Neurology

Question 1

Headache

Answer 1

• Primary (90%) – migraine, tension, cluster or rebound
• Secondary (4%) – meningitis, SAH, etc
• Tension headache
  
  • MC type; thought to be d/t mental stress
  • Clinical Manifestations
    
    • Bilateral, tight, band-like, vise-like
    • No n/v or focal neurologic symptoms
  • Management
    
    • 1^st line = NSAIDs, ASA, acetaminophen
• Migraine Headache
  
  • 2 types
    
    • Migraine w/o aura (common)
    • Migraine w/ aura (classic)
  • Clinical manifestations
    
    • Lateralized, pulsatile/throbbing headache associated w/ n/v, photophobia
      
      • Worse w/ physical activity, stress, ETOH, chocolate, red wine
    • Auras – visual changes MC
  • Management
    
    • Symptomatic (Abortive)
      
      • Triptans or Ergotamines
        
        • CI = CAD or PAD, uncontrolled HTN
      • Dopamine blockers (IV reglan)
        
        • Given w/ Benadryl
    • Prophylactic
      
      • Anti-HTN meds à B-blockers, CCB, anticonvulsants
• Cluster headache
  
  • Severe unilateral periorbital/temporal pain (sharp, lancinating)
  • Bouts last <2hrs
  • Triggers = worse at night, ETOH, stress or ingesting of specific foods
  • Ipsilateral horner’s syndrome, nasal congestion/rhinorrhea, conjunctivitis & lacrimation
  • Management
    
    • 100% O2 6-10L = 1^st line
    • Sumatriptan
    • Prophylaxis
      
      • Verapamil = 1^st line

Question 2

Trigeminal Neuralgia

Answer 2

• Compression of the trigeminal nerve root by superior cerebellar artery or vein
• Clinical manifestations
  
  • Brief, episodic, stabbing/lancinating pain
  • Lasts seconds-minutes worse w/ touch, eating, drafts of wind & movements (often unilateral)
  • Pain starts near the mouth & shoots to the eye, ear & nostril on the ipsilateral side
• Management
  
  • Carbamazepine (Tegretol) = 1^st line
  • Gabapentin
  • Surgical decompression for severe or recalcitrant cases

Question 3

Facial Nerve Palsy

Answer 3

• Idiopathic, unilateral CN VII à hemifacial weakness/paralysis
• Strong association w/ Herpes simplex virus reactivation
• Risk factors = post URI
• Clinical manifestations
  
  • Sudden onset of ipsilateral hyperacusis (ear pain) 24-48hours à unilateral facial paralysis: unable to lift affected eyebrow, wrinkle forehead, smile on affected side, loss of the nasolabial fold, taste disturbance (anterior 2/3)
  • Weakness/paralysis ONLY affects the face (not extremities)
• Differential diagnosis (ex CVA)
  
  • If upper face is OK (able to wrinkle both sides of the forehead) it is NOT Bell Palsy
• Management
  
  • No treatment is required
  • Prednisone (especially if started within 1^st 72h of sx onset)
  • Artificial tears

Question 4

Transient Ischemic Attack

Answer 4

• Transient episode of neuro deficits w/o acute infarction
• Often lasting <24h; MC d/t embolus
• 50% of patients w/ TIA will have a CVA w/I 1^st 24-48 hours afterwards
• Clinical manifestations
  
  • Internal carotid artery
    
    • Amaurosis fugax (monocular vision loss – temporary “lamp shade down on one eye”), weakness contralateral hand
  • Vertebrobasilar
    
    • Brainstem/cerebellar symptoms (gait, proprioception, dizziness, vertigo)
• Diagnosis
  
  • CT head = initial TOC
  • Carotid Doppler – carotid endarterectomy recommended if pt has internal or common carotid artery stenosis ≥**70%
  • CTA, MRA
  • Echo, EKG
  • ABCD2 score to assess CVA risk
    
    • Age
    • Blood pressure
    • Clinical features
    • Duration of sx/Diabetes Mellitus
• Management
  
  • ASA +/- Dipyridamole or Plavix
  • Thrombolytics contraindicated
  • Avoid lowering BP unless >220/120

Question 5

CVA

Answer 5

• Ischemic strokes – 87%
• Anterior cerebral artery
  
  • Contralateral leg weakness and sensory changes
• Middle cerebral artery
  
  • Contralateral hemiparesis (arm > leg), facial plegia, sensory loss
• Posterior circulation stroke
  
  • Unilateral limb weakness, dizziness, vertigo, blurry vision, HA, dysarthria, visual field loss, gait ataxia, cranial nerve VII dysfxn, lethargy
• Basilar artery
  
  • Horner’s syndrome
  • “Locked in” syndrome
• Emergent non-contrast CT head
• Management
  
  • ABC’s
  • Provider evaluation, activate stroke alert
  • Thrombolysis
    
    • Target SBP <185 DBP <110
    • Use Labetalol 10-20mg IV over 1-2 mins or nicardipine 5mg/h titrated to a max of 15mg/h
    • Total dose of rtPA = 0.9mg/kg IV, with a max dose of 90mg
      
