Neurology 6% Flashcards
Name the syndrome:
- Bilateral upper + lower extremity weakness
- Sensory loss of pain and temp in “shawl-like distribution over extremities of upper shoulders”
- Preservation of position, light touch, proprioception
Central Cord Syndrome
Hyperflexion of neck
Name the syndrome:
- Hemiparesis greater in lower extremity than upper
- Urinary incontinence
- Personality changes
- Speech preservation
Anterior Cerebral Artery Infarct Syndrome
Name the syndrome:
- Complete paralysis in lower extremities
- Sensory loss of pain and temp, especially in lower extremities
- Preservation of position, proprioception
Anterior Cord Syndrome
Name the syndrome:
- Loss of proprioception and vibratory sense only
- Pain, light touch, motor sensation preserved
Posterior Cord Syndrome
Name the syndrome:
- Ipsilateral proprioception, vibratory, light touch, motor loss
- Contralateral pain and temp loss
Brown Sequard Syndrome
Unilateral chord lesion
T/F: In Bell’s Palsy, one still has the ability to raise/wrinkle the forehead/eyebrow in the affected side.
False. Bell’s Palsy = idiopathic palsy of FACIAL NERVE (CN 7).
Think STROKE if ability to move forehead is retained.
VDRL tests for ____
Syphilis
“Venereal Disease Research Laboratory”
Recommended imaging modality in acute phase of stroke
Nonconstrast CT
Differentiate b/w ischemic and hemorrhagic stroke
____ therapy initiated for ischemic stroke and TIA.
____ therapy initiated for cardiac emboli/MI.
ANTIPLATELET therapy initiated for ischemic stroke and TIA.
ANTICOAGULANT therapy initiated for cardiac emboli/MI.
MC type of stroke
Ischemic stroke (80%) --> Thrombotic (49%) emboli (31%) Cerebrovascular occlusion
Stroke of the _____ artery is the most common type.
Middle Cerebral Artery (70%)
T/F: Patients w/ strokes w/ facial involvement will NOT be able to raise their eyebrows.
False. Only involve lower half of face
Lacunar Infarct = Penetrating branches of ____
Symptoms (4)
CT scan shows ___
Tx:
Cerebral arteries in pons, basal ganglia
- Pure motor (hemiparesis, hemiplegia)
- Ataxic hemiparesis (weakness, clumsiness leg > arms)
- Dysarthria (clumsy hand syndrome)
- Pure sensory loss (numbness, parasthesias)
Small punched out hypodense areas
Aspirin
Control risk factors (HTN, DM)
Resolves in hours - 6 weeks
Middle Cerebral Artery Stroke causes (Ipsilateral/contralateral) sensory/motor loss/hemiparesis, greater in ____.
Visual disturbance:
(Ipsilateral/contralateral) (homo/heteronymous) hemianopsia. Gaze preference (towards/away from) side of lesion.
Middle Cerebral Artery Stroke causes CONTRALATERAL sensory/motor loss/hemiparesis, greater in FACE, ARMS > leg/foot.
Visual disturbance:
CONTRALATERAL HOMOnymous hemianopsia. Gaze preference TOWARD side of lesion.
LEFT or RIGHT -side dominant MCA stroke?
Broca (expressive), Wernicke (sensory) Aphasia
(Define each)
LEFT
Broca’s aphasia = sparse output, comprehension PRESERVED
Wernicke’s aphasia = fluent, voluminous, meaningless. Markedly IMPAIRED comprehension
LEFT or RIGHT -side dominant MCA stroke?
Spatial deficits, LEFT side neglect
RIGHT
LEFT or RIGHT -side dominant MCA stroke?
Math comprehension, agraphia
LEFT
Agraphia = loss in the ability to communicate through writing
LEFT or RIGHT -side dominant MCA stroke?
