Neurology Flashcards
What is the VAN score?
Weakness and one of Visual disturbance, Aphasia, and Neglect
People w h this should be considered for endovaculat thrombectomy.
What is the BP threshold for post TPA?
SBP 180
What patients get DAPT after CVA?
Two populations:
- low risk stroke (by NHSS score)
- high-risk TIA (by ABCD2)
Review the differentiation between central and peripheral vertigo.
Central:
- Multidirectional nystagmus
- Postural instability
- FND
- Immediate nystagmus that persists > 1 min
Peripheral:
- Horizontal, unidirectional nystagmus
- Mild postural instability
- No FNDs
- Visual fixation helps
- Delayed nystagmus
What questions do you need to ask about headache?
- Onset: Sudden or gradual? Associated with trauma or manipulation?
- Similarity to prior?
- Age and comorbidities?
- Associated symptoms: fever, AMS, neck pain, FNDs, vomiting
What physical exam things should you assess for in a patient with HA?
- Full neuro exam
- Kernig’s (passive leg flexion causing back/HA pain
- Brudzinski’s (bowing the head while supine leads to involuntary flexion of the hips
- Neck tenderness/stiffness
- Rash
Review the HPI for HA.
Emergent diagnoses:
— SAH: sudden-onset maximum pain, AMS, blood thinner use, FNDs, meningismus, different from prior HAs, older patients, trauma, alcoholic
— Clot: OCPs, PMH of cancer, pregnant or recently pregnant
— PRES: HTN, AMS
— Meningoencephalitis: fever, neck pain, meningismus, AMS, local infection, immunocompromised status, different from past HAs
— Dissection of vertebral artery: recent neck trauma (including chiropractic manipulation)
— Cancer: age > 50, PMH of cancer, behind on screenings
— Space-occupying lesion: vomiting in AM, B symptoms, progressively worsening HA
— Pregnancy
— CO poisoning: family all has HA now, winter months
— GCA: vision changes, jaw claudication, neck pain
— Glaucoma: vision changes, eye pain
Non-emergent diagnoses:
— Migraine: photophobia, phonophobia, nausea, aura, association with menses, improves with rest, hallucinations, more often unilateral and throbbing
— Tension: more often bilateral and non-throbbing, typically featureless otherwise
— Cluster: eye symptoms (tearing, conjunctivitis, pain), clustered time-wise, improves with O2
— Sinus: sinus symptoms
— Referred tooth/ear pain: oral/otalgic disorders
— Rebound HA: frequent NSAID use, HA happens after NSAID wears off
Why is a thorough HPI and exam important for patients presenting with headache?
The vast majority of headaches are idiopathic headaches that go away on their own. You should only do a workup with labs and imagining if they have concerning features.
In treating a HA patient, always remember to ________ after any intervention.
reassess, reassess, reassess
The more you know about how they’re doing, the sooner you can make a plan for next steps.
What is sphenopalatine nerve block?
Putting anesthetic in the nose – helpful for frontal headache
- Atomizer
- 3 mL syringe
- 1% lidocaine w/o epinephrine
- 2 10 cm applicator
Soak applicator in lidocaine. Spray 1 mL in each nare. Place applicator in nose for 5-15 minutes.
Review the technique for greater occipital nerve block.
- Draw 5 mL 1% lidocaine w/o epinephrine
- Inject halfway between mastoid and occipital protuberance
Noncontrast head CT is only definitively negative for SAH if it is done within _________ of symptom onset.
6 hours
If it’s after 6 hours and the head CT is negative, then consider an LP or CTA.
LPs will diagnose how many SAHs missed on noncontrast CTs done for SAH r/o?
1 in 90
What disorder that causes a cauda equina-like syndrome can be seen in those with autoimmune disease?
Transverse myelitis
What are common triggers for migraines?
Think Valentine’s Day:
- Wine
- Chocolate
- Aged cheese
Also not in the mnemonic, menses.
The corticospinal tract is in which part of the spine?
Lateral and anterior
The corticospinal tract controls _______________.
ipsilateral motor function
The spinothalamic tract transmits _______________.
contralateral pain and temperature sensation
The spinothalamic tract is in which part of the spinal cord?
Anterolateral
True or false: the dorsal columns transmit proprioception from the ipsilateral side.
True (they cross in the brainstem
Which dermatomes are innervated by the thoracic spine?
From above the nipples (including the medial arms) to the infraumbilical area
The sacral dermatomes primarily innervate the __________ aspect of the body.
dorsal
Review the motor exam by gross nerve root.
C5: shoulder shrug
C6: biceps flexion
C7: triceps extension
C8: wrist extension
T1: finger abduction
L2: hip flexion
L3: knee extension
L4: knee flexion
L5: plantarflexion
S1: dorsiflexion
Embolectomy for LVOs can be up to _______________.
24 hours
Thrombolytics in stroke can be given up to ________ hours.
4.5 (per the ECASS 3 trial)
What is the adult dose of Ativan for seizure?
4 mg IV
Though because this is a higher dose a lot of people do 2 mg followed by another 2 mg immediately if no abatement in seizure.
Do not give thrombolytics if the BP is > _________.
180/110
If it is this elevated, then give labetalol and reassess.
True or false: thrombectomy in LVOs will not require tPA.
False
Thrombolytics are also given to those undergoing thrombectomy.
Opening pressure should be done with the patient in what position?
Lateral recumbent
What factors indicate a pre-LP CT?
FND
Papilledema
New-onset seizure
History of CNS mass
Immunocompromised status (risk factor for abscess)
Broca’s aphasia is typically the __________ division of the ___________ artery.
superior; L middle cerebral
The __________ maneuver leads to resolution of BPPV symptoms.
