Neurology Flashcards
1
Q
Bacterial Meningitis
A
cloudy/turbid
incr. neutrophils
2
Q
Viral Meningitis
A
increased lymphocytes
3
Q
TB meningitis
A
slightly cloudy
VH protein
VL glucose
4
Q
Subarachnoid Hemorrhage
A
blood stained
VH red blood cells
5
Q
Guilliane-Barre Syndrome
A
incr. protein after 1 week
6
Q
MS
A
incr. lymphocytes
incr. protein
7
Q
MC Headache
A
tension ha > migraine > cluster
8
Q
Tx for chronic tension ha
A
Amitriptyline (Elavil)
9
Q
First line Tx for tension ha
A
NSAIDs, acetaminophen, ASA
10
Q
Migraine criteria
A
- >5 attacks lasting 4-72 hours
- at least 2:
- unilateral
- pulsating
- moderate to severe intensity
- exacerbated by daily routine
- at least 1 assoc. symptom:
- nausea/vomiting
- photophobia or phonophobia
- no other attributable causes
11
Q
Acute Tx of migraines
A
Triptans (5HT agonists)
dampen neural stimulation
Sumatriptan (Imitrex)
12
Q
Prophylactic Tx of migraines
A
Beta-blockers (B2 only, no B1)
Propranolol 40-80mg qd up to 320mg
dose 9-12 mo then titrate off
13
Q
Cluster ha symptoms
A
unilateral periorbital or temporal pain
14
Q
Cluster ha Tx
A
100% O2 for 15-20min
Triptans
Sumatriptan 6mg SQ
15
Q
Migraine RED FLAGS
A
- “worst HA ever”
- first severe HA
- subacute worsening over days or weeks
- abnormal neurologic examination
- fever or other systemic signs
- vomiting that preceeds HA
- pain induced by bending, lifting, coughing
- pain that disturbs sleep or immediately when waking
- known systemic illness
- onset after age 55
- pain associated with local tenderness (temporal artery)
16
Q
Migraine secondary RED FLAGS
A
- onset over age 50 or sudden
- increased frequency or severity
- new onset w/ risk factors: HIV, CA
- associated w/ systemic illness
- altered consciousness or focal neuro deficits
- significant trauma
17
Q
Tx for trigeminal neuralgia
A
Carbamazepine 400-1200mg
18
Q
GCS
A
Glasgow Coma Scale
13-15: mild
9-12: moderate
structural injury, hemorrhage
3-8: severe
cognitive/physical disability, death
19
Q
MCC of extradural/epidural hematoma
A
middle meningeal a. bleed w/ temporal fossa fx
20
Q
3 spinal cord syndromes
A
- Brown-Sequard
- loss ipsilateral motor, touch, proprio, vib
- loss contralateral pain, temp
- Central Cord
- “man in barrel”- bilateral UE, LE spared
- proximal weakness
- pain, temp reduced; proprio, vib spared
- Anterior Cord
- loss touch, pain, temp, motor below lesion
- proprio and vibratory intact
- Tx: immobilization, decompress. and fixate, corticosteroids 24-48h, rehab
21
Q
Spinal vs. Neurogenic Shock
A
Spinal
- complete loss below lesion
- paralysis, sensory deficit, - bladder/rectal control
- days to 3 months
Neurogenic
- cervical or upper thoracic injury
- may be in addition to spinal shock
- loss of sympathetic/unopposed parasympathetic
- bradycardia, hypotension, vasodilation, hypthermia
22
Q
Delerium vs. Dementia
A
Delerium
- confusion w/ decr. focus, sustain/shift attention
- develops over hours or days
- memory, visuospatial, language disturbance
- responds to tx
Dementia
- months to years
- chronic deterioration over time
- ADLs intact early then deteriorate
23
Q
Why EG done for delerium
A
looking for metabolic encephalopathy
24
Q
Wernicke-Korsakoff Encephalopathy triad
A
- ophthalmoplegia
- ataxia (40% reversible)
- mental/consciousness disturbances
25
Wernickes Encephalopathy Tx
"banana bag"
500mg thiamine + magnesium
thiamine 30-100mg bid for chronic
26
Wernicke vs. Broca
Wernicke:
* dominant posterior superior **temporal** lobe
* affects verbal and written comprehension
Broca
* dominant posterior inferior **frontal** lobe
* affects speech ("YODA")
27
anterograde amnesia
inability to acquire and recall NEW information
28
Normal pressure hydrocephalus (NPH) triad
1. dementia
2. gait disorder
3. incontinence
\* can be reversible
29
Alzheimer's disease
* insidious onset sx
* hx of worsening condition
* amyloid plaques (b-amyloid, APP, PSEN1, PSEN2)
* neurofibrillary tangles (Tau protein)
* cortical atrophy
30
Vascular Dementia
* cerebral infarctions of hipocampus or thalamus
* cognitive disturbances w/in 3mo of stroke
* neuroimaging evidence of bilateral infarctions rostral to thalamus
31
Frontotemporal Dementia
* atrophy of frontal and temporal lobes
* twisted Tau inclusions
* Pick bodies
32
Dementia w/ Lewy Bodies
* preceding or concurrent with Parkinson's
* Lewy bodies in brainstem/cerebral cortex
* 2+ s/s:
* parkinsonism
* prominent visual halucinations
* substantial fluctuations in alertness/cognition
* REM sleep disorder
* worsening parkinsonism w/ antipsychotics
33
Creutzfeldt-Jakob (Prion) Disease
* rapidly progressing dementia w/ variable focal degeneration of cerebral cortex, basal ganglia, cerebellum, brainstem, spinal cord
* mild global impairment -\> coma
* myoclonus, extrapyramidal signs, cerebellar signs
* LP:
* 14-3-3 protein
* PrPSc
* Endolase
* Neopterin
34
Huntington Disease
* autosomal dominant
* chorea, impulsivity, anger, restlessness, dementia, - memory
35
Reversible Neurologic Diseases
Normal Pressure Hydrocephalus (NPH)
* dementia, gait apraxia, incontinence
* mental slowness, apathy, cognitive dysfunction
* shunt
Chronic Subdural Hematoma
* chronic HA, tenderness
* craniotomy and percutaneous drainage
36
Dx of Epilepsy
Epilepsy
group of disorders characterized by recurrent _unprovoked_ seizures
Criteria:
* two or more unprovoked seizures occur
* one seizure occurs in a person whose risk is at least 60%
* one or more seizure occurs in context of known epilepsy syndrome
37
Generalized vs. Partial (focal) Seizures
Generalized:
* tonic clonic (grand mal)
* absence (petit mal)
* other: tonic, clonic, myoclonic, atonic
Partial (Focal) Seizures:
* simple partial (preservation of consciousness)
* complex partial (temporal lobe, psychomotor, focal w/ dyscognitive features)