Dysarthria, anosognosia
RIGHT
Anosognosia = deficit of self-awareness
Dysarthria = difficult or unclear articulation of speech
Anterior Cerebral Artery Stroke causes (Ipsilateral/contralateral) sensory/motor loss/hemiparesis, greater in \_\_\_\_. T/F: Face affected. T/F: Speech preserved. T/F: Lower motor neuron weakness T/F: Urinary retention T/F: Personality changes (flat affect)
CONTRALATERAL greater in LOWER (leg/foot) > UE –> abnormal gait
F: Face SPARED TRUE: Speech preserved. F: UPPER motor neuron weakness F: Urinary INCONTIENCE TRUE: Personality changes (flat affect)
Posterior circulation of brain (3)
Posterior cerebral artery
Basilar artery
Vertebral artery
Only rTPA effective in ischemic stroke
Alteplase
Posterior Cerebral Artery Stroke causes
(Ipsilateral/contralateral) (homo/heteronymous) hemianopsia.
(Ipsilateral/contralateral) CN deficits
(Ipsilateral/contralateral) muscle weakness
Other symptoms (3)
CONTRALATERAL HOMOnymous hemianopsia.
IPSILATERAL CN deficits + CONTRALATERAL muscle weakness (“Crossed sx”)
Visual hallucinations
Coma
Drop attacks = sudden spontaneous falls while standing or walking, with complete recovery in seconds or minutes
Basilar Artery Stroke causes (4)
Cerebellar dysfunction
CN palsies
Decreased vision
BILATERAL sensory
Vertebral Artery causes (5)
Vertigo N/V Nystagmus Diplopia ISPLATERAL ataxia
MC cause of Subarachnoid Hemorrhage
2ry to rupture of berry aneurysm (MC Circle of Willis)
OR
Arteriovenous Malformation (AVM)
“Worst HA of my life”
What other symptoms?
Subarachnoid hemorrhage
Meningeal sx: Stiff neck, photophobia, delirium
Dx of Subarachnoid hemorrhage
T/F: No focal neuro symptoms
CT scan
If CT scan negative –> LP: xanthochromia (RBCs), increased CSF pressure
TRUE
Epidural Hematoma MC (arterial/venous) bleed Clinical manifestation: CT shows \_\_\_ (Does/doesn't) cross suture line
ARTERIAL bleed
Brief LOC –> LUCID interval –> coma
CONVEX (lens-shaped)
Does NOT cross suture line
Subdural Hematoma MC (arterial/venous) bleed Clinical manifestation: CT shows \_\_\_ (Does/doesn't) cross suture line
VENOUS bleed d/t tearing of bridging veins
MC in elderly. May have focal neuro sx.
CONCAVE (crescent-shaped)
DOES cross suture lines
Amaurosis Fugax
Occurs when:
MONOcular vision loss (“lamp shade down on one eye”)
TIA of Internal Carotid Artery
Carotid endarterectomy recommended for ___ in the setting of TIA
pts who have internal or common carotid artery stenosis 70-99%
Tx of TIA
Aspirin +/- dipyridamole or clopidogrel (Plavix)
Thrombolytics CONTRAINDICATED!
Definitive Dx of TIA
Angiography
TIA may present with (ipsilateral/contralateral) hand-arm weakness w/ sensory loss, (ipsilateral/contralateral) visual symptoms
CONTRALATERAL hand-arm weakness w/ sensory loss, IPSILATERAL visual symptoms
Tx of Subarachnoid Hemorrhage
Supportive: bed rest, mild sedation, stool softeners (prevent straining)
Felbamate
SE:
Anticonvulsant used in pts with seizures unresponsive to other medications
SE: aplastic anemia, hepatic failiure
Tx of absence seizures
Ethosuximide
Valproic acid
Type of seizure characterized by an AURAS and AUTOMATISMS
Complex partial (temporal lobe)
Type of seizure where consciousness is fully maintained
Simple partial
____ levels are increased in seizures
Prolactin
Marcus Gunn pupil =
Bilateral pupil constriction when light in normal eye BUT pupils dilate when like shone quickly in affected eye
Seen in Optic Neuritis, associated with MS
Uhthoff’s phenomenon =
Worsening of symptoms w/ heat (exercise, fever, hot tub)
Seen in MS
Suspect MS in any young paitents who present with ____.
