Neurology Flashcards
Treatment of botulism entails:
- Respiratory support
- Trivalent botulinum antitoxin
- Admission
Carpal tunnel results from compression of the ___ nerve.
Median
- Women 30-55y
- *Signs: numbness and tingling of the thumb, index finger, middle finger, and medial half of ring finger. Nocturnal pain is common. Thenar atrophy in severe cases!
- **Tested with Tinel’s and Phalen’s signs
Compression of ulnar nerve at elbow is known as _____.
Cubital Tunnel
*Causes tingling in 5th and lateral 4th fingers that may progress to paralysis
Reactivation of HSV or VZV can cause facial paresis/inflammatory reaction involving the facial nerve. This is known as ____.
Bell’s Palsy
- RF- pregnancy and DM
- *S&S- facial paralysis, ptosis, ear pain, taste disturbance
ALS/Lou Gherig’s Disease associated with:
o Causes progressive muscle atrophy and weakness
o Upper motor neuron dysfunction causes limb spasticity, hyperreflexia, and emotional lability.
o Lower motor neuron dysfunction causes limb weakness, atrophy, fasciculations, dysarthria, dysphagia, and difficulty in mastication.
o Symptoms are asymmetric.
o Patients may appear to have an acute compressive radiculopathy.
o Respiratory muscle weakness causes progressive respiratory depression.
How is ALS managed?
o Respiratory failure, pneumonia, chocking, and trauma are common ED presentations.
o Optimize pulmonary function with nebulizer treatments, steroids, antibiotics, and intubation as indicated.
o Admit patients with pneumonia or inability to handle secretions.
Weakness of the proximal extremity muscles, neck, extensors, and facial muscles is most commonly seen with _______. Ptosis and diplopia are common presenting symptoms.
Myasthenia Gravis
______ test can differentiate myasthenic crisis from overmedication.
Tensilon
- Give neostigmine if positive
- *Crisis can lead to respiratory muscle weakness
MG treat with airway management and what other options?
High-dose steroids, plasmapheresis, IVIG
Decreased strength, increased tone, hyperreflexia, clonus, decreased vibratory sense and joint proprioception, and reduced pain and temperature sense are associated with what condition?
MS
Optic neuritis is a presenting complaint in 30% of ____ cases.
MS
High dose _____ has been shown to shorten duration of MS exacerbations.
Methylprednisolone
Resting tremor, cogwheel rigidity, bradykinesia, and impaired posture/equilibrium is associated with _____.
Parkinson’s Disease
*Resting arm tremor, pill rolling, which improves with intentional movement is also seen
Some info about migraines…
- Unilateral, with throbbing or pulsating discomfort.
- Triggers → chocolate, red wine, hard cheese, MSG, hormonal changes, exertion, fatigue, stress
- Often associated with N/V, photo and phonophobia
- Usually 4-72 hours in duration
Relief of migraines involves:
- Triptans. CI- CAD, PVD, pregnancy, uncontrolled HTN
- Dopamine blockers- Reglan, Phenergan, Compazine
* Given with Benadryl to prevent EPS - IV fluids, NSAIDs, and tylenol also help
- Prophylactic- beta blockers, calcium channel blockers, TCAs, NSAIDs, anticonvulsants
_____ is the MC type of HA.
Tension
- S&S- tight, band-like pain. Can be a constant, daily HA.
- *Not worsened with activity and usually not pulsatile
- **No N/V/FND
Severe unilateral, periorbital/temporal pain in bouts that last < 2 hours and may occur several times a day over 6-8 week period are known as _____ HAs.
Cluster
Ipsilateral Horner’s syndrome (ptosis, miosis, anhydrosis), nasal congestion/rhinorrhea, conjunctivitis and lacrimation are associated with _____.
Cluster headaches
____ is the 1st line treatment for cluster headaches.
100% Oxygen
- triptans can help during an attack
- *Verapamil for prophylaxis!!
Vibration and position sense in the toes test the posterior columns which degenerate in ____ and _____ deficiency.
Neurosyphilis and B12 deficiency
CT is less sensitive than Mr for lesions of the _____ and is insensitive for acute ischemia.
Posterior fossa
Neurosyphilis is screened for with the ___ and ____ tests.
