Neurology Flashcards
Transient loss of vision in one eye in setting of TIA =
amaurosis fugax
The first branch of the internal carotid artery is the
opthalmic artery (why amaurosis fugax happens in TIA)
TIAs are NEVER caused by
hemorrhage; always by emboli or thrombosis
Anterior cerebral artery lesion symptoms =
contra lower extremity weakness
personality changes
urinary incontinence
mild UE weakness
Middle cerebral artery lesion symptoms=
Profound contra upper extremity weakness Aphasia Apraxia/neglect Eyes deviate TOWARD the lesion side Contra hemonymous hemianopsia w/ macular sparing
Posterior cerebral artery lesion symptoms =
Prosopagnosia (inability to recognize faces)
Vertebrobasilar artery lesion symptoms =
Vertigo Nausea/vomiting Loss of consciousness (drop attack) Vertical nystagmus Dysarthria and dystonia Sensory changes in face/scalp Ataxia BILATERAL FINDINGS
Posterior inferior cerebellar artery lesion symptoms =
Ipsilateral face
Contralateral Body
Vertigo and Horner’s syndromes
Lacunar infarct symptoms =
ABSENCE of cortical deficits Ataxia Parkinsonian signs Sensory probs Hemiparesis (mostly face) Possible bulbar signs
Which test can be positive for stroke within an hour?
MRA
Always do what before treating a stroke?
NON CON HEAD CT
An intracranial neoplasm or mass is an absolute contraindication to
thrombolytic therapy for stroke
CPR within 3 weeks that was traumatic is an absolute contraindication for
thrombolytic therapy for stroke
Up to 6-8 hours after a stroke, what can be done?
Catheter retrieval of the clot (removes it like a corkscrew
Best initial therapy for those arriving late for stroke care?
Aspirin!
Which antiplatelet agent is ALWAYS the wrong answer?
Ticlopidine! No added benefit and it can cause TTP and neutropenia
Manage __ stroke and __ stroke the same way
Anterior and middle cerebral artery strokes are managed the same way
What needs to be done after initial stroke treatment?
Echo to look for clot origin
Carotid dopplers
EKG and holter monitor if EKG is normal
If a-fib is present, start warfarin, dabigatran, or rivaroxaban
Young patients w/ no PMH who present with stroke should also have which tests?
ESR
VDRL or RPR for syphilis
ANA, double stranded DNA
Protein C, S, Factor V Leiden mutation, Antiphospholipid syndromes
The younger the patient, the more likely the stroke is caused by
Vasculitis or hypercoagulable state
Are thrombolytics indicated for TIA?
NO
Therapy for status epilepticus =
Benzos
Fosphenytoin if persists after 10-20 min
Phenobarb after another 10-20 min
General anesthesia after yet another 10-20 min
Which blood tests need to be done on seizing patient?
Sodium Calcium Glucose Creatinine Magnesium Liver and renal function
Which non-blood tests need to be done for seizing patient?
Urine toxicology screen
Head CT urgently
When should a first seizure patient be started on chronic antiepileptics?
Strong family hx of seizures
Abnormal EEG
Status epilepticus requiring benzos
Brain tumor
First line antiepileptics =
valproic acid
carbamazepine
phenytoin
leviteracetam
What is an AE of lamictal (lamotrigine)?
Stevens Johnson syndrome and severe skin reactions
Absence or petit mal seizures should be treated with
Ethosuximide
Treat mild parkinson’s disease under age 60 with
anticholinergic agents such as Benztropine or Hydroxyzine
Treat mild parkinson’s over age 60 with
Amantadine due to danger of anticholinergics in the elderly
First line tx for severe parkinson’s includes
Levodopa/Carbidopa and dopamine agonists (pramipexole, ropinirole, cabergoline)
Additional meds for parkinson’s if first line failes include
COMT inhibitors (tolcapone, entacapone)
MAOi’s
Deep brain stimulation last resort
COMT inhibitors block dopamine metabolism and work best with
Dopamine based medications
The most common abnormality in multiple sclerosis is
optic neuritis
Best initial dx test AND most accurate test for MS is
MRI
Is there any reason to order a CT for MS?
NO
What will you find on CSF of multiple sclerosis?
Oligoclonal bands ONLY if MRI is nondiagnostic
Disease modifying therapies for MS include
beta interferon, glatiramer, mitoxantrone, natalizumab, fingolimod, or dalfampridine
An anti-CD52 drug that inhibits lymphocytes and deters progression of MS is
Alemtuzumab
What is an adverse effect of natalizumab?
PML
For ALL patients with memory loss, order
Head CT
B12 level
Thyroid function testing
RPR or VDRL
Head CT showing diffuse, symmetrical atrophy =
Alzheimer’s disease MAYBE (dx of exclusion)
Standard of care for Alzheimer’s =
Anticholinesterase inhibitors such as donepezil, rivastigmine, and galantamine
Pick’s disease, aka frontotemporal dementia, will show __ on head CT or MRI
focal atrophy of the frontal and temporal lobes. Treat the same as Alzheimers!
