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Neurology Flashcards

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1
Q

Broca aphasia

A

Expressive aphasia
Patients understand language but cannot generate language
Effects spoken and written language

Broken speech

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2
Q

Wernicke aphasia

A

Receptive aphasia
Patients can generate words/sentences for cannot understand what is said to them
Language generated is often incomprehensible

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3
Q

Conduction aphasia

A

Patient cannot repeat what is said to them

Language comprehension and generation are intact

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4
Q

Global aphasia

A

Combination of non-fluent speech, poor comprehension, and poor repetition

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5
Q

Basilar artery region supplied

A

Midbrain and part of the pons

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6
Q

Anterior inferior cerebellar artery (AICA) regions Regions supplied

A

Parts of the pons and cerebellum

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7
Q

Posterior inferior cerebellar a. (PICA) region supplied, results of stroke

A

Inferior cerebellum and lateral medulla

Occlusion causes Wallenberg syndrome - lateral medullary stroke

  • loss of pain and temperature sensation on the contralateral side of the body
  • loss of pain and temperature sensation on the ipsilateral side of the face
  • cerebellar defects - ataxia, past-pointing
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8
Q

Lesion to nondominant parietal lobe (usually the right)

A

Contralateral hemispatial neglect

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9
Q

Lesion to dominant parietal lobe (usually the left)

A

Gertsmann syndrome - agraphia, acalculia, finger agnosia

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10
Q

Lesion to frontal lobe

A

Personality changes

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11
Q

lesion to the bilateral amygdalae

A

Kluver-Bucy syndrome - disinhibition, loss of fear, hyper orality/ hyperphagia, hypersexuality

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12
Q

Lesion to subthalamic nucleus

A

Hemiballismus

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13
Q

Cranial nerve involved in eyelid opening

A

CNIII

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14
Q

Cranial nerve involved in head turning

A

CN XI

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15
Q

Cranial nerve innervate the muscles of mastication

A

CNV

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16
Q

Cranial nerve for taste from anterior two thirds of tongue

A

CN VII

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17
Q

Cranial nerve involved in tongue movement

A

CN XII

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18
Q

Cranial nerves involved in balance

A

VIII

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19
Q

Cranial nerve monitoring carotid body and carotid sinus chemoreceptors in and baroreceptors

A

CN IX

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20
Q

Anterior spinal artery

A

Supplies all except dorsal columns

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21
Q

Dorsal column - medial lemniscus pathway

A

Carry sensory information - pressure, two point discrimination, vibration, proprioception

Tracks ascend ipsilaterally in the fasciculus gracilis (lower body) and fasciculus cuneatus (upper body)

decussate in the medulla

Ascend as the medial lemniscus and the brain stem to the thalamus -> sensory cortex

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22
Q

Spinothalamic tract

A

Carry sensory information - pain and temperature

Nerves enter the spinal cord and ascend 1-2 levels in Lissauer’s tract

Decussates in the anterior white commissure

Ascends contralaterally to the thalamus -> sensory cortex

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23
Q

Lateral corticospinal tract

A

Carries Motor commands for voluntary movements

Signals originate in the motor cortex

decussates in the medullary pyramids

Descends contralaterally and synapses in the anterior horn of the spinal cord -> skeletal muscles

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24
Q

Location of lesion and clinical findings for amyotrophic lateral sclerosis (ALS)

A

Lesion:
Corticospinal tracts
Anterior horn cells

Findings:
Spastic paralysis (UMN)
Flaccid paralysis (LMN)
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25
Q

Location of lesion and clinical findings for poliomyelitis

A

Lesion: anterior horn cells

Findings: flaccid paralysis (LMN)

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26
Q

Location of lesion and clinical findings for syringomyelia

A

Lesion:
Anterior white commissure - spinothalamic tract
+/- anterior horn cells
Most common cervical and upper thoracic

Findings:
Cape like loss of pain and temperature over shoulders and arms
+/- flaccid paralysis in the arms and hands

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27
Q

Location of lesion and clinical findings for tabes dorsalis

A

Lesion: dorsal column and dorsal roots

Findings:
Impaired proprioception
Gait/balance problems

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28
Q

Location of lesion and clinical findings for Brown-Sequard syndrome

A

Lesion: spinal cord hemi section

Findings:
Ipsilateral loss of vibration sense an two point discrimination
Contralateral loss of pain and temperature below lesion
Ipsilateral motor weakness or paralysis

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29
Q

Most common sequelae of meningitis in kids

A

Hearing loss
Intellectual disability
Seizure disorder
Spastic paralysis

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30
Q

Clinical presentation meningitis

A

Fever
Headache
Stiff neck (nuchal rigidity)
photophobia
Brudzinski’s sign - spontaneous hip flexion when neck is flexed passively
Kernig’s sign - pain during knee extension while hip is flexed to 90 in supine

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31
Q

Contraindications to lumbar puncture

A

Relative:
Tendency to bleed
Very low platelets
Increased intracranial pressure - risk herniation

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32
Q

Exam findings to consider CT before LP

A 
Focal neurological deficits
New onset seizure
AMS
papilledema
Immunocompromised
History of CNS disease
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33
Q

CSF analysis associated with bacterial meningitis
Glucose:
Protein:
WBCs:

A

Glucose: low
Protein: high
WBCs: very high - neutrophils

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34
Q

CSF analysis associated with viral meningitis
Glucose:
Protein:
WBCs:

A

Glucose: nl
Protein: nl/slight elevated
WBCs: elevated - lymphocytes 10-500

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35
Q

CSF analysis associated with TB meningitis
Glucose:
Protein:
WBCs:

A

Glucose: low
Protein: high
WBCs: high - lymphocytes 10-500

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36
Q

CSF analysis associated with Fungal meningitis
Glucose:
Protein:
WBCs:

A

Glucose: low
Protein: high
WBCs: high - lymphocytes 10-500

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37
Q

Most common cause and treatment of bacterial meningitis in less than one month old

