px suspected to have neurosyphilis
VDRL
Most common cause of SAH
Trauma
If outside trauma, ruptured saccular aneurysm
Focal seizures that spread to involve both cerebral hemispheres to produce generalized seizures usually originate from which lobe of the brain?
Frontal
What is the most common cause of
seizures in the older adults?
Cerebrovascular dse
The triad of ipsilateral tongue weakness, weakness of contralateral upper and lower extremities, and contralateral loss of vibration and proprioception is characteristic of lesions involving which structure?
medial medulla
What are the degenerative proteins in the ff dementia:
Alzheimers
FTD
Lewy body
Huntington dse
CJD
Alzheimers - AB/Tau
FTD -Tau
Lewy body- alpha synuclein
Huntington dse - polyglutamine repeats
CJD - prions
Although seen only in a minority of patients, how does the classic headache associated with a brain tumor present?
Predominates in the morning and improves during the day
Therapy with dexamethasone for acute meningitis is unlikely to be of significant benefit if it started > hours after antimicrobial therapy is initiated.
6
Hemiparesis is the most common localizing sign of an abscess located in which region of the brain?
frontal
Acute seizures occurring at the time of a stroke are most often seen in which type of strokes?
cardioembolic
Aside from brain imaging, what is the only other diagnostic test needed prior to treatment with IV rTPA?
CBG
Most common primary intracranial neoplasm
Astrocytoma
Primary CNS lymphomas are commonly associated with this virus
EBV
Most common primary brain tumor
Meningioma
Most common mode of spread of tumors metastatic to the nervous system
Hematogenous
Primary rad onco approach to brain metastases
SRS
It can sterilze visible lesins and produce local disease control in 80-90% of px
Can tx up to 10 lesions gowever confined to lesions <= 3 cm and is most effective in <= 1 cm
previously whole brain RT
CSF glucose ____ and elevated CSF protein ___ are pedictive of increased mortality and poorer outcomes
<40mg/dL
>3g/L
In acute viral meningitis PMNs may predominate in the first ___ hours
48 hours
Treatment for subacute meningitis caused by C. neoformans
Amp B + Flucytosine
Treatment for syphilitic meningitis
Aqueous Penicillin G 3-4 million units IV every 4 h for 10-14 days
Possible tx option for JCV
5-HT2a receptor antagonist mirtazapine
Stage of brain abscess formation wherein you can see ring enhancing capsules on imaging
Early capsule formation
Stage of brain abscess formation wherein pus starts to form
Late cerebritis stage
Minimum duration of tx for brain abscess
6-8 weeks
Most common type of primary headache
tension type
The release of this substance in the trigeminal nucleus triggers the underlying vascular mechanism of migraine headaches
Calcitonin gene related protein
The only primary headache more common in males
Cluster headache
Most common schwanommas
vestibular/ acoustic neuroma
NF2 have high incidence of vestibular schwanomma
Most common cause of hemorrhagic metastasis in the brain
Lung CA
but greatest propensity to cause hemorrhage: melanoma, thyroid, kidney CA (these are just not as common as lung CA)
Among patient who suffered from Acute Ischemic Stroke (AIS), a decrease in cerebral blood flow to zero causes death of brain tissue within
10 minutes
most common cause of cerebral embolism overall
Nonrheumatic atrial fibrillation
best sequence to detect brain infarction earlier than CT or other MR sequences.
Diffusion-weighted imaging (DWI)
This is a new drug which functions as a plasminogen activator that has the added advantage of bolus dosing without 1-hour infusion (vs alteplase). It can improve efficiency for patients that need to be transferred to another facility or for those who will undergo endovascular therapy
Tenecteplase
T for transfer
What constitutes ABCD2 score in TIA
Age- >= 60
BP (SBP >140 OR DBP >90)
Clinical symptoms (Unilateral weakness -2,
Speech disturbance without weakness -1)
Duration (>60 m -2, 10-59m -1)
Diabetes -1
in SAH Once ICP is recorded, CSF drainage (if available), osmotic therapy, and blood pressure management can be tailored to maintain cerebral perfusion pressure (MAP - ICP) at least ____ mmHg.
50–70
Most common seizure type resulting from metabolic derangements
Generalized Tonic clonic
EMG pattern that may help distinguish spasms from brief tonic and myoclonic seizures.
Characteristic rhomboid pattern
Most common syndrome associated with focal seizures with impairment of consciousness
Mesial Temporal Lobe Epilepsy Syndrome
Characteristic hippocampal sclerosis on MRI
Treatment for Mesial Temporal Lobe Epilepsy Syndrome
Refractory to treatment with anticonvulsants but responds well to surgical intervention
EEG finding in Mesial Temporal Lobe Epilepsy Syndrome
Unilateral or bilateral anterior temporal spikes
Example of antiseizure drugs with mechanism
Inhibition of Na+-dependent action potentials in a frequency- dependent manner
Phenytoin, carbamazepine, lamotrigine, topiramate, zonisamide, lacosamide, rufinamide, cenobamate
Example of antiseizure drugs with mechanism
Inhibition of voltage-gated Ca2+ channels
Phenytoin, gabapentin, pregabalin
Example of antiseizure drugs with mechanism
Facilitating the opening of potassium channels
Ezogabine
Example of antiseizure drugs with mechanism
Attenuation of glutamate activity
Lamotrigine, topiramate, felbamate, perampanel
Example of antiseizure drugs with mechanism
Potentiation of GABA receptor function
Benzodiazepines and barbiturates
Example of antiseizure drugs with mechanism
Increase in the availability of GABA
Valproic acid, gabapentin, tiagabine
Example of antiseizure drugs with mechanism
Modulation of release of synaptic vesicles
Levetiracetam, brivaracetam
Anti epileptic drug associated with gingiva hyperplasia
phenytoin
Anti epileptic drug associated with SJS
Lamotrigine
Initial tx of choice for status epilepticus
Benzodiazepine (Midazolam, Lorazepam, Diazepam)
In typical amnestic AD, brain atrophy begins in the
medial temporal lobes
most important risk factors for developing Alzheimer’s disease
age and family hx
What constitutes the triad of Huntington’s disease?
