Neurology Flashcards
Which artery in the brain is likely occluded if a patient experiences:
Hemianopia
MCA
Anterior cord syndrome
Due to spinal cord infarction (Anterior spinal artery)
o Below injury patients have loss of movement, pain, and temperature
• Intact touch and proprioception due to sparing of the dorsal columns
Findings at disc level: L3-L4
Weakness of knee extension, dec patellar reflex
EEG shows sharp, triphasic and synchronous discharges
Creutzfeldt-Jakob disease
- rapidly progressive dementia, myoclonus, and EEG changes
Spongiform disease caused by a prion
Visual disturbance with painful eye movement is suspicious for?
Optic neuritis
Atrophy in Alzheimers
Atrophy is most pronounced in the temporoparietal lobes and hippocampus
CSF in SAH
Blood in the CSF
Xanthochromia (yellow color of CSF)
Hemisection of the spinal cord (Brown Sequard)
Usually due to a clean cut injury (knife blade)
- ipsilateral motor loss
- ipsilateral touch, vibration, proprioception loss
- contralateral pain and temp loss
First line imaging modality for stroke
CT head without contrast
Dominant hemisphere infarct vs nondominant hemisphere infarct
dominant hemisphere
- aphasia, agnosia, agraphia, acalculia
nondominant hemisphere
- hemineglect: if R parietal is effected, will only acknowledge the left side of the world
Internuclear ophthalmoplegia results from damage to?….
Medial longitudinal fasciculus
Immune-mediated demyelination
What is a significant risk associated with tumors of the posterior fossa?
Herniation
Dejerine-Roussy syndrome (thalamic pain syndrome)
Occurs in lacunar strokes to the thalamus (pure sensory loss)
- Results in severe paroxysmal burning pain over the affected area that is exacerbated by light touch
If a patient cannot tolerate Ethosuximide, what drug is started to control absence seizures?
Divalproex sodium
If a young patient (<50) presents with a stroke, what should you consider in the workup
Vasculitis, hypercoagulable state, and thrombophilia
- Protein C, protein S, antiphospholipid antibodies
- Factor V Leiden mutation
- ANA, ESR, RF
- RPR, lyme serology
- Transesophageal echocardiogram with bubble study
Patient presents with right arm and face paralysis and loss of sensation to the same areas. where is the infarct?
Left middle cerebral artery (MCA)
Pickwickian syndrome
Obesity associated with hypersomnia
Acute onset of hemiballismus, where is the infarct?
Subthalamic nucleus
Findings at disc level: L4-L5
Weakness of dorsiflexion, difficulty heel walking
Patient presents with wide based gait and incoordination. On exam they have impaired heel to shin but finger to nose is intact. What do you suspect?
Alcoholic cerebellar degeneration
A patient hits their head and loses consciousness for a few seconds. They spontaneously gain consciousness and appear normal for a period of time. Eventually they become somnolent with headache and vomiting, and a blown unilateral pupil. What do you suspect?
Epidural hematoma: brief loss of consciousness followed by a lucid interval. The expansion of the hematoma leads to dec consciousness and inc intracranial pressure (nausea, vomiting, headache)
What should you suspect in a patient with parkinson features with autonomic dysfunction?
Shy Drager Syndrome (Multiple System Atrophy)
Degenerative disease characterized by the following:
- Parkinsonism
- Autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnormal salivation or lacrimation, impotence, gastroparesis, etc)
- Widespread neurological signs (cerebellar, pyramidal or lower motor neuron)
Mesial temporal sclerosis
o Temporal lobe epilepsy
o Most common cause of intractable complex partial seizures in adults
o Dx by MRI – sclerotic hippocampus
o Treatment: surgical resection
Eye deviation in stroke vs seizure
Stroke: Eyes deviates toward infarct
- Because side affected is hyporeactive, so the normal side pushes eyes toward the side of infarct
Seizure: Eyes deviate away from seizure
- Because the side affected is hyperactive and pushes eyes toward the normal side
Landau Kleffner syndrome
Pediatric seizure disorder
Loss of language function and an abnormal EEG during sleep
Brain death (3 features)
- unresponsiveness
- absence of brainstem reflexes (pupillary, corneal, oculocephalic, gag, oculovestibular)
- apnea
Pupil sparing third nerve palsy
ptosis, down and out eye, normal pupil response
Common neuropathy seen in diabetes
Etiology: is microvascular infarction of the central fibers of the oculomotor nerve causing the paralysis of the extraocular muscles while sparing the peripherally located parasympathetic pupillary fibers and hence the preserved pupillary reflex.
What is the most common neurologic complication of chronic renal failure?
