Neurology 6% Flashcards
What is the most common risk factor for developing Alzheimer disease?
old age
The most common form of dementia
Patients with ———– often see an early onset of Alzheimer by the age of 40 due to the presence of APP gene on chromosome 21
Down’s syndrome
Dx of alzheimer’s Dz
Definitive diagnosis is by brain biopsy (after autopsy)
Alzheimer’s disease is essentially a clinical diagnosis; exclude other causes first. Formal neuropsychological testing to confirm the diagnosis
An intellectual decline in 2+ areas of cognition
Documented by MMSE or similar scale
CT scan or MRI showing diffuse cortical atrophy with enlargement of the ventricles strengthens the diagnosis
CBC, CMP, heavy metal, calcium, glucose, TSH, B12, renal, LFT, drug/ETOH levels
Tx for alzheimer’s disease x2
Cholinesterase inhibitors (first line): donepezil, rivastigmine, galantamine - brains of patients with Alzheimer disease have lower levels of acetylcholine
Memantine (NMDA-receptor antagonist): mod-severe
Certain dietary supplements (ginkgo, lecithin) have not been proven to be beneficial.
Avoid anticholinergics
Hemifacial weakness/paralysis of muscles innervated by CN VII due to swelling of the cranial nerve
Upper respiratory infection is a common preceding event
bells palsy
There is an acute onset of unilateral facial weakness/paralysis. Both the upper and lower parts of the face are affected (differentiate quickly from stroke - can wrinkle forehead)
bell’s palsy
Bell’s palsy diagnosis
What to consider in endemic areas?
Consider ——–testing if paresis fails to resolve within 10 days
consider Lyme disease in endemic areas
(Do NOT use steroids if Lyme is suspected!)
EMG testing
Bell’s palsy Tx? x3
A short course of steroid therapy (prednisone) and acyclovir, if necessary
Patient should wear an eye patch at night to prevent corneal abrasion
Surgical decompression of CN VII is indicated if the paralysis progresses or if tests indicate deterioration
Acute onset of focal neurologic deficits resulting from -
diminished blood flow
ISCHEMIC STROKE
Hemorrhage–> gic stroke
Contralateral paralysis, motor function
Right-sided symptoms = left side stroke, Left-sided symptoms = right-side stroke
Amaurosis fugax (monocular blind) which artery?
Carotid/ophthalmic
Aphasia, neglect, hemiparesis, gaze preference, homonymous hemianopsia
Middle cerebral artery
MCA
Leg paresis, hemiplegia, urinary incontinence
ACA
Anterior
homonymous hemianopsia
Posterior cerebral artery
Coma, cranial nerve palsies, apnea, drop attach, vertigo
Basilar Artery
Silent, pure motor or sensory stroke, “Dysarthria-Clumsy hand syndrome”, ataxic hemiparesis
Lacunar infarcts occur in areas supplied by small perforating vessels and result from atherosclerosis, hypertension, and diabetes:
How to Dx stroke?
CT without contrast for acute presentation - important to diagnose as ischemic or hemorrhagic
How to treat stroke?
For occlusive disease treat with IV tPA if within 3-4.5 hours of symptom onset
When to consider intra-arterial thrombolysis?
in select patients (major MCA occlusion) up to 6 hours after onset of symptoms.
When to give warfarin/aspirin for stroke?
For embolic disease and hypercoagulable states give warfarin/aspirin once the hemorrhagic stroke has been ruled out.
When to perform endarterectomy?
Endarterectomy if carotid > 70% occluded
an acute cognitive dysfunction secondary to some underlying medical condition and is usually reversible
Delirium
Acute and rapid deterioration in mental status (hours-days), a fluctuating level of awareness, disorientation
Visual hallucinations are the most common type experienced by patients with delirium
Who are considered high risk for delirium?
High-risk after surgery especially in those with heart disease or diabetes
Delirium, unlike dementia, is usually reversible
Fall precautions - patients with delirium are six more times likely to fall
What is most common presentation of altered mental status in the inpatient setting
Delirium
most common cause of delirium, specifically, delirium tremens
Alcohol abuse
what are organic causes of delirium?
