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3rd year - Family Medicine > Neurology > Flashcards

Neurology Flashcards

1
Q

Definition of vertigo

A

sense of motion (usually spinning) when none exists

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2
Q

Definition of disequilibrium

A

feeling off balance or wobbly when standing or walking

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3
Q

Definition of pre syncope

A

feeling of about to pass out (faint, lose consciousness) or blacking out

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4
Q

Definition of lightheadedness

A

vague symptoms with possible feeling of being disconnected from environment

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5
Q

Causes of vertigo

A

(in order from most common to less common):
benign paroxysmal positional vertigo (BPPV)
Meniere’s disease
vestibular neuritis
labyrinthitis
central: CNS lesion (stroke, tumor), migraine, seizure

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6
Q

Causes of dysequilibrium

A 
Stroke
TIA 
Parkinson’s disease 
diabetic neuropathy 
muscle weakness affecting balance and gait 
poor vision
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7
Q

Causes of presyncope

A

Orthostatic hypotension

cardiac: arrhythmias, myocardial infarction, carotid artery stenosis

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8
Q

Causes of lightheadedness

A

psychiatric disorders including depression, anxiety, hyperventilation syndrome

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9
Q

Causes of dizziness due to medications

A 
Cardiac medications
CNS and psychiatric medications 
Muscle relaxants 
Sedatives 
Urologic medications
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10
Q

What is the Romberg test

A

Romberg’s test for proprioception and vestibular system

swaying towards one side indicative of vestibular dysfunction on ipsilateral side

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11
Q

What type of gait is associated with cerebellar cause of dizziness

A

ataxic gait (slow, wide based, irregular)

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12
Q

What is the purpose of the HINTS exam?

A

HINTS exam = Head Impulse, Nystagmus and Test of Skew

to rule out central cause (stroke, tumor, multiple sclerosis) for acute vertigo

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13
Q

How to conduct head impulse test in HINTS exam

A

1) Head Impulse Test

patient fix eyes on examiner’s nose while examiner move patient head in horizontal plane to left and right

central cause = intact reflex = patient eyes stay fixed on nose

peripheral cause = abnormal reflex = patient eyes do not stay fixed on nose with nystagmus to the side of which the eyes move

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14
Q

How to conduct nystagmus test in HINTS exam

A

2) Nystagmus

evaluation for nystagmus during eye movement exam during patient’s ocular pursuit of physician’s finger as it moves slowly left, right, up and down

nystagmus is involuntary movement of eyes in horizontal, vertical or rotatory plane

nystagmus consist of 2 phases: slow phase (smooth pursuit) and fast phase (saccade)

nystagmus is conventionally described by the direction of the fast phase e.g. nystagmus to the right = fast phase toward right and slow phase toward left

central cause = nystagmus that change direction when patient looks at different directions

peripheral cause = nystagmus always in same direction

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15
Q

How to conduct test of skew in HINTS exam

A

3) Test of Skew

patient focus on examiner’s nose

examiner covers one eye, then quickly uncover the eye

central cause = positive test of skew = patient’s covered and then uncovered eye need to re-align

peripheral cause = negative test of skew = patient’s eyes do not need to re-align with cover and uncover test

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16
Q

Interpretation of central vs peripheral cause for HINTS exam

A

central cause = normal head impulse, nystagmus changing directions and positive test of skew

if acute vertigo with central cause on HINTS test, then urgent CT or MRI to rule out stroke

peripheral test = abnormal head impulse, uni-direction nystagmus, negative test of skew

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17
Q

Hyperventilation test

A

if hyperventilation syndrome suspected (anxiety), then have patient rapidly take 20 deep inhalations and exhalations to reproduce symptoms

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18
Q

Dix Hallpike maneuver

A

positive Dix-Hallpike maneuver = reproduction of nystagmus and dizziness when patient’s head descended

Negative Dix Hallpike does not rule out BPPV

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19
Q

Diagnostic approach to dizziness

A

1) rule out focal CNS lesion (stroke, tumor)
if neurological deficit or HINTS exam suggesting CNS lesion, then urgent CT or MRI head
rule out medication, caffeine, nicotine, alcohol

