Neurology Flashcards
What is the significance of doll’s eyes?
Doll’s eyes, when the eyes keep “looking” in the original direction when the head is turned, signify that the brainstem is working normally.
Which pupil finding can be seen with uncal herniation?
In uncal herniation there is one dilated and nonreactive pupil.
What is the presentation of locked-in syndrome?
In locked-in syndrome a patient is awake and aware of the surrounding environment but may only have the ability to control eye movements.
What is the definition of persistent vegetative state?
A persistent vegetative state is a comatose state lasting more than 4 weeks.
What is akinetic mutism vs. catatonia?
Patients with akinetic mutism are profoundly apathetic, although they register most of what is happening around them. Patients with catatonia are unresponsive although they have preserved oculocephalic reflexes (ie. doll’s eyes).
How is brain death diagnosed? Is an EEG required?
EEG is not required for diagnosis of brain death. Brain death requires knowledge of a preceding catastrophic event (clinical or imaging) responsible for the current state and exclusion of all possible metabolic confounders. Temperature should be normal and SBP >100 (with pressors if needed). Absence of brainstem function can then be documented with loss of spontaneous eye movements, midposition of eyes, loss of oculocephalic reflexes, dilated or midpoint fixed pupils, paralysis of bulbar musculature, absence of motor or autonomic responses to noxious stimuli, and absence of spontaneous respiratory movements.
Name some environmental triggers for seizures in susceptible people.
Triggers for seizures in susceptible people include alcohol, cocaine, intense emotions, strobe lighting, loud music, stress, menses, and lack of sleep.
What are some differences between generalized and focal seizures?
Focal seizures involve 1 side of the body and are not associated with impaired consciousness. Generalized seizures have altered consciousness and usually movement of both sides of the body.
Which test should you order if you suspect recurrent psychogenic nonepileptic seizures (PNES)?
An EEG with video monitoring should be ordered in a patient with suspected PNES.
What is the treatment of status epilepticus?
The treatment of status epilepticus involves correcting hypoglycemia if present with IV thiamine followed by IV dextrose. Then give a benzodiazepine followed by a loading dose of phenytoin.
Which drug is used to treat absence seizures?
Ethosuximide is used only to treat absence seizures.
Which AEDs decrease the effectiveness of oral contraceptives?
The effectiveness of OCPs is reduced by phenytoin, phenobarbital, carbamezpine, lamotrigine, oxcarbazepine, and topiramate.
Which AED serum concentration is reduced by estrogens?
Estrogen can reduce the drug concentration of lamotrigine.
Which AED reduces the serum concentration of progestins?
Lamotrigine can reduce the concentration of progestins.
What is the definition of dementia?
Dementia is a chronic cognitive decline with or without behavioral impairment that is progressive, interferes with normal daily function, and is not due to delirium or underlying psychiatric disorder.
Which 5 domains may be impaired in patients with dementia?
The 5 cognitive domains that may be affected in dementia are memory, executive, perception, language, and behavior.
What is the definition of mild cognitive impairment?
MCI is diagnosed when only 1 domain of cognitive is in decline but does not significantly impact daily functioning.
What is the clinical triad of normal pressure hydrocephalus?
The triad of normal pressure hydrocephalus is gait apraxia, dementia, and urinary incontinence.
How is Alzheimer disease diagnosed?
Alzheimer disease is diagnosed in a patient with insidious, progressive illness with marked impairments in > 2 cognitive domains. Do not diagnose AD in patients with history of significant cerebrovascular disease, clinical features of frontotemporal dementia or dementia with Lewy bodies, has evidence of another psychiatric or neurologic illness, or takes medication that can cause cognitive impairment.
Which class of drugs is the 1st line treatment for Alzheimer disease?
Cholinesterase inhibitors are 1st line therapy for Alzheimer disease.
Which drug is used with a cholinesterase inhibitor for the treatment of advanced Alzheimer disease?
Memantine (Namenda) can be added to a cholinesterase inhibitor in advanced AD.
What is the potential complication from the use of atypical antipsychotics in elderly patients with dementia?
Atypical antipsychotics are associated with increased mortality in AD.
Compare and contrast the features of NPH, AD, and vascular dementia.
NPH presents with a triad of dementia, gait ataxia, and urinary incontinence. AD is predominantly a progressive decline in cognitive function. Vascular dementia often follows a stepwise deterioration.
How does the clinical presentation of frontotemporal dementia differ from that of Alzheimer disease?
Frontotemporal dementia differs from AD in that it has a more rapid onset and more prominent behavioral and personality changes, often with disinhibition or language deficits.
Is CJD insidious or rapid?
CJD causes a rapidly progressive dementia
How do you diagnose CJD?
Gold standard for diagnosis of CJD is brain biopsy. However, T1/T2 MRI with diffusion-weight images, EEG (periodic sharp waves and complexes), and 14-3-3 protein in an otherwise bland CSF can help with diagnosis.
Compare and contrast dementia with Lewy bodies and progressive supranuclear palsy with Parkinson disease dementia.
