Neurology Flashcards
1
Q
Which artery in the brain is likely occluded if a patient experiences:
Hemianopia
A
MCA
2
Q
Anterior cord syndrome
A
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
3
Q
Findings at disc level: L3-L4
A
Weakness of knee extension, dec patellar reflex
4
Q
EEG shows sharp, triphasic and synchronous discharges
A
Creutzfeldt-Jakob disease
- rapidly progressive dementia, myoclonus, and EEG changes
Spongiform disease caused by a prion
5
Q
Visual disturbance with painful eye movement is suspicious for?
A
Optic neuritis
6
Q
Atrophy in Alzheimers
A
Atrophy is most pronounced in the temporoparietal lobes and hippocampus
7
Q
CSF in SAH
A
Blood in the CSF
Xanthochromia (yellow color of CSF)
8
Q
Hemisection of the spinal cord (Brown Sequard)
A
Usually due to a clean cut injury (knife blade)
- ipsilateral motor loss
- ipsilateral touch, vibration, proprioception loss
- contralateral pain and temp loss
9
Q
First line imaging modality for stroke
A
CT head without contrast
10
Q
Dominant hemisphere infarct vs nondominant hemisphere infarct
A
dominant hemisphere
- aphasia, agnosia, agraphia, acalculia
nondominant hemisphere
- hemineglect: if R parietal is effected, will only acknowledge the left side of the world
11
Q
Internuclear ophthalmoplegia results from damage to?….
A
Medial longitudinal fasciculus
Immune-mediated demyelination
12
Q
What is a significant risk associated with tumors of the posterior fossa?
A
Herniation
13
Q
Dejerine-Roussy syndrome (thalamic pain syndrome)
A
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
14
Q
If a patient cannot tolerate Ethosuximide, what drug is started to control absence seizures?
A
Divalproex sodium
15
Q
If a young patient (<50) presents with a stroke, what should you consider in the workup
A
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
16
Q
Patient presents with right arm and face paralysis and loss of sensation to the same areas. where is the infarct?
A
Left middle cerebral artery (MCA)
17
Q
Pickwickian syndrome
A
Obesity associated with hypersomnia
18
Q
Acute onset of hemiballismus, where is the infarct?
A
Subthalamic nucleus
19
Q
Findings at disc level: L4-L5
A
Weakness of dorsiflexion, difficulty heel walking
20
Q
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?
A
Alcoholic cerebellar degeneration
21
Q
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?
A
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)
22
Q
What should you suspect in a patient with parkinson features with autonomic dysfunction?
A
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)
23
Q
Mesial temporal sclerosis
A
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
24
Q
Eye deviation in stroke vs seizure
A
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
25
Landau Kleffner syndrome
Pediatric seizure disorder
| Loss of language function and an abnormal EEG during sleep
26
Brain death (3 features)
- unresponsiveness
- absence of brainstem reflexes (pupillary, corneal, oculocephalic, gag, oculovestibular)
- apnea
27
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.
28
What is the most common neurologic complication of chronic renal failure?
Peripheral neuropathy due to axonal degeneration
Usually improves with dialysis
29
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
30
Carbon tetrachloride
Potent hepatic toxin
31
Lennox Gastaut syndrome
Mental dysfunction
Multiple seizure types
2 Hx generalized spike wave discharges on EEG
32
Most common causes of syringomyelia
Arnold Chiari malfomations
| Prior spinal cord injuries
33
Inheritance of Duchenne and Becker muscular dystrophy
X linked recessive
34
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
35
Lambert Eaton muscle weakness
Proximal
| Improves with repetitive stimulation
36
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
37
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
38
Patient presents with bilateral trigeminal neuralgia, what do you suspect?
Multiple sclerosis
39
An aneurysm involving what arteries can cause compression of CN3?
o Posterior cerebral artery
o Superior cerebellar artery
o Posterior communicating artery
40
Pure sensory lacunar stroke
Involves the thalamus
41
Myasthenic crisis
Respiratory failure
Precipitated by infection, surgery, pregnancy, or certain medications
Treat with intubation and IVIG and steroids
42
Part of the brain responsible for facial recognition
inferior occipitotemporal cortex (fusiform gyrus)
43
Which artery in the brain is likely occluded if a patient experiences:
Abulia
ACA
| Abulia = lack of will or initiative
44
Most common cause of a brain abscess
Streptococcus
45
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
46
Goal LDL in a stroke patient
<70
47
Wernicke Encephalopathy Triad
Dementia
Gait Disturbance
Oculomotor dysfunction
48
Treatment of myasthenic crisis
Intubation to prevent respiratory collapse
| Plasmapharesis or IVIG, and corticosteroids
49
Path finding in Parkinson disease
Lewy bodies (a- synuclein): intracytoplasmic inclusion bodies
50
Carotid Dissection causing stroke
Ipsilateral Horner syndrome
Contralateral hemiparesis
In a young patient, likely 2/2 trauma
51
CSF in Guillain Barre syndrome
albuminocytologic dissociation (increased protein with normal cell count)
52
Which cranial nerve is commonly implicated in lyme disease?
