Neurology Flashcards
A patient presents with sudden onset of weakness on one side of their body and face (sparing upper 1/3 from eyes up), aphasia and partial/total loss of vision. What is the most likely diagnosis?
Stroke or Transient Ischemic Attack (TIA)
What is the difference between stroke and transient ischemic attack (TIA)?
Stroke lasts for 24 hours or longer (associated with permanent residual neuro deficits)
TIAs last less than 24 hours (symptoms resolve)
What is amaurosis fugax?
transient loss of vision in one eye
occurs in TIAs
What is the best initial step for a patient presenting with symptoms suggesting stroke?
Head CT without contrast
rule out hemorrhage before thrombolytics
What cerebral arterial lesion results in profound lower extremity weakness, mild upper extremity weakness, personality changes/ psychiatric disturbances, and urinary incontinence?
Anterior cerebral artery
What cerebral arterial lesion results in profound upper extremity weakness, aphasia, apraxia/ neglect, eyes deviating towards lesion, and contralateral homonymous hemianopsia with macular sparing?
Middle cerebral artery
What cerebral arterial lesion results in prosopagnosia (inability to recognize faces)?
Posterior cerebral artery
What cerebral arterial lesion results in vertigo, N/V, “drop attack” (loss of consciousness), vertical nystagmus, dysarthria, dystonia, sensory changes in face & scalp, and ataxia?
Vertebrobasilar artery
What cerebral arterial lesion results in ipsilateral face symptoms, contralateral body symptoms, vertigo and Horner’s syndrome?
Posterior inferior cerebellar artery
What cerebral arterial lesion results in ataxia, parkinsonian signs, sensory deficits, hemiparesis (mostly in face), and bulbar signs without cortical deficits?
Lacunar artery
What cerebral arterial lesion results in amaurosis fugax (transient loss of vision in one eye)?
Ophthalmic artery
What is the best initial diagnostic test for suspected stroke/ TIA?
Head CT without contrast
What is the most accurate diagnostic test for suspected stroke/ TIA?
Magnetic resonance angiogram (MRA)
What is the best initial treatment for a patient with a non-hemorrhagic stroke/ TIA?
- Thrombolytics (TPA) if within 3 hours of onset
2. aspirin if after 3 hours of onset
What are the two alternate treatments for patient who develop a non-hemorrhagic stroke/ TIA while on aspirin?
- switch to clopidogrel
2. add dipyridamole with aspirin
Other than an anti-platelet (aspirin, clopidogrel, dipyridamole), what other treatment should be initiated for a patient with a non-hemorrhagic stroke/ TIA?
Statin (to control hyperlipidemia)
What are the contraindications to thrombolytic (TPA) treatment? (8)
- hx of hemorrhagic stroke
- presence of intracranial neoplasm/mass
- active bleeding/ surgery within 6 weeks
- bleeding disorder
- traumatic CPR within 3 weeks
- suspected aortic dissection
- stroke within 1 year
- cerebral trauma/ brain surgery within 6 months
What are the diagnostic tests that should be performed in a stroke patient after head CT, thrombolytics and aspirin are given? (3)
- Echocardiogram (assess for clots/ valve vegetation)
- Carotid Dopplers/ duplex (assess for stenosis)
- EKG and Holter monitor (assess for a-fib)
What are additional diagnostic tests for young patients (
- ESR (sedimentation rate)
- VDRL/ RPR (assess for syphillis)
- ANA, double-stranded DNA (assess for lupus)
- protein C
- protein S
- Factor V Leiden mutation
- antiphospholipid syndrome
(rule out vasculitis or hypercoaguable state)
What is the blood pressure goal for patients who had a stroke?
What is the LDL goal for patients who had a stroke?
What is the treatment for paradoxical emboli through a patent foramen?
closure with catheter device
What is the treatment protocol for status epilepticus?
- Benzo (lorazepam)
- Fosphenytoin (after 10-20 mins)
- Phenobarbital (after 10-20 mins)
- general anesthesia (after 10-20 mins; pentobarbital, thiopental, midazolam, propofol)
What are the diagnostic tests that should be performed initially for a patient having a seizure? (4)
- electrolytes (sodium, calcium, glucose, oxygen, creatinine & magnesium level)
- urgent head CT
- urine toxin screen
- liver & renal function test
What should be done for a patient having a seizure after initial diagnostic testing is negative? (2)
- EEG
2. neuro consult
What are the four indications for chronic anti-epileptic drug therapy after a single seizure?
- strong family history of seizures
- abnormal EEG
- status epilepticus
- non-correctable precipitating cause (brain tumor)
What is the best initial treatment for absence (petit mal) seizures?
