Neurology - 7% Flashcards
Altered Level of Consciousness / Coma
D/t systemic infx or metabolic problems or vascular events
Systemic approach to properly ID etiology and treat appropriately to prevent further damage
History and PE - neurological exam to r/o focal deficit
Consider ABC - airway, braething, circulation
- CBC, electrolyte panel, Ca. mg, phosphorus
- urine tox
- Serum ammonia
- ABG
- blood culture
- EKG and CXR
Imaging - CT scan, MRI diffusion and contrast, LP
Tx:
- Admin thiamine and dextrose
- consider naloxone for opiate OD
Alzheimer Disease
Neurocognitive disorders
Progressive cognitive decline; MC > 65yo
Sxs
- apathy
- Loss of executive fx, visual-spatial skill
- anomia - can’t remember regular name for things
- Disorientation
Dx
- abn clock drawing test
- CT scan - cerebral cortex atrophy
- beta amyloid (senile) plaques, neurofibrillary tangles (Tau protein)
Tx
- Acetylholinesterase inhibitors
- Donepezil/Aricept, Rivastigmine/Exelon, Galantamine, Tacrine
- NMDA Antagonist
- Memantine/Namenda
Arteriovenous Malformations
Abn connection btwn arteries and veins, bypassing capillary; risk of ICH & epilepsy;
MC is supratenorial
Sxs
- Seizures
- Headache
- focal neuro deficits
Dx
- Angiography - gold std
Tx
- Surgery - endovascular embolization
Bell’s Palsy
CN VII swelling - compression of nerve => hemifacial weakness/paralysis
A/w Herpes Simplex; r/o Ramsay Hunt Syndrome from Herpes Zoster
Sxs:
- URI preceding
- Acute unilateral facial weakness/paralysis - Upper and lower
- can’t raise eyebrows
- Decreased tearing
- Orbicularis m. - can’t close eyelids
- Dysgeusia - taste impairment
- Ageusia - taste loss
Dx:
- Lyme ddx
- EMG if paralysis > 10 days
Tx:
- short course of prednisone 60-80mg & acyclovir
- eye patch for corneal abrasions
- Sx decompression for CN VII
Cerebral Palsy
Neuromuscular Disorders
CNS disorder a/w muscle tone and postural abnormalities d/t brain injury during perinatal or prenatal period
Sxs
- Spasticity** - hall mark
- Intellectual/learning disabilities and developmental abnromalities
- PE - hyperreflexia, limb-length discrepancies, congenital decfects
Dx
- MRI if early suspicion
Tx
- Tx spasticity w/ Baclofen or diazepam
- braces
Traumatic Brain Injury
Closed Head Injuries
Brain dysfunction d/t outside force via violent blow to head
Sxs
- Immediate or delayed sx = change in LOC
- Personablity change
- amnesia
- increased ICP
- Diploia, posturing
Dx
- GSC
- mild - post traumatic amnesia <1 d
- mod - PTA >1 & < 7
- sev - > 7d
Tx
- golden hour emergency tx
- depends on recoveray stage of pts
- most are mild
Cluster
Headaches
middle aged Males
Sxs:
- unilateral, usually behind eye
- periorbital lacrimation
- Horner’s syndrome
- anhydrosis
- ptsosis
- miosis
- severe
- not relieved by stress- usu pacing
Dx - Brain MRI r/o maladies
Tx:
- 100% O2, 6-10L for 15 minutes
- Subcut sumitriptan
- Prophy w/ CCB - verapamil
Complex Regional Pain Syndrome
Sxs
- Preceded by direct, minor physical trauma
- Pain OOP
- disturbances of color/temp - mottled purple
- Decr ROM
- Dystrophic skin and nails
Tx - NSAIDs, prednisone, PT, antidepressants
Concussion
dx, tx
Dx:
- CT if
- +LOC
- GCS < 15
- Suspected open skull/basilar skull f
- >2 eps of vomiting
- >65 yo
- amnesia > 30 mins prior to contact
- MVA w/ ejection, pedestrian struck by car
- fall > 3 ft
- seizure
- underlying bleeding/anticoag use
- ETOH involvement
- clinical deterioration
- persistently AMS
Tx
- athletic activities resumed gradually -
- single concusion
- +LOC or sxs > 15 mins = return to sports if asymp for 1 week
- repeat concussion
- +LOC or sxs > 15 min = return next season
Concussion
eti, sxs/Grades
Transient, traumatic brain dysfunction; consciousness may be lost but patients manifest only confusion, memory loss, and gait or balance difficulties