* partial seizures with secondary generalization
38
Staticus Epilepticus
* seizure lasting 5-30 min w/out ceasing spontaneously
OR
* seizures recur so frequently that full consciousness is not restored between successive episodes
Medical Emergency
39
Simple Partial Seizures
Focal Seizures with Preserved Consciousness
* begin with motor, sensory, or autonomic phenomenon depending on area affected
* motor: movements of single m. group
* Jacksonian march- spreads to other groups
* autonomic: pallor, flushing, sweating, piloerection, pupil dilation, voming, hypersalivation
* psychiatric: memory distortions, though deficits, hallucinations
* NO LOC
* Postictal focal neuro deficit 30min-36hr indicates focal brain lesion
40
Complex Partial Seizure
Focal Seizure with Dyscognitive Features
* partial seizure where consciousness, responsiveness, or memory is impaire
* MC temporal or medial frontal lobe
* seizure is specific to person
* may begin with aura
* seizures 1-3 min followed by impaired consciousness
* automatisms- coordinated involuntary movements
41
EEG indication of absence seizure in children
3-second spike-and-wave abnormality
42
Phenytoin (Dylantin)
Indications
P, G, S
(partial, generalized, secondary generalized tonic-clonic)
43
Valproic Acid (Pepakote, Depakene)
Indications
G, M, P, A, S
(generalized, myoclonic, partial, absence, secondary)
44
Ethosuximide (Zarontin)
Indications
A
| (absence)
45
Lamotrigine (Lamictal)
Indications
G, P, A, S
(generalized, partial, absence, secondary)
46
Levetiracetam (Keppra)
Indications
G, P, M
| (generalized, partial, myoclonic)
47
Management of Status Epilepticus
1. Initial
* ABC
* labs: serum glucose, calcium, electrolytes, hepatic fx, liver fx, CBC, ESR, toxicology
* IV Dextrose
* LP if meningitis, encephalitis, infection suspected
* postictal pleocytosis (excess lymphocytes)
2. Seizure control
* Diazepam or Lorazepam (Ativan) or Midazolam IV, then
* Phenytoin, then
* repeat 1 and 2 until controlled, then
* Phenobarbitol
3. Special issues:
* cooling blanket for hyperthermia
* lactic acidosis resolves over 1 hr
* monitor CBC for infection
48
Safest Anticonvulsant for Pregnancy
Lamotrigine (Lamictal)
low risk of Steven-Johnson in first 8 weeks
49
Drowsy or Somnolent
aroused by _minimal_ stimulus,
poor attention and falls back to sleep easily
50
Lethargic
aroused by _moderate_ stimuli,
then drifts back to sleep
51
Obtunded
similar to lethargy: lessened interest in environment,
slowed responses to stimulation,
sleeps more than normal with drowsiness between sleep states
52
Stuporous
sleep-like state (not unconscious)
little/no spontaneous activity
aroused only with _vigorous_ stimulation
immediately lapses to unresponsive state when undisturbed
53
Comatose
cannot be aroused, no response to stimuli
54
States of Consciousness
1. conscious
2. confused
3. delirious
4. drowsy/somnolent
5. lethargic
6. obtunded
7. stuporous
8. comatose
9. brain dead
55
Cause of Papilledema & Subhyaloid Hemorrhage
* chronic/acute hypertension OR intracranial pressure
* subarachnoid hemorrhage
56
Sign of Opioid Overdose
pinpoint pupils (1-1.5mm) with OCD intact
57
Coma
* unresponsive and cannot be aroused
* eyes closed and do not respond spontaneously
* pt. does not speak and no purposeful movements
* unresponsive to verbal or painful stimulation
58
Vegetative State
disorder of consciousness where wakefulness is retained but awareness of self and environment is entirely absent
* spontaneous eye opening and sleep-wake cycles
* do not comprehend/produce language and make no purposeful motor responses
59
Diagnosis and Criteria for Brain Death
irreversible cessation of all brain function
1. Preconditions showing irreversibility:
* brain lesion
* no reversible toxic or metabolic encephalopathy
* confirmatory blood flow test
2. Signs of complete cessation
* coma
* apnea- no breathing or respiratory effort (PaCO2\>60)
* brain stem areflexia:
* absent pupillary dark and light reflex
* absent corneal touch reflex
* absent facial movement to noxious stimuli
* absent vestibulo-ocular reflex w/ 50mL ice water
* absent pharyngeal-tracheal gag w/ endotracheal tube suctioning
60
First Line Diagnostic in Stroke Work-up
Non-contrast CT
61
ICA (ischemic cerebrovascular accident)
Presentations
1. **Anterior cerebral artery**- contralateral leg weakness
2. **Middle cerebral artery**- contralateral face and arm weakness greater than leg weakness, sensory loss, visual field cut, aphasia or neglect (depending on side)
3. **Posterior cerebral artery**- contralateral visual field cut
4. **Deep/ lacunar**- contralateral motor or sensory deficit without cortical signs (i.e. aphasia/apraxia/neglect/loss of higher cognitive functions), clumsy hand-dysarthria syndrome and ataxic hemiparesis
5. **Basilar artery**- oculomotor deficits and/or ataxia with crossed sensory/ motor deficits
6. **Vertebral artery**- lower cranial nerve deficits (vertigo/nystagmus/dysphagia or dysarthria and tongue/ palate deviation) and/or ataxia with crossed sensory deficits
62
Lacunar Stroke Syndromes
(occlusion of small penetrating intracranial vessel)
1. **Pure motor stroke**- hemiparesis affecting the face, arm, and leg to a roughly equal extent, without associated disturbance of sensation, vision, or language- usually located in the contralateral internal capsule or pons
2. **Pure sensory stroke**- hemisensory loss, which may be associated with paresthesia, and results from lacunar infarction in the contralateral thalamus
3. **Ataxic hemiparesis**- pure motor hemiparesis is combined with ataxia of the hemiparetic side and usually affects the leg predominantly- results from a lesion in the contralateral pons, internal capsule, or subcortical white matter.