Ethosuximide
What anti-epileptic medication is associated with Stevenes-Johnson syndrome?
lamotrigine
What is the most likely diagnosis for a tremulous patient with a slow, abnormal festinating gait and orthostasis?
Parkinson’s Disease
What are 6 physical findings associated with Parkinson’s disease?
- cogwheel rigidity
- resting tremor
- hypomimia (masklike, under-reactive face)
- micrographia (small writing)
- orthostasis
- intact cognition and memory
What is the best treatment for a younger patient (
anticholinergics (benzotropine, hydroxyzine)
What is the best treatment for an older patient (>60) with mild symptoms of Parkinson’s disease?
Amantadine
anticholinergics worsen memory and increase side effects in elderly
What is the first line treatment for patient with severe symptoms (inability to perform activities of daily living) of Parkinson’s disease? (2)
- Carbidopa-levodopa
2. dopamine agonist (pramipexole, ropinirole, cabergoline)
What are the 3 second line treatments for patient with severe symptoms (inability to perform activities of daily living) of Parkinson’s disease)?
- COMT inhibitors (tolcapone, entacapone w/ dopamine drugs)
- MAO inhibitors (selegiline, rasagiline)
- deep brain stimulation
What treatment can be added when levodopa causes psychosis in a Parkinson’s patient?
Quetiapine
What is the most likely diagnosis for a patient with a tremor at rest and with intention (action)?
Essential tremor
What is the best treatment for a patient with essential tremor?
Propranolol
can also use alcohol if only option
A patient presenting with multiple neurological deficits developing at different times (months to years apart) most likely suffers from …
Multiple sclerosis
What is the most common abnormality associated with multiple sclerosis?
optic neuritis
What is the best initial diagnostic test for a patient with suspected multiple sclerosis?
MRI
What is the most accurate diagnostic test for a patient with suspected multiple sclerosis?
MRI
What is the next best diagnostic tool for a patient with suspected multiple sclerosis if an MRI is nondiagnostic?
CSF (lumbar tap showing oligoclonal bands)
What is the best initial therapy for multiple sclerosis?
steroids (for acute exacerbation)
What is the best therapy for fatigue associated with multiple sclerosis?
amantadine
What is the best therapy for spasticity associated with multiple sclerosis? (2)
- baclofen
2. tizanidine
What is long term treatment for multiple sclerosis?
disease modifying therapy (beta interferon, glatiramer, mitoxantrone, natalizumab, fingolimod, dalfampridine)
What adverse side effect is associated with the use of natalizumab?
PML
What diagnostic tests should be performed in a patient presenting with memory loss? (4)
- head CT
- vitamin B12 level
- thyroid function testing (TSH, T4)
- RPR/ VDRL
What is the only abnormal test result in a patient with Alzheimer’s disease?
head CT showing diffuse, symmetrical atrophy
What is the best initial treatment for a patient with Alzheimer’s disease?
anticholinesterase (donepezil, rivastigmine, galantamine)
A patient presenting with personality and behavioral changes followed by memory loss most likely suffers from …
Frontotemporal dementia
(focal atropy of frontal and temporal lobes)
(treat like Alzheimer’s)
A patient presenting with rapidly progressive dementia and myoclonus most likely suffers from ..
Creutzfledt-Jakob Disease (CJD)
What is the CSF finding associated with Creutzfeldt-Jakob disease?
14-3-3 protein
What diagnostic tests should be performed in a patient with suspected Creutzfeldt Jakob disease? (3)
- EEG
- MRI (no abnormality)
- CSF (14-3-3 protein)
(however brain biopsy is most accurate)
A patient presenting with resting tremor, cogwheel rigidity, wide based gait, vivid & detailed hallucinations, and dementia most likely suffers from …
Lewy Body Disease
A patient presenting with urinary incontinence, dementia, and wide-based gait/ ataxia most likely suffers from …
Normal Pressure Hydrocephalus
wet, wacky, wobbly
What is the best treatment for normal pressure hydrocephalus?
shunt placement
What diagnostic test should be performed in a patient with suspected normal pressure hydrocephalus? (2)
- head CT
2. lumbar puncture
A young patient presenting with dementia, psychiatric disturbances, personality changes, dance-like movements and a family history of similar symptoms most likely suffers from…
Huntington’s disease
What is the best diagnostic test for suspected Huntington’s disease?
specific genetic testing
What is the best treatment for the movement disorder associated with Huntington’s disease?
tetrabenazine
What are 4 common triggers of migraine headaches?