Sxs:
- +/- brief LOC, amnesia => no structural abnormalities and no neurologic deficits
- Negative CT scan
Grade 1
- No LOC,or Post-traumatic amnesia
- other symptoms resolve < 30 mins - return to sports if asymptomatic for 1 wk
- mild TBI, GCS 13-15
Grade 2
- +LOC
- 1 minute or post traumatic amnesia that lasts > 30 min but < 1 wk
- Return to sports when asymp at rest and exertion for at least 7 days
Grade 3
- +LOC > 1 min
- post traumatic amnesia & other symp last > 1 wk
- Return in 1 mo if asymp @ rest and exertion for at least 7 days
Delirium
Neurocognitive Disorders
acute syndrome d/t med conditions, substance, intox, med w/d or SE => temporarily AMS
Sxs
- Sepsis, sundowning, ETOH or opiate w/d
- rapid onset, short term and reversible
- agitation
Dx
- disturbed LOC - decr attention or lack of env awareness
- cognitive change - memory def, language disturbance, visual illusion or hallucinations
- rapid onset w.in hrs or days
- labs, CT, or MRI
Tx - underlying cause, sedation if necessary
- haloperidol
- do not use benzo - worse in elderly
- same structure rountine every day
Diabetic Peripheral Neuropathy
Hyperglycemia -> vascular insufficiency -> nerve infarct
Sxs
- Stocking/glove distribution
- tingling, burning
- abn pain and temp sensation
- Gait imbalance - walk on rope and glass, cant feel position of feet
Dx
- N conduction study
- r/o etoh, nutritional deficient, multi myeloma, vit b12
Tx
- Anticonvuls - Pregabalin, Gabapentin, tramadol
- Tightly control blood glucose
Encephalitis
Eti - usually viral (MCC HSV, CMV if IMC)
Reye’s Syndrome - rapidly progressing encephalopathy w/ hepatic dysfx, usual post-flu/URI
- Babinski, hyperreflexia
- Aspirin/salicylate use, vomiting, confusion => seizures/coma
Sxs:
- Flu like illness
- fever, headaches, AMS
- Seizures
- Personality changes
- exanthema
Dx:
- LP and MRI
- PCR for viruses
- Kernig’s absent
- Brudzinski absent
Tx:
- Supportive care
- Acyclovir 10mg/kg IV q8hr started promptly
- Empiric abx given until bacterial mengitis r/o
Epidural Hematoma
Transient LOC from injury => LUCID => HA, unilateral weakness
traumatic IC hemorrhage after skull fracture => MC Middle menigeal artery => blood fills space btwn dura and skill
Dx
- non contrast CT - unilat convexity - lens usually temporal region => Lemon
Tx
- small - observation
- severe - surgery => burr hole, trephination, craniotomy, craniectomy
- Surgical craniotomy
- ICP management - mannitol, hyperventilate, steroids, or ventricular shunt
Essential Tremor
Movement Disorders
Bilateral tremor of hands, forearm or head; Autosomal Dominant
Sxs
- worse w/ intention (hand and head)
- better w/ alcohol
- no resting tremor
Tx
- Propanolol - if severe or situational
- Primidone (barbituate) if no relief w/ propanolol
Frontotemporal Dementia (Pick’s disease)
Neurocognitive disorders
Localized brain degeneration of frontotemporal lobes
marked personality change before memory changes
apathy, disinhibition -impulsive
Glascow Coma Scale
Score < 8 = coma or severe brain injury
Guillain-Barré Syndrome
Peripheral Neuropathy
Often present after immunization; post infectious cause Campylobacter jejuni = MC, EBV, HIV
Sxs:
- Ascending paralysis - begins In distal limbs
- Leg weakness => total paralysis of all 4 limbs; facial m, eyes, loss of reflexes
Dx
- LP = ele CSF protein, normal WBC
Tx
-
IVIG Plasma exchange - remove circ ab
- monitor PFTs for paralysis of chest m, diaphragm (resp failure)
- good prog
Huntington Disease
Movement Disorders
Autosominal Dominant chromoson 4; incurable neurodegenerative disease; Onset 30-50yo
Sxs
-
Behavioral => chorea* => dementia
- Behaviora - personality, cognitive, irritability
- Chorea - rapid, involuntary or arrhythmic mvmt of face, neck, limbs