4. **Clumsy hand–dysarthria**- dysarthria, facial weakness, dysphagia, and mild weakness and clumsiness of the hand on the side of facial involvement
63
Risk Factors for Subarachnoid Hemorrhage
* hx of cerebral aneurysm
* fhx of aneurysm
* smoking
* heavy alcohol use
* chronic HTN
* **sympathomimetic agents (cocaine, phenylpropanolamine)**
64
Substance that provides temporary relief of
Familial/Essential Tremor Disorder
alcohol
65
4 Cardinal Signs of Parkinson's
TRAP
1. tremor
2. rigidity
3. akinesia (slowing, reduced amplitude, fatiguing, interruption)
4. postural disturbance
66
Parkinson's Treatment
* Anticholinergics- tx tremor and regidity (better in young)
* **Benztropine** (Cogentin)
* **Trihexyphenidyl** (Artane)
* First line drug- mild Parkinsons, tx all motor features, when symptoms interfere with function
* **Amantadine** (Symmetrel)
* MAO-B inhibitor
* alone or with anticholinergic
* Dopaminergic- sx more pronounced or inad. controlled, tx dyskinesis (\*first-line in restless leg)
* Bromocriptine (Parlodel)
* Ropinirole (Requip)
* Pramipexole (Mirapex)
* Apomorphone (Apokyn)- advanced, "severe off"
* If \<65 and cognitively intact- may delay motor complications
* dopamine agonist (above)
* **L-dopa** (Sinemet, Stalevo, Parcopa) if agonist inad.
67
Parkinson enzyme inhibitors
* Monoamine Oxidase B Inhibitors (MAO-B)
* extend life of dopamine in blood
* Selegiline (Eldepryl)
* Rasagiline (Azilect)
* Catehol-O-Methyltransferase Inhibitors (COMT)
* reduce dose requirements of L-dopa
* Entacapone (Comtan)
* Tolcapone (Tasmar)
68
acute and chronic tension headache
bilateral band of pressing or tighness
* acute: acetaminophen, ASA, NSAIDs
* chronic: Amitripyline (Elavil)
69
Migraine
5 attacks, 4-72h,
unilateral/pulsating/mod-severe/exacerbated
NAV/photophobia/phonophobia
* abortives:
* ergots: Migranal, Midrin
* triptans: Sumatriptan (Imitrex)
* prophylactics:
* b-blockers: Propanolol
* CCBs: Verpapmil
* TCAs: Amitriptyline
* anti-epileptics:
* sodium valproate
* Gabapentin (Neurontin)
* Pregabalin (Lyrica)
* Topiramate (Topamax)
* Depakote
* Botox
70
chronic paroxysmal hemicranias
| (HA syndrome)
cluster-type HA 4-12 episodes/day of shorter duration
(20-120 min)
* Idomethacin
71
cluster headache
unilateral periorbital or temporal pain
* acute:
* 100% O2
* Triptans: Sumatriptan
* prevention:
* Verpamil (first line)
* Ergotamine 1-2h before expected attack
* Lithium
* neurostimulation
72
subarachnoid hemorrhage
"worst HA of life" / "thunderclap HA"
* surgery: clip or coil
73
temporal arteritis
temp a. tenderness, swelling, redness, jaw claudication
* high dose steroids
74
trigeminal neuralgia
sharp, electric pain w/ touch, air, chewing, brush teeth
* Carbamezepine first line for neuralgia
* Botox
* surgical decompression or destruction w/ heat, glycerol
75
intracerebral hematoma
bleeding into/within the brain
3-10 days after trauma/stroke
**decreasing LOC**
76
extradural/epidural hematoma
bleeding between skull and dura mater
LOC then lucid period
biconvex lens on CT
**MCC middle meningeal artery bleed**
77
subdural hematoma
bleeding between dura mater and arachnoid space
crescent-shaped CT
**usually venous**
**potentially reversible cause of dementia**
78
diffuse axonal injury
widespread brain injury d/t twisting or acceler/deceleration
prolonged traumatic coma \> 6h
* Mannitol and hypertonic saline for ICP
* antiepileptic drugs for seizures
* fluid and nutrition management
* NO CORTICOSTEROIDS (increases mortality)
79
classic concussion
physiologic and neurologic dysfunction w/out anatomic disruption
LOC \< 6h
anterograde and retrograde amnesia
80
postconcusive syndrome
HA, nervousness, anxiety, irritability, insomia, depression, forgetfulness, fatigue
* reassurance and symptom relief
81
chronic traumatic encephalopathy
| (CTE)
repetitive mild traumatic brain injury
tau protein tangles accumulate in cortex around blood vessels
**high risk of suicide**
82
brown-sequard syndrome
spinal cord injury: lesion to lateral half of cord
* ipsilateral: motor, touch, proprioception, vibration
* contralateral: pain, temp
83
central cord syndrome
spinal cord injury
"man in barrel"
* bilateral loss:
* UE motor (spares LE)
* proximal weakness \> distal weakness
* pain and temp reduced
* proprioception and vibration spared
84
anterior cord syndrome
spinal cord injury: bilateral anterior and lateral cord columns
* loss below lesion:
* touch
* pain
* temp
* posterior column fx intact:
* proprioception
* vibration
85
spinal shock
| (acute spinal cord injury)
complete loss of reflex below lesion
* bladder/rectal control, flaccid paralysis, sensory deficit
* a few days up to 3 mo
86
neurogenic shock
unopposed _parasympathetic_ tone
* cervical or upper thoracic injury
* * vasodilation
* hypotension
* bradycardia
* hypothermia
87
dysreflexia
| (autonomic hyperreflexia)
sudden massive _sympathetic_ discharge
* T5/6 injury or above
