Neurology Flashcards
Factors that can cause/worsen idiopathic intracranial hypertension
GH, tetracyclines and excessive vitamin A and its derivatives (all-trans-retinoic acid, isotretinoin)
Initial tests to get in a patient with suspected myasthenia gravis?
EMG and anti-AChR antibody. If positive and the patient is
Level of sensation loss when it is due to spinal cord compression?
Typically ≥ 2 levels below the compression site.
What is the difference between cauda equina and conus medullaris syndrome?
Cauda equina has asymmetric, radiating pain with hyporeflexia and late onset bowel/bladder dysfunction.
Conus medullaris has symmetric back pain, hyperreflexia and early onset bowel/bladder dysfunction.
Central cord syndrome
Commonly seen with forced hyperextension (whiplash) and presents with burning pain, upper extremity paralysis and lower extremity sparing.
Most common CNS site of hypertensive hemorrhage
Putamen
Lambert-Eaton treatment
Plasmapheresis and immunosuppresion
Dysmetria
Tremor when attempting to touch an object
Dysdiadokinesia
Impaired rapid alternating movements
Which side does a patient tend to fall towards if they are symptomatic from a brain lesion compressing the cerebellum?
Towards the side of the lesion
Early findings seen in Alzheimer’s disease
Memory, visuospatial, cognitive impairment and language difficulty.
Late findings in Alzheimer’s disease
Personality, behavior, neuropsychiatric, incontinence, apraxia and noncognitive neurologic deficits.
Criteria for diagnosing Alzheimer’s disease
MMSE 60 and absence of other neurologic disorder.
Anticholinergic symptoms
Hot as hare, dry as a bone, blind as a bat, mad as a hatter, red as a beet and full as a flask
Trihexylphenidyl and benztropine are what type of drugs?
Anti-cholinergics
Why might a patient get a headache and retro-orbital pain after taking trihexylphenidyl?
Acute angle glaucoma
What is classically the dominant brain hemisphere?
Left, it tends to command verbal and written language
Histologic hallmark of prolonged seizures
Cortical laminar necrosis
Chronic phenytoin use can cause what CNS problem?
Cerebellar atrophy
Symptoms of lacunar infarct
Pure motor hemiparesis, pure sensory stroke, dysarthria-clumsy hand and ataxic hemiparesis.
Why give a hemorrhagic stroke patient nimodipine?
Reduces the risk of cerebral vasospam 3-10 days after bleed
Tinnitus red flags
Unilateral, pulsatile or tinnitus associated with other unilateral otalgic symptoms.
Hearing loss seen in otosclerosis
Conductive
Symptom most specific for dementia vs. normal aging?
Functional impairment
Imaging study of choice in patients with a new unprovoked seizue?
MRI if nonemergent, CT if urgent
Normal age-related cognitive changes
Tiredness, forgetfulness, difficulty word finding and trouble falling asleep.
Most effective medication for trigeminal neuralgia?
Carbamazepine
Comorbidity with the strongest association with strokes
Hypertension > Diabetes and smoking
Core features that must be present for diagnosis of dementia with Lewy bodies
Fluctuating levels of attention/alertness
Hallucinations
Motor features of Parkinsonism
You need at least 2
Treatment of patients with MS exacerbation
High dose corticosteroids, if this fails move on to plasma exchange
Neuroimaging in:
Alzheimer’s
Wilson’s
Huntington’s
Pick’s
Alzheimer’s = diffuse cortical atrophy
Wilson’s = lenticular nucleus atrophy (putamen and globus pallidus)
Huntington’s = caudate atrophy
Pick’s = frontotemporal cortical atrophy
MMSE in patients with pseudodementia
Should improve as depression improves
How long until a patient with acute angle glaucoma lose their vision?
2-5 hours
Most common primary sites of brain mets
Lung (multiple), breast (single), unknown primary, melanoma (multiple) and colon (single)
Treatment of restless leg syndrome
Mild-intermittent: supplement iron if serum ferritin is ≤ 75, leg massage, heating pads, exercise and good sleep hygiene
Moderate-persistent: dopamine agonist (pramipexole, ropinirole) then alpha-2-delta Ca channel ligands (gabapentin)
How do you diagnose CJD?