- Dementia - before 50yo +psychosis
Dx
- CT - cerebral and caudate nucleus atrophy
Tx
- No cure - fatal w/in 15-20 years
- Tetrabenazine for chorea
Lewy Body Disease
Neurocognitive disorders
Gradual, progressive decline in cognitive abilities
Prominent visual hallucinations, delusions
+ Parkinsonian sxs
Meningitis
Eti: bacterial - MC S. pneumo or N. meningitidis (G+ diplococci) - likely if pt has a rash
Neonates = E. Coli / S. agalatiae; >50-60 = Listeria/Cryptococcus neoformans
Aseptic - usu viral and negative blood cultures
Sxs:
- no mental status changes - r/o encephalitis
- Kernig’s sign - neck pain w/ knee extension
- Brudzinski sign - leg raise w/ bent neck
Dx:
- LP - check if ICP and papillaedema - get a CT if unsure
- Bacteria
- Incr Protein, decr glucose (bacteria likes glucose), increased OP
- Viral
- normal pressure, increased WBC
Tx:
- Aseptic - symptomatic or IV acyclovir for HSV
- Bacterial - dexamethasone + empiric IV antibiotics (cephalosporin, Vanco, pencillin)
- Household contacts - Tx with Rifampin, Cipro, Levaquin, azithro, ceftriaxone
Migraines
Headaches
MCC F > M, genetics, usu presents with aura but no auras are MC,
Vessel vasoconstriction => vasodilation, rush of blood returns causing pain = vasospasms
Sxs:
- unilateral, pulsatile
- preceded by aura 4 to 72 hours - sensory indication
- floaters, vision - sensitivity to light
- sound worsens
- gustatory
- worsens w/ activity - patients like dark, quiet rooms
Dx:
- clinical - image when 1st head, change in severity
Tx:
- Abortive therapy
- Mild - Execedrin w/ caffeine, NSAIDs, aspirin, tylenol
- Moderate - Triptans - Sumotriptan
- CI - unctrl HTN, PVD, CAD
- Preventative therapy
- TCAs - Amtriptyline (less sedating)
- Topiramate/Topamax
- Valproic acid
Multiple Sclerosis
Neuromuscular Disorders
Autoimmune - Demyelination of CNS, plaques
Sxs
- motor weakness; impaired coordination
- Sudden vision loss; optic neuritis - monocular - picture on top of each other and upside down
- LHermitte’s sign
- Heat sensitivity - Uhthoff’s Phenomenon
Dx
- CSF - oligoclonal bands w/ IgG
-
T2 flairs on MRI w/ contrast
- Dawson’s fingers
- Visual evoked potential testing
Tx
- Beta interferons or Glatiramer acetate
- IV methylprednisolone 500mg/d x 5d for acute attacks
Myasthenia Gravis
Neuromuscular Disorders
Autoimmune - antibodies against Acetylcholine and attacks muscle
a/w thymoma - block of NM transmission
Sxs
- Muscle weakness that gets progressively worse throughout day
- EOM fatigue*** Diploia; ptosis
- Cogan’s lid twitch - close eye gently and look up rapidly - affected eye falls back into prev position
Dx
- ice bag test for ptosis
- +ACh receptor antibodies
- +MuSK antibodies
Tx
- Pyridostigmine
- Steroids for acute exacerbations, IVIG
- Thymectomy - only after puberty and before 60yo
Neoplasms
MC CNS Tumor in children - Astrocytomas, Medulloblastomas, Ependymonas
MC CNS Tumors adults - Gliomas,
Meningiomas *MC benign, a/w Neurofibromatosis Type 2
Sxs
- Triad
- early morning occurence
- N/V
- very severe
- Increased ICP
- Irritability, lethargy, Changes in behavior, gait and balance
Dx
- Head CT or contrast MRI
Tx
- Complete surgical removal of tumor
- CS to reduce edema
- Anticonvulsants
Parkinson Disease
Movement Disorders
Basal ganglia degeneration in substantia nigra (extrapyramidal system)
loss of Dopamine
Sxs
- Tremor at rest - disappears w/ voluntary movement => pill rolling
- Cogwheel (catching and releasing) Rigidity
- Akinesia - difficulty initiating motion
- masked facies, shuffling gait
Dx
- clinical
Tx
- < 65 yo - Dopamine agonists - used in younger patients to delay levodopa (less SE)
- Bromocriptine/parlodel, pramipexole/Mirapex, ropinirole/requip
- >65
- Sinemet (levodopa/carbidopa)