* stimulation of sensory receptors below lesion
* uncompensated CV response
* HTN up to 300 systolic
* **_brady_**cardia (30-40 BPM)
* sweating _above_ lesion, piloerection
* Tx:
* Nitroglycerin paste above lesion (or CCBs)
* elevate head
* remove stimulus (empty bladder/bowel)
88
delerium
confusional state with depressed LOC
acute onset, resonds to Tx
* Haloperidol PO/IM
* avoid benzodiazapines and meperidine (Demorol)
89
dementia
acquired cognitive impairment
slow, chronic onset
**LOC preserved**
90
dissociative amnesia
inability to recall important personal information
NOT associated with other disorders
91
anterograde amnesia
can't create NEW memories after amnesia event
(old remain intact)
92
retrograde amnesia
can't remember events BEFORE amnesia event
93
amnesias:
lacunar
emotional-hysterical
Korsakoff
posthypnotic
transient gobal
* unable to remember specific event
* temporary amnesia d/t psychological trauma
* memory loss d/t chronic alcoholism
* unable to remember events during hypnosis session
* spontaneous memory loss lasting minutes or hours
94
Wernicke Encephalopathy
| (Wernicke-Korsakoff)
brain atrophy d/t _thiamine deficiency_
* triad:
* ophthalmoplegia
* ataxia
* mental/consciousness disturbances
* alcoholic polyneuropathy: nystagmus, no ankle reflexes
* Tx: "banana bag"
* thiamine + magnesium parenterally
95
Korsakoff syndrome
anterograde and posteriograde amnesia w/out
impaired alertness, attention, extraocular disturbance
"Yoda confabulation"
96
Broca's aphasia
| (expressive aphasia)
expressive language affected but comprehension preserved
97
Wernicke's aphasia
| (repetitive fluent aphasia)
comprehension of written and verbal language impaired
(speech fluent but has little meaning)
98
alzehimer disease
beta-amyloid plaques + tau neurofibrillary tangles
* memory:
* mild to moderate AD: cholinesterase inhibitors
* Aricept (Donepazil)
* Tacrine
* Rivastigmine
* Galantamine
* Memantamine
* moderate to sever AD: NMDA receptor agonist
* Memantadine add-on to Aricept
* disturbances:
* atypical antipsychotics:
* Zyprexa (Olanzapine)
* Quetipine
* antidepressants:
* Sertraline
* Citalopram
99
vascular dementia
less memory loss than AD but acts odd (d/t infarction)
* new cognitive disturbance worsening w/in 3 mo of stroke
* neuroimaging of bilateral brain infarction rostral to but not including thalamus
less memory loss than AD but pt. adds odd
100
frontotemporal dementia
frontal/temporal lobe degeneration
* tau ribbon (AD paired helixes)
* **Pick bodies**
* no beta-amyloids
* apathy, disinhibition, blunted emotions, lack of insight
* fluent aphasia w/ impaired comprehension
101
dementia with lewy bodies
dementia preceeding parkinsonian symptoms
* Tx
* L-dopa for parkinson symptoms
* SSRIs for depression
* low-dose Clonazepam for sleep
* Memantine for memory
* Rivastigmine (cholinesterase inhibitors) for cognitive/behavioral symptoms
102
Creutzfeldt-Jacob (prion) disease
proteinaceous infectious particle causing rapid dementia with focal degeneration of cortex
* 14-3-3 protein (PrPSc)
* relentless invariably fatal with significant psychiatric symptoms
103
Huntinton's disease
expanded CAG repeats in huntingtin gene
* chorea, dementia, impulsivity, depression, anxiety
* Tx:
* Haloperidon for choreiform
* Levodopa for muscle rigidity
104
reversible causes of dementia
* normal pressure hydrocephalus
* "wet, wacky, wobbly" - dementia, ataxia, incontinence
* shunt
* chronic subural hematoma
* papilledema, Babinski sign, HA then confusion, NAV
* surgical evacuation
105
epilepsy
* 2+ _unprovoked_ seizures
* 1 occurs in person with at least 60% risk
* 1 or more in context of epilepsy syndrome
106
partial (focal) seizure
originate within neural networks limited to ONE hemisphere
107
generalized seizure
affect both hemispheres
* tonic clonic
* absence
* tonic
* clonic
* myoclonic
* atonic
108
actions of seizure drugs
* potentiate _inhibitory_ GABA transmission
* inhibit _excitatory_ Glutamate transmission
109
seizure med for P, G, S
phenytoin (Dilantin)
110
seizure med for G, M, P, A, S
valproic acid
\*teratogen
111
seizure med for A
ethosuxamide (Zarontin)
112
seizure med for G, P, A, S
Lamotrigine
\*good in pregnancy
113
seizure med for G, P, M
leveiracetam (Keppra)
114
treatment of coma
* ABC
* if no meningitis suspected:
* 50% dextrose IV
* thiamine and multivitamins
* Naloxone for illicit drugs
* Flumazenil to block benzos
* if meningitis suspected:
* IV antibiotics
* LP
* lower ICP
* Lorazepam for seizures
* look for cause
115
stroke
* sudden onset
* focal involement
* deficits \>24h
* vascular cause
* Tx:
* tPA within 4.5h
116
cerebral ischemia
* symptoms when blood supply \< 50ml/100g/min
* types:
* global- CV collapse
* diffuse- altitude, anemia, pulmonary disease
* cerebral- cytotoxic edema d/t neuronal injury
117
TIA
focal neurologic deficit \< 1h
* aspirin if probable
* afib
* Warfarin 1 day after event
* all pts.