Rapidly progressive dementia, periodic sharp wave complexes on ECG or positive 14-3-3 CSF assay and 2/4:
Cerebellar or visual disturbance
Akinetic mutism
Myoclonus
Pyramidal/extrapyramidal dysfunction
Definitive diagnosis is done with brain biopsy or positive PRNP genetic mutation
Drugs effective in treatment of patients with mild-moderate dementia
Acetylcholinesterase inhibitors: donepezil, galantamine and rivastigmine
Wernicke encephalopathy triad
Encephalopathy, ocular dysfunction and gait ataxia
Drugs used as monotherapy in patients with acute migraine attacks
Antiemetics like prochlorperazine, chlorpromazine or metoclopramide
Cushing reflex
HTN, bradycardia, respiratory depression
Tick-borne paralysis vs. Guillain-Barre
No autonomic dysfunction in tick-born paralysis
Demented patients can benefit from antipsychotics when they become delirious; however, what type of dementia has associated hypersensitivity to neuroleptics?
Lewy body
Characteristic features of brain death
Absent cortical and brainstem functions, spinal cord may remain intact
Side effects of metoclopramide
It’s a dopamine antagonist and can result in extrapyramidal side effects like dystonia, tardive dyskinesia and Parkinsonism.
Tremor improved with intention? Worse?
Improved = Parkinson’s
Worsened = Essential
Treatment of essential tremor
1) Propranolol, then primidone or topiramate
Early and late side effects seen in patients with Parkinson’s treated with levo/carbidopa
Early: confusion, hallucinations, agitation, dizziness, somnolence and nausea
Late: movement disorders like dyskinesia and dystonia
Physical exam finding that is sensitive and specific for upper motor neuron disease
+Pronator drift (note that Romberg test is just them being able to stand without losing balance while eyes are closed and is a cerebellar test)
Strict exclusion for use of tPA in a stroke patient
Hemorrhage, CNS trauma/surgery 185/110, 1.7, PT > 15 or increased aPTT.
Only drug shown to reduce risk of early recurrence of ischemic stroke?
Aspirin, give within 24 hours. Give with dipyramidole if the patient stroked while on aspirin anyway.
LP in patients with Guillain-Barre
Elevated protein, normal cell count
Treatment of Guillain-Barre
IVIg or plasmapheresis
Parkinson’s tetrad
Resting tremor, bradykinesia, rigidity and postural instability
Heat stroke definition
Core body temp > 40C and mental status changes
Uthoff phenomenon and Lhermette’s sign
Uthoff: MS symptoms that worsen with heat
Lhermitte: electric shock sensation down spine when flexing neck
Imaging modality needed to confirm diagnosis of MS
T2 MRI
Brown-Sequard syndrome
Contralateral loss of pain and sensation ~ 2 levels below the lesion.
Ipsilateral loss of motor and proprioception
Factors that can precipitate a myasthenic crisis
Infection, surgery, pregnancy, medications (aminoglycosides, fluoroquinolones, macrolides and beta blockers).
Treatment for acute dystonic reaction to antipsychotics
Benztropine or diphenhydramine
Treatment for akathesia from antipsychotic use
Benzodiazepine
Side effects seen in patients on primidone for essential tremor
Acute intermittent porphyria (abdominal pain, neurologic and psychiatric symptoms)
What does primidone break down to after ingestion?
Phenobarbital and phenylethylmalonamide
Triad of Wernicke’s encephalopathy
Encephalopathy, oculomotor dysfunction and ataxia
Which metal-overload condition results in basal ganglia dysfunction? How is this disease confirmed?
Wilson’s. Confirm the dx with ceruloplasmin
Cupping of the optic disk
Seen in glaucoma
Edema of the optic disk
Seen in optic neuritis
CNIII fibers affected in diabetes
Somatic only (down and out + ptosis). Parasympathetics have better blood supply and are typically not as significantly affected by microvascular hyalinization.
Complications seen in patients with heat stroke
Rhabdomyolysis, coagulopathy, renal failure and ARDS.
Organisms that are most commonly involved in brain abscesses
S. viridans (direct extension from sinuses)
Staph and GNRs (distant spread)
Multiple system atrophy
Parkinsonism
Autonomic dysfunction
Widespread neurologic signs
Criteria needed for clinical diagnosis of Parkinson’s disease
Tremor, rigidity and/or bradykinesia
Medication used for Parkinson’s tremor in younger patients with tremor as their primary symptoms
Trihexylphenidyl
If pyridostigmine doesn’t work for your patient with myasthenia gravis, what next?
Immunosuppress with corticosteroids, azathioprine or mycophenolate mofetil. If myasthenic crisis: steroids + plasmapheresis or IVIg if plasmapheresis is not possible.
Hallmark CSF finding in patients with Guillain-Barre syndrome
Albuminocyotologic dissociation (elevated protein and normal WBC)