Postconcussion Syndrome
Closed Head Injuries
Cognitive or behavioral manifestations present for few days to weeks following concussion
Sxs
- chronic HA
- short term memory difficulty
- difficulty sleeping
- Irritability/mood swings
- Sensitivity to light + noise
Dx - clinical
Tx - symptomatic - PRN analgesic, brain rest
Focal Seizures
Focal - discrete region of brain (in one cerebral hemisphere); structural; MC in eldery
May be proceeded by aura; can progress to generalized
Simple vs Complex
Simple Partial
- consciousness fully maintained
- focal motor sxs or somatosensory sxs w/o loss of consciousness
Complex Partial
- impaired consciousness that lasts > 30secs
- loss of awareness and similar to absence sz
- blank stares, automatism (lip smacking or eyelid fluttering)
- post ictal state - confusion or loss of memory
Dx
- ECG and EEG, CT or MRI in adults
- Electrolytes Na, Ca, Mg
- Glucose, Preg test
Tx
- Tx underlying cause
- Phenytoin
- Phenobarbital
- Valproate
- Lamotrigine
- Gabapentin
Generalized Seizures
Starts midbrain/brainstem and spreads to both cortices
Absence Seizures (Petite Mal)
- kids “blank stare” - brief impairment of consciousness < 15 seconds
- EEG - 3 Hz spike and wave activity
- no post ictal state, loss of body tone
- Resolves by 2oyo, if not progress to Grand mal
- tx ethosuximide
Tonic-Clonic (Grand Mal)
- Tonic - very stiff and rigid 10-60 seconds
- respiration is arrested, hypothermic
- Clonic - generalized convulsion and limb jerking
- Postictal phase - confused state - minutes to hours
- Dx - glucose, CT, EEG (rapid spike)
- tx - phenytoin/dilantin
Status Epilepticus
Single epileptic seizure that lasts > 5 mins OR 2 or more seizures w/in 5 min period w/o person returning to normal btwn them
Two forms - convulsive and non convulsive
Convulsive
- contration/extension of arms and legs
Nonconvulsive
- complex partial status epilepticus and absence status epilepticus
- prolong ep of mental status change
Dx
- check blood sugars, antiepileptic drug levels
Tx
- MED EMERGENCY
- Lorazepam - initial 0.1mg/kg or 4 mg - repeat if still seizing
- phenytoin 20mg/kg
Intracerebral Hemorrhage
Stroke
Hemorrhagic Stroke (15%)
Bleeding into the brain parenchyma
Eti - MC d/t sudden increase in HTN,
- Ischemic stroke converts to hemorrhagic stroke - reperfusion causes bleeding into dead tissues = hemorrhagic
Sxs:
- Abrupt onset of focal neurological deficity - sxs depending on location of bleed
- Anterior or MCA - numbness and muscle weakness
- Broca’s Area - slurred speech
- Wernicke’s area - difficulty undertanding speech
- PCA - vision
- Headache that becomes worse and worse until obtunded
Dx:
- Non contrast CT or MRI
- CT angio for specific location
Tx:
- BP control with IV labetalol
- Reduce ICP - Mannitol
- Craniotomy - skill removed to drain blood and relieve pressure
Stroke - Ischemic
Ischemic (85%) vs Hemorrhagic
Risk factors: HTN*, athersclerotic disease, hypercholesterolemia, DM, Afib, carotid artery disease, smoking, age, fam hx, M
2/3 are thrombic; 1/3 are embolic
- Thrombic - clot that forms inside the brain vessel, usu follows a TIA
- Embolic - clot that forms elsewhere and travels to the brain - acute presentation
Causes lack of blood flow to a specific brain area - surrounding that area is the penumbra (is still perfused by collateral vessles; can be saved if reperfused quickly)
20% are lacunar infarcts, 20% embolic (cardiac or atherothrombic)
Sxs:
- Facial drooping
- Arm weakness
- Speech difficulties
- Time - get reperfused ASAP
Dx:
- Non-contrast Head CT - differentiates btwn hemorrhagic and ischemic
- MRI - tissue changes
- Carotid duplex scan - degree of stenosis
- EKG - MI or A-Fib
- MRA - level of stenosis in head
Tx:
-
t-PA therapy - within 4.5 hours of onset.