VDRL and RPR
Suspect _____ in an elderly patient with a broad-based, shuffling gait, urinary incontinence, and dementia. CT will show–> ventricular dilatation out of proportion to sulcal atrophy.
Normal pressure hydrocephalus
Administer _____ IV to alcoholics and other malnourished individuals who might have Wernicke disease, which is suggested by findings of ataxia, AMS, and ophthalmoplegia.
Thiamine
The MC type of dementia is ______.
Alzheimers
*Associated with amyloid deposition in the brain
_____ is the 2nd MC type of dementia that is due to chronic ischemia and multiple infarctions (lacunar infarcts).
Vascular Dementia
___ is the MC RF for vascular dementia.
HTN
Marked personality changes, with no amnesia, and behavioral symptoms is associated with _____ dementia.
Frontotemporal
Visual hallucinations, delusions, and abnormal neuronal protein deposits are associated with ______.
Diffuse Lewy Body Disease
Upward babinski reflex is associated with a/n _____ (upper/lower) motor neuron lesion.
Upper (UMN)
*upward babinski is only considered normal in infant-2y
The Glasgow Coma Scale…
- Eye Opening:
- Spontaneous: 4
- Response to verbal commands: 3
- Response to pain: 2
- No eye opening: 1
- Best Verbal Response:
- Oriented: 5
- Confused: 4
- Inappropriate Words: 3
- No verbal response: 1
- Best Motor Response:
- Obeys commands: 6
- Localizing response to pain: 5
- Withdrawal response to pain: 4
- Flexion to pain: 3
- Extension to pain: 2
- No motor response: 1
Interpretation of GCS:
- Mild brain injury ≥13
- Moderate brain injury 9-12
- Severe brain injury ≤8
Primary causes of bacterial meningitis include:
S. pneumo, neisseria meningitis, group B strep (esp. in infants)
Type of meningitis broken down by age:
< 1 month- group B strep
1-2 months- E. coli
2 months- Adolescent- S pneumo, N meningitis
Symptoms of meningitis are typically _____ (acute/chronic) with patients presenting within hours or 1-2 days of infxn.
Acute
With that patient supine and thigh flexed to 90°, attempts to straighten or extend the leg are met with resistance is known as ______.
Kernig’s sign
Flexion of the neck causes involuntary flexion of knees and hips is known as _____.
Brudzinski’s sign
Analysis of CSF fluid in bacterial meningitis…
- May be slightly turbid or grossly purulent
- Pressure elevated in more than 90% of cases
- WBC count elevated
- Glucose levels are often decreased (may be less than 40)
Abx treatment of bacterial meningitis:
- Neonates: Ampicillin and Cefotaxime
- Infants- 3 months: See above, maybe higher dose
- Immunocompetent 3 months- 55 y: Ceftriaxone and Vanc
- > 55y or any age with debilitating illness: Amp + Ceftriaxone + Vanc
* Repeat LP, CSF should be sterile after 24 hours
_____ is preceded by nonspecific prodrome of fever, malaise, sore throat, and myalgias. It usually resolves in 2-4 days and may improve after LP.
Viral meningitis
- Often presents as an acute confusional state, especially in kids and young adults
- *In encephalitis, because it involves the brain directly, there may be markedly altered consciousness, seizures, personality changes, and other FND
CSF in VIRAL meningitis:
- Opening pressure usually normal
- WBC count generally < 1000
- Protein, glucose, and serum blood counts are more likely to be normal
Treatment of viral meningitis entails…
- Usually self-limited
- Suspected HSV infection treated with acyclovir
In U.S.- the most common viruses to cause encephalitis are:
West Nile, HSV, HZV, EBV, CMV, and rabies
Consider encephalitis in patients presenting with:
o New psychiatric symptoms
o Cognitive deficits (aphasia, amnestic syndrome, acute confusional state)
o Seizures
o Movement disorders
*Motor and sensory deficits are NOT typical
_____ is the most widely used screening test for West Nile Virus
IgM ELISA
Bell’s palsy must involve the _____ or it could represent a stroke.
Forehead
*Can treat with prednisone
TIAs cause transient ischemic neuro deficits that resolve within ____.