* antiplatelet: ASA, clopidogrel
* statins
* anti-hypertensives
* lifestyle coaching
118
ischemic stroke surgical interventions
* carotid endarterectomy
* carotid artery stenting
* decompression of infarted tissue
* craniectomy decompression to prevent transtentorial herniation
119
vertebrobasilar insufficiency
| (VBI)
vertigo with associated neurologic signs
* digital subtraction angiography is gold standard test
120
intracerebral hemorrhage
| (ICH)
acute spontaneous bleeding into brain parenchyma
from abrupt arterial rupture
* vomiting
* elevated PBA
* severe neurologic deficit
* **midline shift**
* Tx:
* get systolic pressure to 140
* antihypertensives:
* Labetalol
* NIcardipine
* reverse anticoagulation:
* Protamine Sulfate to reverse heparin
* Desmopressin for thrombocytopenia
* Vlla for INR reversal
* ICP:
* Mannitol
* elevate head
* hyperventilate to PCO2 30
* fluids:
* .9 normal saline
* seizures:
* Phenytoin or Fosphenytoin IV
* cooling blankets
* insulin drip to control glucose 120-180
121
subarachnoid hemorrhage
| (SAH)
rupture of vessels on brain surface, blood into ventricles
* "thunderclap headache"
* non-contrast CT
* Tx:
* reduce ICP: Mannitol
* maintain mean arterial pressure at 90
* rebleeding: Aminocarproic acid IV
* rehydration: .9 normal saline
* seizure: fosphenytoin IV
* vasopasm: Nimodipine, trendelenburg
* cooling blanket
* insulin drip
* transfustion to maintain hemoglobin
122
interventricular hemorrhage
blood into ventricles
* 20ml lethal
* survivors have sever neurologic and cognitive disability
123
brain vascular malformation
* hypertension NOT a risk
* arteriovenous malforamations (AVM) MC
* Tx:
* selective embolization
* surgical resection
* radiation-induced thrombosis
124
familial / essential tumor
autosomal d/o of cerebellar purkinje cells
* mild postural tremor in hands spreads to head, voice
* legs spared
* **alcohol provides relief**
* Tx:
* Propranolol
* Primidone
* Topiramate
125
chorea
rapid irregular movements of _different_ body parts
* Tx:
* adults:
* Haloperidol
* Pimozide
* children:
* benzos
* Clonazepam
* Diazepam
* Clobazam
126
Sydenham chorea
late component of rheumatic fever from group A strep
* Tx:
* Valproate
127
ballism
extreme form of chorea
* hemiballism on one side d/t stroke can resolve after 1 week
* Tx:
* treat like chorea
128
Huntington disease
autosomal dominant CAG repeats in huntingtin protein
* Tx movement disorder:
* **Reserpine**
* Teatrabenzine
* Haldol
* Quetiapine (Seroquel) - also treats psychosis
129
dystonia
sustained muscle contractions
* repetitive movements/abnormal postures
* athetosis: slow, sustained, writhing movements
* torticollis: neck twisted
* blepharospasm: forced eye closing, repetitive blinking
* oromandibular - involuntary mouth opening/closing, pursing
* Tx:
* butulinum \*first choice
* anticholinergic: Trihexyphenidyl
* benzo: Diazepam
* dopa-deleting: Tetrabenzine
* dopa-blocking: Haldol
130
tics
repetitive movements or vocalizations
* Tx:
* behavior modifications
* antipsychotics:
* Haldol
* Pimozide
* Risperidone
131
Tourette's syndrome
chronic life-long multiple motor or verbal tic of unknown cause
coprolalia- swearing
* Tx of moderate/severe:
* **Clonazepam** (Klonapin) low dose
* Clonidine
* Guanfacine
* Risperidal, Apiprazole
* Botox injections
132
myoclonus
sudden shock-like very short muscle contractions
and brief inhibition (+ and - jerks)
* Asterixix MC negative
* Tx secondary causes:
* Clonazepam
* Valproic acid
* Carbamazapine
* Levetiracetam
133
restless leg syndrome
unpleasant creeping discomfort in legs
(Fe deficiency sometimes)
* TOC is dopamine agonists:
* Pramipexol (Mirapex)
* Ropinirol (Requip)
* Transdermal Rotigotine
* other:
* Gabapentin (Neurontin)
* L-dopa
134
parkinson disease
loss of dopamine d/t substantia nigra loss in midbrain
(TRAP)
* acetylcholine blockers (avoid in elderly)
* Benztropine (Cogentin)
* Trihexyphenidyl (Artane)
* enhance dopamine
* MOA-B inhibitors:
* Selegiline (Eldepryl)
* Rasagiline (Azilect)
* COMT
* Entacapone (Comtan)
* Tolcapone (Tasmar)
* Stalevo: entacapone + carbidopa + ldopa
* **Amantadine** \*good first drug
* Dopaminergic if uncontrolled:
* Bromocriptine (Parlodel)
* Pramipexole (Mirapex)
* Ropinirole (Requip)
* Apomorphine (Apokyn) - "rescue drug"
* Dopamine if \< 65 and congnition intact (prevent loss)
* Levodopa / Ldopa + carbidopa if dopamine inadequate or too many s/e (these wear off)
* deep brain stimulation
135
multiple sclerosis
disease of lesions seen over time and space
* CNS involvement ONLY (no peripheral NS)- demyelination of brain and spinal cord
* Gliotic scars (plaques)- optic nerve, deep white matter, etc.