A

Listeria monocytogenes
Group B streptococci
E. coli

Ampicillin + gentamicin +/- cefotaxime

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38
Q

Most common cause and treatment of bacterial meningitis in 1-3 mo

A

Group B strep
E. coli
S. pneumo
Neisseria meningitidis

Third-generation cephalosporin - ceftriaxone or cefotaxime
+ vancomycin

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39
Q

Most common cause and treatment of bacterial meningitis in 3m - 50 yo

A

S. pneumo
Neisseria meningitidis - dorms, barracks (petechial rash)
Unvaccinated - HIB

Third-generation cephalosporin + vancomycin

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40
Q

Most common cause and treatment of bacterial meningitis in over 50 yo

A

S. pneumo
Neisseria meningitidis
Listeria monocytogenes

Third-generation cephalosporin
+ vancomycin
+ ampicillin

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41
Q

Intrapartum treatment to prevent Group B strep infection to neonate

A

Ampicillin or penicillin during labor and delivery

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42
Q

Treatment for meningitis in recent neurosurgery

A

Vancomycin + cefepime or meropenem

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43
Q

Treatment for meningitis with CSF leak

A

Third-generation cephalosporin + vancomycin

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44
Q

Circumstances to add dexamethasone to treatment for meningitis

A

Decrease likelihood of neurologic sequelae

Children with HIB meningitis (unimmunized)
S. pneumo meningitis
+/- TB meningitis

Dexamethasone is getting before or with the first dose of antibiotics not started after the antibiotics
-continue 2-4 days

Not given if patient is less than six weeks old

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45
Q

Special precautions in managing the patient with Neisseria meningitidis meningitis

A 
Chocolate isolation
Antibiotics prophylaxis two close contacts
-cipro
-rifampin
-ceftriaxone
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46
Q

Viral meningitis (aseptic meningitis)

A

Clinical presentation:
Mild illness, or severe illness similar to bacterial meningitis
Usually resolve spontaneously without complications

CSF: nl glucose, nl or slightly elevated protein, 10-500 WBCs with lymphocyte predominance

MC viruses:
Enteroviruses
HSV-2

Tx:
Symptomatic - pain control, IV fluids
HSV: acyclovir

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47
Q

Diagnosis and treatment of cryptococcal meningitis

A

Seen in advanced HIV, gradual onset over 1-2 weeks

Cryptococcal antigen in CSF (old way - India ink)

IV amphotericin B + flucytosine for 2 weeks
Followed by oral fluconazole for at least 8 weeks

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48
Q

Tests and treatment for TB meningitis

A

Stain culture for AFB (acid-fast bacilli)
PCR

Treatment:
Rifampin
Isoniazid + B6
Pyrazinamide
Ethambutol
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49
Q

Encephalitis - presentation and diagnostic testing

A

Inflammation of the brain parenchyma

Presentation:
Similar to meningitis - nuchal rigidity, headache, photophobia, fever, altered mental status
Focal neurological deficits
Seizures
Behavioral/personality changes

CSF: mildly elevated WBC (lymphocytes), mildly elevated protein, normal glucose
Elevated opening pressure

Viral cultures, PCR, or antibody studies maybe performed on CSF

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50
Q

HSV encephalitis

A

HSV1 - older patient, latent infection
MRI finding - temporal lobe lesion

HSV PCR on CSF

Tx:
IV acyclovir

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51
Q

West Nile virus

A

Arbovirus - MC in US

Transmission: amplifying host- bird; vector - mosquitoes

Presentation:
often asx
Flulike illness - headache, malaise, back pain, myalgia, anorexia
Neuroinvasive in 1/150 pts: meningitis, encephalitis, Flaccid paralysis (involvement of anterior horn cells)

Dx: detection of virus or WNV IgM in CSF

Tx: supportive

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52
Q

Varicella-Zoster virus encephalitis

A

Complication of herpes zoster
Altered mental status days after rash appears

VZV PCR on CSF

IV acyclovir

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53
Q

Rabies

A

Transmission:
Developing countries - dog bites
US: bats, foxes, skunks, raccoons
Incubation period 1-3 months

Presentation:
Encephalitis: agitation, hydrophobia, pharyngeal spasms, Spasticity of muscles of the head and neck
Progresses to flaccid paralysis, respiratory failure, death

Negri bodies on bx

Prevention of transmission:
-Wash fresh bites with soap and water, apply povidone-iodine
-quarantine/observe animal for 10 days
=ppx if animal developed signs of rabies or if not availabl or if not available for eval
-start ppx immediately for bites on the head or neck (shorter incubation time)

PEP:
Rabies immunoglobulin injected outside of bite and IM
Rabies vaccine - series over 3-4 weeks

100% fatal without tx

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54
Q

Poliomyelitis

A

enterovirus

Fecal – oral spread or droplet respiratory secretions

Mild or subclinical infection
May invade brain or spinal cord -> destruction motor neurons in anterior horns
Asymmetric muscle weakness, muscle atrophy, or flaccid paralysis

Tx: supportive including mechanical ventilation

Prevention:
Inactivated polio vaccine (Salk) - US
Oral poliovirus vaccine (Sabin) - other parts of the world

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55
Q

Toxoplasmosis

A

CNS infection by the protozoan Toxoplasma gondii
-infectious oocytes in infected meat or feces from infected cats

Initial infection - asx
Latent infection - reactivate during immunosuppression -> fever, headache, seizures

MRI shows 1+ ring enhancing lesions
Anti-toxoplasma IgG antibodies

Tx:
Sulfadiazine + pyrimethamine
HIV CD4 less than 100 - TMP-SMX ppx

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56
Q

Brain abscesses

A

Extension of local infection - mastoiditis or sinusitis
Hematogenous spread

Headache, fever, papilledema, seizures

MRI shows ring enhancing lesions
Bx or CT guided aspiration needed

Tx:
Vancomycin + ceftriaxone + metronidazole
Steroids if abscess causing significant mass effect

