Neurology Flashcards
person goes camping, has diarrheal illness, OR RECENT FLU SHOT
few weeks later develops weakness/numbness, hyporeflexia
what’s going on?
campylobacter infection -> postinfectious GBS
step 2 has what variant of MS.
how to dx MS?
relapsing-remittent.
so has episodes, fine in between.
dx with MRI = periventricular white matter/ Dawson’s fingers
this is not how to dx MS for initial diagnostic test, but what will lumbar puncture show?
oligoclonal IgG bands
how to treat MS flare?
how to maintenance treat MS?
flare - high dose IV steroids. 3-5 days
maintenance - interferon, Glatiraner, Fingolimod
what are the complications associated with MS and how to treat?
bladder spasms - baclofen, Cyclobenzaprine, oxybutinin?
urinary retention - bethanechol
urinary incontinence - amitryptiline
neuropathic pain - gabapentin, amitryptiline
how to dx GBS
lumbar puncture
“albuminocytologic dissociation”
lots of protein but few cells
GBS treatment/management
supportive. don’t hesitate to intubate if needed.
IVIg
DONT GIVE STEROIDS. will worsen. and higher chance of relapse.
what is 1st and 2nd line treatment for MG.
tx for MG crisis
1st line: pyridostigmine (anticholinesterase)
2nd line if nonresponsive to 1st line: steroids
crisis: IVIg
btw don’t forget to look for the thymoma. but i’m sure you knew that
what are the antibodies against in MG vs Lambert eaton
MG: post synaptic ACh receptor
LES: Ca channels in presynaptic membrane -> prevent ACh release
since LES is weakness in less used muscles as opposed to in MG, which muscles/presentation have weakness?
proximal muscle weakness.
hard getting out of a chair. reaching up to cabinet/shelf.
how to dx LES?
EMG. initial muscle contraction is small waves. get bigger and bigger the more they contract. opposite pattern of MG
treatment of LES
look for and treat the small cell lung cancer
if not related to cancer, use immunosuppressants (Azathioprine, 6-MP)
patient presents with combined UMN (hyperreflexia, weakness) and LMN (hyporeflexia, fasciculations, weakness) findings (Babinski can be different on each side), with sparing of sensation.
dx? what test to dx?
ALS
Dx by EMG
dopamine agonist treatment med names (older and newer)
when would you use these in Parkinsons?
older - bromocriptine
newer - Ropinirole and Pramipexole
for young (<60-70 years old) and functional people
when do you use ACh R-antagonists like Benztropine in Parkinsons?
young people with tremor only.
side effect profile not worth for elderly.
what are Selegiline and Capones and how are they used in Parkinson’s
Selegiline - MAO-B antagonists
Capones - COMT antagonist
used when Levodopa-carbidopa starts wearing off. they inhibit the enzymes that break down dopamine.
no cure for essential/familial tremor but what can you give for symptomatic control?
BB
what is intention tremor caused by?
cerebellar dysfunction. from stroke or atrophy of cerebellum
elderly male has sciatica like pain and positive straight leg test, no history of heavy lifting. dx/next step?
xray and possibly MRI to rule out compression fracture. if negative, -> osteophyte.
neurosurgery > conservative management
warning sx of lower back pain indicating emergency (6)
what do u give immediately (besides surgical intervention)
- history of cancer
- urine or bowel incontinence or retention
- erectile dysfunction or priapism
- bilateral LE weakness
- sensory deficits in dermatome pattern (saddle anesthesia)
- fever
give dexamethasone!
guy was lifting heavy stuff, now has back pain. positive straight leg test, exacerbated by hip flexion, movement, cough, activity.
dx? tx?
disc herniation
neurosurg better than conservative management at 6 months. same after 1 yr or more
woman with back pain. on physical exam, “point tenderness or vertebral step off”
compression fracture. she has osteoporosis
elderly person with leg and butt pain, pseudoclaudication (positional and sx don’t reach all the way down to feet).
dx?
spinal stenosis.
confirm with MRI. needs surgery
person with back pain, LOSS of pain/temp in cape like disstribution, SPARING of proprioception. can have progressive loss of motor and sensation. BURNS THEMSELVES WHILE COOKING. what is dx?
syringomyelia. (pocket of CSF bulges into anterior cord)
person with hx of HTN, CAD, smoking, probably male. back pain, spastic paralysis and loss of proprioception. what is dx?
AAA with affected anterior spinal artery ASA
elderly person with back pain, relieved by flatulance or BM. dx?
constipation
treatment for MSK back pain (inciting event of heavy lifting but no disc herniation or fracture)?
NSAIDs and stretching.
NOT BEDREST
if person, esp younger, comes in with back pain, what visceral organ stuff do you need to consider?
kidney stone
pyelo
gyn stuff - ovarian torsion, cyst, ectopic preg, severe cramping
management for disc herniation
NSAIDs, bed rest.
as opposed to MSK injury which does NOT require bed rest!
2 things to do that can improve or even cure BPPV
- movement exercises dislodge and break up stones
2. Epley/Semont/Foster/Brandt-Daroff maneuvers
meds for labyrinthitis/vestibular neuritis (2)
often comes few weeks after a URI. if someone comes in with NEW ONSET sx you can give steroids within 72 hours.
otherwise Meclizine for symptom control during episodes until condition naturally resolves in months
tx for Meniere’s dz
diuretics, low salt diet
focal neuro deficits AND vertigo. next step for dx?
probs posterior fossa lesion imposing on cerebellum/brainstem. (tumor, stroke, vertebrobasilar insufficiency)
get MRI. if neg get MRA.
note: if neg, might just be complicated migraine
what can you give for symptomatic vasogenic edema from brain tumor? (HA, vertigo, ataxia, psychotic sx, coma)
steroids
person has stroke or TIA. on carotid ultrasound they have 60-70% stenosis. WHEN should you do a CEA on them? (now vs later)
within 2 weeks. emergent/acute timing.
the 4 Ds of posterior circulation stroke
Dizziness (vertigo)
Diplopia - double vision
Dysarthria
Dysphagia
how many hours from onset of sx can you give tPA for acute stroke NOT due to bleeding
3-4.5 hours
what are contraindications to give tPA? (in other words, even if pt has acute stroke < 3 hours onset, still can’t give tPA)? (
any brain bleed ever
recent bleed in body (like GI bleed)
if stroke is hemorrhagic you can’t give them tPA obvis, but what can you give them whilst calling neurosurg
drop blood pressure sys <150 with IV drip
FFP to raise platelets and stop bleeding. esp if INR is high.
what kind of stroke do u want to lower BP vs raise/permissive HTN? what are the BP goals for these situations?
hemorrhagic - drop BP with IV drip sys <150
ischemic (embolic, thrombotic) - permissive HTN for first 24-48 hours. 210/120 max w/ tPA. 180/105 max w/o tPA
when trying to find etiology of stroke what tests do you do? CT wo contrast is always first. if that’s neg and no signs of bleeding where else do u look?
EKG - look for a-fib (CHADS>2 give warfarin w/o bridge)
Echo - look for thrombus (warfarin w/ bridge)
Carotid US
u do carotid US on person who had stroke/TIA. what is treatment for different % stenosis?
60% and symptomatic (stroke, TIA) or >70% = CEA within 2 weeks (stent if can’t tolerate open surgery)
otherwise just medically treat the artery dz
if post stroke and not on tPA, you start ASA within 24 hours for 2ndry stroke prevention. if on aspirin they get another stroke (aspirin failure) what do you put them on next for antiplatelet?
add 2nd agent -> aspirin + dipyridamole.
note: if allergic to aspirin, can use clopidogrel.