* _optic neuritis_, fatigue, bladder urgency, motor weakness _exacerbated by heat_, paresthesia- TRANSIENT
136
MS Classifications
1. **relapsing/remitting** (85%)- no progression between attacks
2. **primary progressive** (10%)- gradual progression from onset
3. **secondary progressive** (80% after 25 years)- gradually after initial relapsing-remitting pattern
4. **progressive relapsing** (rare)- acute replapses over 1' progressive
137
McDonald's Criteria for MS
* 2+ attacks, 2+ lesions, clinical evidence
* 2+ attacks, 1 lesion, dissemination in space on MRI
* 1 attack, 2+ lesions, dissemination in time on MRI
* 1 attack, 1 lesion, disseminaiton in space and time
* 0 attacks, 1 year disease progression 2 of 3:
* dissemination in space in brain
* dissemination in space in spinal cord w/ 2+ T2 lesions
* positive CSF
138
MS Tests
* **FLAIR T2-weighted MRI** of brain, cervical & thoracic spine
* VEP
* SSEP
* LP
* cell count, protein, glucose, oligoclonal bands, IgG/IgA
139
MS Treatment
* acute episode (including relapse): **Methylprednisone** IV TOC
* relapse prevention:
* interferon B1b: Betaseron and Extavia
* INF-B1a: Avonex, Rebif
* relapse prevention despite 1st line : Natalizumab (Tysabri)
* high disease activity: Natalizumab (Tysabri)
* worsening forms/2' progressive: Mitoxantrone
* disease modifying:
* traditional injectable:
* interferon beta:
* Betaseron
* Avonex
* Rebif
* Glatirimir Acetate
* Capaxone
* humanized monoclonal abx
* Natiluzimab (Tysabril)- must check JC virus
* Sphingosine-1-phosphate receptor modulator (S1P1)
* Fingolomod (Gilenya)
* interferes w/ de novo synthesis fo pyrimidines:
* Teriflunomide (Aubagio)
* anti-inflammatory:
* dimethyl fumerate (Tecfidera)
* lymphocyte depletion
* Alemtuzumab (Lemtrada)
* symptom management:
* Dalfampridine (Ampyra) \*increases walking speed
* Vit D
* prednisone
* methylprednisone
* IVIG
* plasma exchange
140
optic neuritis
painful subacute unilateral visual loss (blurring, scotoma)
* pain 2-3 days before vision loss over 2-3 days
* lasts 2 weeks then starts to resolve
* red color vision loss
* reflective pupillary defect (light-swing test)
* swollen optic disk
* (vs. optic neuropathy)
* Tx:
* IV methylprednisone (NOT ORAL)
141
transverse myelitis
disruption in spinal cord (MS, inflammation, infection)
* sensory, motor, autonomic deficits in limbs and trunk attributable to spinal cord (bladder & bowel s/s)
* clearly defined sensory level
* **Lhermitte sign**- shooting pain
Dx:
* LP: inflammatory CSF profile- low glucose, pleocytosis
* must exclude cord compression by MRI before Tx
Tx:
* IV methylprednisone
* plasema exchange, IV immunoglobulins, cyclophosphamide if steroids not effective
142
CNS Infections by Lab Values
Pressure
Cell Count
Glucose
Protein
Normal
90-180
0-5 lymphs
40-70
15-45
Bacterial
200-300
100-5K PMNs
\<40
100-1,000
Viral
90-200
10-300 lymphs
normal
50-100
TB
180-300
\<500 lymphs
\<40
100-200
Fungal
lymphs
low
143
meningitis
inflammation of arachnoid, pia mater, and intervening CSF
* extends throughout subarachnoid space around brain and spinal cord and invovles the ventricles
* fever, HA, stiff neck, NAV, photophobia, lethargy, confusion
* LP to determine bacterial or viral
* **make decision on antibiotics w/in first 30 min**
* Budzinski's sign (neck lift)
* Kernig's sign (knee/hip flex, extend knee)
* nuchal rigidity
144
bacterial meningitis
medical emergency - fatal if not treated promptly
* hx of URI
* LP FIRST, blood cultures if contraindicated
* CSF: LOW glucose; high protein, WBC, neutrophils
* **_Top 3_**:
* H. influenza
* Cefotaxime
* Strep. pneumonia
* Pen G or Ampicillin
* otitis media
* N. miningitidis (reportable)
* Ampicillin
* petechiae, purpura
* "cidal" abx **within 30 min**
* community acquired: Ceftriaxone + Vanocmycin
* high risk: Vanco + Ceftazidime or Cefepime
145
viral meningitis
| (aseptic meiningitis)
inflammation of meninges
* Enterovirus MCC (from respiratory secretions)
* may have prodromal phase- malaise, sore throat, diarrhea
* CSF: high leukocytes, NORMAL glucose, PCR- enterovirus/HSV2 DNA
* Tx:
* supportive care
* Acyclovir within 72h
* Anticonvulsants for seizures:
* Lorazepam
* Phenytoin
* Midazolam
* Barbiturate
146
encephalitis
diffuse or focal inflammation of parenchyma of the brain
* HSV MCC
* prodrome, fever, HA, malaise, myalgia
* Tests:
* CT to r/o
* LP w/ PCR for HSV, IgM
* Tx:
* ICU mgmt of airway, bladder, electrolytes, nutrition
* Phenytoin for seizure control
* Mannitor for ICP
* Acyclovir for HSV
147
brain abscess
intraparenchymal collection of purulent material d/t infection
* 90% start elsewhere: dental, otogenic, cardiac, pumonary
* Dx:
* MRI is imaging of choice
* surgical aspiration to est. microbial diagnosis
* Tx:
* IV Dexamethasone for cerebral edema
* emperical antibiotics before surgery
* neurosurgery
148
spinal epidural abscess
infection within epidural space and spinal cord