Rapidly progressive dementia and presence of myoclonus =
Creutzfeldt-Jacob Disease. Patients way younger than Alzheimers
CSF shows ___ in CJD
14-3-3 protein (spares the patient a brain biopsy
Parkinson’s disease + dementia =
Lewy Body dementia, VERY VERY VIVID hallucinations
Wet, Wobbly, Wacky =
Normal pressure hydrocephalus. Treat w/ shunt
Dx NPH with
LP plus clinical picture (normal pressure duh)
Diagnose Huntington’s Disease/ Chorea with
specific genetic testing, inheritance is autosomal dominant
Give ___ for huntingtons movement disorder
tetrabenazine
Best initial abortive therapy for migraine is
sumatriptan or ergotamine
4 or more migraines per month, ppx with
beta blockers
Best initial therapy for cluster headache is
triptans or 100% oxygen
Ppx for cluster headaches =
calcium channel blockers such as verapamil
Dx test for temporal arteritis =
ESR is best initial test, but temporal artery biopsy is most accurate!
Delay in steroid treatment for temporal arteritis can result in
permanent vision loss
Obese young woman with headache and double vision =
pseudotumor cerebri
Vitamin A use can cause!
LP in pseudotumor cerebri will show
markedly elevated pressure
Treat pseudotumor cerebri with
weight loss
Acetazolamide
Surgery if those fail
Generally all patients with vertigo should have what test?
MRI of the internal auditory canal
Vertigo alone with no hearing loss, no tinnitus, and no ataxia =
Benign positional vertigo
Idiopathic inflammation of the vestibular portion of the 8th cranial nerve
Vestibular neuritis
Is there hearing loss or tinnitus in vestibular neuritis?
NO
Treat vestibular neuritis with
meclizine
Labyrinthitis is inflammation of
the cochlear portion of the inner ear
What are symptoms of labyrinthitis?
Hearing loss and tinnitis; self-limited
Treat Meniere’s with
salt restriction and diuretics
Ataxia + hearing loss + tinnitus + vertigo =
Acoustic neuroma (8th cranial nerve tumor, related to Von Recklinghausen’s)
Treat Wenicke-Korsakoff syndrome with
Thiamine first, then glucose
When a CNS infection is suspected, some patients will require you to
Do a head CT BEFORE an LP if there is a history of CNS disease, FND, papilledema, seizures, altered consciousness, or significant delay in the time to perform the LP
Gram negative pleomorphic occobacillary organisms on CSF =
Haemophilus
A normal protein level in CSF essentially excludes
bacterial meningitis
Glucose levels below 60 percent of serum levels are consistent with
bacterial meningitis
Best initial therapy for cryptococcus is
amphotericin and 5-flucytosine, followed by oral fluconazole
Treat lyme disease with
IV ceftriaxone or penicillin
Treat Rocky Mountain spotted fever with
doxycycline
The single most accurate test in TB of CSF is
PCR!
How to treat amoebic meningitis
Miltefosine and maybe amphotericine; steroids may help
Fever + AMS+ photophobia + stiff neck =
encephalitis
Almost all encephalitis in the US is caused by
Herpes
How to dx encephalitis?
PCR, NOT brain biopsy
Treat with acyclovir
Ring-enhancing brain lesion basically means either __ or __
cancer or infection
Brain lesions of progressive multifocal leukoencephalopathy are not associated with
ring-enhancement or mass effect
Patient from Mexico with a seizure =
neurocysticercosis
Multiple 1cm cystic lesions on head CT =
neurocysticercosis; treat with albendazole
Neuro symptoms in the setting of hypertensive crisis, preeclampsia, or cytotoxic meds like cyclosporine =
Posterior Reversible Encephalopathy Syndrome
What is the goal pCO2 when trying to constrict cerebral blood pressures in increased ICP?
pCO2 of 28-32 (hyperventilation)
Do steroids help intracranial hemorrhage?
NO
Head trauma, burns, and ET intubation with mechanical ventilation can have what adverse effect?
Stress ulcers; treat with PPIs
Subarachnoid hemorrhage is associated with what EKG finding?
T-wave inversion
To be sure an increased WBC is a sign of infection, check the
ratio of WBCs to RBCs (normal is 1:500)
Diagnose syringomyelia with
MRI
ALS is treated with
Riluzole
How does Riluzole work?
Blocks accumulation of glutamate in ALS
Wasting, fasciculations, and weakness are ___ motor neuron signs
Lower
Radial nerve palsy results in __
wrist drop
High boots pressing at the back of the knee can lead to
peroneal nerve palsy; self limiting
Treat bell’s palsy with
steroids
Chronic regional pain syndrome, AKA reflex sympathetic dystrophy, can be treated with
NSAIDs, gabapentin, and occasionally nerve block. Surgical sympathectomy may be necessary
The most urgent step in suspected Guillain Barre is
peak inspiratory pressure due to impending diaphragm weakness
Best initial test for myasthenia gravis =
Anti-acetylcholine receptor antibodies
If pyridostigmine or neostigmine do not work for myasthenia gravis, last resort is
thymectomy for <60 yo