- cheese
- caffeine
- mensruation
- oral contraception
A pt presents with a unilateral/bilateral headache associated with abnormal smells, aura, flashing lights, photophobia and visual changes most likely suffers from ..
migraine
When should a head CT or MRI be performed for a patient presenting with a headache? (3)
- sudden or severe
- onset after age 40
- associated with focal neurological findings
What is the best initial abortive therapy for migraines?
Triptans or ergotamine
What is the best initial prophylactic therapy for migraines?
Beta Blockers (propanolol) (second line includes calcium channel blockers, TCAs, SSRIs)
A male pt presents with unilateral excruciating headache associated with eye redness, lacrimation, and rhinorrhea most likely suffers from …
Cluster headache
What is the best initial abortive therapy for cluster headaches?
100% oxygen and/or triptans
steroids can also be used
Whats is the best initial prophylactic therapy for cluster headaches?
verapamil
A pt presents with severe headache, temporal area tenderness, visual disturbances and jaw claudication most likely suffers from …
Temporal (giant cell) arteritis
What is the most accurate diagnostic test for temporal arteritis?
Temporal artery biopsy
What is the best initial step in management for a patient with suspected temporal arteritis?
steroids (then perform biopsy) to prevent permanent vision loss
An obese young women presents with a severe headache, double vision, papilledema and history of vitamin A use most likely suffers from….
Pseudotumor Cerebri
What is the most accurate diagnostic test for a pt with suspected Pseudotumor Cerebri?
lumbar puncture with opening pressure measurement (elevated pressures)
What are the 3 treatment options for patients with Pseudotumor cerebri?
- weight loss
- acetazolamide
- surgery (VP shunt, optic nerve sheath fenestration)
What is the best initial diagnostic test for all patients with vertigo (room spinning)?
MRI of internal auditory canal
A pt presenting with vertigo that occurs when quickly changing positions most likely suffers from …
Benign Positional Vertigo (BPV)
otoliths in ear
What disorder is associated with a positive Dix-Hallpike maneuver?
Benign Positional Vertigo (BPV)
What is the best initial treatment for Benign Positional Vertigo (BPV)?
- head maneuvers
2. meclizine
A pt presenting with vertigo and dizziness that is not associated with changing positions, hearing loss or tinnitus most likely suffers from …
Vestibular Neuritis (inflammation of vestibular portion of 8th cranial nerve)
What is the best initial treatment for vestibular neuritis?
meclizine
A pt presenting with a single episode vertigo, hearing loss and tinnitus after a recent viral illness most likely suffers from…
Labyrinthitis (inflammation of cochlear portion of inner ear)
What is the best initial treatment for Labyrinthitis?
meclizine and steroids
A pt presenting with multiple episodes of vertigo, hearing loss and tinnitus most likely suffers from …
Meniere’s disease (overproduction of endolymphatic fluid in ear)
What is the best initial treatment for Meniere’s disease?
salt restriction and diuretics
surgery ablation of 8th cranial nerve if needed
A pt presenting with vertigo, hearing loss, tinnitus, and ataxia who may have a history of neurofibromatosis or Van Recklinhausen’s disease most likely suffers from…
Acoustic Neuroma
8th cranial nerve tumor; tx surgically
What is the best initial step in management for a pt with suspected acoustic neuroma?
MRI of internal auditory canal
A pt presenting with vertigo and hearing loss after head trauma or barotrauma most likely suffers from …
perilymph fistula (rupture in tympanic membrane)
An alcoholic pt presenting with confusion, confabulation, ataxia, memory loss, gaze palsy (ophthalmoplegia) and nystagmus most likely suffers from …
Wernicke-Korsakoff syndrome
What is the best initial treatment for a pt presenting with suspected Wernicke-Korsakoff syndrome?
thiamine followed by glucose
what is the next best step in management for a pt presenting with symptoms suggestive of meningits?
administer antibiotics
followed by blood cultures and lumbar puncture
When should you obtain a head CT before a lumbar puncture? (6)
- history of central nervous system disorder
- focal neurological deficit
- papilledema
- seizures
- altered consciousness
- significant delay in ability to perform lumbar puncture
A CSF gram stain showing gram positive diplococci in suspected meningitis case is suggestive of ….
Pneumococcus
A CSF gram stain showing gram negative diplococci in suspected meningitis case is suggestive of …
Neiserria
A CSF gram stain showing gram negative pleomorphic, coccobacillary organisms in suspected meningitis case is suggestive of…
Haemophilus
A CSF gram stain showing gram positive bacilli in suspected meningitis case is suggestive of …
Listeria
What is the best initial test for the diagnosis of meningitis?