* **Staph aureus MCC**
* back or radicular pain
* Dx:
* Gadolinium enhance MRI imaging of choice
* NO LP- _contraindicated_
* Tx:
* surgical drainage
* CT guided aspiration
* Staph aureus emperic antibiotics
149
septic venous thrombosis
clots or infections propogate retrograde
1. Septic Cavernosis Sinus
* spread from parnasal sinuses or dental abscesses to orbit or middle 3rd of face
* Staph aureus MCC
* surgery and heparin
2. Lateral Sinus
* spread from middle ear infection
* ear pain, fever, HA, hearing loss, vertigo
* MR venography, IV antibiotics, ENT to drain
3. Septic Sagittal Sinux
* consequence of purulent meningitis, ethmoid/maxilary infection
* elevated ICP
* MR venography, IV antibiotics, surgical drainage
150
upper motor neuron disease
* nerve cell bodies begin and end in CNS
* descending pathways from brain to spinal cord
* spinal reflex arcs and circuits
* injury- initial paralysist then partial recovery
* S/s:
* weakness: spastic, clonus
* DTRs: increased
* Babinski: present
* atrophy: absent
* fasciculations/fibrillations: absent
151
lower motor neuron disease
* cranial and spinal motor neurons
* originate in anterior horn of cord and extend to PNS
* transmit signals directly to muscles
* injury- permanent paralysis
* S/s:
* weakness: flaccid
* DTRs: decreased
* Babinski: absent
* atrophy: marked
* Fasciculations/fibrillations: present
152
amyotrophic lateral sclerosis
| (ALS)
cell death to upper AND lower motor neurons
* obvious muscle atrophy
* **Bulbar** involvement:
* swallowing, chewing
* breathing, speaking (dysarthria)
* wasted/fasciculating tongue
* UL/LL fatigue, weakness, stiffness, twitching, wasting, cramps, vague sensory, weight loss, cognitive changes
* Dx:
* clinical
* Anti-GM1 gangliosides, Anti-myelin assoc. glycoprotein (MAG) antibodies
* Tx:
* multidisciplinary: tx family, nutrition (high fat), speech/swallow mgmt (PEG tube), communication devices, respiratory mgmt (cPAP/byPAP), PT/OT/LSW
* aggressively tx symptoms:
* disease therapy: Riluzole (Rilutek) adds 2-3m
* antiox./supplements: Vit E, Co-Q10, Deanna, Clev.
* alt therapy: accupuncture, reiki, chelation
* cramps: Quinine Sulfate
* spasticity: Dantrolene, Tizaidine, Clonazepam
* dry mouth: Guaifenesin, Propranolol
* Sialorrhea: Gloycopyrrolate, Amitriptyline
* PBA: Dextromethorphan, Amitriptyline
* fatigue: Modafanil, Ritalin
153
peripheral neuropathy
* muscle wasting, fasciculations, weakness
* stocking glove sensory loss
* cold, discolored (small fiber sensory loss)
* sensory ataxia (large fiber sensory loss)
* absence of reflexes
* gait test (unable to heel-toe walk)
* Dx:
* if not diabetic, alcoholic, malnourished start checking for heavy metals and other odd causes
* Tests:
* electrodiagnostic (ENMG)
154
Diabetic Neuropathy
* impaired sensation or pain in hands or feet
* slowed digestion
* carpal tunnel
* muscle weakness, cramps
* prickling, numbness, pain
* **sexual dysfunction**, vomiting, diarrhea, poor bladder control
* Dx:
* foot exam
* nerve conduction study
* electromyographic exam (EMG)
* US to check blood flow
155
distal _symmetric_ polyneuropathy
* MC form
* "stocking-glove" loss in hands and feet
* pain, paresthesia
* loss of vibratory sensation
* complications:
* ulcers
* Charcot arthropathy
* dislocations, stress fratures
* amputation
* Tx:
* pain control:
* Tricyclic antidepressants: Amitriptyline (Elavil)
* topical creams: Cesatian (lidocaine)
* anticonvulsants
* foot care:
* annual exam, visual inspection w/ every visit
* preventive: lotions, nail care, shoes, socks
* meds:
* Pregabalin (Lyrica)
* Duloxetine (Cymbalta)
* Gabapentin (Neurontin) if others fail
156
diabetic _autonomic_ neuropathy
affects nn. controlling internal organs:
peripheral, genitourinary, GI, cardiovascular
* peripheral:
* Charcot foot
* aching, pulsating, tightness, cramping
* dry skin, prurutis, edema, sweating abnormalities
* foot elevation, diuretics, support stockings
* genitourinary:
* anorexia, NAV, early satiety
* enteropathy resulting in diarrhea and constipation
* cath, antihistamine, sildenafil/tadalafil
* gastrointestinal:
* small frequent meals
* Metoclopramide (Regalin), Erythromycin for gastroparesis
* Loperamide, antibiotics, stool softener for enteropathy
* cardiovascular:
* exercise intollerance (syncope w/ hypotension)
* postural hypotension
* slow postural changes, increase plasma volume
157
diabetic _compressive_ mononeuropathy
* carpal tunnel, cubital tunnel, unilateral foot drop
* numbness, edema, pain, prickling
158
infectious neuropathies
* herpes zoster postherpetic neuralgia
* virus in dorsal root ganglia undergo hemorrhagic necrosis creates hypersensitization
* lyme disease
* spirochete Borrelia burdorferi
* erythema migrans
* joint arthritis, stiff neck, HA, photophobia
* CN VII facial palsy, neuropathy (rare for Bell's palsy)
* HIV neuropathy
* distal symmetric polyneuropathy MC
* progressive polyradiculopathy
