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Clinical Medicine II > Neurology > Flashcards

Neurology Flashcards

1
Q

Bacterial Meningitis

A

cloudy/turbid

incr. neutrophils

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2
Q

Viral Meningitis

A

increased lymphocytes

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3
Q

TB meningitis

A

slightly cloudy

VH protein

VL glucose

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4
Q

Subarachnoid Hemorrhage

A

blood stained

VH red blood cells

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5
Q

Guilliane-Barre Syndrome

A

incr. protein after 1 week

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6
Q

MS

A

incr. lymphocytes
incr. protein

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7
Q

MC Headache

A

tension ha > migraine > cluster

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8
Q

Tx for chronic tension ha

A

Amitriptyline (Elavil)

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9
Q

First line Tx for tension ha

A

NSAIDs, acetaminophen, ASA

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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
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11
Q

Acute Tx of migraines

A

Triptans (5HT agonists)

dampen neural stimulation

Sumatriptan (Imitrex)

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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

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13
Q

Cluster ha symptoms

A

unilateral periorbital or temporal pain

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14
Q

Cluster ha Tx

A

100% O2 for 15-20min

Triptans

Sumatriptan 6mg SQ

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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)
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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
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17
Q

Tx for trigeminal neuralgia

A

Carbamazepine 400-1200mg

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18
Q

GCS

A

Glasgow Coma Scale

13-15: mild

9-12: moderate

structural injury, hemorrhage

3-8: severe

cognitive/physical disability, death

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19
Q

MCC of extradural/epidural hematoma

A

middle meningeal a. bleed w/ temporal fossa fx

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20
Q

3 spinal cord syndromes

A
  1. Brown-Sequard
    • loss ipsilateral motor, touch, proprio, vib
    • loss contralateral pain, temp
  2. Central Cord
    • “man in barrel”- bilateral UE, LE spared
    • proximal weakness
    • pain, temp reduced; proprio, vib spared
  3. Anterior Cord
    • loss touch, pain, temp, motor below lesion
    • proprio and vibratory intact
  • Tx: immobilization, decompress. and fixate, corticosteroids 24-48h, rehab
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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
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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
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23
Q

Why EG done for delerium

A

looking for metabolic encephalopathy

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24
Q

Wernicke-Korsakoff Encephalopathy triad

A
  1. ophthalmoplegia
  2. ataxia (40% reversible)
  3. mental/consciousness disturbances
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25
Q

Wernickes Encephalopathy Tx

A

“banana bag”

500mg thiamine + magnesium

thiamine 30-100mg bid for chronic

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26
Q

Wernicke vs. Broca

A

Wernicke:

  • dominant posterior superior temporal lobe
  • affects verbal and written comprehension

Broca

  • dominant posterior inferior frontal lobe
  • affects speech (“YODA”)
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27
Q

anterograde amnesia

A

inability to acquire and recall NEW information

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28
Q

Normal pressure hydrocephalus (NPH) triad

A
  1. dementia
  2. gait disorder
  3. incontinence

* can be reversible

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29
Q

Alzheimer’s disease

A
  • insidious onset sx
  • hx of worsening condition
  • amyloid plaques (b-amyloid, APP, PSEN1, PSEN2)
  • neurofibrillary tangles (Tau protein)
  • cortical atrophy
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30
Q

Vascular Dementia

A
  • cerebral infarctions of hipocampus or thalamus
  • cognitive disturbances w/in 3mo of stroke
  • neuroimaging evidence of bilateral infarctions rostral to thalamus
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31
Q

Frontotemporal Dementia

A
  • atrophy of frontal and temporal lobes
  • twisted Tau inclusions
  • Pick bodies
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32
Q

Dementia w/ Lewy Bodies

A
  • 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
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33
Q

Creutzfeldt-Jakob (Prion) Disease

A
  • 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
      ​
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34
Q

Huntington Disease

A
  • autosomal dominant
  • chorea, impulsivity, anger, restlessness, dementia, - memory
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35
Q

Reversible Neurologic Diseases

A

Normal Pressure Hydrocephalus (NPH)

  • dementia, gait apraxia, incontinence
  • mental slowness, apathy, cognitive dysfunction
  • shunt