Peripheral neuropathy due to axonal degeneration
Usually improves with dialysis
Presentation of thrombotic vs embolic stroke
Thrombotic: classically the patient awakens from sleep with neurologic deficits
Embolic: rapid onset (within seconds), deficits are initially maximal
Carbon tetrachloride
Potent hepatic toxin
Lennox Gastaut syndrome
Mental dysfunction
Multiple seizure types
2 Hx generalized spike wave discharges on EEG
Most common causes of syringomyelia
Arnold Chiari malfomations
Prior spinal cord injuries
Inheritance of Duchenne and Becker muscular dystrophy
X linked recessive
What is seen in pathology of HIV dementia
Microglial nodules
o Gross brain atrophy and inflammatory activation of microglial cells – activated macrophages and microglial cells form groups (microglial nodules) around small areas of necrosis
Lambert Eaton muscle weakness
Proximal
Improves with repetitive stimulation
First line treatment for a cluster headache
high flow 100% O2
Unilateral, associated with ipsilateral lacrimation, rhinorrhea, red eye, stuffy nose, and can be accompanied by horner syndrome
Complication of placement of ventriculoperitoneal shunt for normal pressure hydrocephalus
subdural hematoma due to the reduction in CSF volume may cause the brain to pull away from the covering meninges, stretching and potentially rupturing the bridging veins
Patient presents with bilateral trigeminal neuralgia, what do you suspect?
Multiple sclerosis
An aneurysm involving what arteries can cause compression of CN3?
o Posterior cerebral artery
o Superior cerebellar artery
o Posterior communicating artery
Pure sensory lacunar stroke
Involves the thalamus
Myasthenic crisis
Respiratory failure
Precipitated by infection, surgery, pregnancy, or certain medications
Treat with intubation and IVIG and steroids
Part of the brain responsible for facial recognition
inferior occipitotemporal cortex (fusiform gyrus)
Which artery in the brain is likely occluded if a patient experiences:
Abulia
ACA
Abulia = lack of will or initiative
Most common cause of a brain abscess
Streptococcus
Why is lamotrigine not an ideal choice in the acute setting? What should you start instead?
Lamotrigine needs to be slowly titrated up over several weeks due to risk of rash
Can immediately start patient on Keppra
Goal LDL in a stroke patient
<70
Wernicke Encephalopathy Triad
Dementia
Gait Disturbance
Oculomotor dysfunction
Treatment of myasthenic crisis
Intubation to prevent respiratory collapse
Plasmapharesis or IVIG, and corticosteroids
Path finding in Parkinson disease
Lewy bodies (a- synuclein): intracytoplasmic inclusion bodies
Carotid Dissection causing stroke
Ipsilateral Horner syndrome
Contralateral hemiparesis
In a young patient, likely 2/2 trauma
CSF in Guillain Barre syndrome
albuminocytologic dissociation (increased protein with normal cell count)
Which cranial nerve is commonly implicated in lyme disease?
CN 7
Central cord syndrome
- mechanism
- findings
Occurs with hyperextension injuries in elderly patients with pre-existing degenerative changes in the cervical spine
o Impair pain and temperature by interrupting the crossing sensory fibers as they cross to the contralateral STT.
o If involves anterior horn, then causes lower motor weakness
Stroke Risk Factors
- age
- HTN
- smoking
- DM
- HLD
- a fib
- CAD
- Family hx of stroke
- carotid bruits
TIA
- What differentiates it from a stroke?
- How long does it last
- Pathophysiology
Transient Ischemic Attack
- neurologic deficit that lasts from a few minutes to no more than 24 hours
- Usually lasts less than 30 mins
- Usually embolic
- Inc risk of stroke
If a pt has asterixis what test should you order?
Complete metabolic panel
Common vs classic migraine
o Migraine without aura = common migraine
o Migraine with aura = classic migraine
Aura = clAssic
Patient with HIV has ring enhancing lesions on MRI. What is your differential
toxo: multiple lesions
Lymphoma: solitary lesions
Definitive diagnosis with stereotactic brain biopsy
Muscle weakness in myasthenia gravis
Worsens with repeated stimulation
Improves with rest (more ACh to overcome the autoantibodies)
Resting tremor vs intention tremor
Resting = parkinsons Intention = Essential tremor
Why are there increased amounts of RBCs in HSV encephalitis
Due to hemorrhagic destruction of the temporal lobes
Parinaud syndrome
aka Dorsal midbrain syndrome
- Upward gaze palsy (Inability to look up) often presenting as diplopia
- loss of pupillary light reflex
- convergence-retraction nystagmus
- upper eyelid retraction
due to lesion in superior colliculi (midbrain)
Stroke, hydrocephalus, pinealoma
Infant botulism vs adult botulism
o Adult botulism: ingestion of preformed toxin
o Infant botulism: ingestion of spores that germinate and form the toxin (usually in honey, also environmental)
When a seizure includes an olfactory aura, where is the seizure likely localized?