159
herpes zoster postherpetic neuropathy Tx
* treat shingles hard to prevent postherpetic neuralgia
* antivirals within 72 h:
* Acyclovir (Zovirax)
* Valacyclovir (Valtrax)
* Famciclovir (Famvir)
* corticosteroids:
* prednisone w/ antivirals to reduce pain and PHN
* pain management:
* OCT analgesics for mild-moderate
* Topicals:
* Calamine
* Capsaicin (Zostrix) after lesions crust
* Lodocaine topical (Xylocaine)
* TCAs:
* **Amitriptyline** (Elavil)
* Desipramine (Norpramine)
* anticonvulsants:
* Pregabalin (Lyrica)
* prevention:
* Zostravax live attenuated varicella zoster virus
* can give if reactivation and pt. not vaccinated
160
lyme disease Tx
* Stage 1:
* Doxycycline (Amoxicillin if Peds \< 12 or pregnant)
* Stage 2:
* normal CSF:
* Doxicycline
* Amoxicillin
* abnormal CSF:
* Ceftriaxone
* Stage 3:
* Doxy or Amoxicillin
* if fails: Ceftriaxone or Cefotaxime (Peds Cefotaxime low dose)
161
alocohol peripheral neuropathy Tx
symptoms similar to diabetic neuropathy
* IV thiamine
162
acquired inflammatory peripheral neuropathies
* Guillain-Barre syndrome
* acute inflammatory demyelinating polyneuropathy (AIDP) MC
* ascending symptoms from legs (moves into arms)
* weakness, lack of reflexes in LE
* **CSF high protein with low/normal cell counts**
* Dx:
1. progressive weakness 2+ limbs w/ neuropathy
2. areflexia
3. disease course \< 4 weeks
4. exclusion of other causes
* Tx:
* hospitalization to monitory respiratory compromise (
* plasmapheresis
* IV immunoglobulin
* chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
* "Guillain-Barr w/out the respiratory impact"
* autoimmune macrophage destruction of myelin
* insidious onset weakness and sensory loss
* loss of proprioception
* DTRs absent
* **facial weakness**- ptosis, opthalmoparesis
* **CSF: WBC \<10, protein \>60, low cell count**
* Tx:
* corticosteroids: Prednisone
* IVIG like Guillain-Barr except qmo up to 6+
* plasma exchange to remove harmful antibodies
163
hereditary neuropathies
* Charcot-Marie-Tooth Disease Type 1
* autosomal dominant
* dysmyelination-demyelination-remyelination
* sensory loss in 1st 2 decades, slow runners, fine movement of hands impaired, feet lack musculature, **high arch and hammer toes, clawed hands, thin calves** d/t atrophy
* **high stepping/foot slap, foot drop**
* Dx:
* genetic testing
* nerve conduction velocity testing
* Tx:
* genetic counseling
* orthotics
* surgery to correct inverted feet, pes cavus, hammertoes
164
CNS tumors general s/s, dx, tx
* S/s:
* generalized typically with ICP: NAV, HA, lethargy, personality change
* lateralized per tumor location: hemoparesis, aphasia, visual field impairment, seizures
* Dx:
* MRI best in all cases of suspected tumor
* with and without gadolinium
* Tx:
* symptomatic:
* glucocorticoids
* antiepileptics
* Heparin to prevent venous thromboembolism
* definitive:
* surgery
* radiation (cyber knife): PET scan to ID radiation necrosis or recurrence
* chemo
165
meningioma
* tumor in intracranial cavity but NOT brain tissue
* usually benign
* grow slow but can get large
* Dx:
* MRI: diffusely enhancing w/ dural tail
* Tx:
* surgery
* radiation
* chemo UNEFFECTIVE
166
glioblastoma / astrocytoma
* MC glial cell tumor
* 20-30: astrocytoma; 55-60: glioblastoma
* HA, seizures, lateralizing signs: aphasia, visual field deficit
* Dx:
* MRI
* Tx:
* surgery + radiation + chemo
167
pituitary tumor
* micoradenoma \< 1cm; macroadenoma larger
* micro:
* typically secreting- endocrine symptoms
* macro:
* typically non-secreting but compress surroundings
* Dx:
* MRI **with pituitary protocol**
* Tx:
* transphenoidal pituitary surgery
* radiation of recurrent/residual
168
nerve sheath tumor
* Schwannomas and neurofibromas
* radicular pain
* Tx:
* surgical removal
169
CNS mets
* systemic cancer that metastasizes to brain
* melanoma has greatest propensity to go to brain
* breast, lung, colon, kidney
* HA, seizures, lateralizing pains
* Dx:
* MRI with gadolinium
* Tx:
* surgical excision
* whole brain radiation
* gamma knife
170
spinal tumors
* Types:
* extradural- arise from bone, compress cord
* neurologic symptoms
* intradural- arise from pacymeninges/nerve roots
* radicular symptoms or cord compression
* intramedullary- arise from spinal cord parenchyma
* biologically similar to brain tumors
* extramedullary
* Tx:
* IMMEDIATE Tx REQUIRED
* HIGH DOSE corticosteroids (IV Dexamethasone)
* surgery
* radiation
171
Familial/Essential Tremor
Propranolol 40-160mg PO bid
172
Chorea & Sydenham's Chorea
Adults: Haloperidol or Pimozide Children: Benzos- Conazepam, Diazepam, Sydenham's: Valproate
173
Ballism
Tx like chorea
174
Huntington's
Reserpine "rose serpent", Quetiapine (Seroquel)
175
Dystonia
Botulinum
176
Tics
Haldol
177
Myoclonus
Clonazepam "clown hands"
178
Restless Leg Syndrome
Pramipexol (Mirapex) "prom pix", Ropinirole (Requip), Transdermal Rotigotine, Gabapentin (Neurontin), L-dopa
