Neurology Flashcards
This type of stroke presents as weakness or sensory loss on the opposite side of the lesion, homonymous hemianopsia, and aphasia
Middle cerebral artery (MCA)
This is loss of visual field on the opposite side of the stroke. A left-sided MCA stroke results in loss of the right visual fields. The eyes can’t see the right side.
homonymous hemianopsia
This type of stroke presents as personality/cognitive defects such as confusion, urinary incontinence, and leg more than arm weakness.
Anterior cerebral artery (ACA)
This type of stroke presents as ipsilateral sensory loss of the face, 9th and 10th cranial nerves, contralateral sensory loss of the limbs, and limb ataxia
Posterior cerebral artery (PCA)
What is the best initial test for any kind of stroke?
CT Scan
What is the best initial therapy for a nonhemorrhagic stroke?
Less than 3 hours since onset of stroke: thrombolytics
More than 3 hours since onset of stroke: aspirin
Hemorrhagic stroke: nothing
What if the patient is already on aspirin at the time of the stroke? What would you give?
Add dipyridamole or Switch to Clopidogrel
What would you give for prevention of a stroke?
Aspirin or Clopidogrel
Do not combine them!
When will you do a surgical correction for carotid stenosis?
symptomatic CVD and more than 70% stenosis
This type of headache is associated with visual disturbance (flashes, sparks, stars, luminous hallucinations), photophobia, aura, relationship to menses, association with food (chocolate, red wine, cheese). It may be precipitated by emotions. It is also associated with nausea and vomiting.
Migraine Headache
This type of headache is frequent, short duration, high intensity headaches, with men affected 10 times more than women.
Cluster headache
This type of headache is associated with visual disturbance, systemic symptoms such as muscle pain, fatigue, and weakness. Jaw claudication is also present.
Giant cell (temporal) arteritis
This type of headache is associated with obesity, venous sinus thrombosis, oral contraceptives, and vitamin A toxicity. It can mimic a brain tumor with nausea, vomiting, and visual disturbance.
Pseudotumor cerebri
How would you diagnose Pseudotumor cerebri?
CT or MRI to exclude an intracranial mass lesion and a lumbar puncture (LP) showing increased pressure
How would you diagnose Giant cell arteritis?
Biopsy (most accurate test)
markedly elevated ESR
How would you treat Tension headache?
NSAIDs and other analgesics
How would your treat Migraine?
triptans, ergotamine, or 100% oxygen as abortive therapy
How would you treat Giant cell (temporal) arteritis?
Prednisone
How would you treat Pseudotumor cerebri?
Weight loss and Acetazolamide
This is the best preventive therapy for migraine.
Propanolol
Patient presents with bilateral “bandlike” pressure headache that can last up to 4-6 hours with normal physical exam. What is the most likely diagnosis?
Tension headache
Patient presents with or without aura, photopobia, can be related to food/emotions/menses, and sometimes aphasia, numbness, and dysarthria. What is the most likely diagnosis?
Migraine
Patient presents with episodic head pain, unilateral periorbital intense pain, lacrimation, eye reddening, nasal stuffiness, and lid ptosis. What is the most likely diagnosis?
Cluster headache
This is an idiopathic disorder of the fifth cranial nerve resulting in severe, overwhelming pain in the face. Attacks of pain can be precipitated by chewing, touching the face, or pronouncing certain words in which the tongue strikes the back of the front teeth. Patients describe the pain as feeling as if a knife is being stuck into the face.
Trigeminal Neuralgia
How would you treat Trigeminal Neuralgia?
Oxcarbazepine or carbamazepine
If after giving oxcarbazepine, trigeminal neuralgia doesn’t improve, what is the next step?
Gamma Knife Surgery
This is a seizure that us focal to one part of the body. For instance, a patient may have a seizure that is limited just to an arm and leg. It can either be simple or complex.
Partial seizure
This is a generalized seizure with varying phrases of muscular rigidity followed by jerking of the muscles of the body for several minutes.
Tonic-clonic seizure
This is the best initial therapy for a persistent seizure.