If recent brain surgery - vancomycin + ceftazidime

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57
Q

Neurocysticercosis

A

Central/South America
Fecal-oral - Taenia solium eggs
Eggs hatch in small intestine -> intestinal wall invasion -> Brain

New onset seizures
CT or MRI - cysts +/- visible scolex, cysts may calcify

Tx:
Antiepileptics - phenytoin if seizures
Antiparasitics - albendazole
Corticosteroids

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58
Q

Reye syndrome

A

Rapidly progressive encephalopathy following a viral illness (flu or chickenpox) and aspirin treatment
Vomiting, confusion, elevated LFTs, hypoglycemia

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59
Q

Risk factors and presentation of TIA

A 
Risk factors:
Family history
Over 55 years old
Hypertension
Diabetes
Coronary artery disease
Tobacco use
Hyperlipidemia
Hypercoagulable state
S/S:
Weakness
Paresthesias
Brief unilateral blindness - amaurosis fugax
Other vision abnormalities
Impaired coordination
Vertigo
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60
Q

Large artery low flow TIA

A

Due to atherosclerosis - internal carotid artery

Recurrent, short event

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61
Q

Embolic TIA

A

Often extra cranial - atrial fibrillation

Longer duration, single event

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62
Q

Lacunar TIA

A

Occlusion of small arteries arising from the middle cerebral, basilar, or vertebral artery

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63
Q

Imaging for TIA

A 
MRI - better to detect infarction
CT - faster, better to detect hemorrhage
Ultrasound of carotids
MRA or CTA - vascular defects
ECHO - evaluate for source of embolus
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64
Q

Treatment of TIA

A

Antiplatelet therapy - clopidogrel and aspirin/dipyridamole prefered; aspirin alone is alternative

Anti-lipid - high intensity Staten therapy in all - atorvastatin 80 mg

BP: treat all with >140/90

Embolic TIA: warfarin + heparin or dibigatran, rivaroxaban, or apixaban

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65
Q

Indications for carotid endartectomy

A

Symptomatic with narrowing of 70 to 99%
Symptomatic men narrowing of 50 to 69%
Asymptomatic with narrowing of 62 to 99%, with life expectancy more than five years, surgeon with perioperative complication rate less than 3%

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66
Q

Anterior cerebral artery stroke

A

Contralateral lower extremity and trunk weakness

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67
Q

Middle cerebral artery stroke

A

Most common

Face and upper extremity weakness, aphasia, neglect, and inability to perform learned actions

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68
Q

Posterior cerebral artery stroke

A

Visual abnormalities

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69
Q

Basilar artery stroke

A

Cranial nerve abnormalities - visual abnormalities, vertigo

Occlusion of one of the branches (median and paramedian branches) - contralateral weakness

Complete occlusion - bilateral long track signs, herald hemiparesis -> b/l

AMS or coma
Sensory defects
Loss of coordination
Difficulty speaking

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70
Q

Stroke risk

A 
Advanced age
Hypertension
History of stroke or TIA
Diabetes
Hyperlipidemia
Smoking
Atrial fibrillation
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71
Q

Lacunar infarct - pure motor hemiparesis

A

Weakness of the face, arm, and leg on one side of body
Absent sensory or cortical signs - a phaser, neglect, apraxia, hemianopsia

Most common - about 50% lacunar strokes

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72
Q

Lacunar infarct - Pure sensory stroke

A

Sensory defects (numbness) a face, arm, leg on one side Of the body

Absent motor or cortical signs

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73
Q

Lacunar infarct - ataxic hemiparesis

A

Ipsilateral weakness and limb ataxia out of proportion to motor defect, Possible gait deviation to the affected side

Absent cortical signs

74
Q

Lacunar infarct - sensorimotor stroke

A

Weakness and numbness of the face, arm, and leg on one side

Absent cortical signs

75
Q

Lacunar infarct - dysarthria, clumpsy hand syndrome

A

Facial weakness, dysarthria, dysphasia, and slight weakness and clumsiness of one hand
Absent sensory or cortical signs
Least common

76
Q

Imaging for strokes

A

CT - faster, better to detect hemorrhage - blood bright white
MRI -better to detect infarction
Ultrasound of carotids
Echocardiogram - check source of embolus
MRA or CT angio - identify artery occluded
If hemorrhagic - coagulation studies

77
Q

Treatment of ischemic strokes

A

Thrombolytic therapy - Alteplase first line
-within 3 to 4.5 hours

Antiplatelet therapy

  • acute - aspirin ASAP unless received thrombolytics, delay 24 hours
  • Long term - clopidogrel or ASA/dipyridamole (aspirin alone if can’t tolerate)

Atorvastatin 80 mg in all

Permissive htn 220/120, treat if over or if CAD (labetalol, nicardipine)

Heparin or LWMH - if afib, mural thormbosis

  • prevent further emboli
  • progressive thromboembolism
  • higher mortality otherwise
78
Q

Contraindication for thrombolytic therapy

A

Hemorrhage on CT
Recent surgery/ hemorrhages
On anticoagulation
BP > 185/110

79
Q

Hemorrhagic stroke treatment

A

ABCs to stabilize
Stop anticoagulants - vit K and FFP if warfarin
Keep SBP below 220, below 180 if signs of increased ICP

Control intracranial pressure
-elevate head of bed 30°
-analgesia and sedation
-mannitol
-hyperventilation to PaCO2 25-30 (temporary)
Surgical decompression
80
Q

Causes of seizures in infants, children, adults, elderly

A

Infants: hypoxic injury, metabolic defects, genetic or congenital abnormalities such as PKU, infection

Children: idiopathic, infection, fever, trauma

Adults 18-35: trauma, alcohol withdrawal, brain tumor
Adults - general: idiopathic, metabolic defects (hyponatremia, hypoglycemia), drugs, trauma, neoplasm, infection, cerebrovascular disease
-toxoplasmosis, neurocysticercosis, HSV
-hemorrhagic stroke