2) for vertigo (usually in primary care setting) with neurological symptoms already ruled out classify on history vertigo vs disequilibrium vs pre syncope vs lightheadedness

a) if dizziness suggests vertigo
- migraine symptoms (aura, headache, photophobia, phono phobia) suggest migraine
- if associated with hearing loss, determine if episodic or persistent (episodic vertigo with hearing loss suggest Meniere’s disease, persistent vertigo with hearing loss suggest labyrinthitis)
- if no hearing loss, determine if episodic or persistent vertigo (episodic vertigo with no hearing loss and positive Dix-Hallpike suggest BPPV, persistent vertigo without hearing loss suggest vestibular neuritis)

b) if dizziness suggests disequilibrium
- decreased sensation in foot and legs suggest peripheral neuropathy
- TRAP (tremor, rigidity, akinesia, postural instability) suggest Parkinson’s disease
- poor vision suggest poor vision as cause of disequilibirum
- Romberg test
- ataxic gait and abnormal cerebellar testing suggest cerebellar cause of disequilibirum

c) if dizziness suggests pre syncope
- history of cardiac disease (arrhythmia, myocardial infarction, aortic stenosis) or abnormal cardiac examination suggest cardiac disease as cause for pre syncope - consider cardiac testing including resting ECG, echocardiogram, cardiac stress test
- postural changes in blood pressure or pulse suggest orthostatic hypotension

d) if dizziness suggests lightheadedness history of psychiatric symptoms / diagnoses (anxiety or depression) or positive hyperventilation provocation test suggest psychiatric cause

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20
Q

Vertigo management

A
  1. Address underlying cause
  2. Anticholinergic Meclizine to increase motion tolerance
  3. Antihistamine Dimenhydrinate to prevent motion sickness and decrease severity of dizziness
  4. Lorazepam to suppress vestibular system
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21
Q

Orthostatic hypotension management

A
  1. Lifestyle modification - increase fluid intake, sleep with bed elevated, increase salt intake, regular exercise
  2. Alpha 1 agonist Midodrine (Proamatine) to increase blood pressure
  3. Mineralocorticoid Fudrocortisone to increase water retention
  4. Pseudoephedrine to increase blood pressure
  5. Paroxetine to increase blood pressure
  6. Desmopressin to increase water retention
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22
Q

Anxiety related hyperventilation dizziness management

A
  1. Breathing control exercises, breathing into paper bag
  2. Beta blocker
  3. Anti-anxiety agents (SSRI, benzos)
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23
Q

BPPV pathophysiology

A

calcium debris (cupulolithiasis) in posterior semicircular canals

24
Q

What is considered a positive Dix Hallpike

A

Reproduction of symptoms

reversibility = nystagmus changes direction with different position of Dix-Hallpike test

latency = nystagmus occur only after a few moments after patient is in supine position during Dix-Hallpike test

25
Q

How do you conduct an Epley maneuver

A

1) patient sit on examination table, with eyes open and head turned 45 degrees to affected side A
2) examiner support head as patient quickly goes to supine position with head extended
3) physician turns patient head to other side B 90 degrees, remaining for 30 seconds
4) physician turns patient head to other side B 90 more degrees while patient rotate body 90 degrees in same direction, remaining for 30 seconds

maneuver of series of positions to relocate particle back into utricle

80% success with 1 treatment; 100% success with multiple treatment

patient can learn this as vestibular rehabilitation exercise

26
Q

Meniere’s disease pathophysiology

A

Idiopathic, but proposed mechanism is excessive endolymph fluid in inner ear (endolympahtic hydrous), which cause swelling of endolymphatic sac that eventually burst and flow into other areas

27
Q

Meniere’s disease clinical presentation

A
  1. episodic debilitating rotational vertigo, which can be severe, incapacitating and unpredictable lasting minutes to hours to days
  2. vertigo can be accompanied by nausea and vomiting
  3. fluctuating unilateral or bilateral low frequency sensorineural hearing loss
  4. unilateral or bilateral tinnitus
  5. sensation of fullness or pressure in ear
  6. signs include ataxia and nystagmus during acute event
28
Q