CSF cell count (elevated neutrophils suggest bacterial meningitis
What CSF glucose level findings are consistent with bacterial meningitis?
glucose levels below 60% of serum levels
What is the best step in management of a pt with suspected meningitis who has elevated CSF neutrophils?
start IV ceftriaxone, vancomycin, and steroids
An HIV pt presents with subtle signs of neck stiffness, headache, fever, and photophobia and found to have a CD4 count less than 100 most likely suffers from ..
Cryptococcus
What is the best initial test for suspected Cryptococcus?
India Ink
What is the most accurate test for suspected Cryptococcus?
Cryptococcal antigen
What is the best initial therapy for Cryptococcus infection?
Amphotericin and 5-flucytosine (5FC)
What determines whether 5-FC is continued in an HIV pt with recent Cryptococcus infection?
CD4 cell count (if less than 100, continue until above 100)
A pt presenting with headache and meningeal signs alone with a history of joint pain, 7th cranial nerve palsy, a rash with central clearing after camping/hiking most likely suffers from …
CNS Lyme disease
What is the treatment for CNS lyme disease?
IV ceftriaxone or penicillin
What is the most accurate diagnostic test for CNS lyme disease?
specific serologic or western blot testing on CSF
A pt presenting with fever, headache and malaise followed by a rash that starts on wrists and ankles then moves towards the trunk after camping or hiking most likely suffers from….
Rocky Mountain Spotted Fever
What is the most effective therapy for Rocky Mountain Spotted Fever?
doxycycline
An immigrant pt with a history of lung tuberculosis that develops a fever, headache, and stiff neck over weeks to months and CSF from lumbar puncture shows extremely high protein levels most likely suffers from…
TB Meningitis
acid fast stain of CSF positive in 10%; acid-fast culture requires 3 high volume taps
What is the treatment for TB Meningitis?
RIPE plus steroids
rifampin, isoniazid, pyrazinamide, ethambutol and steroids
A pt presenting with fever, headache, stiff neck, photophobia and a lymphocytic pleocytosis in the CSF most likely suffers from …
Viral meningitis
An adolescent/ military/ asplenic/terminal complement deficient pt presents with fever, headache, stiff neck, photophobia, petechial rash and elevated neutrophils most likely suffers from …
Neisseria meningitis
What is the next best step in management of a pt with suspected Neisseria meningitis? (3)
start antibiotcs (IV ceftriaxone and vancomycin) and enforce respiratory isolation and prescribe rifampin to close contacts
An elderly/ neonate/ HIV or immunocompromised pt presents with headache, fever, stiff neck, photophobia and elevated neutrophils in the CSF most likely suffers from ….
Listeria meningitis
What is the best initial step in a patient with suspected Listeria meningitis?
add ampicillin to antibiotic treatment
A pt presenting with fever and altered mental status developing over a few hours most likely suffers from …
Encephalitis (herpes encephalitis is most common in US)
What is the best initial test for suspected Herpes encephalitis?
Head CT scan
What is the most accurate test for suspected Herpes encephalitis?
PCR of the CSF
What is the best initial therapy for suspected herpes encephalitis?
acyclovir (foscarnet if acyclovir resistant pt)
A pt presents with a fever, headache and focal neurological deficits, what is the next best step in management?
CT scan (look for abscess- ring enhancing lesion)
What is the next best step in management of a non-HIV pt who presented with fever, headache and focal neuro deficits and was found to have a ring enhancing lesion on CT scan?
brain biopsy
What is the next best step in management of a HIV pt who presented with fever, headache, and focal neuro deficits and was found to have a ring enhancing lesion on CT scan?
treat for Toxoplasmosis (pyrimethamine and sulfadiazine)
What is the best treatment for a HIV patient with brain lesions (non enhancing and no mass effect) suggestive of progressive multifocal leukoencephalopathy (PML)?
anti-retrovirals to treat HIV and raise CD4 count
A pt from Mexico presenting with seizures and is found to have multiple cystic lesion on CT scan most likely suffers from …
Neurocysticercosis
What is the best initial therapy for Neurocysticercosis?
albendazole and steroids (prevent reaction to dying parasite ) if lesions are active and uncalcified
What is the next best step in management for a pt presenting with loss of consciousness or altered mental status after head trauma?
Head CT scan
A pt presenting with loss of consciousness or altered mental status after head trauma and a lens shaped collection of blood on CT scan most likely suffers from….
Epidural hematoma
A pt presenting with loss of consciousness or altered mental status after head trauma and a crescent shaped collection of blood on CT scan most likely suffers from….