Epley
The Epley maneuver helps dislodge __________ otoliths.
posterior (the most common site where they get stuck)
How do you do the Dix-Halpike?
Have the patient sit upright and turn their head 45º to the affected side. Then have them bend back and dangle their head off the side of the bed.
Repeat on the other side.
What is it called when the eyes are deviated in an extrapyramidal reaction?
Oculogyric crisis
Pain out of proportion to exam, skin changes such as mottling, temperature fluctuations, and pain to minor touch such as with sheets (a phenomenon called allodynia) are features of what diagnosis?
Complex regional pain syndrome
CRPS is thought to occur when an injury leads to changes in neuropeptides that produces dysautonomia and hyperalgesia.
In severe cases, transient osteoporosis can develop.
People who do frequent squatting in their work can get impingement of the ___________ nerve which leads to numbness on the outer aspect of the thigh.
lateral femoral cutaneous
The syndrome is called meralgia paresthetica. Treat this with weight loss and avoidance of tight garments around the waist.
Which CN controls the tongue?
Hypoglossal nerve (XII)
Review the neuromuscular pathway and note the disorders at each step that can cause weakness.
Upper motor neurons: stroke, B12 deficiency, and CNS mass
Anterior horn cells: ALS, polio, and SMA
Peripheral nerves: diabetic neuropathy, lead poisoning, amyloidopthy, Guillain-Barre
Neuromuscular junction: myasthenia gravis, Lambert-Eaton, organophosphate poisoning, botulism
Muscle fibers: myositis, myopathy (HIV, statins, steroid)
Review the presentation of dural venous sinus thrombosis.
- Headache feels different than past headaches the person has had
- Is persistent and gradually worsening
- Worse in the morning and with maneuvers that increase intracranial pressure (Valsalva, coughing, vomiting)
- Risk factors of increased clot risk (OCPs, pregnancy, thrombophilic disorder, h/o intracranial infection or masses)
- Exam findings of papilledema and FNDs
The first-line treatment for preventing cluster headaches is _____________.
verapamil 240 mg daily
Propranolol is a preventive medicine for which class of headaches?
Migraine
First-line treatment for acute cluster headache is ____________.
100% oxygen by facemask
An elderly person with dementia who has “severe sensitivity to antipsychotics”, such as developing extrapyramidal symptoms from low doses, may have ______________.
Lewy body dementia
The oculomotor nerve emerges between what two cerebral vessels?
Posterior cerebral artery (superior to the vessel) and superior cerebellar artery (inferior to the vessel)
What cranial nerves exit between the pons and medulla?
Abducens, facial, vestibulocochlear
The olfactory nerve exits from the inferior cerebrum.
The optic nerve exits from the midbrain.
The oculomotor nerve exits just between the superior pons and the cerebral crus.
The trochlear nerve exits from the lateral junction of the superior pons and cerebral crus.
The trigeminal nerve exits from the lateral pons.
The abducens, facial, and vestibulocochlear nerves exit from the area between the inferior pons and the superior medulla.
The glossopharyngeal, vagus, and accessory nerves exit from the lateral medulla.
The hypoglossal nerve exits from the medial medulla.
The ____________ arteries come together to form the pontine artery.
vertebral
The abducens nerve exits between which two vessels?
Labyrinthine and anterior inferior cerebellar artery
The posterior inferior cerebellar artery is inferior to which cranial nerve?
Accessory nerve
Ptosis and anisocoria are often seen with ___________ aneurysms.
posterior communicating artery
True or false: acute transverse myelitis presents with hyperreflexia.
False
That is a chronic finding. Acute transverse myelitis presents with flaccidity and hyporeflexia.
What is the one test you need to order in evaluating someone with restless leg syndrome?
Ferritin
Supplemental iron is indicated for those who have RLS and a ferritin level less than 75 ug/L.
Review the risk factors for pseudotumor cerebri.
- Obesity
- Female sex
- Medications: isotretinoin, ATRA, tetracyclines, steroids, Macrobid
- Endocrine disorders: hypothyroidism, hypoparathyroidism, Cushing syndrome
True or false: Parkinsonism is usually bilateral in onset.
False
Parkinsonism is and usually remains asymmetric.
The triad of Parkinsonism is _____________.
bradykinesia, rigidity, and a resting tremor
True or false: entacapone is one of the best treatments for early symptomatic Parkinsonism.
False
Entacapone is a catechol-O-methyl-transferase (COMT) inhibitor that helps prolong levedopa. It has no effect by itself.
When should you consider pramipexole instead of SInemet?
Sinemet works well but is thought to ultimately hasten the progression of Parkinson disease due to increased degradation of the substantial nigra. As such, Sinemet is reserved for the elderly (older than 65) or those with severe symptoms. Pramipexole doesn’t work as well but is not thought to hasten the progression of the disease, so it is usually the first-line medicine for those with mild symptoms or age younger than 65.
Walking with one foot directly in front of and in line with the other is referred to as _________ walking.
tandem
The pineal gland is where?
On the posterior aspect of the brainstem, superior to the superior collicuii which are on the posterior aspect of the cerebral cruri.
Pineal gland tumors present with what signs and symptoms?
Parinaud’s syndrome:
- Ataxia
- Headache (from obstructive hydrocephalus)
- Vertical gaze paralysis
- Loss of pupillary reaction
Don’t forget that Sydenham chorea presents with jerky movements and _____________.
emotional lability
Explain the “get up and go” test.
This is a common test used to screen for need of physical therapy or other assistive needs in the elderly. To perform it, you have a person stand from an armless chair, walk around the room, and return to the chair. If they have difficulty with any part of it, refer for physical therapy or a home screen.