- Do not initiate if
- > 3 h
- unctrl HTN <185/110
- bleeding disorder or anticoagulated,
- hx of recent trauma or surgery
- Do not give Aspirin within 24 hrs if + t-PA
- Do not initiate if
-
Aspirin - best If given w/in 24 hr of symptom onset
- if within 3 h - give thrombolytics
- if > 3 h = give aspirin, if allergic give Clopidergrel/Plavix
- Supprotive tx - ABC, O2, IV fluids
-
Gradual BP control
- IV labetalol 20mg
- Do not give antihypertensives unless SBP >200, DBO > 120, MAP >130mmHg
- Carotid endarterectomy - if > 70% stenosed
Stroke - Ischemic
Treatment
t-PA therapy - within 4.5 hours of onset.Do not initiate if
- > 3 h
- unctrl HTN <185/110
- bleeding disorder or anticoagulated,
- hx of recent trauma or surgery
- Do not give Aspirin within 24 hrs if + t-PA
Aspirin - best If given w/in 24 hr of symptom onset
- if within 3 h - give thrombolytics
- if > 3 h = give aspirin, if allergic give Clopidergrel/Plavix
- Supportive tx - ABC, O2, IV fluids
Gradual BP control
- IV labetalol 20mg
- Do not give antihypertensives unless SBP >200, DBO > 120, MAP >130mmHg
Carotid endarterectomy - if > 70% stenosed
Maintenance
- BP control
- Antiplatelet - ASA and Plavix
- Statin
- Aticoag with Afib
- Blood glucose
- Stop smoking
Subarachnoid Hemorrhage
Stroke
Bleeding into the CSF - outside brain parenchyma
Eti:
- Traumatic injury
-
Aneurysms - MCC saccular cerebral aka berry aneurysms
- most on anterior Half
- marfan’s syndrome
- Rupture with ICP
- Arteriovenous Malformation
Sxs:
-
Sudden onset severe headache - THUNDERCLAP headache
- worse headache of life
- Nuchal rigidity - blood irritating meniges
- Seizures
- N/V
- Decr LOC
Dx
-
Non contrast CT
- most are negative if < 2 hrs, most sensitive > 12 h
- if negative - do CSF
-
CSF via LP
- Xanthochromia - yellowish blood
- Fresh Red blood
- C/i if ele ICP (??)