Benzodiazepine (Lorazepam or diazepam IV)
If the seizure persists after benzodiazepine, what would you give?
Phenytoin or Fosphenytoin
This is the best therapy for absence seizures
Ethosuximide
A 38-year-old man is evaluated for seizures. He achieves partial control with the addition of a second antiepileptic medication. He drives to work each day.
What do you do about his ability to drive?
a. Confiscate his license
b. Allow him to drive if he is seizure-free for 1 year.
c. Allow him to drive as long as his seizure history is noted on his license.
d. Recommend that he find an alternative means of transportation
e. Do not let him leave the office unless he is picked up by someone; no further driving
f. Allow him to drive as long as he is accompanied
D
This is caused by the rupture of an aneurysm that is usually located in the anterior portion of the circle of Willis. Aneurysms are present in 2% of routine autopsies. The vast majority never rupture. They are more frequent in those with: Polycystic kidney disease Tobacco smoking Hypertension Hyperlipidemia High alcohol consumption
Subarachnoid Hemorrhage
This is a sudden onset of an extremely severe headache with meningeal irritation (stiff neck, photophobia) and fever. Loss of consciousness occurs in 50% of patients. What is the most likely diagnosis?
Subarachnoid Hemorrhage
What is the best initial test for Subarachnoid Hemorrhage?
CT without contrast
This is the most accurate test for Subarachnoid Hemorrhage.
Lumbar puncture showing blood
This drug can prevent subsequent ischemic stroke.
Nimodipine
A woman comes to the emergency department with a severe headache starting one day prior to admission. On physical examination she has a temperature of 103F, nuchal rigidity, and photophobia. Her head CT is normal. LP shows CSF with 1250 white blood cells and 50,000 red blood cells.
What is the most appropriate next step in the management of this patient?
a. Angiography
b. Ceftriaxone and vancomycin
c. Nimodipine
d. Embolization
e. Surgical clipping
f. Repeat the CT scan with contrast
g. Neurosurgical consultation
B. The number of WBCs in the CSF in this patient far exceeds the normal ratio of 1 WBC to each 500 to 1000 RBCs. With 50,000 RBCs, there should be no more than 50 to 100 WBCs. The presence of 1250 WBCs indicates an infection, and ceftriaxone and vancomycin are the best initial therapy for bacterial meningitis. Contrast is not useful when looking for blood.
This presents as loss of all function except for the posterior column (position and vibratory sensation intact), flaccid paralysis below the level of the infarction, loss of deep tendon reflexes (DTRs) at the level of the infarction. What is the most likely diagnosis?
Anterior Spinal Artery Infarction
Patient can have B12 deficiency or neurosyphilis. Position and vibratory sensation are lost.
a. Subacute Combined Degeneration of the cord
b. Spinal Trauma
c. Brown-Sequard Syndrome
d. Syringomyelia
A
There is acute onset of limb weakness and/or sensory disturbances below the level of the injury with the severity in proportion to the degree of injury. Sphincter function is impaired. Loss of DTRs at the level of the injury followed by hyperreflexia below the level of the trauma.
Spinal Trauma
After unilateral hemisection of spinal cord from an injury such as a knife wound cutting half the cord or compression from a mass lesion, patients lose pain and temperature on the contralateral side from the injury, and lose motor function as well as position and vibratory sense on the ipsilateral side of the injury.
Brown-Sequard Syndrome
There is loss of pain and temperature bilaterally across the upper back and both arms. It also causes loss of reflexes and muscle atrophy in the same bilateral distribution. What is the most likely diagnosis?
Syringomyelia
What is the most accurate test for Syringomyelia?
MRI
This is the best treatment for Syringomyelia.
Surgical removal of tumor if present and drainage of fluid from cavity
This is a collection of infected material within the parenchyma of the brain tissue acting as a space-occupying lesion.
Brain abscess
What is the best initial test for brain abscess?
CT or MRI
What is the most accurate test for brain abscess?
Brain biopsy
What is the empiric therapy for brain abscess?