trigeminal neuralgia
Charcot’s Neurologic Triad =
nystagmus
stacatto speech
intentional tremor
Seen in MS
Dx of MS
MRI w/ gadolinium –> white matter plaques (hyperdensities)
Tx of MS
Acute exacerbations:
Relapse-remitting/progressive disease:
Fatigue sx:
Acute exacerbations: STEROIDS, Plasma exchange if unresponsive
Relapse-remitting/progressive disease: Beta-interferon
Fatigue sx: Amantadine
CSF finding in MS
Increased IgG (oligoclonal bands)
CSF findings in Guillain Barre Syndrome
High protein
NORMAL WBC
CSF findings in Bacterial Meningitis
High protein
INCREASED WBC (polymorphonuclear neutrophils) (100-100,000**)
DECREASED glucose
CSF findings in Aseptic Viral Meningitis
Normal glucose INCREASED WBC (lymphocytes) (10-300)
CSF findings in Fungal Meningitis
Increased WBCs (lymphocytes) Decreased glucose
Lhermitte’s Sign
Neck flexion causes lighting-shock pain radiating from spine down the leg w/ neck flexion
Seen in MS
Amyloid depositions (senile plaques) and neurofibrillary tangles (tau protein) seen in ___
Alzheimer Disease
Tx of Alzheimer Disease
Acetycholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine
NMDA antagonist: Memantine
MOA of NMDA antagonists
reduces glutamate excitotoxicity
Frontotemporal dementia (a.k.a. ___) presents with ___
A.k.a Pick’s Disease
Marked personality changes
Primitive reflexes = frontal release signs –> palmar grasp, rooting reflexes
Vascular dementia presents as
forgetfulness in absence f depression and inattentiveness
Prophylactic tx of choice for cluster HA
verapamil
Triptans are ____ that cause ____
serotonin 5HT-1 agonists
vasoconstriction
Tx of benign essential tremor
Propranolol: beta blocker
Primidone: if propranolol fails
Parkinson disease: Degeneration of cells in the ___, causing deficiency of ____ and imbalance of ____ and ____.
Degeneration of cells in the SUBSTANTIA NIGRA, causing deficiency of DOPAMINE and imbalance of DOPAMINE and ACETYLCHOLINE.
Parkinson Disease features (4)
RESTING tremor: pill rolling
Bradykinesia: slow, shuffling gait, masklike facies
Rigidity (Cogwheel)
Postural instability
Tx of Parkinson disease:
Mild anticholinergic used for mild symptoms but no disability
Amantadine
Tx of Parkinson disease:
Anticholinergic drugs
Benzotropine
Trihexyphenidyl
Levodopa
Converts to dopamine
Tx of Parkinson
Carbidopa
Used in combination with Levodopa, allows lower doses of levodopa and reduce side effects
Tx of Parkinson
Bromocriptine
Dopamine agonist
Used for refractory Parkinson to levodopa/carbidopa therapy
Selegiline
Monoamine oxidase B inhibitors
Inhibits breakdown of dopamine
Tolcapone
Entacapone
Cetecholamine-O-Methyltransferase inhibitors (COMT)
Reduce metabolism of levodopa to 3-O-methyldopa
Allows lower doses of levodopa and reduce side effects
Huntington Disease is autosomal ___ d/o. The gene is on ___ chromosome.
Autosomal dominant
Short arm of chromosome 4
Huntington Disease characterized by ___
CT shows ____ & ____ atrophy.
Treatment:
Progressive chorea and dementia
Caudate nucleus and cerebral atrophy
Treatment:
Phenothiazine: dyskinesia
Haloperidol, clozapine: behavioral disturbances
Tourette syndrome characterized by ___
Dx: Volumertric MRI shows ____
Motor tics (80%) and phonic tics
Volume loss in caudate nucleus
CT, MRI are normal. EEG not helpful.