Elderly: same as adults but higher percentage of CVA and metabolic defects

81
Q

Medications or medication withdrawals known to cause seizures

A

Theophylline - neuro/cardiotoxicity
Bupropion (SSRIs, TCAs)
Narcotics - fentanyl, meperidine, propoxyphene
Psychoactive stimulants - amphetamines, cocaine methylphenidate
Phencyclidine (PCP)
Neuroleptics - clozapine, phenothiazines
Abx: isoniazid (ppx against by adding B6), PCNs, metronidazole
alcohol toxicity/withdrawal

82
Q

Todd paralysis

A

Unilateral weakness/paresthesias after generalized seizure

83
Q

Treatment of status epilepticus

A 
ABC's
IV/IM benzo - diazepam, lorazepam
Phenobarbital
Intubate
Phenytoin or fosphenytoin to prevent recurrence
84
Q

First-line treatment of eclampsia

A

magnesium-sulfate
+/- benzo: diazepam, lorazepam
C-section after stop a seizure

85
Q

Cs of Huntington disease and treatment

A

CAG repeat disorder on chromosome 4 (huntingtin gene)
ACh and GABA decreased
Choreiform movements
Cognitive decline (dementia)
Caudate nucleus (basal ganglia) atrophy on MRI
40 yo average onset

Tx:
Dopamine antagonists - treat choreiform - tetrabenazine
Antipsychotics - risperidol, olanzapine

86
Q

Presentation of multiple sclerosis

A

Focal inflammatory demyelinating lesions affecting the brain and spinal cord

MC - women 20-40

Lesions separated in and both space and time

  • slowly progressive, with remissions and relapses
  • symptoms exacerbated by overheating

Sensory deficits

Paresthesias
-Lhermitte’s sign - neck flexion causes electric shock like tingling radiating down the back and into the extremities

Motor weakness - limbs, face, diplopia, ptosis

Bowel or bladder dysfunction - urgency, incontinence, retention

Unilateral optic neuritis
Internuclear ophthalmoplegia

87
Q

Unilateral optic neuritis

A

Acute eye pain worse with eye movement

Central vision loss

Afferent pupillary defect (Marcus Gunn Pupil)

  • no constriction of either pupil when light is shone into affected eye
  • both pupils constrict when light is shone into the unaffected eye
88
Q

Internuclear ophthalmoplegia

A

Damage to the media longitudinal fasciculus (MLF)

Ipsilateral I cannot adduct on lateral gaze - stare at side of lesion

Horizontal nystagmus in the contralateral eye during lateral gaze

Normal convergence

89
Q

Evaluation and treatment of multiple sclerosis

A

CSF:
elevated protein
mild elevated WBC count
Oligoclonal bands - IgG antibodies seen on gel electrophoresis

MRI of brain and orbits and MRI of the spinal cord - demyelinated White matter lesions of various ages

Tx:
Acute attacks: high-dose glucocorticoids (methylprednisolone 500-1000 mg qD x5 days)

Maintenance therapy:
Interferon beta - decreases the frequency of exacerbations
Glatiramer

2/3rd line: Natalizumab - increased risk for adverse side effects

Dimethyl fumerate
Teriflunomide

90
Q

Syringomyelia

A

Cystic degeneration of the spinal cord -> expansion of the cavity compresses adjacent neural tissue
-develops months to years after cervical spinal injury

Features:
Compression of crossing fibers of the spinothalamic tract in the anterior white commissure -> loss of pain and temperature sensation 1-3 segments below the syrinx (arms)
Compression of LMNs in anterior horns -> UE weakness, flaccid paralysis, atrophy of hand muscles
Decreased DTRs
Muscle fasciculations

Tx: surgical decompression and shunting

91
Q

Causes of dementia

A 
Alzheimer's disease
Dementia with Lewy bodies
Vascular dementia
Frontotemporal dementia (Pick Dz)
Parkinson disease
Huntington disease
Normal pressure hydrocephalus
Vit B12 deficiency
Thiamine deficiency (Wernicke-Korsakoff syndrome)
Niacin deficiency (pelagra)
Hypothyroidism
Wilson's disease
Brain tumors
HIV infection
Creutzfeldt-Jakob disease
Neurosyphillis
92
Q

Pseudodementia

A

Day to day memory loss
Realize they have a problem (True dementia don’t know)
Causes: depression MC, others

93
Q

Differentiate Alzheimers from vascular dementia

A

CT or MRI to distinguish - old ischemic damage in vascular dementia

94
Q

Dementia workup

A 
CMP
CBC
UA
Vit B12
TSH
PRP
HIV test
non cont CT or MRI - infarct, hydrocephalus
95
Q

Alzheimer’s disease

A

Dementia characterized by amyloid plaques, neurofibrillary tingles, and neuronal atrophy

Risk factors:
Advancing age
Family history
Downs syndrome - Amyloid precursor protein (APP) gene on Chr 21 -> more amyloid plaques

Clinical features:
Progressive short-term memory loss
Loss of executive function -> difficulty completing complex tasks
Disinhibition, personality changes, and delusions possible

Dx of exclusion
MRI the brain shows cortical atrophy - nonspecific, not diagnostic

Tx:
Cholinesterase inhibitors:
-Donepezil
-Galantamine
-Rivastigmine
Memantine - NMDA receptor blocker
96
Q

Unique clinical features of dementia with Lewy bodies

A

Dementia
Parkinsonian features - bradykinesia, tremor, cogwheel rigidity, fenestrating gait
Visual hallucinations
Episodes of syncope - repeated falls

97
Q

Unique clinical features of frontotemporal dementia (Pick disease)

A

Dementia plus inappropriate social behavior - personality change

Dementia plus Progressive aphasia - naming, comprehension, and expressing

98
Q

Delirium causes

A 
Drugs:
Benzodiazepines
Anticholinergics
Antihistamines
Glucocorticoids - agitation and psychosis
Alcohol and drugs of abuse
UTI - hospital and elderly
CNS insults - stroke, encephalitis
Hypoxia - especially in PE (tachycardia, tachypnea)
99
Q