Temporal lobe; hippocampus or parahippocampal gyrus
Which artery in the brain is likely occluded if a patient experiences:
urinary incontinence
ACA
Signs of uncal herniation
The uncus is the innermost part of the temporal lobe
Signs
• Ipsilateral pupil dilation (compression of CN3)
Pupillary fibers run on the outside of CN3, so they are easily compressed by the uncus
• Ipsilateral visual field deficit/hemianopia (compression of posterior cerebral artery)
• Ipsilateral hemiparesis (compression of contralateral cerebral peduncle)
False localization sign
Patient presents with muscle wasting of the small muscles of the hand and loss of pain and temperature to the bilateral upper extremities.
syringomyelia
Subarachnoid bleed: caused by what and what is an important sequela to take under consideration
Secondary to rupture of ordinary arteries and veins (berry aneurysm), fills sulci and cisterns
- Bleeding between the arachnoid mater and pia mater
- Berry aneurysms are associated with EDS and ADPKD
- Can also be due to trauma and AV malformations
4-10 days after hemorrhage, vasospasm can occur and cause an ischemic infarct (prevent this with Nimodipine – Calcium channel blocker)
Painless, rapid, and transient (<10 mins) monocular vision loss. Pt describes it as a curtain descending over the visual field
- What is this
- What are risk factors
- How do you diagnose it
Amaurosis fugax: Retinal ischemia due to atherosclerotic emboli originating from the ipsilateral internal carotid artery –> ophthalmic artery
RF: HTN, HLD, smoking
Dx: with duplex US of the neck
Cheyne Stokes breathing
apnea is followed by gradually increasing then decreasing tidal volumes until the next apneic period
Episodes of apnea cause hypercapnia, and then the body compensates by hyperventilating, which overshoots and causes hypocapnia → leads to another apneic episode to inc CO2 levels
Seen in neurologic disease (stroke, brain tumors, TBI) and is a poor prognostic sign
• Indicates bihemispheric dysfunction
Patient presents with left leg weakness and loss of sensation, where is the infarct?
Right anterior cerebral artery (ACA)
Bilateral acoustic neuromas
Neurofibromatosis type 2
Chromosome 22
In an MCA infarct where will the eyes deviate?
Toward the side of infarct
Pure motor lacunar stroke
Involves the internal capsule
AICA vs PICA infarct
Similarities:
o Vomiting, vertigo, nystagmus (vestibular nuclei)
o Dec pain and sensation to ipsilateral face (spinal trigeminal nucleus) and contralateral body (lateral spinothalamic tract)
o Ipsilateral ataxia and dysmetria (cerebellar peduncles)
o Ipsilateral Horner Syndrome (sympathetic fibers)
PICA (lateral medullary syndrome)
Hoarseness/dysphagia (Nucleus Ambiguus)
* Think Pikachu (PICA, Can’t chew)
AICA (Lateral pontine syndrome)
Ipsilateral upper and lower facial paralysis (facial nucleus CN7)
*Think fACIAl (has AICA spelled backwards)
Lumbar spine stenosis presentation
Worse with standing, relieved by sitting
Worse with walking downhill
Less severe with walking uphill
Which cranial nerve is commonly implicated in sarcoidosis?
CN7 – Bell Palsy
Findings at disc level: L5-S1
Weakness of plantarflexion, difficulty in toe walking, dec Achilles reflex
Therapy for acute stroke
- fibrinolytic therapy (tPA)
2. Aspirin, if the patient is not a candidate for tPA
Diabetic neuropathy
- a symmetric, distal, lower limb, sensory polyneuropathy with a variable degree of motor and autonomic involvement.
- It develops when diabetes mellitus has been present for several years.
- A highly significant association has been found between the presence of polyneuropathy and retinopathy or nephropathy
- Tx with pregabalin
Most common causes of intraparenchymal hemorrhage
HTN
- less commonly due to cerebral amyloid angiopathy
Tests for myasthenia gravis
Ice pack test: an ice pack is applied over the eyelids for several minutes, leading to an improvement in the ptosis
• The cold temperature improves muscle strength by inhibiting the breakdown of Ach at the NM junction
Edrophonium: short acting acetylcholinesterase inhibitor
Which cancers metastasize to the brain?
Solitary lesions
Multiple lesions
Multiple lesions: Lung, melanoma
Single lesions: Breast, colon, kidney
Treatment of acute spinal injury
High dose IV steroids within the first 8 hours
EBV DNA in CSF of an AIDS patient indicates?