Parkinson disease dementia primarily affects executive functions and attention in its early stages. When dementia precedes or develops within one year of motor symptoms in PD, consider dementia with Lewy bodies. Progressive supranuclear palsy presents with dementia, gaze palsy, and falls.
What is the problem with using antipsychotic drugs to treat patients with Parkinson disease?
Antipsychotic drugs have an increased risk of death in patients with PD.
What are the clinical features of Huntington disease?
Huntington disease causes dementia, chorea, and psychiatric disturbances, including personality changes, depression and psychosis.
Name some features that distinguish depression from dementia.
Patients with dementia often have frontal release signs (grasp, root, suck, and palmomental reflex) which are not seen in depression. Also, immediate recall is poor in depression due to poor attention but are preserved in early dementia.
What are the 2 hallmarks of delirium?
The clinical hallmarks of delirium are decreased attention span and varying states of confusion.
What are two ocular presentations of multiple sclerosis?
Two ocular presentations of MS are optic neuritis and internuclear ophthalmoplegia. In INO the patient has difficulty with horizontal eye movements but normal convergence.
Which findings in CSF are helpful for the diagnosis of MS?
Oligoclonal bands are IgG directed at myelin. There presence in CSF is helpful in diagnosis of MS.
What is the treatment for an acute exacerbation of MS?
Treatment for acute exacerbation of MS is steroids.
Natalizumab can cause what neurologic disease?
Natalizumab has been associated with PML.
What is the cause of central pontine myelinolysis? Which clinical findings are seen in this condition?
Central pontine myelinolysis is seen with overly rapid correction of hyponatremia. It can present with quadriparesis, mutism, pseudobulbar palsy, chewing or swallowing dysfunction, or locked-in syndrome.
What are the 4 motor features of parkinsonism?
The 4 motor features of PD are: 1) resting tremor, 2) rigidity and flexed posture, 3) retarded movement, and 4) loss of postural reflexes.
Name some drugs commonly used to treat Parkinson disease.
Drugs that are commonly used to treat PD are levodopa + carbidopa, non-ergotamine dopamine receptor agonists (ropinirole, pramipexole, and rotigotine), amantadine, anticholinergics, and MAO-B inhibitors (selegiline and rasagiline).
What is the potential side effect of anticholinergic drugs when used to treat Parkinson’s? Ropinirole has which side effects?
Anticholinergics can cause altered mental status. The dopamine receptor agonists like ropinirole can cause impulse control disorders like hypersexuality, compulsive shopping, and pathological gambling.
Selegiline can cause serotonin syndrome when combined with which other drugs?
Selegiline combined with tricyclics or SSRIs can trigger serotonin syndrome.
What is the clinical presentation of serotonin syndrome?
Serotonin syndrome presents with cognitive impairment, autonomic effects (hyperthermia, tachycardia, shivering, and sweating), and somatic effects such as hyperreflexia, clonus, twitching, and tremors.
What is the potential complications of an L-dopa dose reduction in a patient with Parkinson psychosis?
P
atients with PD psychosis are at risk for neuroleptic malignant-like syndrome with dose reduction of L-dopa.
What is the classic eye finding of progressive supranuclear palsy?
Patients with progressive supranuclear palsy develop vertical ophthalmoplegia within 2 years of diagnosis which progresses to complete ophthalmoplegia in all directions.
What is the clinical presentation of essential tremor? What improves it?
Essential tremor is a fine action tremor. It tends to decrease with alcohol intake.
What causes tardive dyskinesia? How is it treated?
Tardive dyskinesia is caused by long-term antipsychotic use. Mild TD can be treated with benzodiazepines. More severe cases can be treated with botulinum toxin.
What is the clinical presentation of neuroleptic malignant syndrome?
Neuroleptic malignant syndrome presents with hyperthermia, rigidity, diaphoresis, autonomic instability, and altered mentation. Labs often show leukocytosis, electrolytes disturbances, and elevated CK.
Which comorbidities are associated with Tourette syndrome?
Tourette syndrome is associated with the comorbid conditions of ADHD, OCD, learning disorders, and conduct disorders.
Which antihypertensive drug is used to treat tics in Tourette syndrome?
Clonidine is 1st line treatment of Tourette syndrome.
What is the classic triad of symptoms observed in patients with brain abscess?
The classic triad of brain abscess is fever, headache, and focal neurologic symptoms.
How does treatment of a varicella infection differ from the treatment of herpes simplex?
Varicella zoster infection requires higher doses of antiviral medicines than herpes simplex.
What is the diagnostic test for West Nile virus encephalitis?
Diagnosis of West Nile virus requires demonstration of antibody in spinal fluid.
Aside from patients with AIDS, PML can occur in which patients? What are the symptoms of PML?
In addition to AIDS patients, PML is seen in patients on immunosuppressive therapy and who are receiving natalizumab.
What is the treatment for CNS toxoplasmosis?
CNS toxoplasmosis is treated with sulfadiazine, pyrimethamine, and leucovorin.