(like diseases) x 7
UTI, pneumonia, metabolic changes, CVA, MI, TBI, medications (anticholinergics, benzodiazepines, opioids)
Work up for delirium includes
x3
1st MMSE
2nd LABS: CMP, B12/folate
LP: if febrile, delirious patient (Cerebral edema)
when to give haldol in delirium patient?
for agitaiton/psychosis
What is second most common type of dementia? Stepwise deterioration with periods of clinical plateaus
May cause a sudden decline
Vascular disease
Associated with arteriosclerotic small vessel disease
Multi-infarct, usually correlated with a cerebrovascular event and/or cerebrovascular disease
How to treat vascular dementia?
Control the BP
Language difficulties, personality changes, and behavioral disturbances
Personality changes precede memory changes
frontotemporal lobar degeneration dementia
Hallucinations and delusions, gait difficulties, and falls
Parkinsonian symptoms
Lewy Body Disease
Cognitive decline associated with HIV infection
Substantial memory deficits, impaired executive functioning, poor attention and concentration, mental slowing, and apathy
Cerebral atrophy is typically evident on brain imaging
HIV dementia
what are the 4 main categories of dizziness?
Vertigo: False sense of motion, possibly spinning sensation
Disequilibrium: Off-balance or wobbly (up to 16%)
Presyncope: Feeling of losing consciousness or blacking out (up to 14%)
Lightheadedness: Vague symptoms, possibly feeling disconnected with the environment (approximately 10%)
episodic vertigo without hearing loss
Loose otolith in semicircular canals causing a false sense of motion
Positive findings with Dix-Hallpike maneuver (position changes)
Benign paroxysmal positional vertigo (vertigo)
Episodic vertigo, tinnitus, nausea, and hearing loss
Not associated with URI
MC in elderly and feeling of fullness in ear
Meniere disease (vertigo)
Increased endolymphatic fluid in the inner ear
Continuous vertigo. There is an absence of neurologic deficits
Labyrinthitis (vertigo)
Acute onset, vertigo, hearing loss, and tinnitus of several days to a week. Often preceded by a viral respiratory illness
Vertigo without position changes
No hearing loss or tinnitus (inflammation of the vestibular portion of CN VIII)
Vestibular neuronitis (vertigo)
Like labyrinthitis, it is often associated with a viral illness
How to differentiate labrynthitis from vestibular neuronitis?
The features of acute labyrinthitis are similar to those of vestibular neuronitis, except labyrinthitis includes significant sensorineural hearing loss which is NOT present in vestibular neuronitis.”
Labrynthitis =significant sensorinural hearing loss
Dysfunction in gait causing imbalance and falls
Shuffling gait with reduced arm swing and possible hesitation
Parkinson’s
Decreased tactile response when walking causes the patient to be unaware when feet touch the ground, leading to imbalance and falls
Decreased sensation in lower extremities, particularly the feet
Peripheral neuropathy
tremor - Hands and head
Shaking occurs with simple tasks such as tying shoelaces, handwriting, shaving or simply holding hands against gravity
Symptoms may be aggravated by stress, fatigue, caffeine, and temperature extremes
Better with alcohol
Intention/Action
Essential Tremor
is essential tremor autosomal dominant or recessive?
: Family history, autosomal dominant. Elderly patients
How to treat essential tremor?
x3
1st line
PROPRANOLOL
2nd line Primidone, alprazolam, small amounts of alcohol, gabapentin, topiramate, or nimodipine
Drug-resistant cases - Deep brain stimulation
Unilateral, excruciating, sharp, searing, or piercing pain (often at night), lacrimation, and nasal congestion
Males > Females
CLUSTER HA
Treat with oxygen 100% at 6–12 L/min for 15 minutes via a nonrebreathing mask provides relief within 15 minutes and sumatriptan (Imitrex)
A headache of varying intensity, often unilateral, and accompanied by nausea and sensitivity to light and sound
Pulsating, duration of 4–72 hours, unilateral, nausea, disabling, associated with photophobia and phonophobia
MIGRAINE
Without aura = most common, N/V, photophobia, phonophobia
Aura: scotoma, flashing lights, sound
HA follows aura w/in 30 min; visual = MC
Migraine treatment:
x2
abortive
prophylaxis
Abortive: Triptans (do not use in ischemic heart disease), ergotamine (do not use in pregnant women)
Prophylaxis: Atenolol, propranolol, verapamil or TCAs
Bilateral, squeezing sensation, mild to moderate, dull pain
Tx: x2?
