Neurology (5-10%) Complete Flashcards
Lateral medullary syndrome:
AKA? ___________
Vessel involved? ___________
Signs and Symptoms? ___________
AKA? Wallenburg
Vessel involved? PICA or vertebral artery
Signs and Symptoms?
- ipsilateral ataxia (wide-based, staggering gait)
- ipsilateral Horner’s (ptosis, miosis, anhidrosis)
- ipsilateral face: loss of pain/temp sense (& reduced corneal reflex
- Ipsilateral absent/reduced gag reflex
- contralateral body: loss of pain/temp sense
- Vertigo
- Nystagmus (fast phase beating away from lesion)
- Dysphagia
- Hoarseness
- Hiccups
- Coordination: Ipsilateral dysmetria with Finger-to-Nose & Heel-to-Shin, Ipsilateral dysdiadochokinesia with rapid alternating movements
-Motor: Normal strength, Normal reflexes
Medial medullary syndrome:
Vessel involved? ___________
Signs and Symptoms? ___________
Vessel involved? Anterior spinal artery.
Signs and Symptoms?
1. Ipsilateral tongue weakness.
2. Contralateral arm, and leg weakness.
3. Contralateral body vibration, loss of proprioception.
Mid-brain Stoke:
AKA? ___________
Vessel involved? ___________
Signs and Symptoms? ___________
AKA? Weber
Vessel involved? PCA affected.
Signs and Symptoms?
- Ipsilateral CN 3 palsy (ptosis, mydriasis, diplopia (down & out))
2. Contralateral hemiplegia (face, arm, leg)
What are the findings of ACA infarct?
Contralateral leg weakness
Contralateral leg numbness
Contralateral grasp reflex
Other frontal signs
What are the findings?
LEFT MCA -
superior branch involvement
Broca’s (expressive/non-fluent) Aphasia
Right weakness face & arm > leg
Gaze deviation to left
What are the findings?
LEFT MCA -
inferior branch involvement
Wernicke’s (receptive/fluent) Aphasia
Right cortical sensory loss
Right “pie-in-the-sky” = right homonymous
superior quadrantonopsia
What are the findings?
LEFT MCA -
main branch (M1)
- Global aphasia + findings of the both superior and inferior branch
What are the findings?
Right MCA -
superior branch involvement
Left weakness face & arm > leg
Gaze deviation to right
What are the findings?
Right MCA -
Inferior branch involvement
Left cortical sensory loss
Left hemineglect
Left “pie-in-the-sky” = left homonymous
superior quadrantonopsia
What are the findings of PCA infarct?
Contralateral homonymous hemianopia.
Findings of Lacunar infarct:
Pure Motor?
Possible localizations?
Artery?
Symptoms?
Possible localizations: Posterior Limb Internal Capsule, Corona Radiata, Midbrain - cerebral peduncle, Ventral Pons
Artery? Anterior Choroidal, Small MCA branch, Small PCA branch, Basilar
Symptoms? Contralateral face, arm, & leg weak
Findings of Lacunar infarct:
Pure SENSORY?
Possible localizations?
Artery?
Symptoms?
Possible localizations: Thalamus
Artery? Thalamoperforators from PCA or MCA
Symptoms? contralateral face, arm, leg sensory sx
Duration of Holter needed if you suspect cardioembolic stroke?
2 weeks
tPA Inclusion Criteria?
________ stroke causing ________ neurologic deficit in patient _________ year old
Time from last known well (onset of stroke symptoms) _________
Ischemic stroke causing a disabling neurologic deficit in patients >18yo
Time from last known well (onset of stroke symptoms) <4.5h
Disabling = NIHSS ≥6
Disabling = aphasia, hemianopia, weakness limiting sustained effort against gravity, visual/sensory extinction
Absolute exclusion criteria for tPA?
Active hemorrhage or any condition that increases risks of major hemorrhage with tPA
Any hemorrhage on brain imaging
*if on DOAC, cannot give tPA, but can consider EVT
EVT Inclusion Criteria
_____ year old w/ disabling stroke AND functionally independent and life expectancy > ______
______ hours from onset of stroke or last known well
CT Head shows ___________________ (ASPECTS score of _________)
CTA shows occlusion in the _____________
No evidence for EVT in ___________ stroke, but can consider it for __________ because of ____________
EVT Inclusion Criteria
>18yo w/ disabling stroke AND functionally independent and life expectancy >3m
<6h* from the onset of stroke or last known well
CT Head shows small-to-moderate ischemic core (ASPECTS score of 6 or higher)
CTA shows occlusion in the anterior circulation of the proximal large vessel (distal ICA
or MCA)
no evidence for EVT in proximal posterior circulation stroke, but can consider it for basilar thrombus because of high morbidity/mortality
BP Management in acute ischemic stroke?
if getting/got tPA, ________ x 24h
if tPA and EVT, ________ x 24h
if no tPA, __________ (treat BP only if SBP ______ or DBP __________) x 24h
if getting/got tPA , <180/105 x 24h
if tPA and EVT, <180/105 x 24h
if no tPA, <220/120 (treat BP only if sBP>220 or dBP>120) i.e. permissive HTN x 24hr
Antiplatelets in acute ischemic stroke?
All acute stroke pts + not on antiplatelet + no tpa + CT no bleed = ASA 160mg (or sometimes Dual Antiplatelet)
if tPA = wait ____ hours before starting ASA ( ____ dual antiplatelet)
if tPA = wait 24h before starting ASA (no dual antiplatelet)
ABCD2 score?
High-Risk TIA score?
Risk-stratification tool to identify patients at high risk of stroke following a transient ischemic attack (TIA).
