Neurology 6% Flashcards
Complex regional pain syndrome, presentation
Non-dermatomal limb pain usually following a trauma or surgery.
Upper or lower limb pain, swelling, reduced range of motion, skin changes, and bone demineralization.
Pain is disproportionate to the injury with continuing pain that is disproportionate to any inciting event.
Complex regional pain syndrome, symptoms; signs
Sensory: hyperalgesia and/or allodynia.
Vasomotor: skin, temperature, color asymmetry.
Pseudomotor/edema: edema, sweating changes, or sweating asymmetry.
Motor/trophic: decreased range of motion or motor dysfunction and/or trophic changes (hair, nail, skin).
Peripheral neuropathies
Symmetric distal sensory loss along with burning pain or weakness.
Peripheral neuropathies, slow onset in stocking glove (hands and feet) pattern; fast onset; ascending
Diabetes mellitus, uremia.
Drugs.
Guillain-Barre Syndrome.
Cluster headache
Severe, unilateral, periorbital pain, lacrimation, and nasal congestion.
More common in men (4:1).
Treatment: 100% oxygen.
Migraine
Unilateral (70%), throbbing, disabling pain, nausea, vomiting, photophobia.
Classic: Aura.
Common: No aura (80% of migraines).
Migraine, treatment
Abortive: Triptans (do not use in ischemic heart disease), ergotamine (do not use in pregnant women).
Tension headache
Bilateral, non-throbbing, band-like or “vice like” pain.
A tension-type headache is typically described as bilateral, mild to moderate, dull pain, whereas a migraine is typically pulsating, unilateral, and associated with nausea, vomiting, and photophobia or phonophobia.
Tension headache, treatment
NSAIDs, Excedrin, muscle relaxer.
Encephalitis
May present similar to meningitis but will see altered mental status, seizures, personality changes, exanthema.
Encephalitis is clinically differentiated from meningitis by altered brain functioning.
Encephalitis, etiology
Usually viral: Most common species: HSV or Immunocompromised: CMV.
Meningitis, symptoms; signs
Classic Triad: Fever, headache, stiff neck, petechiae (especially N. meningitidis).
Kernig’s sign: knee extension causes pain in neck (Remember K = Kernig’s and K = Knee).
Brudzinski’s sign: leg raise when bend neck.
Meningitis, CSF findings: bacterial; viral
↑ Protein, ↓ Glucose (bacteria love to eat glucose) there is a markedly increased opening pressure.
Normal pressure, increased WBC (lymphocytes).
Essential tremor
Bilateral intention tremor of the hands, forearm, and/or head without resting component.
Family history in 50-70% of patients, autosomal dominant inheritance.
Elderly patients.
Worse on intention. Hands and head.
Better with alcohol.
Less likely to be unilateral.
Huntington Disease
Inherited autosomal dominant neurodegenerative disease characterized by progressive motor and psychiatric dysfunction, dementia, and chorea (nonrepeating, complex, involuntary rhythmic movements that may appear purposeful).
Genetic testing: 40+ CAG repeats.
Parkinson disease
Resting/pill rolling tremor, masked facies, cogwheel (catching and releasing), bradykinesia, and shuffling gait.
Decreased dopamine in substantia nigra.
Lewy bodies.
Cerebral aneurysm
Weak, bulging spot on the wall of a brain artery very much like a thin balloon or weak spot on an inner tube.
Usually found either incidentally or when a patient presents with subarachnoid hemorrhage.
Cerebral aneurysm, symptoms
Before a larger aneurysm ruptures, the individual may experience such symptoms as a sudden and unusually severe headache, nausea, vision impairment, vomiting, and loss of consciousness.
A key symptom of a ruptured aneurysm is a sudden, severe headache (the worst headache of my life).
Cerebral aneurysm, types
Saccular (Berry), Fusiform, dissecting, Mycotic, and Traumatic. Ruptured saccular (berry) aneurysm accounts for approximately 75% of nontraumatic cases of SAH and has a mortality rate of 50%.
Cerebral aneurysm, diagnosis
Noncontrast head CT is the initial investigational modality for suspected SAH. Lumbar Puncture (LP) with evaluation of CSF reveals markedly elevated opening pressures and RBC in CSF. Xanthochromia (CSF protein > 150 mg/dL or serum bilirubin > 6 mg/dL) - if the blood has been in the CSF for over 2 hours. Cerebral angiography (Gold Standard) should be done to evaluate the entire vasculature.
Cerebral aneurysm, treatment
Surgical clipping or endovascular coiling is usually performed within the first 24 hours.
Intracranial hemorrhage, epidural hematoma:
Transient loss of consciousness from an injury, period of lucency, then neurologic deterioration.
CT: lens-shaped, biconvex.
Intracranial hemorrhage, subdural hematoma
Elderly patient with a history of multiple falls who is now presenting with neurological symptom. May be chronic, taking days to weeks to develop symptoms.
CT scan: Crescent shaped density in the brain.
Intracranial hemorrhage, subarachnoid hemorrhage
“Explosive thunderclap” headache described as “the worst headache ever.” Aneurysm or AVM rupture.
Stroke
Acute onset of focal neurologic deficits resulting from - diminished blood flow (ischemic stroke) or hemorrhage (hemorrhagic stroke).
Contralateral paralysis, motor function. Right-sided symptoms = left side stroke, Left-sided symptoms = right side stroke.
Stroke, Carotid/Ophthalmic
Amaurosis fugax (monocular blind).
Stroke, MCA
Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia.
Stroke, ACA
Leg paresis, hemiplegia, urinary incontinence.
Stroke, PCA
Homonymous hemianopsia.
Stroke, Basilar Artery
Coma, cranial nerve palsies, apnea, drop attach, vertigo.
