Neurology Flashcards
Bacterial Meningitis: ETIOLOGY/Pathogens for: NEWBORNS INFANTS TODDLERS - 6Y/O TEENAGERS + YOUNG ADULTS ADULTS
NEWBORNS: Group B Strep
INFANTS; E. Coli
TODDLERS- 6 y/o: Haemophilis Influenza (HIB)
TEENS: Neisseria Meningitidis
ADULTS: Strep Pneumoniae (70% of all cases are Strep)
Kernig’s vs Brudzinksi’s
Kernig: Pt is supine with hips and knees flexed to 90 degrees. Positive Kerning’s is pain with extending the knee with hips flexed
Brudzinski’s: pt is supine, when neck is flexed, pt will involuntarily flex hips and knees
Petechial rash associated with what infection?
Nesseria Meningitidis
LP for meningitis
Elevated WBC (from normal of 5 to up to 10,000 during infection) Protein elevated (normal 5-60, elevated to 100-500) Decreased glucose (normal is 60% of serum, during infection down to 40%)
Bacterial Meningitis tx
Newborns and infants: gentamicin and ampicillin
Young children-early adulthood: 3rd gen Cephalosporin + vanco or chloramphenicol
Adults: PCN
Follow tx with serial LPs
Essential Tremor tx?
Avoid triggers (fatigue, stress, caffeine)
1st: B blockers
2nd: anti-epileptics: topiramate, gabapentin
2nd: BZDs
What chromosome affected by Huntington’s?
4
CT findings in Huntington’s
Atrophy of caudate nucleus and cerebral atrophy
TX of chorea in Huntington’s
Typical and atypical neuroleptics: olanzapine, risperidone haldol
What vaccination greatly reduces Meningitis in infants?
H Flu
Triad sx for normal pressure hydrocephalus
Gait disturbance
Urinary incontinence
Dementia
How many pts with syphilis will develop neurosyphilis?
7%
Argyll Robertson pupils
Pupils react poorly to light but well to accommodation
S/S Tabes Dorsalis (late stage syphilis)
Impaired proprioception vibratory sense Loss of DTRS at knees and ankles Argyll Robertson pupils Lightning pains Progressive ataxia Impaires sensation Weakness and hypotonia of muscles Joint damage (Charcot's joints) especially LE Neurogenic bladder with overflow incontinence Optic atrophy with visual loss
DX Syphilis
CSF pleocytosis , + VDRL, or FTA-ABS (fluorescent treponemal Ab absorption) in serum
TX syphilis
IV Pen G 18-24 million U/day x 10-14 days
TX syphilis if PCN allergic
Mild PCN allergic: Ceftriaxone 2g IV qd x 10-14d
Anaphylaxis with PCN: densensitation to B lactams under direction of allergist
Serum VDRL titer should decrease after therapy
FTA-ABS remain reactive for life
CSF WBCs are normal 6 months after tx completed, if CSF WBCs are still abnormal after 6 months, pt needs to be retreated
Most common meningitis pathogen in adults?
Strep pneumoniae
Infant with irritability, lethargy, anorexia and bulging fontanelles, suspect what?
meningitis
TX viral meningitis
Symptomatic: analgesics for HA, antiemetics for nausea, not required to be inpatient. Excellent prognosis: 1-2 weeks
ABX therapy for meningitis (empiric) age 2 mo-adult
Ceftriaxone + vanco. Add ampicillin if elderly. Consider corticosteroids (dexamethasone)
Viral encephalitis: most common pathogen?
HSV (70% mortality rate if left untreated). Typically affects the temporal lobe. PCR very sensitive and specific. CT with contrast 60% positive. MRI: 90% have temporal lobe abnormalities.
CLinical manifestations West Nile virus?
diffuse paralysis + peripheral neuropathy
TX CMV encephalitis
Gancivlovir+ Foscarnet. Watch for SIADH syndrome.
Name 3 associated conditions with Bell’s Palsy
Diabetes Pregnancy Herpes Zoster Positive family history Immunodeficiency
S/S Myasthenia Gravis
Diplopia
Ptosis, weakness of eye closure ( in 90% of pts)
Difficulty chewing
Regurgitation of fluids
Dysphagia
Nasal speech or low voice volume
Disease then progresses until weakness noted in the limbs, neck and respiratory muscles. PUPILS ARE NORMAL
Myasthenia Gravis associated with what other disorders
SLE, RA, thymic tumors, thyrotoxicosis (because it is an autoimmune disease)
Diagnostics for Myasthenia Gravis?
Serum anti-Ach receptor antibody levels
EMGs, Thyroid function, CXR (r/o thymoma)
Tensilon test (goal is to abate muscle weakness in 1-2 minutes)
Neostigmine 1.5mg IM improves weakness in 10-15 min
Ice pack test: place ice pack on eyelids to cool muscles x 1 minute, test for ptosis
Tx Myasthenia Gravis
Anti cholinesterase agents: Pyridostigmine 15-90mg q 6 hours and 180mgLA bedtime
Neostigmine 15mg before activity or meals OBSERVE for cholinergic crisis (nausea, vomiting, sweating, pallor, salivation, colic, diarrhea, meiosis, bradycardia)
Parkinson’s Patho: loss of what neurotransmitter?
Dopamine
What area of the brain affected in Parkinson’s?
Substantia nigra
Pharmacologic management Parkinson’s
Dopamine agonists: Parlodel, Mirapex, Requip
MAO inhibitors: selegiline, rasagiline
Levodopa + peripheral dopa decarboxylase inhibitor (bc levodopa does not cross BB barrier well): Sinemet
Amantadine: antiviral that allows release of dopamine from presynaptic storage sites
Anticholinergis: useful for the tremor
Adverse effects of levodopa/carbidopa?
