Neurology Flashcards
incontinence, abnormal gait, dementia
Normal pressure hydrocephalus
- decreased absorption of CSF
Side effects of levodopa/carbidopa
early: hallucinations, confusion, somnolence
late: dyskinesia
unilateral, intermittent sharp pain of the right cheek and lip that lasts several seconds triggered by minor stimuli
trigeminal neuralgia
CSF in Guillian Barre
High protein, normal wbc, rbc and glucose
organophosphate poisoning
- farmer trying to commit suicide
- sx of cholinergic excess (bradycardia, miosis, bronchorrhea, muscle fasiculations, salivation, lacrimation)
- tx: atropine and remove clothes to prevent further absorption
periodic sharp wave complexes on EEG with rapidly progressive dementia, myoclonus and mood sx (depression)
Creutzfeldt-Jakob disease
- positive 14-3-3 assay
Most common cause of CN III palsy (ptosis with eye looking down and out)
ischemic neuropathy from uncontrolled DM
14 year old girl with progressive ataxia, loss of vibratory sense, degeneration of spinal cord in cervical region
Friedreich ataxia - excessive number of trinucleotide repeats (GAA)
- most common in teens
Rapidly progressive demetia, myoclonus with EEG showing sharp, triphasic, synchronus discharges
Creutzfeldt-Jakob - prions
Major cause of death after SAH
first 24 hours: recurrent bleeding
day 3-10: vasospasm –> prevented with nimodipine
7 year old boy presents after a seizure. The axillary and inguinal folds has multiple freckles. Chest and back have 6, darkly pigmented macules.
Neurofibromatosis 1
- > 5 cafe0au0lait macules, >1 neurofibroma, axillary or inguinal freckling, optic glioma, >1 iris hamartoma (Lisch nodules, bone lesions
- seizures, scoliosis and short stature, pseudoarthrosis
unilateral motor impairment, no sensory or cortical deficits, no visual field abnormalities - lesion location
Posterior limb of internal capsule (lacunar infarct)
contralateral somatosensory & motor deficit (face, arm, leg), conjugate eye deviation towards the side of the lesion, homonymous hemianopia, aphasia (dominant hemisphere), hemineglect (nondominant) - lesion location
Middle cerebral artery
contraleteral somatosensory and motor deficit (primarily LE), abulia (lack of will or initiative), dyspraxia, emotional disturbance, urinary incontinence - lesion location
Anterior cerebral artery
alternate syndromes with contralateral hemiplegia & ipsilateral cranial nerve involvement, possible ataxia - lesion location
vertibrobasilar system (supplying the brainstem)
Straight lines appearing wavy
Macular degeneration
anticholinergic drugs (trihexphenidyl) can precipitate
angle-closure glaucoma
Most common CNS tumor in children. Supretentorial location presents with seizures, weakness, sensory changes, signs of increased ICP (HA)
Pilocytic astrocytoma (high grade astrocytoma = glioblastoma)
CNS tumor in children that’s usually located in 4th ventricle and cause obstruction of CSF
Ependymoma
CNS tumor in children that arises in the sella turcica and appears as cystic structures with calcifications
Cranipharyngioma
Patient presents with upper extremity weakness, areflexia, and loss of pain and temperature sensations. No sx in lower extremities.
Syringomyelia (Arnold Chiari malformation type 1)
- “cape distribution” of loss of pain and temp
- dorsal columns not affected usually
- can progress to anterior horn of grey matter –> areflexic weakness
Pt with history of severe alcohol and tobacco use presents with wide based gait and postural instability. Unable to perform heel to shin but able to perform finger to nose.
Alcoholic cerebellar degeneration
- damage to the Purkinje cells of the cerebellar vermis
- truncal coordination is impaired but limb coordination is intact
57 year old man complains of progressive difficulty with gait. Mild atrophy and weakness of upper extremities with decreased triceps reflex. Bilateral lower extremity strength is 4/5 with positive Babinski reflex.
Cervical myelopathy due to advanced spodylosis at C-spine.
- LMN signs (UE) - atrophy, dec reflexes
- UMN sign (LE) - babinski, hyperreflexia
Tx for alzheimers
Cholinesterase inhibitors
donepazil, rivastigmine, galantamine
Tx for myasthenic crisis
Intubation for deteriorating respiratory status
Plasmapheresis or IVIG & steroids
Homeless women presents with encephalopathy, ocular dysfunction, and gait ataxia.