Coprolalia =
Involuntary obscene word tic
Seen in Tourette syndrome in 40%
Treatment of Tourette syndrome
Fluphenazine
Pimozide
Haloperidol
Tetrabenazine
Clonazepam, clonidine used to minimize SE of long term haloperidol use.
Cerebral palsy is characterized by ____
(Hyper/hypo)reflexia?
chronic impairment of muscle tone, strength, coordination or movement
Hyperreflexia
Tx of Restless leg syndrome
1st line: Dopamine agonists (pramipexole, ropinirole)
2nd line: Benzos (clonazepam)
Trial of iron therapy recommended if ALL pts w/ RLS (those w/o iron overload)
Bell palsy affects CN ___. Thought to be caused by ___, resulting in ____.
Paralysis involves ____.
Weakness peaks in about ___. Recovery usually within ___.
Treatment:
CN 7
Herpes simplex virus activation
Damage to myelin layer of facial nerve
FOREHEAD, lower face
Pain around ipsilateral ear
21 days
6 months
Oral prednisone begun at onset of symptoms shows increased % of pts with complete recovery
Guillain-Barre Syndrome =
MC precipitant of Guillain-Barre Syndrome =
Muscle weakness progresses (asymmetrically/symmetrically) (ascending/decending) pattern. (Decreased/increased) DTR.
CSF findings =
Post infection immune mediated demyelination & axonal degeneration slows impulses
Campylobacter jejuni
Symmetrically ASCENDING
DECREASED DTR
CSF = High protein w/ NORMAL WBC
Tx of Guillain-Barre Syndrome
Plasmapheresis ASAP
IVIG = good for cadiovascular instability pts and children
75% of pts w/ Myasthenia Gravis also have ____
thymic abnormalities (hyperplasia or thymoma)
Clinical manifestations of Myasthenia Gravis
- Ocular weakness:
Extraocular muscle weakness –> diplopia
Ptosis
2.
- Generalized mm weakness worsening w/ repeated muscle use, relieved by rest
- Weakness w/ prolonged chewing, dysphagia
- Respiratory failure –> Myasthenic crisis!!
Edrophonium/ Tensilon test
Rapid response to short acting IV edrophonium
Dx of Myasthenia Gravis
Serum tests for Myasthenia Gravis
Ach-receptor Ab MuSK Ab (ab to muscle specific tyrosine kinase)
Treatment of Myasthenia Gravis
Pyridostigmine, Neostigmine = acetylcholinesterase inhibitors
-MOA: increase acetylcholine by decreasing Ach breakdown
Cholinergic crisis =
How to tell difference from myasthenic crisis?
d/t excess Ach d/t Ach-esterase inhibition
-weakness, N/V, pallor, sweating, salivation, diarrhea, miosis, bradycardia, respiratory failure
If flaccid paralysis improves with Tensilon = Myasthenic crisis
If worsens w/ Tensilon = Cholinergic crisis
Myasthenic syndrome (Lambert-Eaton)
Ab preventing Ach release
Associated w/ small cell lung CA
Weakness IMPROVED w/ continued use (unlike Myasthenia Gravis)
Kernig’s sign
Brudzinski’s sign
Kernig’s sign = inability to straighten knee w/ hip flexion
Brudzinski’s sign = neck flexion produces knee/hip flexion
MC pathogen in bacterial meningitis in < 1 month old
Treatment:
Group B strep (Streptococcus agalactiae)
Tx: Ampicillin + (Cefotaxime or Aminoglycoside)
MC pathogen in bacterial meningitis in 1 month - 18 y/o
Treatment:
N. meningitidis*, S. pneumo
Tx: Ceftriaxone + Vancomycin
MC pathogen in bacterial meningitis in 18 y/o - 50 y/o
Treatment:
S. pneumo*, N. menigitidis
Tx: Ceftriaxone + Vancomycin
Petechial rash associated with what pathogen in bacterial meningitis?