Chronic Subdural Hematoma

  • chronic HA, tenderness
  • craniotomy and percutaneous drainage
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36
Q

Dx of Epilepsy

A

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
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37
Q

Generalized vs. Partial (focal) Seizures

A

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
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38
Q

Staticus Epilepticus

A
  • 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

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39
Q

Simple Partial Seizures

A

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
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40
Q

Complex Partial Seizure

A

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
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41
Q

EEG indication of absence seizure in children

A

3-second spike-and-wave abnormality

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42
Q

Phenytoin (Dylantin)

Indications

A

P, G, S

(partial, generalized, secondary generalized tonic-clonic)

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43
Q

Valproic Acid (Pepakote, Depakene)

Indications

A

G, M, P, A, S

(generalized, myoclonic, partial, absence, secondary)

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44
Q

Ethosuximide (Zarontin)

Indications

A

A

(absence)

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45
Q

Lamotrigine (Lamictal)

Indications

A

G, P, A, S

(generalized, partial, absence, secondary)

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46
Q

Levetiracetam (Keppra)

Indications

A

G, P, M

(generalized, partial, myoclonic)

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47
Q

Management of Status Epilepticus

A
  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
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48
Q

Safest Anticonvulsant for Pregnancy

A

Lamotrigine (Lamictal)

low risk of Steven-Johnson in first 8 weeks

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49
Q

Drowsy or Somnolent

A

aroused by minimal stimulus,

poor attention and falls back to sleep easily

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50
Q

Lethargic

A

aroused by moderate stimuli,

then drifts back to sleep

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51
Q

Obtunded

A

similar to lethargy: lessened interest in environment,

slowed responses to stimulation,

sleeps more than normal with drowsiness between sleep states

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52
Q

Stuporous

A

sleep-like state (not unconscious)

little/no spontaneous activity

aroused only with vigorous stimulation

immediately lapses to unresponsive state when undisturbed

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53
Q

Comatose

A

cannot be aroused, no response to stimuli

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54
Q

States of Consciousness

A
  1. conscious
  2. confused
  3. delirious
  4. drowsy/somnolent
  5. lethargic
  6. obtunded
  7. stuporous
  8. comatose
  9. brain dead
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55
Q

Cause of Papilledema & Subhyaloid Hemorrhage

A
  • chronic/acute hypertension OR intracranial pressure
  • subarachnoid hemorrhage
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56
Q

Sign of Opioid Overdose

A

pinpoint pupils (1-1.5mm) with OCD intact

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57
Q

Coma

A
  • 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
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58
Q

Vegetative State

A

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
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59
Q

Diagnosis and Criteria for Brain Death

A

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
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60
Q

First Line Diagnostic in Stroke Work-up

A

Non-contrast CT

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61
Q

ICA (ischemic cerebrovascular accident)

Presentations

A
  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
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62
Q

Lacunar Stroke Syndromes

(occlusion of small penetrating intracranial vessel)

A
  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
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63
Q

Risk Factors for Subarachnoid Hemorrhage

A
  • hx of cerebral aneurysm
  • fhx of aneurysm
  • smoking
  • heavy alcohol use
  • chronic HTN
  • sympathomimetic agents (cocaine, phenylpropanolamine)
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64
Q

Substance that provides temporary relief of

Familial/Essential Tremor Disorder

A

alcohol

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65
Q

4 Cardinal Signs of Parkinson’s

A

TRAP

  1. tremor
  2. rigidity
  3. akinesia (slowing, reduced amplitude, fatiguing, interruption)
  4. postural disturbance
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66
Q

Parkinson’s Treatment

A
  • 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.
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67
Q

Parkinson enzyme inhibitors

A
  • 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)
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68
Q

acute and chronic tension headache

A

bilateral band of pressing or tighness

  • acute: acetaminophen, ASA, NSAIDs
  • chronic: Amitripyline (Elavil)
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69
Q

Migraine

A

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
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70
Q

chronic paroxysmal hemicranias

(HA syndrome)

A

cluster-type HA 4-12 episodes/day of shorter duration

(20-120 min)