24 hours
*80% resolves within 60 minutes
______ can result from a TIA and is defined as painless temporary loss of vision in one or both eyes.
Amaurosis fugax
_____ is the definitive study for a TIA.
Arteriography
*But MRA also used and less invasive
______ therapy is initiated when a TIA is not cardiogenic.
Prophylactic antiplatelet therapy
*Aspirin, clopidogrel
Cardiogenic TIA requires _______.
Anticoagulants
- Initially with IV heparin for those who are admitted to the hospital and with warfarin for long-term therapy
- *Carotid endarterectomy may be indicated in patients with anterior circulation TIAs
Expressive aphasia is associated with _____ (Broca’s/Wernicke’s) area.
Receptive aphasia is associated with ______ (Broca’s/Wernicke’s) area.
- Expressive- Broca’s
- Receptive- Wernicke’s
Unilateral headache, visual field defects, dizziness, vertigo, diplopia, dysphagia, ataxia, cranial nerve deficits, or bilateral limb weakness are suggestive of a ______ stroke.
Posterior circulation
If not a candidate for thrombolysis do NOT intervene with BP unless it is > _____.
220/120
*Labetalol
If a candidate for thrombolysis, target is ≤ ____.
185/110
*Labetalol or NG paste
Institute tPA for acute ischemic stroke if ≤ ___ hours from symptom onset.
3
*For those ≥18y
Absolute Contraindications to tPA include:
- Current intracranial or subarachnoid hemorrhage
- Previous head trauma or stroke within preceding 3 months
- Prior intracranial hemorrhage, AVM, or aneurysm
- Use of heparin within preceding 48 hours and a prolonged aPTT
- Platelet count < 100,000/mm3
- Pretreatment BP >185/110
Some say can still give if < 4.5 hours since symptom onset, but there are additional contraindications:
- Age > 80 years
- Severe stroke as assessed clinically (NIHSS score > 25)
- Combination of previous stroke and diabetes mellitus
- Blood glucose <50 mg/dL or >400 mg/dL
- Oral anticoagulant treatment
If an ischemic stroke presents outside tPA therapeutic timeline, supportive care in the ED including…
Aspiration prevention, normalization of glucose level, falls precaution, treatment for comorbidities
NIHSS
http://stroke.ahajournals.org/content/48/Suppl_1/AWP276
What is the 5-point Hunt-Hess system with relation to SAH severity?
o Grade 1 → mild headache and slight nuchal rigidity
o Grade 2 → CN palsy, severe headache, nuchal rigidity
o Grade 3 → mild focal deficit, lethargy, or confusion
o Grade 4 → stupor, hemiparesis, early decerebrate rigidity
o Grade 5 → deep coma, decerebrate rigidity, moribund appearance
CT is sensitive to detect SAH within ___ hours of symptom onset. Otherwise do a LP.
12 hours
Initial medical treatment of SAH is to control HTN with IV medications, specifically _____.
Labetalol
Mannitol for increased ICP, Phenytoin for prophylactic seizure management
Monitor serum ____ with SAH.
Sodium!! HYPOnatremia is common.
Treatment options for SAH/Cerebral aneurysm:
- Emergency external ventricular drainage to decrease ICP
- Rare cases w/ progressive neuro deterioration- emergency craniotomy and evacuation of a blood clot to prevent herniation
- Definitive treatment is obliteration by microsurgical clipping or endovascular coiling of the aneurysm
Administer _____ before glucose in hypoglycemic patients with a history of alcohol abuse or malnutrition.
Thiamine
*Empiric naloxone is a good option for AMS
What is catatonia?
o Symptom complex associated with severe psychiatric disease with:
• Stupor, excitement, mutism, posturing
• Can also be seen in organic brain disease: encephalitis, toxic and drug-induced psychosis
Following a concussion ______ concentration is increased.
Potassium
An arterial laceration of the _______ is associated with Epidural Hematomas.
Middle meningeal artery
Epidural hematomas are usually due to ______ (MOI).
- High-energy deceleration injury
2. Lateral blow to the temporal bone
A lens shaped mass is associated with _____ hematoma.
