Neurology Flashcards
1
Q
What artery is primarily affected in strokes within the anterior circulation?
A
Internal Carotid Artery and its branches
This includes the Middle Cerebral Artery (MCA) and Anterior Cerebral Artery (ACA) among others.
2
Q
What are the common causes of strokes in the anterior circulation?
A
Atherosclerotic, dissection, or embolic
These causes can lead to various types of strokes, including those affecting the MCA and ACA.
3
Q
What is the most common cause of occlusion in the Middle Cerebral Artery (MCA)?
A
Embolus occlusion
This often occurs at the stem of the artery.
4
Q
What are the clinical features of complete MCA syndrome?
A
- Contralateral hemiplegia
- Hemianesthesia
- Homonymous hemianopsia
- Ipsilateral preferential gaze
- Dysarthria
These features arise from the occlusion at the MCA origin.
5
Q
What is the result of occlusion in the inferior division of the MCA?
A
Wernicke’s aphasia +/- weakness
This condition affects language comprehension and may present with jargon speech.
6
Q
What syndrome results from occlusion of a lenticulostriate vessel?
A
Pure motor or sensory-motor stroke
This affects the internal capsule and can lead to specific weakness patterns.
7
Q
What is the effect of occlusion of both A2 segments of the Anterior Cerebral Artery (ACA)?
A
Profound abulia and bilateral pyramidal signs
This can lead to paraparesis or quadriparesis.
8
Q
What does the Anterior Choroidal Artery supply?
A
Posterior limb of the internal capsule and posterolateral white matter
Occlusion here can cause significant deficits.
9
Q
What is a common symptom associated with the Internal Carotid Artery?
A
Recurrent transient monocular blindness (amaurosis fugax)
This is described as a horizontal shade across the field of vision.
10
Q
What might bilateral common carotid artery occlusions indicate?
A
Takayasu’s arteritis
This condition can lead to various symptoms similar to those seen with ICA occlusions.
11
Q
What regions of the brain are affected by strokes in the posterior circulation?
A
- Cerebellum
- Medulla
- Pons
- Midbrain
- Subthalamus
- Thalamus
- Hippocampus
- Medial temporal and occipital lobes
These areas are supplied by the Posterior Cerebral Artery (PCA).
12
Q
What are the manifestations of P2 syndrome in the PCA?
A
- Contralateral homonymous hemianopia without macular sparing
- Acute memory disturbance
- Alexia without agraphia (if dominant hemisphere affected)
- Visual agnosia
These symptoms arise from occlusion affecting the medial temporal and occipital lobes.
13
Q
What is Wallenberg’s syndrome?
A
Vertigo, numbness of ipsilateral face and contralateral limbs, diplopia, dysarthria, dysphagia
This arises from occlusion of the vertebral artery affecting the lateral medulla.
14
Q
What is the primary complication of basilar artery occlusion?
A
Locked-in syndrome
This condition involves preserved consciousness with quadriplegia and cranial nerve signs.
15
Q
What is the clinical presentation of Medial Medullary Syndrome?
A
- Contralateral hemiparesis of arm and leg
- Contralateral loss of joint position sense
- Ipsilateral tongue weakness
This syndrome occurs due to infarction of the pyramid and adjacent structures.
16
Q
What are the groups of arteries supplied by the Basilar Artery?
A
- Paramedian branches
- Short circumferential branches
- Long circumferential branches
Each group supplies different regions of the pons and cerebellum.
17
Q
What can cause symptoms of vertigo and unsteadiness in relation to basilar artery TIAs?
A
Atherothrombotic occlusion on the distal vertebral or proximal basilar artery
Symptoms may present as swimming, swaying, or light-headedness.
18
Q
What is the primary symptom of embolic occlusion at the top of the basilar artery?
A
Sudden onset of bilateral signs
This includes ptosis, pupillary asymmetry, and somnolence.
19
Q
A
20
Q
What does AVM stand for?