      • 10% of the dose is administered as a bolus, w/ the remaining amount infused over 60 mins
  • If TIA –
    
    • Use ABCD2 score to asses stroke risk
    • ASA 75mg-325mg PO daily
    • Plavix 75mg PO daily

Question 6

Tremors

Answer 6

• Essential familial tremor (benign)
  
  • AD inherited disorder of unknown etiology
  • Clinical manifestations
    
    • Intentional tremor – postural, bilateral action tremor of the hands, forearm, head, neck or voice
      
      • MC in the UE & head; usually spares the legs
      • Worsened w/ emotional stress & intentional movement
      • On finger to nose testing, tremor increases as the target is approached
      • Tremor shortly relieved w/ ETOH
  • Management
    
    • Propranolol may help if severe

Question 7

Parkinson’s Dz

Answer 7

• Idiopathic dopamine depletion
• Loss of pigment cells seen in the substantia nigra
• Clinical manifestations
  
  • Tremor = often 1^st symptom
    
    • Resting tremor MC sign (Pill rolling)
    • Worse at rest & w/ emotional stress
    • Lessened w/ voluntary activity, intentional movement & sleep
  • Bradykinesia = slowness of voluntary movement & ¯**automatic movements
    
    • Shuffling gait
  • Rigidity = cogwheel, flexed posture
  • Face involvement = fixed facial expressions
    
    • Myerson’s sign à tapping the bridge of nose repetitively causes a sustained blink
  • Postural instability
• Management
  
  • Levodopa/Carbidopa (Sinemet) = most effective tx
  • Dopamine agonists (Bromocriptine, Pramipexole, Ropinorole)
    
    • Used in young patients to delay the use of Levodopa
  • Anticholinergics (Benztropine)
    
    • <70y w/ tremor predominance
  • Amantadine
  • MAO-B inhibitors (Selegiline, Rasagiline)
  • COMT inhibitors (Entacapone, Tolcapone)

Question 8

Alzheimer’s Dz

Answer 8

• MC type of dementia
• Amyloid deposition (senile plaques) in the brain, neurofibrillary tangles (tau protein)
• Cholinergic deficiency à memory, language, visuospatial changes
• Clinical manifestations
  
  • 1^st symptom = short-term memory loss
  • Progresses to long-term memory loss, disorientation, behavioral & personality changes
• Diagnosis
  
  • CT scan à cerebral cortex atrophy
• Management
  
  • Ach-esterase inhibitors – Donepezil, Rivastigmine, Galantamine, Tacrine
  • NMDA Antagonist – Memantine ​
• Can test via APOE-e4 gene
• Alzheimers accounts for 2/3 of dementia cases in US

Question 9

Multiple Sclerosis

Answer 9

• Autoimmune, inflammatory demyelinating dz
• Axon degeneration of white matter of the brain, optic nerve, & spinal cord
• MC type = relapsing-remitting
• Clinical manifestations
  
  • Sensory deficits
    
    • Pain, fatigue, numbness, paresthesias in the limbs, muscle cramping
    • Trigeminal Neuralgia
    • Uhthoff’s phenomenon = worsening of symptoms w/ heat
    • Lhermitte’s sign = neck flexion causes lightning-shock type pain radiating from the spine down the leg
  • Optic neuritis
    
    • Unilateral eye pain worse w/ eye movements, diplopia, vision loss
  • Motor
    
    • UMN involvement = spasticity & positive (upwards) Babinski
  • Charcot’s neuro triad
    
    • Nystagmus
    • Staccato speech
    • Intentional tremor
• Diagnosis
  
  • Clinical
  • MRI w/ gadolinium = test of choice to confirm MS
    
    • White matter plaques
  • Lumbar Puncture
    
    • ­**IgG in CSF
• Management
  
  • Acute exacerbations
    
    • IV high dose steroids = 1^st line
    • Plasmapheresis if not responsive to steroids
  • Relapse-remitting/progressive dz
    
    • Beta-interferon or Glatiramer acetate
  • Amantadine for fatigue

Question 10

Dementia/Pseudodementia

Answer 10

• Progressive, chronic intellectual deterioration of selective fxn’s
  
  • Memory loss
  • Loss of impulse control, motor, & cognitive fxns
  • Language dysfxn, disorientation, inappropriate social interaction
• Wandering, screaming, aggression, restlessness/agitation, hallucinations
• MC = aphasia (difficulty word-finding), and apraxia (inability to perform motor tasks such as cutting a loaf of bread), agnosia (inability to recognize objects), impaired executive fn (poor abstraction, mental flex, planning, judgement)

Question 11

Delirium

Answer 11

• Acute confusional state
• Reduced ability to focus, sustain, or shift attention
• Short period of time, fluctuates over the course of the day
• Acute, abrupt transient confused state d/t identifiable cause (ex – meds, infxn, etc)
• Rapid onset associated w/ fluctuating mental status changes & marked deficit in short-term memory
• Develops over a time course of days, fluctuating throughout the day and worsening at night
• Usually full recovery within 1 week in most cases