  • Idomethacin
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71
Q

cluster headache

A

unilateral periorbital or temporal pain

  • acute:
    • 100% O2
    • Triptans: Sumatriptan
  • prevention:
    • Verpamil (first line)
    • Ergotamine 1-2h before expected attack
    • Lithium
    • neurostimulation
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72
Q

subarachnoid hemorrhage

A

“worst HA of life” / “thunderclap HA”

  • surgery: clip or coil
73
Q

temporal arteritis

A

temp a. tenderness, swelling, redness, jaw claudication

  • high dose steroids
74
Q

trigeminal neuralgia

A

sharp, electric pain w/ touch, air, chewing, brush teeth

  • Carbamezepine first line for neuralgia
  • Botox
  • surgical decompression or destruction w/ heat, glycerol
75
Q

intracerebral hematoma

A

bleeding into/within the brain

3-10 days after trauma/stroke

decreasing LOC

76
Q

extradural/epidural hematoma

A

bleeding between skull and dura mater

LOC then lucid period

biconvex lens on CT

MCC middle meningeal artery bleed

77
Q

subdural hematoma

A

bleeding between dura mater and arachnoid space

crescent-shaped CT

usually venous

potentially reversible cause of dementia

78
Q

diffuse axonal injury

A

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
Q

classic concussion

A

physiologic and neurologic dysfunction w/out anatomic disruption

LOC < 6h

anterograde and retrograde amnesia

80
Q

postconcusive syndrome

A

HA, nervousness, anxiety, irritability, insomia, depression, forgetfulness, fatigue

  • reassurance and symptom relief
81
Q

chronic traumatic encephalopathy

(CTE)

A

repetitive mild traumatic brain injury

tau protein tangles accumulate in cortex around blood vessels

high risk of suicide

82
Q

brown-sequard syndrome

A

spinal cord injury: lesion to lateral half of cord

  • ipsilateral: motor, touch, proprioception, vibration
  • contralateral: pain, temp
83
Q

central cord syndrome

A

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
Q

anterior cord syndrome

A

spinal cord injury: bilateral anterior and lateral cord columns

  • loss below lesion:
    • touch
    • pain
    • temp
  • posterior column fx intact:
    • proprioception
    • vibration
85
Q

spinal shock

(acute spinal cord injury)

A

complete loss of reflex below lesion

  • bladder/rectal control, flaccid paralysis, sensory deficit
  • a few days up to 3 mo
86
Q

neurogenic shock

A

unopposed parasympathetic tone

  • cervical or upper thoracic injury
    • vasodilation
      • hypotension
      • bradycardia
      • hypothermia
87
Q

dysreflexia

(autonomic hyperreflexia)

A

sudden massive sympathetic discharge

  • T5/6 injury or above
    • stimulation of sensory receptors below lesion
    • uncompensated CV response
    • HTN up to 300 systolic
    • bradycardia (30-40 BPM)
    • sweating above lesion, piloerection
  • Tx:
    • Nitroglycerin paste above lesion (or CCBs)
    • elevate head
    • remove stimulus (empty bladder/bowel)
88
Q

delerium

A

confusional state with depressed LOC

acute onset, resonds to Tx

  • Haloperidol PO/IM
  • avoid benzodiazapines and meperidine (Demorol)
89
Q

dementia

A

acquired cognitive impairment

slow, chronic onset

LOC preserved

90
Q

dissociative amnesia

A

inability to recall important personal information

NOT associated with other disorders

91
Q

anterograde amnesia

A

can’t create NEW memories after amnesia event

(old remain intact)

92
Q

retrograde amnesia

A

can’t remember events BEFORE amnesia event

93
Q

amnesias:

lacunar

emotional-hysterical

Korsakoff

posthypnotic

transient gobal

A
  • 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
Q

Wernicke Encephalopathy

(Wernicke-Korsakoff)

A

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
Q

Korsakoff syndrome

A

anterograde and posteriograde amnesia w/out

impaired alertness, attention, extraocular disturbance

“Yoda confabulation”

96
Q

Broca’s aphasia

(expressive aphasia)

A

expressive language affected but comprehension preserved

97
Q

Wernicke’s aphasia

(repetitive fluent aphasia)