A
Arteriovenous Malformation
AVMs are congenital shunts between arterial and venous systems.
21
Q
What are common manifestations of AVMs?
A
- HA - hemicranial and throbbing
- Focal seizures
- Rupture risk based on history
- Hemorrhage
- Unruptured AVMs: 2-4% per year
- Previously ruptured AVMs: 17% per year
- Large AVM in MCA territory effects
- Large AVM of the anterior circulation effects
22
Q
True or False: AVMs are more common in men than women.
A
True
23
Q
What familial syndrome is associated with AVMs?
A
Osler-Rendu-Weber syndrome
This syndrome is autosomal dominant and involves mutations in either endoglin or active receptor-like kinase 1.
24
Q
What imaging technique is preferred for diagnosing AVMs?
A
MRI > CT
Conventional X-ray Angiography is the gold standard for AVM diagnosis.
25
What is the treatment approach for hemorrhaging AVMs?
* Surgery + Preoperative embolization
* Alternative: Stereotaxic radiation - slow sclerosis
26
What is the prognosis for patients with AVMs?
Higher future bleeding risk
## Footnote
Risk factors include smaller lesions and the presence of deep venous drainage, venous outflow stenosis, and intranidal aneurysms.
27
What are venous anomalies in the context of vascular malformations?
Should not be disturbed
28
What are capillary telangiectasias?
True capillary malformations with extensive vascular networks through an otherwise normal brain structure
## Footnote
Commonly located in the pons and deep cerebral white matter.
29
What are cavernous angiomas?
Tufts of capillary sinusoids in deep hemispheric white matter and brainstem with no intervening neural structures
## Footnote
Usually less than 1 cm in size.
30
What are dural arteriovenous fistulas?
Acquired connections usually from a dural artery to a dural sinus
## Footnote
They may develop months to years after venous sinus thrombosis.
31
What symptoms may be associated with dural arteriovenous fistulas?
* Pulse synchronous cephalic bruit
* Pulsatile tinnitus
* Headaches
32
What are the treatment options for acquired vascular lesions?
Surgical and endovascular techniques are curative
33
What types of bleeding can occur due to trauma?
Bleeding in subdural and epidural spaces
## Footnote
This refers to the different spaces in the brain where bleeding can occur due to traumatic injury.
34
What is SAH and what causes it?
SAH: Trauma and rupture of intracranial aneurysms
## Footnote
SAH stands for subarachnoid hemorrhage, which can result from trauma or the rupture of aneurysms.
35
What imaging technique is used for diagnosis of brain hemorrhage?
Non-contrast CT of the brain
## Footnote
A CT scan without contrast is commonly used to identify hemorrhagic events in the brain.
36
What is the target blood pressure (BP) for patients with suspected brain injury prior to CT results?
Maintain initial BP until results of CT scan are reviewed
## Footnote
This involves monitoring blood pressure closely until imaging can confirm the injury.
37
What is the recommended management for BP in patients with BP 150-220?
Lower acutely and rapidly to SBP <140
## Footnote
This is based on findings from the Interact2 Trial.
38
What does CPP stand for in the context of brain injury management?
Cerebral perfusion pressure
## Footnote
CPP is calculated as MAP - ICP and is crucial for maintaining adequate blood flow to the brain.
39
What are the first-line non-vasodilating IV drugs used in brain injury management?
* Nicardipine
* Labetolol
* Esmolol
## Footnote
These medications help manage blood pressure without causing vasodilation.
40
What is the most common site for hypertensive intraparenchymal hemorrhage?
Basal ganglia (Putamen)
## Footnote
Other common sites include the thalamus, cerebellum, and pons.
41
What is the typical time frame for the development of hypertensive intraparenchymal hemorrhage?
Develops within 30-90 mins
## Footnote
Anticoagulant-associated hemorrhage may develop within 24-48 hours.
42
What presentation is typical for thalamic hemorrhages?