Penicillin plus metronidazole plus ceftriaxone
This disease presents with neurological abnormalities such as seizures, progressive psychomotor retardation, slowly progressive mental disorientation, skin abnormalities such as adenoma sebaceum, shahreen pateches, and ash leaf patches. Retinal lesions and cardiac rhabdomyomas can also occur.
Tuberous Sclerosis
What is the treatment for Tuberous Sclerosis?
No specific treatment. Control seizures.
This disease presents with soft, flesh-colored lesions attached to peripheral nerves, eight cranial nerve tumors, cutaneous hyperpigmented lesions (cafe au lait spots), meningioma and gliomas.
Neurofibromatosis (von Recklinghausen Disease)
This disease presents with port-wine stain of the face, seizures, CNS problems such as homonymous hemianopsia, hemiparesis, mental subnormality.
Sturge-Weber Syndrome
This is the best therapy for Essential tremor
Propanolol
Patient is usually at age 50 to 60 or older who presents with a tremor, muscular rigidity, bradykinesia (slow movements), and a shuffling gait with unsteadiness on turning and a tendency to fall. There is also cogwheel rigidity, hypomimia, and micrographia.
Parkinsonism
What is the treatment for Parkinsonism with mild symptoms?
Anticholinergic medications (benztropine and trihexyphenidyl) relive tremor and rigidity.
You can give this in older patients with Parkinsonism intolerant of anticholinergic medications.
Amantadine
This is the best initial therapy for those with severe parkinsonism (inability to care for themselves, orthostatic.)
Dopamine agonists (Pramipexole and Ropinirole)
This is the most effective medication for severe parkinsonism.
Levodopa/carbidopa
This extend the duration of levodopa/carbidopa by blocking the metabolism of dopamine.
COMT inhibitors (Tolcapone, Entacapone)
This is used as adjunct to levodopa/carbidopa which also block metabolsim of dopamine.
MAO inhibitors (rasagiline, selegiline)
Why should you avoid tyramine-containing foods (cheese) with MAO inhibitors?
they precipitate hypertension
Which of the following is most likely to slow the progression of parkinsonism?
a. Pramipexole
b. Levodopa/carbidopa
c. Rasagiline
d. Tolcapone
e. Amantadine
C. Only the MAO inhibitors are associated with the possibility of retarding the progression of parkinsonism
A 70-year-old man with extremely severe parkinsonism comes by ambulance to the emergency department secondary to psychosis and confusion developing at home. He is maintained on levodopa/carbidopa, ropinirole, and tolcapone.
What is the most appropriate next step in management?
a. Stop levodopa/carbidopa
b. Start clozapine
c. Stop ropinirole
d. Stop tolcapone
e. Start haloperidol
B. When a patient has very severe parkinsonism, you cannot stop medications because the patient will become “locked in” with severe bradykinesia. Psychosis and confusion are a known adverse effect of antiparkinsonian treatment. Use antipsychotic medications with the fewest extrapyramidal (antidopaminergic) effects
Patients report an uncomfortable sensation in the legs that is “creepy” and “crawly” at night. The discomfort is worsened by caffeine and relieved by moving the legs.
Restless Leg Syndrome
How would you treat Restless Leg Syndrome?
Dopamine Agonists (Pramipexole)
This is a hereditary disease characterized by CAG trinucleotide repeat sequences on chromosome 4. It presents with choreaform movement disorder (dyskinesia), dementia, behavior changes (irritability, moodiness, antisocial behavior), and onset between 30 and 50 with positive family history.
Huntington Disease
This is an idiopathic disorder that presents as vocal tics, grunts, and coprolalia, motor tics (sniffing, blinking, frowning), obsessive-compulsive behavior.
Tourette Disorder
This is an idiopathic disorder exclusively of CNS (brain and cord) white matter. MS is more common in white women who live in colder climates. The most common presentation is focal sensory symptoms, with gait and balance problems. Blurry vision or visual disturbance from optic neuritis is no longer common as the first presentation.
Multiple Sclerosis
Internuclear ophthalmoplegia (INO) is the inability to adduct one eye with nystagmus in the other eye and i characteristic of _______.
Multiple Sclerosis
This is the best initial and most accurate test for Multiple Sclerosis.