Thiamine deficiency
- must give thiamine before glucose because glucose can worsen encephalopathy
Tx for generalized convulsus status epilepticus
- seizure lasting for 5 or more min or 2 or more seizures occur before pt regains consciousness
- IV benzos for termination (lorazepa, diazepam)
- Medication to prevent recurrence: fosphenytoin, phenytoin, levetiracetam, valproic acid
Tx for Bell’s palsy (unilateral facial weakness of upper and lower face due to peripheral neuropathy of facial nerve). May have prodrome of auricular pain
Steroids
MRI findings of late Alzheimers
temporal lobe atrophy most prominent in the hippocami and surrounding medial temporal lobes
Young obese woman with papilledema, CN VI palsy, peripheral visual field defect
pseudotumor cerebri (idiopathic intracranial HTN) - get LP with opening pressure >250
Eye problem found in MS
Bilateral internuclear opthalmoplegia
- affected eye (ipsilateral to lesion) is unable to adduct and contralateral side abducts with nystagmus
- damage to medial longitundinal fasiculus (mediated communication btwn CN III and VI)
- unilateral lesions can occur in lacunar stroke in pontine artery distribution
Pts at risk for MS
vitamin D deficiency, colder climates, reduced sunlight exposure
- HLA-DRB1 patients
Pt has pure motor hemiplegia
Lacunar stroke (hypertensive vasculopathy) - affecting posterior limb of internal capsule
3 week infant born at home has a seizure and 101 temp. brain imaging reveals patchy areas of increased cerebral attenuation with edema and hemorrhage in left temporal lobe.
HSV
Neurofibromatosis type 1
NF1 gene - neurofibromin
von Recklinghausen disease
chrom 17
cafe au lait spots, freckling in skin folds, neurofibromas, Lisch nodules, optic gliomas
Neurofibromatosis type 2
NF2 gene - merlin
central NF
chrom 22
bilateral acoustic neuromas
Pt has an ischemic stroke 4 weeks ago and has hemianesthesia on the right side of body. Her sx have improved but she now has paroxysmal burning pain over the affected area that is exacerbated by light touch (allodynia)
Thalamic stroke with thalamic pain syndrome (lacunar stroke)
Conjunctival injection, tarsal inflammation, and pal follicle preceded by URI sx
Trachoma
- caused by chlamydia trachomatous
- tx: azithromycin
Pt with alzheimer’s is found to have a brain bleed on CT. What is the cause
Cerebral amyloid angiopathy
- cause spontaneous lobar hemorrhage due to beta amyloid deposition in the arterial walls
- seen in alzheimers
patient with ascending weakness of the lower extremities after a respiratory illness. CSP shows elevated protein
Guillian Barre
- tx with IVIG
Sleep onset insomnia with excessive daytime sleepiness after switching work shifts from night to regular 8-5. When allowed to sleep to her circadian rhythm on the weekends she gets a full nights sleep from 2-11.
delayed sleep-wake phase disorder
- inability to fall asleep at traditional bed times
Pain develops 3 months after a BKA. There is TTP
Neuroma - transection of nerve fibers
- relieved with local anesthetic injection
Cranial nerves involving the eye
CN II - carry visual info to brain, pupillary light reflex
CN III - majority of movement
CN V V1 - corneal sensation
Meningitis tx
Age 2-20: Vanc + 3rd gen ceph Age >50: vanc + amp + 3rd gen ceph IC: vanc + amp + cefepime Neurosurg/penetrating trauma: Vanc + cefepime *add steroids
Pt with cerebellar and retinal hemangioblastomas. US of kidneys reveal multiple cysts. Father died from cerebral hemorrhage
Von Hippel-Lindau disease
- cerebellar and retinal hemangioblastomas
- pheochromocytoma
- renal cell carcinoma
Area of brain affected in Huntington disease
caudate nucleus
Pain and swelling over the medial aspect of the right eye. Slight pressure causes expression of purulent material
Dacryocystitis - infection of lacrimal sac
Etiology of Bell’s palsy
Reactivation of a neurotrophic virus (HSV) that causes inflammation of the facial nerve and degeneration of the myelin sheath
What can still be present in brain death
DTRs
meningitis tx
Neonates < 1month of age: ampicillin and cefotaxime
Children to Adults < 50 years of age: ceftriaxone and vancomycin
Adults >50 years of age: ceftriaxone, vancomycin, and ampicillin
tx of parkinson’s tremor
Trihexphenidyl
metabolic acidosis after a seizure is due to
lactic acidosis - transient (will resolve)
60 year old female presents with new onset bilateral temporal headache. She has decreased visual acuity with dilated, segmented, tortuous retinal veins. She also has decreased pinprick sensation and loss of bilateral ankle reflexes. Elevated total protein and normal albumin
Waldenstrom macroglobulinemia
- headaches, dizziness, blurry vision, large gamma gap (diff btwn total protein and albumin), and “sausage link” retinal changes
- monoclonal IgM antibodies
tx of acute glaucoma
mannitol, acetazolamide, pilocarpine, or timolol
*avoid atropine!