Chorea, behavioral disturbance, and executive impairment
Triad of Normal pressure hydrocephalus
clinical triad includes an abnormal gait (ataxic or apractic), dementia and urinary urgency or incontinence
Slow vertical saccades are seen in what type of dementia causing dse?
Progressive supranuclear palsy
What can be given to px with Lewy Body Dementia that is a selective inverse agonist of the serotonin 5-HT2A receptor that does not block dopamine receptors
Pimavanserin
Patients with Lewy Body Dementia should not be exposed to typical neuroleptics that can lead to a neuroleptic malignant syndrome and death, or anticholinergics or dopamine agonists that can exacerbate their symptoms.
one dopamine agonist is comparable to levodopa, but must be administered parenterally
Apomorphine
Most common parkinsonism?
Parkinson’s dse
Only oral agent for PD that has been to shown to reduce dyskinesia without worsening parkinsonian feature
Amantadine
Preferred prophylactic antibiotic for meningococcal meningitis contacts who are also pregnant
Ceftriaxone
Otherwise Rifampin
What does F.A.S.T. stand for?
Facial weakness, Arm weakness, Speech abnormality, Time
Illegal drugs that have strong association with stroke
Cocaine and amphetamine
Among solid tumors,Leptomeningeal metastases are more commonly associated with which type of primary cancer?
breast, lung and melanoma
Expected EEG findings in HSV encephalitis
periodic, stereotyped, sharp-and-slow complexes
Progressive multifocal leukoencephalopathy is associated with what virus
JC virus
Size of brain abscess that may be treated medically
2-3 cm
Cushing reflex triad
Hypertension
Bradycardia
irregular breathing
CSF abnormalitis in bacterial meningitis
Treatment for meningtis due to H. capsulatum
AmB (0-7-1.0 mg/kg/day) for 4-12 weeks (total of 30mg/kg is recommended)
Duration of chronic meningitis
> 4 weeks
Etiology of chronic meningitis associated with multiple cyst in basal meninges with hydrocephalus
cysticercosis
Treatment for SSPE
No definitive therapy for SSPE is available.
Treatment with isoprinosine (Inosiplex, 100 mg/kg per day), alone or in combination with intrathecal or intraventricular interferon-α, has been reported to prolong survival and produce clinical improvement in some patients but has never been subjected to a controlled clinical trial.
Stage of brain abscess formation wherein central core of coagulative necrosis begins to form
Early cerebritis
Stage of brain abscess formation wherein there is a well-formed necrotic center and dense collagenous capsule
Late capsule formation
in TIA The risk of stroke after a TIA is ~___% in the first__ months, with most events occurring in the first __ days.
10–15
3
2
Target BP to reduce risk of stroke
< 130/80
Cerebellar hematomas >_ cm in diameter will require surgical evacuation
3
How is sacculary aneurysm managed?
> Lower the SBP to below 160 mmHg using nicardipine, labetalol, or esmolol. Cerebral perfusion pressure targeted to 60–70 mmHg.
> Treatment with the calcium channel antagonist nimodipine (60 mg PO every 4 h) improves outcome
> Euvolemia is targeted. Free-water restriction is contraindicated
> Pneumatic compression stockings applied to prevent PE.
> Unfractionated heparin administered subcutaneously for DVT prophylaxis can be initiated within 1–2 days following endovascular treatment or craniotomy
Headache symptoms that suggest a serious underlying condition
MOA of rimegepant
CGRP antagonists
When is triptan given in px with migraine
when aura is completed and headache has begun
What migraine prophylactic medication is contraindicated could aggravate parkinson’s disease
flunarizine
brain tumors has distinctive histopathologic feature of perinuclear clearing (giving rise to a “fried egg” appearance) and a
reticular pattern of blood vessel growth?
Oligodendrogliomas
Mutation associated with oligodendroglioma
codeletion of 1p/19q
extrinsic brain tumors that arise from the dura mater and are completely composed of neoplastic meningothelial (arachnoid cap) cells
meningoma
Tumors with a strong propensity to metastasize
to axial skeleton
and has Tumors with a strong propensity to metastasize to axial skeleton
prostate CA, brain CA
EEG finding in ATYPICAL absence seizure
EEG shows a generalized, slow spike- and-slow-wave pattern with a frequency of ≤2.5 per second
EEG finding in atonic seizure
Brief, generalized spike-and-wave discharges → immediately by diffuse slow waves