- Cerebral angiograph y - gold to id area
Tx:
- emergency surgery
- Clip artery - pressure
- Catheter to insert coil to promote clot formation
- BP control - CCBs to prevent vasospasms
Transient Ischemic Attack
Transient ep of neurologic dysfunction d/t focal brain, retinal or cord ischemia = no acute Infarction
Sxs:
- Sudden onset neurological deficit < 24 hrs
- Lasts < 1-2 hr
- Atherosclerotic plaques reducs BF in ICA
- 10% of TIA will have a stroke in 30 days
Dx:
- Non contrast CT
- MRI more sensitive
- Carotid doppler US
Tx:
- ABCD2 Score - likelihood of stroke In 2 days
- risk is highest 24 hrs after initial event
- Carotid endarterectomy if ICA or CCA stenosis >70%
Subdural Hematoma
Head injury from fall => Sudden blow tears blood vessels, usu eldery w/ multiple falls => presents w/ neurological sx (AMS/neuro signs) => etoh or elderly
Sxs:
- injury to bridging veins - acute = 48 hrs
- subacute 3- 14 days
- chronic > 2 wks = elderly
- Blood collects btwn dura and arachnoid* mater
Dx
- non contrast CT - crescent shape concave hyper density
Tx
- same as epidural
Syncope - Cardiac
Life threatening cause of syncope
Strng fam hx - sudden cardiac death before 50 yo, heart dz, symptoms (CP, palps, SOB)
eti:
- Arrhythmias - MCC of cardiac syncope
- ischemia
- Valvular abn
- aortic stenosis
- cardiac tamponade
- pacemaker malfunction
Syncope - Neurogenic, Orthostatic, Metabolic, Psychiatric
Loss of consciousness/postural tone 2/2 acute decrease in cerebral blood flow - rapid recovery in consciousness w/o resuscitation
Four main etiologies
Neurogenic Syncope
- Carotid sinus hypersensitivity
- Prodrome sxs before LOC - dizziness, warm/cold, N, pallor, visual disturbances, hearing abns
- Normal PE, and normal EKG
Orthostatic Hypotension
- drop in systlic BP > 20mmHg or
- Reflex tachcyardia of > 20bpm
- Failure of veins to constrict when patient is upright = reduce cardiac output
- MCC deH2O, meds (CCB/BB, alpha Blockers, nitrates, diuretics, TCA)
Metabolic
- hypoglycemia, hypoxia
Psychiatric
- aniety and panic disorders
- young, no cardiac dz, multiple eps
Syncope Work Up/ Diagnosis
Conditions that can mimic syncope but not true syncope - Seizures, stroke, sleep disturbances, ad incjury
Dx:
- PE and comprehensive Hx
- Get the #, frequency, and duration of episodes
- Onset, triggers, position & recent changes prior to syncopal eps
- Most patient w/ prodromes - Neurocardiogenic or orthostatic hypotension
- Medications
- Vital signs
- EKG
- TTE - structural heart disease
- CT Scan
Tension
Headaches
MC type, younger in 30s, stress*
Sxs:
- a/w with stress triggers
- bilateral, band like
- non pulsatile, squeezing
- can last 30 mins to 7 days
Dx: clinical
- episodic - <15 days/month
- chronic - > 15 days / month
Tx:
- NSAID
- Aspirin
- Acetaminophen
- Head & muscle relaxants
Tourette Disorder
Movement Disorder
Involuntary motor and vocal tics; sxs present for > 1yr and age onset < 18yo
Sxs
- throat clearing, blinking, lip smacking
- Echolalia - imitate what you’re saying
- Echopraxia - do
- Palilalia - do or say
- Coprolalia - curse word
Dx
- Tourette - both motor and vocal ticks > 1 year before 21yo
- Persistent Chronic Tic disorder
- sing or multiple motor or vocal tick > 1 year
- Provisional tic disorder
- single or multiple motor and/or vocal tics present < 1 year
Tx
- Clonidine or antipsychotic
- tics tend to lessen over time
- Pimozide
- Haldol
- Tetrabenazine
Vascular Dementia
Neurocognitive disorders
2nd MC type - brain disease d/t chronic ischemia and multiple infarctions (lacunar infarcts)
HTN - most important RF
Sxs
- Cortical - forgetfulness, confusion, amnesia, executive diff, speech abn
- Subcortical - motor def, gait abn, urinary diff, personality changes
Tx - control HTN
Vertigo
Sensation of movement in the absence of actual movement
Peripheral
- sudden onset - intermittent
- tinnitus
- hearing loss
- nystagmus - horizontal w/ rotary component
- Dx with Dix Hallpike
Central
- eti MS, brain tumor, head injury
- Gradual onset - continuous
- N/V
- Vertical nystagmus
- No auditory symptoms
- motor, sensory, cerebellar deficits
- Romberg sign
Dx:
- Dix Hallpike - for nonfatigable causes = central etiology
- Audiometry
- EMG
- MRI
Tx:
- Peripheral
- Vestibular suppressants to help w/ auditory sxs
- Diazepam, Meclizine
- Epley manuveur
- Central
- Deep head hanging manuveur
- tx source