A

comprehension of written and verbal language impaired

(speech fluent but has little meaning)

98
Q

alzehimer disease

A

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
Q

vascular dementia

A

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
Q

frontotemporal dementia

A

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
Q

dementia with lewy bodies

A

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
Q

Creutzfeldt-Jacob (prion) disease

A

proteinaceous infectious particle causing rapid dementia with focal degeneration of cortex

  • 14-3-3 protein (PrPSc)
  • relentless invariably fatal with significant psychiatric symptoms
103
Q

Huntinton’s disease

A

expanded CAG repeats in huntingtin gene

  • chorea, dementia, impulsivity, depression, anxiety
  • Tx:
    • Haloperidon for choreiform
    • Levodopa for muscle rigidity
104
Q

reversible causes of dementia

A
  • normal pressure hydrocephalus
    • “wet, wacky, wobbly” - dementia, ataxia, incontinence
    • shunt
  • chronic subural hematoma
    • papilledema, Babinski sign, HA then confusion, NAV
    • surgical evacuation
105
Q

epilepsy

A
  • 2+ unprovoked seizures
  • 1 occurs in person with at least 60% risk
  • 1 or more in context of epilepsy syndrome
106
Q

partial (focal) seizure

A

originate within neural networks limited to ONE hemisphere

107
Q

generalized seizure

A

affect both hemispheres

  • tonic clonic
  • absence
  • tonic
  • clonic
  • myoclonic
  • atonic
108
Q

actions of seizure drugs

A
  • potentiate inhibitory GABA transmission
  • inhibit excitatory Glutamate transmission
109
Q

seizure med for P, G, S

A

phenytoin (Dilantin)

110
Q

seizure med for G, M, P, A, S

A

valproic acid

*teratogen

111
Q

seizure med for A

A

ethosuxamide (Zarontin)

112
Q

seizure med for G, P, A, S

A

Lamotrigine

*good in pregnancy

113
Q

seizure med for G, P, M

A

leveiracetam (Keppra)

114
Q

treatment of coma

A
  • 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
Q

stroke

A
  • sudden onset
  • focal involement
  • deficits >24h
  • vascular cause
  • Tx:
    • tPA within 4.5h
116
Q

cerebral ischemia

A
  • symptoms when blood supply < 50ml/100g/min
  • types:
    • global- CV collapse
    • diffuse- altitude, anemia, pulmonary disease
    • cerebral- cytotoxic edema d/t neuronal injury
117
Q

TIA

A

focal neurologic deficit < 1h

  • aspirin if probable
  • afib
    • Warfarin 1 day after event
  • all pts.
    • antiplatelet: ASA, clopidogrel
    • statins
    • anti-hypertensives
    • lifestyle coaching
118
Q

ischemic stroke surgical interventions

A
  • carotid endarterectomy
  • carotid artery stenting
  • decompression of infarted tissue
  • craniectomy decompression to prevent transtentorial herniation
119
Q

vertebrobasilar insufficiency

(VBI)

A

vertigo with associated neurologic signs

  • digital subtraction angiography is gold standard test
120
Q

intracerebral hemorrhage

(ICH)

A

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
Q

subarachnoid hemorrhage

(SAH)

A

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
Q

interventricular hemorrhage

A

blood into ventricles

  • 20ml lethal
  • survivors have sever neurologic and cognitive disability
123
Q

brain vascular malformation

A
  • hypertension NOT a risk
  • arteriovenous malforamations (AVM) MC
  • Tx:
    • selective embolization
    • surgical resection
    • radiation-induced thrombosis
124
Q

familial / essential tumor

A

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
Q

chorea

A

rapid irregular movements of different body parts

  • Tx:
    • adults:
      • Haloperidol
      • Pimozide
    • children:
      • benzos
        • Clonazepam
        • Diazepam
        • Clobazam
126
Q

Sydenham chorea

A

late component of rheumatic fever from group A strep

  • Tx:
    • Valproate
127
Q

ballism

A

extreme form of chorea

  • hemiballism on one side d/t stroke can resolve after 1 week
  • Tx:
    • treat like chorea
128
Q