Stroke, Lacunar infarcts
Occur in areas supplied by small perforating vessels and result from atherosclerosis, hypertension, and diabetes (silent, pure motor or sensory stroke, “Dysarthria-Clumsy hand syndrome”, ataxic hemiparesis).
Stroke, diagnosis; treatment
CT without contrast for acute presentation - important to diagnose as ischemic or hemorrhagic.
For occlusive disease treat with IV tPA if within 3-4.5 hours of symptom onset.
Can consider intra-arterial thrombolysis in select patients (major MCA occlusion) up to 6 hours after onset of symptoms.
For embolic disease and hypercoagulable states give warfarin/aspirin once the hemorrhagic stroke has been ruled out.
Endarterectomy if carotid > 70% occluded.
Transient ischemic attack
An episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction.
Transient ischemic attack, large artery low flow TIA (stenosis
Likely carotid stenosis causing short live (minutes) decrease in flow to the brain.
Transient ischemic attack, embolic TIA
Emboli often form in the heart (afib, septic emboli from endocarditis).
Transient ischemic attack, clinical manifestations, internal carotid artery
Amaurosis Fugax (monocular vision loss - temporary “lampshade down on one eye”) weakness in the contralateral hand.
Transient ischemic attack, clinical manifestations, ICA/MCA/ACA
Cerebral hemisphere dysfunction. Sudden headache, speech changes, confusion.
Transient ischemic attack, clinical manifestations, PCA
Somatosensory deficit.
Transient ischemic attack, clinical manifestations, vertebrobasilar
Brainstem/cerbral symptoms (gait and proprioception).
Transient ischemic attack, diagnosis
CT (without contrast), MRI more sensitive, carotid doppler to look for stenosis, CT angiography, MR angiography.
Transient ischemic attack, treatment
Carotid endarterectomy if internal or common carotid artery stenosis is > 70%.
Aspirin within 24 hours. Antiplatelet therapy (e.g., aspirin or clopidogrel or aspirin-dipyridamole) should be then initiated.
Level of consciousness
A. Eye opening: 4- spontaneous 3- voice 2-pain 1-none
B. Verbal: 5-oriented 4-confused 3-inappropriate words 2-incomprehensible 1-none
C. Motor: 6-obeys commands 5-localizes pain 4-withdraws 3-abnormal flexion (decorticate) 2-abnormal extension (decerebrate) 1-none
Scoring
Maximum score is 15 which has the best prognosis
Minimum score is 3 which has the worst prognosis
Less than 9 is a coma
Cerebral palsy
Prenatal injury perinatal hypoxia or ischemia, preterm baby.
Hyperreflexia, rigidity, intellectual impairment, seizures.
Concussion, Grade 1
No LOC, post traumatic amnesia and other symptoms resolve in < 30 minutes.
Athlete may return to sports if asymptomatic for one week.
Concussion, Grade 2
+ LOC , 1 minute or post-traumatic amnesia and other symptoms last > 30 minutes but < 1 week.
Athlete may return to sports in 2 weeks if asymptomatic at rest and exertion for at least 7 days.
Concussion, Grade 3
+ LOC > 1 minute or post-traumatic amnesia and other symptoms last > 1 week.
Athlete may return to sports in 1 month if asymptomatic at rest and exertion for 7 days.
Concussion, repeat concussions
If associated with either loss of consciousness or symptoms for more than 15 minutes NOT to return to play sports for that season.
Dementias, Alzheimer’s disease
Most common.
Definitive diagnosis on autopsy - beta amyloid plaques and neurofibrillary tangles.
Abnormal clock drawing test.
Treat with Anticholinesterase drugs (Tacrine, Donepezil).
Dementias, vascular dementia
2nd most common type.
Correlated with a cerebrovascular event and/or cerebrovascular disease.
Stepwise deterioration with periods of clinical plateaus.
Dementias, Lewy body dementia
Fluctuating cognition associated with parkinsonism, hallucinations and delusions, gait difficulties, and falls.
Dementias, frontotemporal dementia
Personality changes precede memory changes.
Delirium
Acute, fluctuating mental status change caused by a medical condition.
Delirium is rapid in onset, short term and reversible.
Delirium, underlying organic causes; treatment
UTI, pneumonia, metabolic changes, CVA, MI, TBI, medications (anticholinergics, benzodiazepines, opioids). Treat underlying cause.
Guillain-Barré syndrome
Symmetrical ascending paralysis beginning in distal limbs, following Campylobacter jejuni infection, will often present after immunization.
Weakness begins in lower extremities; respiratory paralysis if no treatment.
Treatment: admit, plasmapheresis or IVIG.
Good prognosis.
Multiple sclerosis
Autoimmune - antibodies against myelin sheath.
Multiple sclerosis, symptoms
Often first finding: retrobulbar optic neuritis.
Other symptoms: numbness, tingling, balance disturbance, diplopia.
Multiple sclerosis, diagnosis
MRI: Dawson fingers (white matter lesions).
CSF: Elevated IgG, oligoclonal bands.
Multiple sclerosis, relapsing remitting
Most common, 85% (symptoms come and go).
Multiple sclerosis, secondary progressive
Relapsing remitting progresses to steady decline.
Multiple sclerosis, primary progressive
No remission, steady decline from onset.
Multiple sclerosis, progressive relapsing
Combination. Worse overtime with acute relapses. Most rare.
Myasthenia gravis
Autoimmune attack of acetylcholine receptors at the neuromuscular junction results in motor problems.
Myasthenia gravis, presentation
Young women, older men. Weakness in everyday activities like brushing hair.
Proximal to distal weakness: eyes: ptosis usually first.
Myasthenia gravis, diagnosis
Diagnose with acetylcholine receptor antibodies.
Tensilon test/edrophonium test- short acting anticholinesterase.