* Contralateral hemiplegia or hemiparesis
* Prominent sensory deficit
* Aphasia or constructional aphasia depending on dominance
## Footnote
Thalamic hemorrhages can lead to various neurological deficits based on their location.
43
What symptoms are associated with pontine hemorrhage?
* Deep coma
* Quadriplegia
* Prominent decerebrate rigidity
## Footnote
These symptoms indicate severe brainstem involvement and dysfunction.
44
What are the common symptoms of cerebellar hemorrhage?
* Occipital headache
* Repeated vomiting
* Gait ataxia
## Footnote
These symptoms arise from pressure and dysfunction of cerebellar structures.
45
What is the primary treatment for cerebral amyloid angiopathy?
Avoid oral anticoagulant medications
## Footnote
This condition can lead to recurrent lobar hemorrhages, particularly in the elderly.
46
What type of stroke can sympathomimetic drugs like cocaine cause?
* Intracerebral hemorrhage
* Ischemic stroke
* SAH
## Footnote
The use of stimulant drugs is associated with various types of cerebrovascular accidents.
47
What findings are associated with hypertensive encephalopathy?
* Headache
* Nausea/Vomiting
* Confusion
* Focal neurologic signs
## Footnote
These symptoms indicate a severe reaction to high blood pressure affecting the brain.
48
What laboratory tests are important for evaluating hemorrhagic events?
* Platelet count
* PT/INR
* PTT
## Footnote
These tests help assess the coagulation status of the patient.
49
What is a common complication of venous sinus thrombosis?
Cortical vein hypertension, cerebral edema, venous infarction
## Footnote
This condition can lead to serious complications in brain function.
50
What imaging technique can detect ongoing bleeding in the brain?
CTA or postcontrast CT imaging
## Footnote
The 'spot sign' indicates ongoing bleeding and is associated with increased risk of hematoma expansion.
51
What is the treatment for coagulopathy in patients with VKA?
Infuse of PCC + Vitamin K
## Footnote
If PCC is not available, FFP can be used for reversal.
52
What is the recommended action for a hematoma larger than 3 cm?
Surgical evacuation
## Footnote
Larger hematomas often require surgical intervention to relieve pressure.
53
Early and prominent finding of DMD
Hypertrophy of muscles, especially in the calves
54
How to demonstrate myotonia in patients with myotonic dystrophy?
Percussion of the thenar eminence or asking patients to close
their fingers very tightly and then relax.
54
What are the cardiac findings of Emery-Dreifuss Dystrophy?
Atrial rhythm and conduction blocks - Afib and paralysis, and AV heart block
55
Muscle dystrophy presenting as “hatchet-faced” appearance
Emery-Dreifuss Muscular Dystrophy
“hatchet-faced” appearance due to temporalis, masseter, and facial muscle atrophy and weakness
56
Mutation of McArdle
PYGM --> Causing myophosphorylase deficiency
57
Presentation of McArdle
* Exercise
* CK
* Forearm exercise
* Slow induction phase (Warm-up) or brief periods of rest, allowing for the start of the second wind phenomenon (Switching to utilization of FA)
* CK: 100x normal + Myoglobulinuria
* Blunted rise in venous lactate with normal ammonia during forearm exercise
58
What is the most common systemic adverse effect of topiramate?
Formation of renal stones
59
What anti-seizure medication will have a reduced blood level when administered together with estrogen containing oral contraceptives?
Lamotrigine
* Carbamazepine, phenytoin, phenobarbital and topiramate
60
The release of this substance in the trigeminal nucleus triggers the underlying vascular mechanism of migraine headaches.