Workup and management of delirium

A 
Dx:
Electrolytes
Urinalysis
Pulse oximetry
Thorough review of medications
CT of brain if H&P or testing does not reveal dx

Tx:
Treat underlying cause
Environmental changes - reorient the patient, turn on lights, open the blinds, sitter
Avoid restraints if possible
Antipsychotics - haloperidol - prn for acute agitation
Avoid benzodiazepines and anticholinergics

100
Q

Work up for syncope

A

Rule out orthostatic hypotension via till test:
-+ if SBP drops >20, DBP drops >10, HR increases >20

Rule out seizure by history and physical

CBC, electrolytes, BUN/Cr, glucose

Assessed value status

Pulse oximetry - r/o hypoxia

ECG - r/o arrhythmias

Review medications

Serial cardiac enzymes and ECGs r/o MI

Echocardiogram - exertional syncope, murmur, HOCM, AR/AS

Cardiac stress test if older pt

Bilateral carotid duplex

24 hour Holter monitor or event monitor

CT head without contrast and EEG

101
Q

Causes of coma

A

AEIOU TIPS

Alcohol
Epilepsy and environment (hypothermia)
Insulin - hypo/hyper
Overdose or opioids
Uremia
Trauma
Infection
Psychogenic
Stroke
102
Q

Pupils large and nonreactive in coma patient

A

CN III involvement below the mid brain, supratentorial Mass effect -> uncal herniation

103
Q

Pupils small and reactive in coma patient

A

Thalamic involvement, possible tentorial herniation

104
Q

Pupils pinpoint in coma patient

A

Opioid overdose, organophosphate poisoning

105
Q

Ocular motility in coma patient - immobile but reactive

A

Metabolic cause, benzodiazepine overdose

106
Q

Ocular motility in coma patient - oculovestibular reflex

A

Conjugate deviation towards icewater, nystagmus in opposite direction of ice water - intact brainstem

No deviation of eyes - CN III or VI involvement, suggests brainstem damage

Deviation but no nystagmus - cerebral hemisphere damage or suppression

107
Q

Ocular motility in coma patient - Oculocephalic maneuver (Doll’s eye test)

A

Present - fixed on particular point in room: intact brainstem

Reflex absent (like eyes painted on) - Brain death

108
Q

Spastic paralysis in a coma patient

A

UMN lesion or high spinal cord injury

109
Q

Decorticate posturing in a coma patient

A

Elbows flexed, Legs extended

Cortical lesion or lesion below cortices

110
Q

Decerebrate posturing in a coma patient

A

Elbows and legs extended

Midbrain involvement

111
Q

Responses to pain in a coma patient

A

No response - Pontine-medullary involvement, reticular activating system damage

Appropriate responses - superficial cause

112
Q

Nightmares versus night terrors

A

Nightmares: during REM - Little to no muscle tone

Night terrors: during N3 - appear to wake up, and immediately fall back asleep

113
Q

Narcolepsy

A

Excessive daytime sleepiness

When initiating sleep, straight to REM

Hallucinations and cataplexy

Dx: polysomnography - short sleep latency

Tx:
Regular sleep schedule - nap
Improve daytime sleepiness: modafinil, armodafinil, ampthetamines
Reduce REM: venlafaxine, fluoxetine, atomoxetine
Severe sx: sodium oxybate

114
Q

Restless leg syndrome (RLS)

A

Unpleasant paresthesias -> voluntary, spontaneous, continuous movements that temporarily relieve the sensations
-creepy crawling feeling

Secondary RLS - Iron deficiency, ESRD, diabetic neuropathy, Parkinson disease, pregnancy, RA, varicose veins, caffeine

Tx:
pramipexole
ropinirole
gabapentin
pregabalin
carbidopa-levodopa
increase exercise
decrease caffeine
115
Q

Constructive sleep apnea

A

Repetitive collapse of the upper airway during sleep

Risk factors: older age, obesity, male

Presentation: Excessive daytime sleepiness, snoring, choking or gasping a night

Dx: polysomnography

Tx:
Weight loss
Avoid alcohol, hypnotic medicines
CPAP
Oral appliances
Uvulopalatopharyngoplasty - if refractory
Modafinil, armodafinil, amphetamines for chronic daytime fatigue

116
Q

Primary CNS neoplasms presentation

A 
Headache that worsens over weeks to months
Neuro deficits
Vision changes
Seizures
Altered mental status
117
Q

Adult brain tumors

A

Most supratentorial

“MGM Studios”

Metastasis
Glioblastoma
Meningioma
Schwannoma

118
Q

Glioblastoma

A

Astrocytoma

MC primary brain tumor in adults
Very Poor prognosis - 6 mo - 1 yr survival
Located in cerebral hemisphere
Irregular masses with necrotic center surrounded by edema

Tx: resection, chemo, radiation

119
Q

Meningioma

A

Arachnoid cells
2nd MC primary brain tumor in adults
MC parasagital area
Women>Men

Slow growing tumor with good prognosis
Often asx
Located near the surfaces of brain

Tx: resection

120
Q

Schwannoma

A

Benign
Localized to CN VIII - acoustic neuroma

Presentation: tinnitus and hearing loss
B/L - neurofibromatosis type II

Treatment: resection

121
Q

Neurofibromatosis type II

A

B/L Schwannomas - acoustic neuromas
Intracranial meningiomas and spinal tumors

S/S:
Hearing loss
Tinnitus
Unsteady gait
Dizziness
Rare trigeminal nerve/facial nerve involvement - face numbness or paralysis

Dx: MRI or CT

Tx: surgery, radiation
Observation - if small, slow growing

122
Q

Pediatric brain tumors

A

Infratentorial

“Animal kingdom, Magic kingdom, Epcot”

Astrocytoma
Medulloblastoma
Ependymoma

123
Q

Pilocytic astrocytoma

A

MC primary brain tumor in kids
posterior fossa
Slow-growing with good prognosis
Tx: resection

124
Q

Medulloblastoma

A

2nd MC Brain tumor and kids
Cerebellar tumor - malignant

Presentation: headache and ataxic gait
Compression of 4th ventricle -> non-communicating hydrocephalus