Huntington disease

A

autosomal dominant CAG repeats in huntingtin protein

  • Tx movement disorder:
    • Reserpine
    • Teatrabenzine
    • Haldol
    • Quetiapine (Seroquel) - also treats psychosis
129
Q

dystonia

A

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
Q

tics

A

repetitive movements or vocalizations

  • Tx:
    • behavior modifications
    • antipsychotics:
      • Haldol
      • Pimozide
      • Risperidone
131
Q

Tourette’s syndrome

A

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
Q

myoclonus

A

sudden shock-like very short muscle contractions

and brief inhibition (+ and - jerks)

  • Asterixix MC negative
  • Tx secondary causes:
    • Clonazepam
    • Valproic acid
    • Carbamazapine
    • Levetiracetam
133
Q

restless leg syndrome

A

unpleasant creeping discomfort in legs

(Fe deficiency sometimes)

  • TOC is dopamine agonists:
    • Pramipexol (Mirapex)
    • Ropinirol (Requip)
    • Transdermal Rotigotine
  • other:
    • Gabapentin (Neurontin)
    • L-dopa
134
Q

parkinson disease

A

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
Q

multiple sclerosis

A

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
Q

MS Classifications

A
  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
Q

McDonald’s Criteria for MS

A
  • 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
Q

MS Tests

A
  • FLAIR T2-weighted MRI of brain, cervical & thoracic spine
  • VEP
  • SSEP
  • LP
    • cell count, protein, glucose, oligoclonal bands, IgG/IgA
139
Q

MS Treatment

A
  • 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
Q

optic neuritis

A

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
Q

transverse myelitis

A

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
Q

CNS Infections by Lab Values

A

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
Q

meningitis

A

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
Q

bacterial meningitis

A

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
Q

viral meningitis

(aseptic meiningitis)

A

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
Q

encephalitis

A

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
Q

brain abscess

A

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
Q

spinal epidural abscess

A

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
Q

septic venous thrombosis

A

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
Q

upper motor neuron disease

A
  • 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
Q

lower motor neuron disease

A
  • 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
Q

amyotrophic lateral sclerosis

(ALS)

A

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
Q

peripheral neuropathy

A
  • 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
Q

Diabetic Neuropathy

A
  • 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
Q

distal symmetric polyneuropathy

A
  • 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
Q

diabetic autonomic neuropathy

A

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
Q

diabetic compressive mononeuropathy

A
  • carpal tunnel, cubital tunnel, unilateral foot drop
  • numbness, edema, pain, prickling
158
Q

infectious neuropathies

A
  • 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
Q

herpes zoster postherpetic neuropathy Tx

A
  • 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
Q

lyme disease Tx

A
  • 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
Q

alocohol peripheral neuropathy Tx

A

symptoms similar to diabetic neuropathy

  • IV thiamine
162
Q

acquired inflammatory peripheral neuropathies

A
  • 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
Q

hereditary neuropathies

A
  • 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
Q

CNS tumors general s/s, dx, tx

A
  • 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
Q

meningioma

A
  • 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
Q

glioblastoma / astrocytoma

A
  • 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
Q

pituitary tumor

A
  • 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
Q

nerve sheath tumor

A
  • Schwannomas and neurofibromas
  • radicular pain
  • Tx:
    • surgical removal
169
Q

CNS mets

A
  • 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
Q

spinal tumors

A
  • 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
Q

Familial/Essential Tremor

A

Propranolol 40-160mg PO bid

172
Q

Chorea & Sydenham’s Chorea

A

Adults: Haloperidol or Pimozide Children: Benzos- Conazepam, Diazepam, Sydenham’s: Valproate

173
Q

Ballism

A

Tx like chorea

174
Q

Huntington’s

A

Reserpine “rose serpent”, Quetiapine (Seroquel)

175
Q

Dystonia

A

Botulinum

176
Q

Tics

A

Haldol

177
Q

Myoclonus

A

Clonazepam “clown hands”

178
Q

Restless Leg Syndrome

A

Pramipexol (Mirapex) “prom pix”, Ropinirole (Requip), Transdermal Rotigotine, Gabapentin (Neurontin), L-dopa

Clinical Medicine II (5 decks)

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