Meniere’s disease treatment

A

1) lifestyle modification
smoking cessation
salt restriction (<2g sodium per day)

2) diuretics
Hydrochlorothiazide / Triamterene (Dyazide)

3) medication for symptomatic relief
antihistamine Behahistine

if severe vertigo refractory to medication, then surgical labyrinthectomy (removal of affected inner ear)

29
Q

Vestibular neuritis pathophysiology

A

Idiopathic, but proposed mechanism is infection of vestibular nerve ganglion causing inflammation

30
Q

Vestibular neuritis clinical presentation

A

onset may be preceded by upper respiratory tract

infection sudden onset debilitating vertigo lasting days

can have n/v

ataxia, nystagmus

31
Q

Vestibular neuritis treatment

A

vestibular neuritis usually self limited and improves over 3-6 weeks

patients should be reassured and recommended to rest

1) systemic steroid Methylprednisolone PO (Depo-Medrol)

2) medication for symptomatic relief
antihistamine Gravol
serotonin antagonist Ondansetron

32
Q

Meniere’s disease investigations

A

audiometry: low frequency sensorineural hearing loss

ENG: decreased vestibular activity

33
Q

Vestibular neuritis investigations

A

audiometry: no hearing changes

ENG: reduced vestibular activity

34
Q

What is tested by the Romberg test

A

With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability - vision, proprioception, and vestibular sense.

If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open.

When the patient closes their eyes, however, visual input is removed and instability can be brought out.

If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open.

Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia, so these should be tested for separately in other parts of the exam.

35
Q

Headache red flags, corresponding differential diagnosis and investigations

A

1) onset age >50 years

differential diagnoses include temporal arteritis, brain

tumor work up includes head imaging (CT or MRI), ESR

2) sudden onset headache (reaching maximal intensity in seconds or minutes), first headache or worst headache

differential diagnoses include intracranial bleed especially SAH or brain tumor

work up includes head imaging (CT or MRI) and follow up lumbar puncture if head imaging is negative

3) headache with change of increased frequency or severity (i.e. change form previous pattern)

differential diagnoses includes brain tumor, subdural hematoma, medication induced headache

insidious progressive headache over course of days to months or headache worse at night or upon awakening suggests brain tumor

work up includes drug screen, head imaging (CT or MRI)

4) new onset headache in high risk population (immunocompromised)

differential diagnoses include meningitis, brain abscess and brain metastases

work up includes head imaging (CT or MRI) and lumbar puncture

5) headache with systemic illness (fever, meningismus, rash)

differential diagnoses include meningitis, encephalitis, systemic infection, collagen vascular disease, temporal arteritis

work up includes head imaging (CT or MRI), lumbar puncture, ESR and serology

6) focal neurological deficits, confusion, loss of consciousness, change in personality

differential diagnoses include brain tumor, stroke, vascular malformation, collagen vascular disease, brain abscess, venous sinus thrombosis, encephalitis

work up includes head imaging (CT or MRI), connective tissue work-up

7) papilledema

differential diagnoses includes mass lesion, meningitis, idiopathic intracranial hypertension

work up includes head imaging (CT or MRI), lumbar puncture

8) head trauma

differential diagnoses include intracranial hemorrhage and hematoma (epidural hematoma, sub-dural hemorrhage)

work up includes head imaging (CT or MRI), X-ray of skull and C-spine

9) headache during pregnancy or post partum period headache

suggest cortical vein or venous sinus thrombosis, carotid dissection or pituitary apoplexy

36
Q

Pharmacologic symptomatic relief of secondary headache

A

Acetaminophen or NSAID
may consider prescribing opioids for severe headache

if nausea, then anti-emetics or sedatives such as diphenhydramine, prochlorperazine, chlorpromazine, droperidol, metoclopramide

37
Q

Migraine stages

A
  1. Prodrome
    - hours to days before headache
    - non specific symptoms due to hypothalamus activity ( yawning, mood, thirst, hunger, etc)
  2. Aura
    - visual, sensory, speech positive or negative symptoms
    - Occurs gradually over 5-20 minutes and lasts <1 hour
  3. Headache
    - unilateral throbbing and pounding headache usually localized to frontotemporal region aggravated with exertion 4 hours to 3 days in duration
  4. Post drome
    - hours to days after headache - fatigue, soreness, confusion etc
38
Q

