Neurology Flashcards
Essential Tremor
The most common neurologic cause for an action tremor
Presentation:
- Bilateral action tremor of hands (may experience tremor in additional places such as head or voice)
- Absence of neurological symptoms or deficits
Diagnosis:
- Bilateral arm tremor
- With or without tremor anywhere else
- For a minimum of 3 years
- Absence of neurological symptoms
Treatment:
- Mild/situational: Propranolol
- Unresponsive to the first line or more symptoms: Primidone
Parkinson’s disease
Most common cause for a rest tremor
Presentation:
- Tremor
- Bradykinesia (Slowness of movement)
- Rigidity (Inability to be bent or be force out of shape)
Treatment:
- Levodopa
- Effective at improving motor function, quality of life and well tolerated
- Alternative options
- MAO B Inhibitors: Rasagiline, Safinamide and Selegiline
- Dopamine agonists: Bromocriptine, pramipexole, ropinirole, rotigotine
- Amantadine: Rarely used as monotherapy and only for < 70 years old.
Headaches that indicate ER referral
- “Thunderclap” Headache
- Maximal intensity within a few seconds to less than one minute
- Papilledema
- Swelling of the optic disc causes concern for increased cranial pressure (ICP)
- Neurological symptoms present
- HA occurs with exertion or position changes
- Systemic symptoms such as fever/stiff neck: Concern for Meningitis
- Post Trauma
- Headache with possible carbon monoxide exposure
SNNOOP10
- Systemic symptoms including fever
- Neoplasm history
- Neurologic deficit
- Onset is abrupt
- Older than 50 years
- Pattern change
- Positional headache
- Precipitated by sneezing, coughing or exercise
- Papilledema
- Progressive headache and atypical presentation
- Pregnancy or postpartum
- Painful eye with autonomic features
- Post-traumatic onset of headache
- Pathology of the immune system (HIV)
- Painkiller over use (analgesic)
Cluster Headache
More common in males and tobacco users
Presentation:
- Headache that is often sharp or stabbing in quality and unilateral (often occurring around one eye)
- Pain is episodic, may last from 15 minutes to 3 hours and can occur 1 to 8 times a day
- Patient may experience remission for 3 to 12 months and have recurrent attacks
- Often autonomic symptoms ipsilateral to the side that the headache is occurring on
Treatment:
- MRI should be done for initial evaluation of all patients with suspected cluster headaches to rule out a structural abnormality
- Oxygen
- Triptans (Sumatriptan)
- Verapamil for preventative treatment
Migraine Headache
Presentation: Recurrent attacks and generally has 4 phases
- Prodrome: Increased yawning, euphoria, depression, irritability, food cravings, constipation, and neck stiffness
- Aura: About 25% experience an aura (most often visual)
- Headache: Generally unilateral, throbbing or pulsating with nausea, vomiting, photophobia or phonophobia
- Postdrome: Exhaustion or euphoria
Diagnosis (Migraine without aura):
- 5+ attacks generally lasts 4 to 72 hours and at least 2 of the following are present:
- Unilateral, pulsating, moderate to severe in intensity, worsens with activity, and with at least 1 of the following:
- Nausea, vomiting, photophobia, phonophobia
Treatment:
- Simple analgesics
- Triptans
- NSAIDs
- Anti-emetics
Indication for preventative treatment
- 4 or more attacks a month
- Non-responsive to acute therapies
- Negatively affects quality of life
- Preventative options include beta blockers, antidepressants and anticonvulsants
Tension Headache
Most prevalent type of Headache
Presentation:
- Bilateral, non-throbbing headache
- Described as a “band-like” pressure
- Normal neurologic exam
Treatment:
- Simple analgesics
- Caffeine
Indications for preventative treatment:
- Headaches > 2 days a week
- Headaches > 4 hours
- Headaches unresponsive to acute therapies
- Headaches impair daily functions
Temporal Arteritis
Most common systemic vasculitis
Presentation: Consider diagnosis with patients > 50 years old, with at least 1 of the following (especially in the presence of an elevated CRP or ESR)
- New headache or change in headaches
- Abrupt vision changes
- Jaw claudication
- Unexplained fever or other systemic symptoms
- Evidence of vascular compromise
- Limb claudication, decreased pulses, asymmetry of blood pressure
- Current diagnosis or history of polymyalgia rhematica increased the likelihood of temporal arteritis
Diagnosis:
- Confirmed with temporal artery biopsy or temporal artery color Doppler ultrasound