Tx: resection, chemo, radiation

125
Q

Ependymoma

A

3rd MC Brain tumor and kids - rare
Compression of 4th ventricle
Tx: resection and radiation

126
Q

Metastatic CNS neoplasms

A

“Lots of Bad Stuff Kills Gila”

Long
Breast
Skin (melanoma)
Kidney (renal cell carcinoma)
G.I. tract (colon cancer_

Dx: pan CT - head, neck, chest, abdomen, pelvis
Bone scan

127
Q

Neurofibromatosis type 1

A

MC
“Von Recklinghausen disease”
NF1 gene - Chr 17

Presentation:
Café au lait spots
Axillary and/or inguinal freckling
Lisch nodules - hamartomas of iris
Neurofibromas - benign peripheral nerve sheath tumors, cutaneous, risk of malignancy
Optic pathway gliomas - vision loss, color vision problems, abnormal pupillary function, proptosis

Tx: supportive

128
Q

Myasthenia Gravis

A

autoimmune disorder - Ab against AChR
Assoc with: thymoma or neoplasms of thymus

Presentation:
Muscle weakness that worsens throughout the day
Ptosis, diplopia
Dysarthria, dysphasia
dyspnea - severe d/t diaphragm weakness
Dx:
AChR Ab
Edrophonium (Tensilon) test AChE-I
EMG
After dx: CT chest - evaluate thymoma
Tx:
AChE-I - neostigmine, pyridostigmine
Thymectomy
Immunosuppressants (prednisone, azothioprine)
Plasmapheresis
IVIG if refractory
129
Q

Lambert-Eaton Syndrome

A

Autoimmune - Ab against presynaptic voltage gated calcium channels - inhibit ACh neurotransmission

Assoc with small cell lung cancer - paraneoplastic Sn

Muscle weakness improves with use

Tx:
Treat underlying causes
AChE-I - pyridostigmine
immunosuppressants
Plasmapheresis
130
Q

Guillian-Barre Sn

A

Acute inflammatory demyelinating polyradiculopathy
Preceded by infection - campylobacter jejuni, HIV, CMV, EBV, mycoplasma, recent immunization

Presentation:
Symmetric muscle weakness that begins in the distal legs and ascends
Respiratory paralysis
Facial muscle weakness - B/l bell’s palsy
Autonomic dysfunction - tachycardia
Absent or depressed DTRs
Minimal sensory deficits - may have paresthesias

Dx:
CSF: albuminocytologic dissociation - elevated protein, normal WBC, normal opening pressure
Nerve conduction studies and EMG - demylination

Tx:
Hospitalize - respiratory failure
Plasmapheresis
IVIG
No glucocorticoids

Prognosis:
Spontaneous regression by one year
5-10% prolonged disease
5% die

131
Q

Bell’s palsy

A

Involving entire facial nerve resulting in facial muscle paralysis - upper and lower

Cause: reactivation of HSV, VZV, Lyme dz (b/l)

Onsets over 1-2 days
Progressive weakness for 3 wks
Recovery within 6 mo

Tx:
Eye care: prevent corneal trauma - hourly tears, patch at night
Glucocorticoids within 3 d of onset of sxs
Valacyclovir for severe diseases

132
Q

motor cortex stroke vs bell’s palsy

A

Lesion to motor cortex - lower face, u/l paralysis

CN VII lesion - U/l - upper and lower face

133
Q

essential tremor

A

Fixed oscillation of hands or head

Tx:
alcohol - suppresses tremor

1st line: B-blockers - propranolol
Benzos - alprazolam, clonazepam - risk for abuse
Primidone

Refractory: thalamotmy, deep brain stimulation

134
Q

Chorea

A

Dance like movements

Assoc with: hyperthyroidism, Huntington’s disease, lupus, levodopa, rheumatic fever

Treat underlying causes

135
Q

Athetosis

A

Snakelike movements

Assoc with: cerebral palsy, encephalopathy, Huntington disease, Wilson’s disease

Treat underlying disease

136
Q

Dystonia

A

Sustain contractions of proximal limb and trunk

Assoc with: neuroleptic drugs, Wilson’s disease, Parkinson’s disease, cerebral palsy, Huntington disease, encephalitis

Tx: levodopa, carbidopa, Botox
Stop neuroleptic

137
Q

Hemiballismus

A

flinging movements of extemities

Assoc with stroke of subthalamic nucleus

Tx: haloperidol

138
Q

Tics

A

Involuntary movements like blinking, grimacing, grunting, sniffing, throat clearing

Assoc with: tourette’s syndrome, OCD, ADHD

Tx:
fluphenazine
pimozide
tetrabenazine

139
Q

Complex regional pain syndrome

A

Features:
Regional pain (distal extemity) not associated with a specific neurological lesion or dermatomal distribution
-deep burning, stinging pain

May include sensory disturbances, heat or cold sensitivity, Motor impairment

May include skin/ muscle atrophy, joint contraction, edema, nail changes, bone resorption

Begins following injury or trauma, surgery, MI or stroke

Dx:
CT and MRI r/o other causes
Bone scintigraphy - bone lesions and demineralization

Tx:
PT/OT
pain: NSAIDs, TCAs (amiltryptyline) and/or gabapentin
Bisphosphonates or calcitonin to prevent bone resorption

140
Q

Eye innervation

A

CN II - vision

CN III - EOM - except Superior oblique and Lateral rectus; levator palpebrae muscle (raise eyelid)
-parasympathetic Control of ciliary muscles and pupillary spincter

CN IV - superior oblique m. - depresses the eye when adducted

CN VI - lateral rectus - abducts eye

141
Q

Light reflexes when optic nerve damage distal to pretectal nucleus

A

Afferent defect

No construction of either pupil when light shone on side of lesion

Both pupils construct when light shone on normal side

142
Q

Light reflexes when oculomotor nerve (CNIII) damaged

A

efferent defect

Affected side will not respond to light shone in either eye
Opposite pupil will constrict one light shown in either eye