MRI
This is the best initial therapy for acute exacerbation for Multiple Sclerosis.
High-dose steroids
Patient presents with weakness of unclear etiology starting in 20s to 40s with unique combination of upper and lower motor neuron loss. The most serious presentation is difficulty in chewing and swallowing and a decrease in gag reflex. This leads to pooling of saliva in the pharyns and frequent episodes of aspiration. What is the most likely diagnosis?
Amyotrophic Lateral Sclerosis
This is the most common cause of death in ALS
Respiratory Failure
This is a genetic disorder with loss of both motor and sensory innervation leading to distal weakness and sensory loss, wasting in the legs, decreased deep tendon reflexes, and tremor. Foot deformity with a high arch is common (pes cavus). The legs look like inverted champagne bottles.
Charcot-Marie-Tooth Disease
A 38-year-old carpenter comes with pain near his ear that is quickly followed by weakness of one side of his face. Both the upper and lower parts of his face are weak, but sensation is intact.
What is the most common complication of his disorder?
a. Corneal ulceration
b. Aspiration pneumonia
c. Sinusitis
d. Otitis media
e. Deafness
f. Dental carries
A. Corneal ulceration occurs with seventh cranial nerve palsy because of difficulty in closing the eye, especially at night. This leads to dryness of the eye and ulceration. This is prevented by taping the eye shut and using lubricants in the eye. Dental caries don’t happen because although there is drooling from difficulty closing the mouth, saliva production is normal. Rather than deafness, sounds are extra loud. Aspiration does not occur because gag reflex and cough are normal.
This is an autoimmune damage of multiple peripheral nerves. There is no CNS involvement. A circulating antibody attacks the myelin sheaths of the peripheral nerves, removing their insulation.
Guillain-Barre Syndrome
This presents as weakness in the legs that ascends from the feet and moves toward the chest, associated with a loss of DTRs. It is associated with respiratory muscle weakness.
Guillain-Barre Syndrome
This is the most specific diagnostic test for GBS.
Nerve conduction studies/electromyography
This is the treatment for GBS.
IVIG or plasmapheresis (only one, combining them is a wrong answer)
A woman comes to the emergency department with bilateral leg weakness developing over the last few days. She has lost her knee jerk and ankle jerk reflexes. The weakness started in her feet and progressed up to her calves and her thighs. She is otherwise asymptomatic.
Which of the following is the most urgent step?
a. Pulmonary function testing
b. Arterial blood gas
c. Nerve conduction study
d. Lumbar puncture
e. Peak flow meter
A. The most dangerous thing that can happen with GBS is dysautonomia or involvement of the respiratory muscles. Peak inspiratory pressure or a decrease in forced vital capacity (FVC) is the earliest way to detect impending respiratory failure.
It is a disorder of muscular weakness from the production of antibodies against acetylcholine receptors at the neuromuscular junction. It presents with double vision and difficulty chewing, dysphonia, or weakness of limb muscles worse at the end of the day.
Myasthenia Gravis
This is the best initial test for Myasthenia Gravis
Acetylcholine Receptor Antibodies
This is the most accurate test for Myasthenia Gravis
Electromyography - shows decreased strength with repetitive stimulation
This is the best initial treatment for Myasthenia gravis
Neostigmine or Pyridostigmine
If medications does not control disease progression of Myasthenia Gravis, what is the most appropriate next step in management?
Thymectomy (if patient is under 60)
Prednisone (if patient above 60)
This is an anticholinergic drug that blocks muscarinic receptors; decreases the drooling and diarrhea that occur as adverse effects of neostigmine and pyridostigmine.
Glycopyrrolate
How would you treat acute myasthenic crisis.
IVIG or Plasmapheresis
This is the most common cause of dementia
Alzheimer disease
These are treatment options for Alzheimer disease
Donepezil, rivastigmine, and galantamine -> all increase acetylcholine levels
Memantine
This is a rapid progressive dementia with myoclonic jerks. It is normal in MRI or CT. CSF with 14-3-3 protein.
Creutzfeldt-Jakob Disease
This is the most accurate test for Creutzfeldt-Jakob Disease.
Biopsy