Calcitonin-gene-related protein
61
Indication of rTPA for acute ischemic stroke (4)
Clinical diagnosis of stroke
>/= 18 years old
No hemorrhage or edema of > 1/3 of the MCA
Onset to time of administration
62
Contraindication of rTPA for acute ischemic stroke (6)
Recent MI: Thrombolysis-induced myocardial hemorrhage
BP > 185/110 despite tx
GI bleed within 21 days
Major surgery within 14 days
Recent head trauma or intracerebral hemorrhage
Bleeding diathesis
63
What antithrombotic primary stroke prevention should be given to patinets with mitral valve prolapse
1. Asymptomatic
2. Cryptogenic stroke/TIA
3. Atrial fibrillation
1. Asymptomatic: None
2. Cryptogenic stroke/TIA: Aspirin
3. Atrial fibrillation: Aspirin + Oral anticoagulant
64
What antithrombotic primary stroke prevention should be given to patients with nonvalvular fibrillation
1. CHA2DS2VAsc 0
2. CHA2DS2VAsc 1
3. CHA2DS2VAsc 2
1. CHA2DS2VAsc 0: Aspirin or no oral anitcoagulant
2. CHA2DS2VAsc 1: Aspirin or oral antithrombotic
3. CHA2DS2VAsc 2: Oral anticoagulant
65
What antithrombotic primary stroke prevention should be given to patients with rheumatic MV disease?
Oral anticoagulation
If with embolization or appendage clot despite anticoagulation: Oral anticoagulation + Aspirin
66
What antithrombotic primary stroke prevention should be given to patients with patent foramen ovale?
Aspirin or closure with device for otherwise cryptogenic stroke or TIA
67
What antithrombotic primary stroke prevention should be given to patients valves
1. Mechanical
2. Bioprosthetic
3. IE
1. Mechanical: VKA
2. Bioprosthetic: Aspirin
3. IE: AVOID
68
Most common sites of hypertensive ICH
Mnemonic for most common sites of ICH: BATA PA C LOLO
Basal ganglia (putamen, internal capsule)
Thalamus
Pons
Cerebellum
Lobes
69
What to do in intracerebral hemorrhage with the following sizes:
* < 1cm in dm, awake, w/o focal brainstem signs
* 1-3cm in dm
* > 3cm in dm
* > 3cm in dm: Surgical evacuation
* < 1cm in dm, awake, w/o focal brainstem signs: No need for surgery
* 1-3cm in dm: observe for impaired consciousness and precipitous respiratory failure
70
Features suggestive of cardioembolic stroke (10)
Features suggestive of cardioembolic stroke:
* Sudden onset of maximal deficit (<5 minutes)
* Decreased level of consciousness
* Rapid regression of initially massive symptoms ("spectacular shrinking deficit")
* Wernicke's aphasia or global aphasia without hemiparesis
* Visual field abnormalities
* Onset of symptoms after a Valsalva-provoking activity (e.g. coughing, bending)
* Infratentorial ischemic stroke (cerebellar, PCA, and multi-level infarcts, top-of-the basilar syndrome)
* Hemorrhagic transformation and early recanalization of occluded intracranial vessel
* Neuroimaging finding of acute infarcts involving multiple vascular territories in the brain (predominantly carotid and MCA territories) or multiple levels of the posterior circulation
71
The time window for acute stroke thrombolysis may be extended up to 4.5 hours provided that not have any of the following additional exclusion criteria (4)
Patients older than 80 years old -› A
Patients with NIHSS score > 25 -› B
Patients on oral anticoagulants, regardless of the INR -› C
Patients with a history of both ischemic stroke & diabetes -› D
72
Triad of Lennox-Gestaut Syndrom
1. Multiple types of seizure
2. EEG: Slow (<3Hz) spike-and-wave discharge
3. Cognitive impairment
73
Which of the following anti-seizure medications may confer the greatest benefit in terms of seizure control if given as monotherapy in Lennox-Gestaut syndrome?
Valproic Acid: ONLY drug effective in controlling multiple seizure types
74
Factors that necessitates need to start anti-seizure in patients with seizure (3)?