Symptoms associated with migraine headache

A

N/V
Photophobia
Phonophobia

39
Q

Migraine management

A

1) lifestyle modification

2) medication abortive therapy to relieve symptoms during current headache
abortive therapy options include triptans, ergots, conventional analgesics, narcotic analgesics

prophylactic therapy taken everyday to prevent headaches
prophylactic therapy options include tricyclic antidepressants (amitriptyline), anti-epileptics (divalproex, topiramate), beta blockers (propranolol) and serotoninergic compounds (methysergide, pizotylline)

40
Q

What is the goal of abortive therapy for migraines?

A

Full relief of pain within 2 hours of initiation

41
Q

Algorithm step up for abortive therapy in migraines?

A

Mild migraine: acetaminophen and NSAID

Moderate: acetaminophen, NSAID, triptans

Severe: triptans, opioids, corticosteroids (and possible ergotamine)

If n/v use anti-emetics (parenterally)

42
Q

Triptans MOA

A

Serotonin agonist that activates 5HT1B/1D receptors on pre synaptic 1st order C fiber neuron of the trigeminal nerve endings.
This inhibits release of NTs by presynaptic neuron to inhibit neuro transmission of pain

5HT1B1D agonism also causes vasoconstriction of cranial vessels, which may help alleviate vasodilation related headache

43
Q

Triptan contraindications

A

Ischemic cardiac disease

CVD

PVD

Uncontrolled severe HTN

Pregnancy

44
Q

Ergotamine MOA

A

mixed partial agonist at 5HT1B/1D and alpha-adrenoceptors

45
Q

Ergotamine side effects

A

Prolonged vasoconstriction, whcih can result in distal necrosis of limbs

Uterine spasm

46
Q

Ergotamine contraindications

A

same as triptans

47
Q

Indications for prophylactic migraine therapy

A

2-3 migraine attacks per month

migraine attack lasting >2 days

inadequate abortive therapy relief

migraine attack after prolonged aura

migraine severely disrupting quality of life

48
Q

First line prophylactic migraine therapy medications with established efficacy

A

Propranolol, metoprolol

Amitriptyline

Valproic acid, topiramate

49
Q

Tension headache clinical presentation

A

Band like or vice like pressure headache, usually bl, mild to moderate

50
Q

Tension ha management

A

Lifestyle - stress

Analgesic (NSAID, acetaminophen) for episodic tension ha

Tricyclic antidepressant amitriptyline is 1st line for chronic tension ha

NaSSA (Mirtazapine) or SNRI (Venlafaxine) is 2nd line for chronic tension ha

51
Q

Cluster ha clinical presentation

A

Recurrent severe unilateral ha, typically behind eye

Pain usually stabbing, burning or squeezing

Usually at night, 1-3 times in a day, lasting 15 min to 3 hours

Accompanied by autonomic symptoms, restlessness, difficulty concentrating

52
Q

Cluster ha management

A

Abortive therapy - oxygen and triptans

Prophylactic - lithium or CCB

53
Q

Medication overuse headache management

A

Detox by discontinuing all analgesic and ha related medication

If patient has history of migraine, during detox, start prophylactic medication for migraine

Detox may require medical supervision

54
Q

Cervicogenic ha diagnosis

A

Pain referred from source in neck

Evidence of lesion in neck

Evidence that pain can be attributed to neck through clinical signs or relief with anesthetic block of C1-C4

Pain resolves within 3 months after tx of neck lesion

55
Q

Cervicogenic ha treatment

A
  1. Physical therapy
  2. Anesthetic blockade
  3. Radiofrequency neurotomy, glucocorticoid injections, surgery
56
Q

Indications for surgery for cervicogenic ha

A
  1. C2 spinal nerve compression by structures
  2. OA of lateral C1-2 joint
  3. Upper cervical intervertebral disc pathology

3rd year - Family Medicine (9 decks)

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