Treatment:
- High dose systemic glucocorticoids
- If not vision loss at the time of initiation of glucocorticoids, <1% chance of vision loss
Benign positional paroxysmal vertigo (BPPV)
- Vertigo is a symptom that causes the illusion of movement that is often worsened with head movement
- BPPV is the most common cause for peripheral vertigo
Presentation:
- Recurrent brief (<1 minute) episode of vertigo that are provoked by head movement
Diagnosis:
- Dix-Hallpike maneuver may elicit nystagmus and is used to confirm diagnosis
- BPPV does not cause prolonged or sustained vertigo, hearing loss, tinnitus, or neurologic deficits
Treatment:
- Epley maneuver: Repositions particles/debris in the inner ear
Central Vertigo
Examples: Brainstem ischemia, cerebellar infraction, multiple sclerosis
Presentation:
- Severe instability, often unable to walk or falls
- Generally absence of hearing loss or tinnitus
- Neurological symptoms often present
Treatment:
- Refer to ER
Dementia
- Gradual decline in cognitive function
- Dementia with Lewy bodies is most common type of
Screenings:
- Mini-mental state examination (MMSE)
- Mild dementia: 23 to 18 on MMSE
- Mod dementia: 18 to 10 on MMSE
- Severe dementia: <10 on MMSE
- Montreal Cognitive assessment (MoCA)
Diagnosis: DSM-5 diagnostic criteria
- Evidence of significant cognitive decline from a previous level of performance in one or more of the following cognitive domains:
- Learning and memory
- Language
- Executive function
- Complex attention
- Perceptual motor
- Social cognition
- The cognitive deficits interfere with independence in every day activities
- The cognitive deficits do not occur exclusively in the context of delirium
- The cognitive deficits are not better explained by another mental disorder
Dementia Key points and Treatment
Key points:
- Check drug interactions as these can cause cognitive changes (Analgesics, anticholinergics and sedatives)
- Consider MRI or CT of the head with initial diagnosis
Treatment:
- Mild-Mod: Trial cholinesterase inhibitors
- Mod-Severe: Memantine as monotherapy or adjunct therapy
Delirium
A clinical syndrome caused by a medical condition, substance intoxication or withdrawal or medication side effect
Presentation:
- Abrupt decline
- Impaired attention and orientation
- A fluctuating level of consciousness
- Incoherent or disorganized speech
- Variable, fluctuating memory impairment
Lab tests indicated
- Glucose, electrolytes, complete blood count, urinalysis, toxicology screen, liver function testing and arterial blood gas if needed.
Bells Palsy
- Facial nerve palsy (Cranial nerve VII)
- Possibly related to the activation of the herpes simplex virus
Presentation:
- Acute/sudden onset
- Typically over hours up to 48 hours
- One sided facial paralysis
- Not bale to wrinkle forehead
Diagnosis: Made clinically
Treatment:
- High dose oral glucocorticoids ASAP
- Preferably within 3 days of symptom onset
- Adjunct antiviral therapy
- In severe cases…. Valcyclvoir
- Protect from corneal injury
Refer to ER if neurological symptoms present
Bells Palsy = Both parts…. Bell’s palsy makes both mouth and forehead involved
Multiple Sclerosis (MS)
Autoimmune disease of the spin and brain with peak incidence between 15 and 50 years old
- Distinctive episodes of relapses and remissions
Presentation:
- Optic neuritis (Pain & temporary vision loss)
- Lhermitte sign (Electric shock sensation from the back of the neck down to the spine)
- Fatigue
- Sensation of pins and needles
- Heat sensitivity
Diagnosis:
- MRI
Gillian-Barre Syndrome (GBS)
Acute illness that may be triggered by a bacterial or viral infection
Presentation:
- Progressive and symmetric muscle weakness
- Absent or depressed deep tendon reflexes
Diagnosis:
- Requires CSF analysis and electrodiagnostic studies
- Elevated CSF protein with a normal white blood cell count
Myasthenia Gravis
Disorder of neuromuscular transmission
Presentation:
- Fluctuating degree of weakness in ocular, bulbar (Can cause difficulty with talking, chewing and swallowing), limbs and respiratory muscles
- Muscle fatigue
Diagnosis:
- Serologic tests for autoantibodies and electrophysiologic studies
Cranial Nerve I
Olfactory
Smell
Cranial Nerve II
Optic
Vision
Cranial Nerve III
Oculomotor
Eye movement and pupil reflex
Cranial Nerve IV
Trochlear
Eye movement
Cranial Nerve V
Trigeminal
Face sensation and chewing
Cranial Nerve VI
Abducens
Eye movement
Cranial Nerve VII
Facial
Face movement and taste