CN 7
53
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
54
Stroke Risk Factors
1. age
2. HTN
- smoking
- DM
- HLD
- a fib
- CAD
- Family hx of stroke
- carotid bruits
55
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
56
If a pt has asterixis what test should you order?
Complete metabolic panel
57
Common vs classic migraine
o Migraine without aura = common migraine
o Migraine with aura = classic migraine
Aura = clAssic
58
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
59
Muscle weakness in myasthenia gravis
Worsens with repeated stimulation
| Improves with rest (more ACh to overcome the autoantibodies)
60
Resting tremor vs intention tremor
```
Resting = parkinsons
Intention = Essential tremor
```
61
Why are there increased amounts of RBCs in HSV encephalitis
Due to hemorrhagic destruction of the temporal lobes
62
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
63
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)
64
When a seizure includes an olfactory aura, where is the seizure likely localized?
Temporal lobe; hippocampus or parahippocampal gyrus
65
Which artery in the brain is likely occluded if a patient experiences:
urinary incontinence
ACA
66
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
67
Patient presents with muscle wasting of the small muscles of the hand and loss of pain and temperature to the bilateral upper extremities.
syringomyelia
68
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)
69
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
70
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
71
Patient presents with left leg weakness and loss of sensation, where is the infarct?
Right anterior cerebral artery (ACA)
72
Bilateral acoustic neuromas
Neurofibromatosis type 2
| Chromosome 22
73
In an MCA infarct where will the eyes deviate?
Toward the side of infarct
74
Pure motor lacunar stroke
Involves the internal capsule
75
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)
76
Lumbar spine stenosis presentation
Worse with standing, relieved by sitting
Worse with walking downhill
Less severe with walking uphill
77
Which cranial nerve is commonly implicated in sarcoidosis?
CN7 -- Bell Palsy
78
Findings at disc level: L5-S1
Weakness of plantarflexion, difficulty in toe walking, dec Achilles reflex
79
Therapy for acute stroke
1. fibrinolytic therapy (tPA)
| 2. Aspirin, if the patient is not a candidate for tPA
80
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
81
Most common causes of intraparenchymal hemorrhage
HTN
- less commonly due to cerebral amyloid angiopathy
82
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
83
Which cancers metastasize to the brain?
Solitary lesions
Multiple lesions
Multiple lesions: Lung, melanoma
| Single lesions: Breast, colon, kidney
84
Treatment of acute spinal injury
High dose IV steroids within the first 8 hours
85
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
86
CSF in multiple sclerosis
inc immunoglobulins with oligoclonal IgG bands and myelin basic protein
87
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.
88
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
89
Which antiemetic should not be started in patients with Parkinsons
Metoclopramide (dopamine blocking activity)
Start Zofran
90
First step in evaluation of acute stroke
Head CT without contrast -- to evaluate for acute hemorrhage
| cant give tpa if they have a hemorrhage
91
Treatment of essential tremor
Action tremor
Treat with B blocker (propranolol) or primidone
92
Therapeutic hyperventilation
Used to reduce intracranial pressure
Blow of excess CO2 which causes cerebral vasoconstriction, leading to a decrease in intracranial pressure
93
Periodic paralysis can be associated with which electrolyte?
Potassium
| hyperkalemic or hypokalemic periodic paralysis
94
Most common cause of spontaneous lobar hemorrhage?
Cerebral amyloid angiopathy
| Particularly common in people >60 without HTN
95
Contraindications to t-PA
```
Unknown time of stroke
Uncontrolled HTN (>185/90)
Bleeding disorder
Anticoagulant use
Recent trauma/surgery
```
96
what is Lambert Eaton syndrome associated with?
Paraneoplastic syndrome: Small Cell Carcinoma of the lung
97
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
98
3 causes of stroke
1. ischemia due to atherosclerosis
2. afib with clot emboli to brain
3. septic emboli from endocarditis
99
Lacunar infarct is often due to....
HTN -- Causes thickening of the vessel wall (narrowing of the arterial lumen)
100
Most common cause of TIA/CVA
Emboli
| then thrombosis, lacunar, and nonvascular causes like low cardiac output or anoxia
101
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)
102
4 cardinal features of Parkinson disease
Resting tremor, bradykinesia, rigidity, postural instability
103
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)
104
Which anti-epileptic is associated with kidney stones?
Topiramate
105
Which anti-epileptic is associated with liver dysfunction?
Valproic acid
106
Which anti-epileptic is associated with megaloblastic anemia?
Phenytoin -- inhibits folate
107
Which anti-epileptic is associated with nystagmus?
Phenytoin
108
3 cardinal findings in brain death
unresponsiveness, absence of brainstem reflexes and apnea
109
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
110
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
111
Memory center of the brain
Medial temporal lobe (hippocampus)
112
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
113
What drug can worsen tinnitus?
Aspirin
114
Difference between ADEM and MS?
ADEM is monophasic: one episode, is not recurring like MS
115
What can improve outcome of a patient with severe traumatic head injury
Hypothermia
116
Age related macular degeneration
Progressive bilateral loss of central vision