Subdural hematoma
What is the best step in management for a pt presenting with a large intracranial hemorrhage with mass effect? (3)
- Incubate/ hyperventilate (pCO2 to 28-32)
- Mannitol
- Surgical evacuation
What are the three indicators for use of proton pump inhibitors as prophylaxis against stress ulcers?
- Head trauma
- Burns
- Endotracheal intubation with mechanical ventilation
A pt presenting with sudden onset severe headache, stiff neck, loss of consciousness, and focal neuro deficits most likely suffers from…
Subarachnoid hemorrhage
Blood irritates meninges and bowel
What is the most accurate diagnostic test for subarachnoid hemorrhage?
Lumbar puncture (greater ratio than 500 RBC to 1 WBC) if CT negative
What is the treatment protocol for a subarachnoid hemorrhage? (4)
- Angiogram (detect site of bleed)
- Embolize site
- Insert VP shunt if hydrocephalus
- Nimodipine
A pt presenting with loss of sensation of pain and temperature in the upper extremities bilaterally in a cape like distribution over the neck, shoulders and down both arms most likely suffers from…
Syringomyelia
What is the best diagnostic test and best treatment for Syringomyelia?
MRI; surgery
A pt presents with back pain and tenderness of the spine and may have a history of cancer most likely suffers from…
Cord compression
What is the best initial diagnostic test and most accurate diagnostic test?
MRI; biopsy
What is the best next step for a patient with suspected cord compression?
Steroids (to decrease swelling from inflammation)
A pt presenting with back pain, spinal tenderness and fever most likely suffers from …
Spinal epidural abscess
A pt presents with back and leg pain that is worse when walking downhill and leaning backward but improved with walking uphill most likely suffers from …
Spinal stenosis
A pt presents with sudden loss of all sensation except position and vibratory sense from a spinal level down most likely suffers from …
Anterior spinal artery infarction (no treatment)
A pt presents with loss of ipsilateral position and vibration sense and loss of contralateral pain and temperature sense after traumatic injury most likely suffers from …
Brown Sequard syndrome
A pt presents with hyperreflexia, up going toes on plantar reflex, spasticity, weakness, muscle wasting, and fasciculations most likely suffers from…
Amyotrophic Lateral Sclerosis (upper and lower motor neurons)
What is the only treatment available for amyotrophic lateral sclerosis (ALS)?
Riluzole (blocks accumulation of glutamate)
What is the best initial treatment for diabetic peripheral neuropathy?
Gabapentin or pregabalin
A pt presents with pain and weakness in the first three digits of the hand and worsened by repetitive use most likely suffers from …
Carpal tunnel syndrome
What is the best initial therapy for carpal tunnel syndrome?
Splinting
What is the next best step in management of carpal tunnel syndrome if splinting is not helpful?
Steroid injections
A pt presents with wrist drop after falling asleep with pressure on the arms underneath the body or arms outstretched/ draped over back of chair most likely suffers from….
Radial nerve palsy (Saturday night palsy)
A pt presents with foot drop and inability to evert the foot after wearing high boots that press at the back of the knee most likely suffers from ….
Perineal nerve palsy (resolves on own)
A pt presents with hemifacial paralysis of both the upper and lower parts of the face, loss of taste of the anterior 2/3 of the tongue, hyperacusis and inability to close the eye at night most likely suffers from….
Bell’s Palsy (7th cranial nerve palsy)
What is the treatment for Bell’s palsy (7th cranial nerve palsy)?
Steroids
A pt with a history a previous injury to the extremity presents with extreme burning like pain with light touch of the extremity most likely suffers from…
Reflex sympathetic dystrophy (chronic regional pain syndrome)
What is the treatment for reflex sympathetic dystrophy (chronic regional pain syndrome)?
NSAIDs, Gabapentin, nerve block
A patient’s partner complains of pain and bruises in the legs and the patient complains of uncomfortable feelings in the legs relieved by movement most likely suffers from..
Restless legs syndrome
What is the treatment for restless legs syndrome?
Pramipexole or ropinirole
A pt presenting with ascending weakness with loss of deep tendon reflexes after a recent illness most likely suffers from …
Guillian Barre syndrome
What is the most urgent step in a patient with suspected Giillian Barre syndrome?
Peak inspirations pressure (diminishes as diaphragm weakens; detect respiratory failure)
A pt presents with difficulty finishing meals, blurry vision, and drooping of eyelids as the day progresses most likely suffers from …
Myasthenia gravis
What is the best initial test and most accurate test for myasthenia gravis?
Anti-acetylcholine receptor antibodies (ACHR)
Clinical presentation and ACHR
What is the best initial therapy for myasthenia gravis?
Pyridostigmine or neostigmine
Who should receive a thymectomy for myasthenia gravis?
Patients