Dyskinesias: include head wagging, restlessness, grimacing, lingual-labial dyskinesia
Psychiatric: Depression, nightmares, hallucinations
Simple partial seizure: definition
consciousness is preserved. Types: motor (focal twitching of extremity), somatosensory (flashing lights, paresthesias), autonomic (pallor, flushing, sweating, vomiting), psychic (dysphasia, distortion of memory, forced thinking, fear, deja vu)
Complex partial seizures: definition
focal seizure activity with transient impairment of consciousness (illusions or hallucinations): automatisms (lip smacking, repeated swallowing), Jacksonian march if motor, usually begin with an aura
Most common type of adult seizure?
Complex partial
Absence seizure is what type of seizure?
Generalized (abrupt LOC)
60% of absence seizures spontaneously remit
Atonic
loss of postural tone (drop attacks) resulting in falls
TX Absence seizures
Valproic acid, ethosuxamide, lamictal
TX partial seizures
carbamazapine, neurontin
Status epilepticus: definition
continuous seizure activity or frequent seizures without return to baseline > 15-20 minutes duration.
Is the most common neurologic emergency
TX status epilepticus
- Airway and o2, consider intubation
- CMP and to screen
- Give thiamine and D50
- Lorazepam 0.02mg/kg, valium or versed similar doses
- Load with Dilantin, rate not to exceed 50mg/min due to risk of arrhythmias or hypotension
IF PERSISTENT ACTIVITY AT 30-60M : add Dilantin 5-10mg/kg, Phenobarbital 50-100mg/min
IF MORE THAN 60MIN: Pentobarbitol load or propofol
What percent of strokes are hemorrhagic vs ischemic?
Ischemic: 80%
Hemorrhagic: 20%
Why would you do an LP in a pt with suspected CVA?
If suspicious for SAH and negative CT scan. Look for xanthochromia. Only perform LP if no contraindications
Use of tPA?
Within 3 hours of symptoms
First R/O hemorrhage with CT.
Can give intra-arterial tPA if within 6 hours of sx and have identified an acute occlusion.
Prognosis of TIA?
1/3 of pts continue to attacks without sequelae
1/3 of pts spontaneously resolve
1/3 of pts suffer brain infarction
Cluster HA’s have a familial predisposition?
No
Triggers for Cluster HA?
ETOH
Nitrates and other vasodilators
TX Cluster HAs
100% O2 x 20m pt upright
Subcutaneous or nasal triptans
Methylsergide, prednisone, verapamil, lithium
Basal migraine: definition
typical migraine except visual phenomena occupy total of both visual fields. Also may include vertigo, staggering, dysarthia, diplopia, tingling of hands and feet and perioral areas.
Danger signs for migraines
- Worsening pattern
- associated focal neurologic deficit
- associated fever or neck pain
- first or worst
- new onset 50 y/o
Preventive meds for migraine
-B blockers
-CCBs
ACEI and ARBS
NSAIDs
Pseudotumor Cerebri (aka Benign Intracranial HTN, not benign FYI) associated with what etiologies?
Obese young women
OCPs
Tetracycline
Vitamin D
Bell’s Palsy vs Stroke: facial weakness?
Stroke does not affect the ability to close the eye or raise affected brow.
What does the CSF look like in SAH?
Bloody. Or Xanthochromia (yellow, from degraded RBCs).
Need to do an RBC count on the first and last tube from the LP. If the last tube does not have RBCs it was from a traumatic LP, NOT from SAH.
What does the CSF show in MS?
Oligoclonal bands
What WBC type in viral vs bacterial meningitis?
Bacterial: polymorphic leuks (Polys)
Viral: lymphocytes or monocytes
DTRs, what level? Achilles Patellar Biceps Triceps
Achilles: S1/S2 Patellar (quad): L3/L4 Biceps: C5/6 Triceps: C7/8 (aka 1/2, 3/4, 5/6, 7/8)
HA with papilledema concerning for what?
Brain tumor
Severe HA with visual loss or blurred vision, papilledema and negative MRI?
Suspicious for brain tumor but negative MRI R/O. HA with visual loss concerning for Pseudotumor Cerebri. Normal mental status.
TX of pseudotumor cerebri?
Weight loss
Diuretics
Steroids
Repeat LP to remove CSF and decrease ICP
When is it appropriate to lower BP in a pt with ischemic stroke?
If other indications like angina or HF
Pts receiving tPA
Lower cautiously to
Most severe complication of temporal arteritis?
Blindness from thrombosis of ophthalmic artery
Temporal arteritis: 50% of pts report what other sx?
Muscle aches consistent with Polymyalgia Rhematica
Most common intracerebral neoplasm
glioma
Horner’s syndrome
Unilateral
Demyelination of posterior and lateral columns associated with what disease process?
B12 deficiency
Sensory disturbance of the middle finger indicates hernia room of disc in what region?
C7
C5 is thumb side
Middle cerebral artery infarct causes what?
Contralateral hemiparesis
Aphasia
Manifestations ALS
Asymmetric muscle weakness
Atrophy
Fasiculations
Hypereflexia
Sx wernickes encephalopathy
Nystagmus
Gaze palsies
Gait ataxia
(Thiamine deficiency, involves oculomotor, abducens)
Glasgow coma scale evaulates what 3 areas?
Eye opening
Best motor response
Best verbal response
=12 minor injury
Broca’s
Speech. Pts can usually understand but cannot perform motor output of speech