CSF of bacterial vs viral meningitis
Bacterial: >1000 WBC, <40 glucose, >250 protein
Viral: 10-500 WBC, 40-70 glucose, <150 protein
Vital signs suggestive of impending brain herniation
Cushing triad
- widened pulse pressure
- bradycardia
- irregular respirations
CSF in Gullian Barre (gastroenteritis followed by leg weakness)
Normal cell count with increased protein
EMG findings of MG
decreased response to repetitive stimulation of motor nerves on EMG
impaired consciousness, pupillary abnormalities, neuro-ophthalmic abnormalities, especially of vertical gaze, and acute confusional state
“top of the basilar syndrome”
- rostral basilar artery embolism
Vertigo, nystagmus, diplopia, nausea, and vomiting. ptosis and miosis
Loss of sensation of the ipsilateral face
lateral medullary syndrome or Wallenberg syndrome
- most often caused by an ipsilateral vertebral artery or posterior inferior cerebellar artery occlusion
- Vestibular nuclei (N/V, diplopia, vertigo, nystagmus)
- Horner syndrome caused by dysfunction of the descending sympathetic tract (pitosis, miosis)
- descending tract and nucleus of the fifth nerve
vestibular malfunction (dizziness, nystagmus, leaning toward the side of the lesion), autonomic malfunction (hypotension without heart rate response, tachycardia, intermittent bradycardia, Horner’s syndrome), bulbar motor dysfunction (dysphagia leading to aspiration, dysphonia, ipsilateral palatal, pharyngeal, and vocal cord paralysis), and sensory symptoms (loss of pain and temperature sensation on the ipsilateral face and contralateral body, tingling and numbness in the ipsilateral face)
Wallenberg syndrome - PICA infarction (may also be caused by vertebral artery infarction)
How does hyperventilation decrease ICP
CBF relies on partial pressures of O2 and CO2. Hyperventilation causes CO2 washout and vasoconstriction.
Common locations of berry aneurysms
branch point of the anterior communicating artery with the anterior cerebral artery
the junction of the posterior communicating artery and the internal carotid artery
the bifurcation of the middle cerebral artery
Brain tumor that can cause hypothyroidism, adrenal failure, and diabetes insipidus due to mass effect on the hypothalamus
Craniopharyngioma
Most significant RF for CVA
HTN
wide based gait, ataxia, dysarthria, scoliosis, loss of DTRs in a 15 year old
Friedreich’s ataxia
- AR loss of function in frataxin gene (GAA)
- pt’s most likely die from hypertrophic cardiomyopathy
guillian barre with ataxia and areflexia
Miller Fisher Sydrome (anti-GQ1b)
Phenytoin toxicity
cerebellar dysfunction
- ataxia, horizontal nystagmus, hyperreflexia, AMS
Momentary vision loss with head position changes, headaches and enlarged blind spots
papilledema
Young woman with loss of vision in left eye, colors appear “washed out,” central scotoma (smudge), and has a pupillary aferent defect in left eye
optic neuritis
- associated with MS
central retinal artery occlusion tx
ocular massage and high flow oxygen
fever, malaise, focal back pain, progressive neurologic findings in an HIV patient still using ID.
spinal epidural abscess
Presence of EBV DNA in CSF and ring enhancing lesion
primary CNS lymphoma
unilateral head and neck pain, ipsilateral horner syndrome, and signs of cerebral ischemia (focal weakness) after trauma
carotid artery dissection
hoffman sign
flicking nail of middle finger causes ipsilateral thumb to flex and adduct
- corticospinal tract lesion
- sign of cervical myelopathy
restless leg syndrome tx
- dopamine agonists (pramipexole)
2. alpha-2-delta calcium channel ligands (gabapentin enacarbil)
first line tx for pseudotumor cerebri
acetazolamide
lower motor neuron signs in the upper extremities and upper motor neuron signs in the lower extremities with shock like sensation down the spine
cervical spinal cord compression
sympathetic opthalmia
“spared eye injury”
- immune mediated inflammation of one eye after penetrating injury to other eye
- uncovering of hidden antigens
SE of succinycholine
depolarizing neuromuscular blocker
- can cause life-threatening hyperkalemia in patients with a condition leading to upregulation of postsynaptic ACh receptors (skeletal muscle injury, burn injury, stroke)
Broca’s aphasia lesion
dominant frontal lobe
common cause of conductive hearing loss in young adults in their 20-30s
otosclerosis
toxic neuropathy
alcohol, meds, heavy metals
b/l symmetric distal polyneuropathy, parathesia, burning pain and ataxia
contralateral hemiparesis and sensory loss with conjugate gaze towards side of the lesion
basal ganglis (putamen) infarct
headache that is worse at night, occasional falls and blurred vision
intracranial hypertension
Cushing reflex: HTN, bradycardia, and respiratory depression (brainstem compression)
large brain lesion with irregular borders with ring enhancement and central hypointensity
glioblastoma multiforme
wernike’s encephalopathy effects what part of the brain
mamillary bodies
refers to a collection of blood in the anterior chamber of the eye
hyphema
- most often follows blunt trauma to eye