Tension
whereas a migraine is typically pulsating; unilateral; and associated with nausea, vomiting, and photophobia or phonophobia
NSAIDS, muscle relaxer
Caused by degeneration of basal ganglia in the substantia nigra leading to loss of dopamine-containing neurons located in the substantia nigra and locus coeruleus
Parkinson disease
REsting tremor
Lewy bodies
Acetylcholine/Dopamine imbalance
What are the medications causing parkinson disease?
neuroleptics (chlorpromazine, metoclopramide, reserpine)
Three cardinal features: Rest (pill-rolling) tremor, cogwheel rigidity, and bradykinesia (slowness of movement)
Other clinical features: Mask facies, loss of postural reflexes, decreased blink rate, shuffling gait, hypophonia, micrographia, gait arrest, and backward falling
PArkinsons
Gold standard for Dx parkinson?
neuropathologic exam
MRI: for V Dz, tumor, or multiple system atrophy
What is Tx for parkinson?
< 65 dopamine agonists: bromocriptine, pramipexole, ropinirole
Directly stimulates dopamine receptors. Fewer side effects than Levodopa. Used in younger patients to delay the use of Levodopa
Treatment for restless leg syndorme?
Ropinirole
DA agonist
Tx > 65 parkinsons?
Levadopa/carbidopa
Side-effects of levodopa/carbidopa?
Common side effects of L-dopa: Gastrointestinal upset with nausea and vomiting, vivid dreams or nightmares, psychosis, and dyskinesias
seizures with retained awareness (consciousness maintained)
This type of focal seizure was previously known as a simple partial seizure
No alteration in consciousness. Abnormal movements or sensations
seizures with a loss of awareness (consciousness impaired)
Present with a postictal state (confusion and loss of memory) which differentiate them from absence seizures
This type of focal seizure may also be called a focal dyscognitive seizure (previously known as complex partial seizures)
Altered consciousness, automatisms (ie. Lip-smacking)
what is treatment of focal seizures?
phenytoin, and carbamazepine are drugs of choice
Characterized by a brief impairment of consciousness with an abrupt beginning and ending.
At times involuntary movements may occur, but they are uncommon and the patient has no recollection and witnesses commonly miss them
Absence seizures
Treat with ethosuximide or valproic acid.
Bilaterally symmetric and without focal onset
Begins with a sudden loss of consciousness—a fall to the ground
Tonic clonic
Tonic phase: very stiff and rigid 10-60 seconds.
Clonic phase: generalized convulsions and limb jerking
Postictal phase: a confused state
(also known as drop attacks)
Looks like syncope, sudden loss of muscle tone
Atonic seizure
fall like a tree
Extreme rigidity then immediate LOC, but not followed by a clonic phase
Tonic seizure
Muscle jerking, but not the tonic phase, occurs in the morning
myoclonic seizure
Convulsion associated with an elevated temperature greater than 38°, > 6 mos < 5 years, absence of central nervous system infection or inflammation
FEbrile seizure
Infantile spasms are a type of epilepsy seizure but they do not fit into the category of focal or generalized seizures
Infantile spasms
a single epileptic seizure lasting more than five minutes or two or more seizures within a five-minute period without the person returning to normal between them
Status epilepticus seizure
Two forms: convulsive and nonconvulsive
Convulsive status epilepticus presents with a regular pattern of contraction and extension of the arms and legs
Nonconvulsive status epilepticus includes complex partial status epilepticus and absence status epilepticus
What is the prefered initial treatment for status epilepticus seizure?
Benzodiazepines
LORAZEPAM
after which PHENYTOIN
a transient loss of consciousness/postural tone secondary to an acute decrease in cerebral blood flow
Characterized by a rapid recovery of consciousness without resuscitation
Syncope
What are the 4 major categories of syncope you must rule out?