A - Age>60 (1 point)
B - BP>140/90 (1 point)
C - Clinical features (unilateral weakness = 2 points, speech disturbance without weakness = 1 point)
D - Duration of symptoms (>/= 60 mins (2 points), 10-59 minutes (1 point)
D - Diabetes (1 point)
High-Risk TIA score? >/= 4 points
Antiplatelets in stroke?
For high risk TIA (ABCD2 _____) or minor stroke (NIHSS _____) of __________ origin:
___________ for _______ days then ___________
For high risk TIA (ABCD2 ≥4) or minor stroke (NIHSS ≤3) of non-cardioembolic origin
Clopidogrel + ASA for 21days then antiplatelet monotherapy.
Minimal loading dose of clopidogrel 300-600mg and 160 mg of acetylsalicylic acid should be given at the start of the treatment
Start ASAP after brain imaging, within 24 hours of symptom onset, ideally within 12 hours.
Antiplatelets in Stroke?
Patients with TIA/stroke in last ___ days + ______% stenosis in major intracranial vessel and ___ bleeding risk = consider _________ for ________ days, followed by ________
Patients with TIA/stroke in last 30 days + 70-99% stenosis in major intracranial vessel and low bleeding risk = consider dual antiplatelet (ASA & Clopidogrel) x 3 months (followed by single antiplatelet) + LDL lowering, BP treatment, structures lifestyle medication (smoking cessation, exercise, diet)
When to do a Carotid endarterectomy (CEA)?
Men with 50%–99% symptomatic carotid stenosis & women with 70%–99% symptomatic carotid stenosis
LDL Target after stroke?
target LDL<1.8
PFO: High-risk features favoring PFO closure?
High-risk anatomical features:
1. Atrial septal aneurysm
2. Large right-to-left shunt (>20 microbubbles)
3. Large diameter (≥2mm)
Intracranial hemorrhage:
1. Imaging preferred?
2. Acute BP target?
3. Long-term BP target?
- Do CTA to r/o underlying lesion (aneurysm/ AVM/ venous thrombosis causing ICH). CTA is better than MRA to detect vascular lesions.
- SBP <140-160mmHg for first 24-48h
- <130/80
Levo-Dopa/Carbi-Dopa:
Side effects?
Non-motor: nausea, vomiting, orthostatic hypotension, sedation, confusion, hallucinations
Motor: dyskinesia
Special: dopa dysregulation (addiction)
Parkinson’s drug leading to orange urine?
Entacapone
Orthostatic hypotension in Parkinson’s disease can be treated with?
Orthostatic hypotension in Parkinson’s disease can be treated with midodrine, fludrocortisone, and domperidone
Progressive Supranuclear Palsy (PSP)?
Symmetrical parkinsonism (rigidity/bradykinesia)
Axial rigidity (neck and trunk) more than limb
No tremor
Early falls
Vertical supranuclear gaze paresis/ ** impaired vertical saccades**
Hyperfrontalis (wide-eyed stare)
Severe dysarthria
Mild dementia (frontal lobe dysfunction - Personality changes)
Poor response to levodopa
Parkinsonian features with alien limb phenomenon
Cortico-Basal Degeneration (CBD)
Scenario: vasculopath with sudden, complete, painless unilateral vision loss. Cherry red spot on the Ophthalmoscopy.
Diagnosis?
Central retinal Artery Occlusion
Scenario: pt with lung cancer and new severe morning headaches. Ophthalmoscopy shown.
Diagnosis?
Bilateral disc edema = likely papilledema
Scenario: young female, unilateral eye pain and vision loss. Ophthalmoscopy shown.
Diagnosis?
disc edema = Acute Optic Neuritis
Scenario: same young female, vision loss has mostly recovered, now examining a few months later. Ophthalmoscopy shown.
Diagnosis?
pale disc = Prior Optic Neuritis
Scenario: older person (>60), poor peripheral vision, no pain, eye pressure elevated
Ophthalmoscopy shown.
Diagnosis?
large cup-to-disc ratio and pale disc = glaucoma
Scenario: diabetic patient
cotton wool spots, microaneurysms, hard exudates,
neovascularization, flame hemorrhages
Diagnosis?
diabetic retinopathy
Scenario: hypertensive patient
cotton wool spots, hard exudates, flame hemorrhages, AV nicking, copper wiring, disc edema
Diagnosis?
hypertensive retinopathy
Scenario: fever, new cardiac murmur
Diagnosis?
roth spot = infective endocarditis
1) Horner’s on L
2) Horner’s on R
3) 3rd N palsy on L, pupil involved
4) 3rd N palsy on R, pupil spared
5) 6th N palsy on R
6) 4th N palsy on L
7) R 7th N (bell’s) palsy
Third nerve palsy
must rule out?
Posterior communicating aneurysm
Horners syndrome
Must rule out?
Carotid dissection in neck
L5 vs Peroneal Nerve - Both have foot drop. How to differentiate?
MOTOR
Ankle inversion - Tibia, nerve (L5): Spared in peroneal
Hip adduction - Superior Gluteal nerve (L5): Spared in peroneal
SENSORY
Lateral Malleolus (Peroneal nerve, S1): Spared in L5
C8 T1 vs Ulnar neuropathy: Weak hand, grip, difficulty opening jars,
FPL affected in C8, T1 (Median Nerve): Spared in ulnar
APB affected in C8, T1 (): Spared in ulnar
C7 vs Radial neuropathy: Wrist drop and Finger drop
Check Brachio-radials (C-5 C-6 in terms of root and radial nerve) - spared in C7
Check Pronator Teres: C7 and median nerve: spared in radial injury