First Unprovoked seizure
* If with evidence of increased risk of recurrence of further seizures
* If with EEG finding consistent with the seizure : Start medication
* 60% chance of seizure
* Presence of prior brain insult
* Nocturnal seizure
75
Management of cluster headache for acute attack
1. 100% O2 at 10-12L/min for 15-20 mins
2. Sumatriptan 6mg SC
* Shorten attack to 10-15mins
* Oral is not effective
3. Sumatriptan 20mg and Zolmitriptan 5mg nasal spray
4. nVNS (Non invasive vagus nerve stimulation)
* Three 2-min stimulation cycles applied consecutively
* Repeated after 9 mins
76
Preventive treatment for cluster headache
* SHORT:
* Prednisone 60mg daily for 7 days and followed by a rapid taper (total of 10 day course)
* Greater occipital nerve injection with lidocaine and corticosteroid, effect lasts 6-8 weeks
* Galcazenumab - CGRP monoclonal Ab, reduces attack frequency
* CHRONIC/PROLONGED BOUTS
* Verapamil 40-80mg BID (initial dose) - as high as 960mg/day ECG after 10 days - dose >240mg daily
* Neuromodulation therapy
77
What 2 tests should be ordered for patients with SUNCT/SUNA to rule out intracranial tumor
All patients with SUNCT/SUNA should be evaluated for pituitary function tests and a brain MRI with pituitary views
78
4 major causes of delayed neurologic deficits in aneurysmal subarachnoid hemorrhage
1. Rerupture
2. Hydrocephalus
3. Delayed cerebral ischemia
4. Hyponatremia
79
Triad of Wernicke's Encephalopathy
Ophthalmoplegia, ataxia and global confusion
Inflammation and necrosis of periventricular midline structures - dorsomedial thalamus (Memory loss), mammillary bodies, midline cerebellum, periaqueductal GM and trochlear and abducens nuclei
Tx: Parenteral thiamine 100mg IV for 3 days followed by daily oral dosage
80
MRI findings of patients presenting with irreversible profound amnestic syndrome or even death
MRI: Mamillary body atrophy in chronic phase
Korsakoff: irreversible profound amnestic syndrome or even death
* Unable to recall new information
* Confused,disoriented, cannot store information for more than few minutes
* Confabulation
81
Well-established risk factors for MS (4)
1. Vitamin D Deficiency
2. EBV exposure early in childhood
3. Cigarette smoking
4. Genetic predisposition
82
Increased risk of AVM rupture (4)
1. Deep venous drainage
2. Smaller lesion
3. Venous outflow stenosis
4. Intranidal aneurysm
Treatment: Surgical excision, endovascular embolization, SRS
83
What is the MRI finding of patients with Marchiafava-Bignami Disease?
T2 hyperintense lesion within the substance of the corpus callous
Presents as Dementia + seizures with degeneration of the corpus callosum in male Italian red wine drinkers or in chronic alcoholism
84
MRI Finding of patients with meningioma
Dural-based enhancing tumors with dural tail, (+) compress but do not invade the brain
85
Conventional x-ray angiography findings of Moya-Moya disease
Puff of smoke on conventional x-ray angiography: Lenticulostriae arteries develop a rich collateral circulation around the occlusive lesion:
Tx: Surgical bypass of extracranial carotid arteries to the dura or MCAs
86
Presents as disorder of orderly visual scanning (Palinopsia, Asimultanagnosia) of the environment resulting from low flow in the “watershed” between the distal PCA and MCA territories (e.g. cardiac arrest)
Balint's Syndrome
OOPS: Occular ataxia, Occular agnosia, Prosopagnosia, Simultagnosia
87
What is the presentation of patients presenting with Weber's Syndrome?
Ipsilateral oculomotor nerve palsy
Contralateral hemiplegia
88
Muscle dystrophy causing early involvement of the distal muscles of the UE and proximal muscles of the legs
Inclusion body myositis
89
4 cardinal features of Parkinsons Disease
1. Rigidity
2. bradykinesia
3. resting tremor
4. postural instability
* Freezing of gait
ASSYMMETRIC presentation