N. meningitidis
MC pathogen in bacterial meningitis in > 50 y/o
Treatment:
S. pneumo
Listeria monocytogenes
Tx: Ampicillin + Ceftriaxone (+/- Vancomycin)
MC pathogen of viral meningitis
Enterovirus (Echovirus, Coxsackie)
MC pathogen of viral encephalitis
HSV-1
Tx of brain abscess
IV PCN G
OR Ceftriaxone + Metronidazole
+ Vancomycin if suspect Staph Aureus
Lowest - highest score on the Glasgow Coma Scale
3-15
Where's the brain tumor? Progressive intellectual decline Slowing mental activity Personality changes (Ipsilateral/contralateral) grasp reflexes Expressive Aphasia
Frontal lobe
Contralateral grasp reflexes
Where's the brain tumor? Seizures Olfactory/gustatory hallucinations Licking/smacking of lips Depersonalization Emotional, behavioral changes Visual field defects Auditory illusions
Temporal lobe
Where’s the brain tumor?
(Ipsilateral/contralateral) disturbances of sensation
Cortical sensory loss (impaired stereognosis)
Inattention
Parietal lobe
Contralateral disturbances of sensation
Where's the brain tumor? Crossed (homo/hetero)nymous hemianopia Partial field defect Visual agnosia Unformed visual hallucinations
Occipital lobe
Crossed homonymous hemianopia
MC type of primary intracranial neoplasms?
Glioma (50%)
CSF of brain neoplasm shows
Xanthochromia
Increased protein
Normal WBC
Normal Glucose
Nightmares occur during ___
REM sleep
Sleep terrors occur during ____
stage 3 and 4 delta sleep
Sleep walking occurs during ____ in 1st 1/3 of night and with ____ later in night.
3 or 4 delta sleep
REM sleep
Tx of narcolepsy
Stimulants: dextroamphetamine, modafinil
Tx of nocturnal myclonus
clonazepam
Tx of Sleep terror and sleepwalking
Benzodiazepines
Dreaming occurs during ___
REM sleep
Delta sleep =
stage 3 and 4 of sleep
Dx of Narcolepsy
Multiple sleep latency test
Carbamazepine SE
Monitor w/:
Aplastic anemia, agranulocytosis, hyponatremia
CBC, LFT, Na testing
UPPER motor neuron lesions cause (spastic/flaccid) paralysis (hypertonia/hypotonia), (decreased/increased) DTR, (with/without) fasciculations, (upward/downward) Babinski, (with/without) muscle atrophy.
UPPER motor neuron lesions cause SPASTIC paralysis, HYPERTONIA, INCREASED DTR, WITHOUT fasciculations, UPWARD Babinski, WITHOUT muscle atrophy.
LOWER motor neuron lesions cause (spastic/flaccid) paralysis (hypertonia/hypotonia), (decreased/increased) DTR, (with/without) fasciculations, (upward/downward) Babinski, (with/without) muscle atrophy.
LOWER motor neuron lesions cause FLACCID paralysis HYPOTONIA, DECREASED DTR, WITH fasciculations, DOWNWARD Babinski, WITHmuscle atrophy.
3 cardinal features of Normal pressure hydrocephalus
dementia + gait disturbance + urinary incontinence
Myerson sign (a.k.a glabellar reflex)
Seen in ____
reflexive, sustained eye blinking in response to repetitive tapping above the nasal bridge between eyes
Parkinson disease
Diabetes mellitus is a common cause of CN ___ palsy. Pupil sizes are (constricted/normal/dilated) in diabetics.
CN 3 (also 4, 6) BUT NORMAL (other CN 3 palsy will have dilated pupils)
Multiple sclerosis associated with CN ___ palsy, causing diplopia.
CN 6 (Abducens nerve)
Cerebral aneurysm associated with CN ___ palsy
CN 3
Sarcoidosis associated with CN ___ palsy
CN 7
Lyme disease associated with CN ___ palsy
CN 7
