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
Cranial Nerve VIII
Vestibulochochlear
Hearing and balance
Cranial Nerve IX
Glossopharyngeal
Throat sensation, taste and swallowing
Cranial Nerve X
Vagus
Movement, sensation and abdominal organs
Cranial Nerve XI
Accessory
Neck movement, innervates sternocleidomastoid and trapezius muscles
Cranial Nerve XII
Hypoglossal
Tongue movement, sensation and abdominal organs