Primary CNS lymphoma
MRI reveals a weakly ring-enhancing mass that is usually solitary and periventricular
CSF in multiple sclerosis
inc immunoglobulins with oligoclonal IgG bands and myelin basic protein
Afferent pupillary defect (aka Marcus Gunn pupil)
Due to optic nerve damage or severe retinal injury
Shine light in affected eye: both eyes do not constrict to a normal extent but the affected pupil shows less constriction than the unaffected pupil.
Shine light in normal eye: both eyes constrict normally and equally.
It is because of a decrease in afferent input reaching the pretectal pathway responsible for the pupillary light response in the midbrain via damaged optic nerve, but efferent fibers to the affected eye are delivered via cranial nerve III.
What does pronator drift test for? What does a positive test look like?
Sensitive and specific for upper motor neuro or pyramidal/corticospinal tract disease
- The affected arm drifts downward and the palm turns (pronates) toward the floor
Which antiemetic should not be started in patients with Parkinsons
Metoclopramide (dopamine blocking activity)
Start Zofran
First step in evaluation of acute stroke
Head CT without contrast – to evaluate for acute hemorrhage
cant give tpa if they have a hemorrhage
Treatment of essential tremor
Action tremor
Treat with B blocker (propranolol) or primidone
Therapeutic hyperventilation
Used to reduce intracranial pressure
Blow of excess CO2 which causes cerebral vasoconstriction, leading to a decrease in intracranial pressure
Periodic paralysis can be associated with which electrolyte?
Potassium
hyperkalemic or hypokalemic periodic paralysis
Most common cause of spontaneous lobar hemorrhage?
Cerebral amyloid angiopathy
Particularly common in people >60 without HTN
Contraindications to t-PA
Unknown time of stroke Uncontrolled HTN (>185/90) Bleeding disorder Anticoagulant use Recent trauma/surgery
what is Lambert Eaton syndrome associated with?
Paraneoplastic syndrome: Small Cell Carcinoma of the lung
Jacksonian March
Sequential seizure: the patient develops focal seizure activity that is primarily motor and spreads
Often becomes generalized and the patient has an LOC and may have a generalized tonic clonic seizure
3 causes of stroke
- ischemia due to atherosclerosis
- afib with clot emboli to brain
- septic emboli from endocarditis
Lacunar infarct is often due to….
HTN – Causes thickening of the vessel wall (narrowing of the arterial lumen)
Most common cause of TIA/CVA
Emboli
then thrombosis, lacunar, and nonvascular causes like low cardiac output or anoxia
Treatment of bacterial meningitis
Older than 1 month, younger than 65: Vancomycin and ceftriaxone
Older than 65: Vancomycin, Ceftriaxone and Ampicillin (to cover for Listeria)
4 cardinal features of Parkinson disease
Resting tremor, bradykinesia, rigidity, postural instability
Part of the brain implicated in Wilson Disease
o Effects the putamen and globus pallidus– hyperkinetic movements
o A rare AR mutation that results in impaired cellular transport of copper and dec excretion into bile and blood → Causes copper to leak from injured hepatocytes and accumulate in the liver, brain, and eye.
o Neuropsych signs and symptoms= depression, rigidity, personality changes, impulsivity, basal ganglia injury (ataxia, parkinsonism, tremor)
Which anti-epileptic is associated with kidney stones?
Topiramate
Which anti-epileptic is associated with liver dysfunction?
Valproic acid
Which anti-epileptic is associated with megaloblastic anemia?
Phenytoin – inhibits folate
Which anti-epileptic is associated with nystagmus?
Phenytoin
3 cardinal findings in brain death
unresponsiveness, absence of brainstem reflexes and apnea
Which nerves are most commonly implicated in neuropathies? How does this clinically present?
small, unmyelinated and lightly myelinated nerve fibers (pain and temperature)
• Complain of burning pain and paresthesias
Vitamin B12 deficiency neurologic defects
Subacute combined degeneration
Causing anemia, ataxia, paresthesia, impaired position and vibration sense.
o Demyelination of (SCD)
• S: Spinocerebellar tracts
• C: lateral Corticospinal tracts
• D: Dorsal columns
Memory center of the brain
Medial temporal lobe (hippocampus)
Is unilateral deafness peripheral or central, or are both possible?
Peripheral
Cochlear nuclei project to both temporal lobes
If there is unilateral deafness, it is a peripheral process
What drug can worsen tinnitus?
Aspirin
Difference between ADEM and MS?
ADEM is monophasic: one episode, is not recurring like MS
What can improve outcome of a patient with severe traumatic head injury
Hypothermia
Age related macular degeneration
Progressive bilateral loss of central vision