Cardiac syncope - arrhythmias
(e.g. AV block, sick sinus syndrome), -
obstruction of blood flow (e.g. aortic stenosis, hypertrophic cardiomyopathy), massive MI
Vasovagal syncope (neurocardiogenic) most common cause
Orthostatic hypotension - defect in vasomotor reflexes, common in elderly, diabetics, patients taking certain medications (e.g. diuretics, vasodilators)
Cerebral vascular disease - a rare cause of syncope
Other
what are some non cardiogenic causes of syncope?
x4
noncardiogenic causes include metabolic causes
(e.g., hypoglycemia, hyperventilation), hypovolemia (e.g., hemorrhage),
hypersensitivity (syncope precipitated by wearing a tight collar or turning the head),
mechanical reduction of venous return (e.g., Valsalva maneuver, postmicturition),
various medications (e.g., β-blockers, nitrates, antiarrhythmic agents)
A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
Sudden onset of neurologic deficit, lasting minutes to <1 h (15-30 min on average), a reversal of symptoms within 24 h
TIA Blockage in blood flow does not last long enough to cause permanent infarction
Amaurosis Fugax (monocular vision loss - temporary “lampshade down on one eye”) weakness in the contralateral hand
Which artery is affected for TIA?
Internal carotid artery
Cerebral hemisphere dysfunction. Sudden headache, speech changes, confusion
Which arteries? x3
ICA/MCA/ACA
somatosensory deficit which artery?
PCA
brainstem/cerebral symptoms (gait and proprioception)
Vertebrobasilar
How to Dx TIA?
WORKUP for TIA?
CT (without contrast), MRI more sensitive, carotid doppler ultrasound to look for stenosis, CT angiography, MR angiography of the neck
What to do with TIA? Tx options
Aspirin within 24 hours. Antiplatelet therapy (e.g., aspirin or clopidogrel or aspirin-dipyridamole) should be then initiated
what to do for new-onset and recurrent TIA, unless a confident diagnosis of the cause of the event can be made
Admit to hospital
what can help to distinguish central vs peripheral vertigo?
Duration and presence of hearing loss or nystagmus can help with diagnosis and differentiation between central vertigo and peripheral vertigo
Vertical nystagmus No auditory symptoms Gradual onset Continous vertigo Nausea or vomiting
+ve Romberg sign
CENTRAL VERTIGO
Causes of central vertigo?
x7
- Medications
- AV malformations
- Brainstem vascular disease
- brain tumor
- head injury
- multiple sclerosis
- vertebrobasilar migraine
Horizontal nystagmus
HEARING LOSS
Sudden onset,
intermittent N/V
Peripheral vertigo (inner ear)
What are the causes of peripheral vertigo?
x5
- Labrynthitis
- BPPV
- Endolymphatic hydrops aka MEniere syndrome
- Vestibular neuritis
- head injury
What does it mean by non-fatigable nystagmus?
Central cause
can be elicited with dix-hallpike maneuver
How to treat peripheral vertigo? BPPV
treat with Epley’s maneuver, vestibular suppressants help with acute symptoms: diazepam (Valium), meclizine
hearing loss + continuous vertigo + URI
Labyrinthitis
NO Hearing loss
+ vertigo
+URI
Vestibular neuronitis
HEARING LOSS
+EPISODIC vertigo
+NO URI
Meniere disease
NO HEARING LOSS
+EPISODIC Vertigo with
POSITION CHANGE
BPPV
UNILATERAL hearing loss
Insidious onset vertigo & ATAXIA
+/- FACIAL NUMBNESS
Acoustic neuroma
What are 6 reversible causes of Alzheimer’s disease?
- Secondary to an infection of the CNS (neurosyphilis)
- Metabolic and nutritional dementias (vitamin B12 deficiency)
- Inflammatory dementias (vasculitis involving cerebral blood vessels)
- Dementia caused by a structural defect impinging on the brain (a subdural hematoma or tumor)
- NPH
- Endocrine-related dementia (hypothyroidism)
Different type of Alzheimer’s and specify which one when diagnosing.
Alzheimer’s disease - slow decline in memory and ability to take care of oneself Frontotemporal lobar degeneration Lewy body disease Vascular disease - sudden decline in mental status Traumatic brain injury Substance/medication use HIV infection Prion disease Parkinson’s disease Huntington’s disease
Initial eval of all patient with dementia screening study?
CT then MRI (expensive