143
Q

Horner syndrome

A

Ptosis
miosis
anhydrosis

Associated with Pancoast tumor - apex of lung

144
Q

Argyll robinson pupils

A

pupils accomondate but don’t react

Assoc with neurosyphilis

145
Q

Review visual field defects

A

page 263

146
Q

Most common causes of blindness by age group

A

over 55 - macular degeneration
Under 55 - DM
Blacks any age - glaucoma

147
Q

Astigmatism

A

Warped or asymmetrical cornea -> blurred vision at all distances

Tx: corrective lenses

148
Q

myopia

A

Axial length of eye too long for the refractive power of the cornea and lens -> blurred distance vision (“nearsightedness”)

Tx: corrective lenses or laser surgery

149
Q

hyperopia

A

axial length of the eye is too short for the refractive power of the cornea and lens -> blurred near vision (“farsightedness”)

Tx:
Corrective lenses or laser surgery

150
Q

Amblyopia

A

Severe reflective error or eye misalignment -> developmental defect in neural pathway -> unilateral vision loss

Tx:
Vision training - patch good eye
MC cause is strabismus

151
Q

Strabismus

A

Misalignment of the eyes -> diplopia, may result in amblyopia

Tx:
Vision training - patching
Surgical correction

152
Q

Cataracts

A

opacification of lens due to build up of epithelial cells

Risk factors: Advanced age, diabetes, glucocorticoid use, tobacco/ alcohol use

Presentation:
Usually bilateral but not symmetrical
Painless progressive decrease in vision manifested by difficulty driving at night, Reading roadsigns, Reading FinePrint
Possible debilitating glare in bright sunlight or from oncoming headlights (MC with steroid induced)
Nearsightedness - early manifestation

Tx:
Surgical removal of the opacified lens and replacement with synthetic lens

153
Q

Age-related macular degeneration (ARMD)

A

Degeneration of the macula -> loss of central vision

Presentation:
Dry (atrophic) ARMD: Cellular debris (drusen - pale yellow dots) accumulate on the retina -> gradual loss of vision

Wet (exudative) ARMD: neovascularization (leaky new vessels) -> hemorrhage -> sudden vision loss, more rapid progression

Dx:
Slit lamp - dry
Fluorescein angiography - wet

Tx:
Smoking cessation
Antioxidant supplements - beta-carotene, vitamin C, lutein, selenium, zinc
Wet: injections of anti-VEGF drugs (ranibizumab) into the vitreous humor

154
Q

Retinal detachment

A

Presentation:
Painless and vision loss
Flashing lights and floaters -> curtain pulled over the eye

Exam: wrinkled, pale area of detached retina “billowy cloud”

Tx:
Laser photocoagulation
Cryotherapy
Surgical reattachment

155
Q

Central retinal artery occlusion (CRAO)

A 
Risk factors:
Atherosclerosis
Hypertension
Diabetes
Atrial fibrillation
Valvular heart disease

Presentation:
Acute, painless vision loss - more profound than retinal detachment
Exam: pale retina with Cherry red spot

Tx:
Thrombolytics
Acetazolamide or mannitol to reduce IOP
Anterior chamber paracentesis - removal of aqueous humor
Hyperbaric oxygen
156
Q

Central retinal vein occlusion

A

Presentation:
Gradual, painless vision loss
Exam: retinal edema, flame hemorrhages, venous dilation, cotton wool spots

Tx:
VEGF inhibitors
Laser photocoagulation

157
Q

Cherry red spot ddx

A

central retinal artery occlusion
Niemann Pick dz
Taysachs
Other lysosomal storage diseases

158
Q

B/L bells palsy ddx

A

Guillian Barre Sn

Lyme Dz

159
Q

Acute angle closure glaucoma

A

lens pushes anteriorly against the iris -> blocking flow of aqueous humor through the pupil -> increased intraocular pressure

Presentation:
sudden onset, u/l eye pain
+/- frontal headache, N/V
Blurred vision and color halos encircle light sources
Affected eye: red and tearing, hazy cornea, pupil fixed and mid-dilated
Eye feels rock hard

Dx:
tonometry shows elevated IOP
Gonioscopy - measure iridocorneal angle
Do not dilate pupil

Tx:
Immediate referral to ophtho -> laser peripheral iridotomy

Initial meds:
Pressure lowering eye regime:
-1 drop 0.5% timolol
-1 drop 1% apraclonidine
-1 drop 2% pilocarpine
Acetazolamide 250 mg two tabs at once

If refractory -> IV mannitol once dx confirmed

160
Q

Open-angle glaucoma

A

Impermeability of the trabecular meshwork -> reduce resorption of aqueous humor -> gradual increase in IOP

Features:
Develops insidiously
Need new glasses every few months
Usually bilateral
Gradual loss of peripheral vision -> permanent blindness

Dx:
Tonometry shows a elevated IOP (air puff)
Cup to disc ration >50%

Tx:
Prostaglandins - latanoprost - increased outflow aqueous humor
B-blockers - timolol - inhibit aqueous humor production
alpha 2 - adrenergic agonist - apraclonidine, brinomidine - reduce aqueous humor production and increase outflow
Cholinergic agonists - pilocarpine - cause miosis and open trabecular meshwork -> increased outflow of aqueous humor
Topical acetazolamide- reduce aqueous humor production

Surgery: laser trabeculoplasty

161
Q

Orbital vs periorbital cellulitis

A

Orbital cellulitis involves contents of the orbit - fat, EOMs

Both orbital and periorbital cellulitis - eye redness, swelling, pain

Orbital cellulitis presentation:
Proptosis
Pain with eye movement
Ophthalmoplegioa - weak EOM -> diplopia
rare vision impairment

Complications orbital cellulitis -> permanent vision loss, 1-2% mortality

162
Q

Chalazion

A

Inflammation of an internal Meibomian sebaceous glands - eyelid swelling

Tx: self-limited
Can be treated with surgical excision and/or intralesional steroid injection

