Neurology Flashcards
What are the findings of lateral medullary syndrome?
PICA or vertebral artery infarct.
- Ipsilateral Horners
- Facial loss of pain/temp
- Contralateral body loss of pain/temp
- Vertigo, nystagmus
- Dysphagia and hoarseness
- Hiccups
What are the findings in medial medullary syndrome?
Anterior spinal artery.
- Ipsilateral tongue weakness.
- Contralateral arm, leg weakness.
- Contralateral body vibration, loss of proprioception.
What are the findings of midbrain infarct (weber’s)?
PCA affected.
- Ipsilateral CN3 palsy
- Contralateral hemiplegia
What are the findings of ACA infarct?
Contralateral leg weakness and numbness
Contralateral grasp weakness (frontal signs)
What are the findings of left MCA infarct?
Superior branch - Broca’s aphasia, right weakness arm>leg, gaze deviation to the left.
Inferior branch - Wernicke’s aphasia, right cortical sensory loss, right pie in the sky.
What are the findings of right MCA infarct?
Superior branch - Left weakness face and arm > leg, gaze deviation to the right.
Inferior branch - left cortical sensory loss, left hemineglect, left pie in the sky.
What are the findings of PCA infarct?
Contralateral homonymous hemianopia.
What are the findings of lacunar infarct?
Motor - diffuse contralateral weakness
Sensory - diffuse contralateral sensory symptoms
What are neurological signs of B12 deficiency?
Subacute combined degeneration: Posterior cord (vibration/proprioception) AND corticospinal tract (motor)
= dorsal/posterior cord syndrome
- UMN weakness
- Hyper-reflexia and UPGOING toes
- Dementia
- Loss of proprioception/vibration sensing
What are neurological signs of tertiary syphilis?
dorsal/posterior cord syndrome
Preferential loss of vibration sense and proprioception
ALSO associated with
Argyle Robertson Pupils (Prostitute pupils - accomodate, but do not constrict)
When do you need to obtain imaging prior to LP?
focal neuro deficits new seizures GCS < 10 or altered LOC Immunocompromised Anatomical issue (previous spine sx) Local skin infection/chiari malformation
What is the BP target in acute stroke?
Permissive hypertension.
Treat BP in first 24hr if > 220/120
What is the BP target for acute ICH?
systolic < 180
What are indications for PFO closure in setting of stroke?
age 18-60
stroke is NON-lacunar by imaging
PFO is most likely the cause after ruling out others
What do you do with antiplatelet therapy if patient presents with stroke > 24 hours after onset?
no DAPT. Single antiplatelet
What are side effects of levodopa/carbidopa?
Dyskinesias
Orthostatic hypotension
Hallucinations
What are the time and age criteria for TPA?
Ischemic stroke causing DISABLING deficits (NIHSS>5) in patients > 18 y.o
Time from last well known < 4.5h
What are the exclusion criteria for TPA?
Active hemorrhage or any condition that increases risks of major hemorrhage with tPA
Any hemorrhage on brain imaging
Not on DOAC (can consider EVT)
What are contraindications to LP?
INR > 1.7
Plt < 50
Papilledema/raised ICP secondary to mass
Can’t safely tolerate procedure
What is central cord syndrome? How does it present?
Often due to cervical spondylosis, hyperextension injury etc
Greater motor deficit in upper than lower extremities with varying degree of sensory loss and autonomic involvement
What do you use to treat vertebral/carotid artery dissections?
EXTRAcranial: either antiplatelet or anticoagulant (both are reasonable)
INTRAcranial: antiplatelet (no evidence for anticoagulation)
What are causes of Horner’s?
Stroke - lateral medullary syndrome
Pancoast tumour
Carotid dissection/aneurysm
What are stenosis criteria for carotid endararterectmy? When should it be offered?
Asymptomatic = medical management
Symptomatic + 50-69% stenosis = CEA MAY be offered
TIA/non disabling stroke + ipsilateral 70-99% stenosis = CEA or CAS if not a CEA candidate
CEA should be:
within 48 hr of symptom onset OR
within 2 weeks if not stable within first 48 hours
CEA better than stenting in pts > 70 y.o
How do you differentiate ischemic CN III palsy from compressive?
Pupil is spared in ischemic
There is mydriasis in compressive, as well as pain (parasympathetic fibres along the surface of CN III gets compressed)
What are symptoms of brown sequard syndrome?
Ipsilateral loss of motor function
Ipsilateral loss of vibration and proprioception sense
Contralateral loss of pain and temperature
How long do patients remain on DAPT post stroke? when do you start?
Ideally start ASAP after brain imaging (<24h, ideally <12)
DAPT x 3-4 weeks, then monotherapy
What is the definition of status epilepticus? What makes it refractory?
>= 5min clinical or EEG activity OR >= 2 seizures without recovery in between
Refractory when:
Failure of benzo + 1 AED
What are treatments for Guillain Barre syndrome?
IVIG OR
PLEX
STEROIDS NOT INDICATED (indicated for CDIP)
When should you intubate for Guillain Barre syndrome or Myasthesia Gravis crisis?
20 - 30 - 40 rule
FVC < 20ml/Kg
MIP < 30 cm H2O
MEP < 40 cm H2O
What is the classic finding on LP for Guillain Barre syndrome?
Albuminocytologic dissociation
Protein > 0.45 + WBC < 5
If WBC also up, check HIV status
What are treatments for myasthenic crisis?
PLEX OR
IVIG
Need to hold pyridostigamine when intubated due to increased airway secretions
High dose prednisone - caution, can worsen respiratory status
What are the 3 subtypes of multiple sclerosis?
Relapsing remitting
Secondary progressive
Primary progressive
What is the role of steroids in MS?
Does NOT alter degree of recovery
Does NOT reduce future attacks
Only speed recovery
When are DAPT indicated in acute stroke?
<24hr
NIHSS <4 (higher NIHSS associated with hemorrhagic transformation)
ABCD2 > 4
What is the ABCD2 score for stroke/TIA
A - Age>60
B - BP>140/90
C - clinical features (unilateral weakness = 2, speech disturbance without weakness = 1)
D - Duration of symptoms (10-59 minutes = 1, >1h = 2)
D - Diabetes
TOTAL /7
What are inclusion criteria for EVT?
- > 18 years
- Disabling stroke
- Functionally independent
- Life expectancy > 3months
- Anterior circulation occlusion of proximal large vessel
- Small to moderate ischemic core (ASPECT>5)
What are BP targets when giving tPA
Excluded if BP>185/110, target <180/105
When can antiplatelets be started post-tPA?
After 24h repeat CT head shows no bleed, start heparin for DVT prophylaxis and SAPT.
Who should be treated with DAPT
Very high risk TIA (ABCD2>/=4) or minor stroke (NIHSS3) of non-cardioembolic origin
When can anticoagulants be started post-stroke?
TIA - 1 day
Small - 3 days
Moderate - 6 days
Large - 12 days