Epidural
_______ (Epidural/Subdural) hematoma commonly presents as a head injury followed by an initial loss of consciousness, recovery (honeymoon period, lucid interval), and then progressive deterioration.
Epidural
GCS of < ___ requires immediate endotracheal intubation for airway protection and rapid neuro eval
8
Airway control and emergency cranial decompression must be performed for patients with a depressed skull fracture and neuro exam showing decreasing LevelOC
fyi
Source of subdural hematoma is from ruptured _____.
Bridging veins
Patients at an increased risk for a subdural hematoma are:
Older patients, those with brain atrophy, and patients treated with anticoagulants
Symptoms of subdural hematoma are:
Headache, drowsiness, unilateral neurologic symptoms are the presenting symptoms
o Seizure and papilledema are uncommon
A head CT showing a crescent shape that crosses suture lines is evidence of a _______ hematoma.
Subdural
- Consider MRI- more sensitive
- *If not trauma- may use angiography to identify the root cause
Treatment of subdural hematoma includes:
o Nonoperative management is limited to patients with small lesions and no evidence of herniation
o Patients with significant neurologic deficits secondary to mass effect may need urgent burr-hole decompression or craniotomy
o Other indications for surgical management → lesion >10mm, >5mm of midline shift, or declining GCS
o Important to identify and ligate the bleeding vessel
Secondary seizures may result from:
- Congenital abnormalities or perinatal injury
- Metabolic disorders
- Trauma or tumors
- Vascular disease
- Infectious disease
- Degenerative diseases such as Alzheimer’s
A ______ (generalized/partial) seizure causes sudden loss of consciousness. Can be convulsive (grand mal or tonic-clonic) or nonconvulsive (absence).
Generalized
A bit about Absence seizures…
• Begin in childhood, are often familial, and typically subside before adulthood.
• Signs and symptoms:
o Brief, often unnoticeable, episodes of impaired consciousness lasting only seconds and occurring up to hundreds of times per day. Present as staring spells.
*Treatment- Ethosuximide
Signs and Symptoms of a Tonic-Clonic seizure are…
o Begin suddenly with loss of consciousness and tonic extension of the back and extremities, continuing with 1-2 minutes of repetitive, symmetric clonic movements.
o Seizures are sometimes marked by incontinence and tongue biting
o Patients may also appear cyanotic during the ictal period owing to poor respiratory function during the seizure.
o Consciousness is slowly regained in the postictal period.
o Postictally, the patient may complain of fatigue, muscle aches, and headaches
Treatment of Tonic-Clonic Seizures involves
o Emergent treatment with benzodiazepines to abort the seizure
o Protect the airway
o Manage the underlying cause
o Give antiepileptics for secondary prevention:
• Phenytoin, phenobarbital, valproate, lamotrigine, levetiracetam, zonisamide, gabapentin, topiramate, rufinamide.
______ seizures can be simple or complex. They arise from a discrete region of 1 cerebral hemisphere.
Partial
A little about SIMPLE partial seizures…
- Simple partial seizures are NOT accompanied by an impairment of consciousness
- May be an isolated tonic or clonic activity of a limb or transient altered sensory perception, which may spread to include the entire side of the body in a “jacksonian march”
A little about COMPLEX partial seizures…
• Complex partial (temporal lobe, then frontal, then occipital) seizures often are characterized by an aura (transient abnormalities in sensation, perception, emotion, or memory)
- Followed by impaired consciousness lasting for seconds to minutes.
- Nausea or vomiting, focal sensory perceptions, and focal tonic or clonic activity may accompany a complex seizure
Treatment of partial seizures involves…
Adult partial seizures:
•Phenytoin, carbamazepine, oxcarbazepine, phenobarbital, valproate, lamotrigine, levetiracetam, zonisamide, gabapentin, topiramate, rufinamide, lacosamide
Pediatric partial seizures:
• Phenobarbital
Postictal → _____ may be seen → weakness or paralysis that is often unilateral and resolves over 24-48 hours