163
Q

hordeolum

A

Infection of the external sebaceous glands of Zeiss or Mol
Tender, red swelling at the lid margin

tx:
Warm compress 3-4 Times a day for 10-15 min
If unresolved in 48 hours - abx ointment q3 hr
+/- I&D

164
Q

Anterior blepharitis

A

Infection of the eyelids and lashes
Secondary to seborrhea
Red, swollen lid margins + dandruff on lashes

Tx:
Wash lid margins daily with shampoo
Remove scales daily with cotton ball
Abx ointment to lid margins

165
Q

Viral conjunctivitis

A

MC - adenovirus

Watery discharge -eyelid may be sealed in AM

Highly contagious
+/- fever, URI, LAD, pharyngitis, diarrhea

Tx: supportive

166
Q

Bacterial conjunctivitis

A

S. aureus
S. pneumo
N. gonorrhoeae
C. trachomatis

purulent, copious discharge, 24 hrs/day

Tx: erythromycin ointment or eye drops

167
Q

Allergic conjunctivits

A

Pollen, pet dander

Bilateral watery discharge
eyelid may be sealed in AM

pruritis, other allergy sxs

Tx: topical or systemic antihistamines

168
Q

HSV keratitis

A

HSV infection of the cornea - branching pattern

-> corneal ulceration

169
Q

Treatment for a corneal abrasion

A

thorough eye exam with removal of foreign body by irrigation

Topical abx QID x 3-5 days or until sxs free for 24 hours
-erythromycin, sulfacetamide, ciprofloxacin, ofloxacin

OTC lubricant

Patch less than 24 hrs

Pain: systemic opioids or ophthalmic NSAIDs - diclofenac, ketorolac

NEVER topical anesthetic or steroids

24 hr f/u for: contact lens abrasion, abrasion >= 3 mm, or abrasion with diminished vision

170
Q

Anterior Uveitis

A

Causes:
Assoc with HLA-B27 seronegative sponyloarthropathies
juvenile idiopathic arthritis
sarcoidoisis

presentation:
Pain and redness of iris, may extend to conjunctiva
+/- photophobia

Tx systemic inflammatory dz with topical or systemic glucocorticoids

171
Q

Posterior uveitis

A 
Causes:
HSV
CMV
Toxoplasma gondii
Bartonella spp.
Treponema pallidum

Presentation: paniless, mild vision abnormalities

treat infection with topical antibiotics

172
Q

Vitamin A deficiency

A

Night blindness or complete blindness
Xerophthalmia
Bitot spots - areas of abnormal squamous cell proliferation and keratinization of the conjunctiva (white spot on top of vessels)

173
Q

Acute otitis media

A

6-18 mo
S. pneumo, H flu, Moraxella catarrhalis, RSV, rhinovirus, adenovirus, influenza

Dx: bulging TM, purulent effusion

Tx:
Abx for under 2 yo
Observation over 2 yo with mild sxs

First line: high dose amox (90 mg/kg)
Alternatives: azithromycin, cefdinir

recurrent - tubes - more than 3 in 6 mo

Complications:
Hearing loss
Bullous myringitis - painful bulla on TM
Acute mastoiditis - erythema, swelling and pain behind external ear - confirm with CT

174
Q

MC bacterial causes of otitis externa

A

Pseudomonas
S. epidermidis
S. aureas
fungal

175
Q

Otitis externa

A 
Ear pain worse with manipulation
Pruritis
Hearing loss
Drainage/discharge
External canal maybe swollen or erythematous

Dx: clinical

Tx:
Clean ear canal - water irrigation
Topical Abx: ofloxacin, ciprofloxacin, polymyxin B/neomycin
Topical glucocorticoids

176
Q

Benign paroxysmal positional vertigo

A

Brief lesson one minute episodes of room spinning provoked by head movement, nystagmus

Caused by otoliths in inner ear

Dx: Dix-Hallpike maneuver

Tx: Epley maneuver

R/o CNS pathology, schwannoma

177
Q

Vestibular neuritis

A

+ hearing loss: Labrynthritis

Episodes last days - weeks

Viral or post viral inflammatory disorder of vestibular portion of CN VIII

Exam:
Horizontal nystagmus that can be suppressed with visual fixation
Fast phase away from the affected side
Head thrust: rapid head turn patient is unable to maintain Visual fixation

Tx:
Corticosteroid taper
antiemetics, antihistamines, anticholinergics

178
Q

Meniere disease

A

Excessive fluid in inner ear

Vertigo lasting at least 20 minutes
Low frequency hearing loss
tinnitis

Tx:
Limit salt, caffeine, nicotine, alcohol
Diuretics - HCTZ
Destructive therapy - gentamicin injected into ear

last resport - labrynthrectomy or vestibulectomy

179
Q

Weber test

A

Normal -> midline (both ears)
Conductive hearing loss -> lateralizes to the side of the affected ear
Sensorineural hearing loss -> lateralizes to side opposite affected ear

180
Q

Rinne test

A

Normal -> air conduction > bone conduction

Conductive hearing loss -> bone conduction > air conduction

181
Q

Cholesteatoma

A

Overgrowth of desquamated keratin debris in middle ear -> erode ossicles

Causes:
Negative middle ear pressure - Eustachian tube dysfunction
Direct growth of epithelium through a TM perforation

Assoc with chornic middle ear infection

Grayish-white “pearly” lesion behind or involving TM
Conductive hearing loss
vertigo

Tx:
Surgical removal - tympanomastoidectomy and reconstruction of ossicular chain

182
Q

Ramsay Hunt Syndrome

A

herpes zoster oticus
Reactivation of VZV in ear - latent in geniculate ganglion

S/S: 
Ipsilateral facial paralysis
Ear pain
Vesicles in auditory canal/auricle
Abnormal taste perception
Tinnitis
vertigo
Abnormal lacrimation

Tx: narcotic analgesia
Oral steroids
Antivirals - Val/acyclovir, famciclovir

DIT Level 2 (49 decks)

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