Todd’s paralysis
_______ seizures are psychogenic whereas true seizures are electrical.
Pseudoseizures
Serum _____ levels are usually elevated after a true tonic-clonic seizure
Prolactin
Systemic processes that can provoke seizures…
- Hypoglycemia or hyperglycemia
- Hyponatremia, hypocalcemia
- Hyperosmolar states
- Hepatic encephalopathy
- Uremia
- Porphyria
- Drug OD, drug withdrawal
- Eclampsia
- Hyperthermia
- Hypertensive encephalopathy
- Cerebral hypoperfusion
ED care and dispo of seizures…
o IV anticonvulsants are not indicated during an uncomplicated seizure
o In patients with a known seizure disorder whose anticonvulsant levels are low, supplemental doses may be appropriate
• Phenytoin (oral or IV)
*If it’s the first seizure and they have a normal workup, they can be discharged
Outpatient treatment for seizures…
o Correction of hyponatremia, hypoglycemia, or drug intoxication may be all that is necessary to control seizures
o Anticonvulsant therapy typically is not indicated in the setting of a single unprovoked seizure in a patient with a normal neuro exam and normal brain imaging and EEG
_______ is diagnosed when seizures fail to cease spontaneously or recur so frequently that full consciousness is not restored between successive episodes.
Status epilepticus
MEDICAL EMERGENCY
Management of Status Epilepticus
- Ensure airway
- Manage hyperthermia- cooling blanket or induction of motor paralysis
- Diazepam or lorazepam IV until seizure stops.
* If seizure persists, give midazolam or propofol
An acute, rapidly progressive peripheral demyelinating disease that is believed to be autoimmune in nature and often associated with a viral URI is _______.
Guillain-Barre Syndrome
*85% of patients make a complete or near-complete recovery
Guillain-Barre is associated with rapidly progressing ______ (ascending/descending) paralysis.
ASCENDING
*DTRs absent
DDX for Guillain Barre is:
o Botulism, diphtheria, polio, MG, and poisoning or toxin-mediated conditions
Workup of Guillain Barre includes:
o EMG and nerve conduction studies will show diffuse demyelination but may not be present in the early course of the disease.
o LP reveals a CSF protein level >55 with little or no pleocytosis (albuminocytologic dissociation)
• Normal cell count (or low white cell count)
o MRI of the spinal cord to exclude cord compression.
Treatment of Guillain Barre involves:
o Admit to ICU for close monitoring. Be prepared to intubate patients if they develop impending respiratory failure from paralysis of the diaphragm and accessory respiratory muscles.
o Plasmapheresis and IVIG are first-line treatments.
*Steroids are not indicated in GBS but may be used in CIDP.
What is Central Cord Syndrome?
• Typically occurs with cervical hyperextension when the ligamentum flavum buckles into the spinal canal and pinches the cord
-The primary damage occurs in the central gray matter and usually manifests as weakness that is greater in the upper extremities than the lower extremities.
Good recovery :)
Brown-Sequard Syndrome:
- Occurs when a lateral half of the spinal cord is injured at a specific level (e.g. from penetrating trauma). The syndrome presents as ipsilateral motor paralysis and contralateral sensory loss (of pain and temperature) distal to the injury. Bowel and bladder function is usually maintained.
- Good prognosis
Anterior Cord Syndrome:
- Occurs when the anterior aspect of the spinal cord is injured by bone fragment compression, disc herniation, or ischemia resulting from anterior spinal artery compromise.
- The syndrome manifests as complete paralysis and loss of pain and temperature sensation distal to the injury. Because the posterior columns are unaffected, position, touch, and vibration sense is usually preserved.
Poor prognosis :(
What is NEXUS criteria?
Set of validated elements that allow clinical clearance of the cervical spine without radiographic imaging
Imagine of spine…
-Plain films are an option
o CT of the spine is a more sensitive modality for detecting fracture, especially in the setting of severe degenerative joint disease that may make plain film interpretation difficult.
o MRI of the spine is the most sensitive imaging modality for detecting spinal cord injury, ligamentous injury, and hematomas.
Treatment of spinal cord injuries…
o Spinal immobilization, move using log-roll precautions.
oIf intubation is required, remove cervical collar while maintaining manual inline cervical spine stabilization before attempting intubation.
o Spinal shock → IV fluids, sympathomimetics
o Patients suffering from acute, blunt, spinal cord injury may benefit from high-dose IV methylprednisolone if administered within the first 8 hours of injury.
