Neurology Flashcards
What condition looks a lot like catatonia?
Akinetic mutism from left anterior cerebral artery stroke. Anterior Cingulate is the structure impacted.
When language is impacted, what artery you thinking?
MCA. Broca’s and wernicke’s.
Locked in syndrome
Can only move eyes. Tip of basilar artery deficit.
Pt has disinhibition, emotional lability, impulsive, lack empahty
Oribitofrontal or anterior thalamus
Pt has memory , eecutive function, perseveration, planning deficits
Dorsolateral Frontal Cortex
Pt has akinetic mutism, apathy
anterior cingulate
Pt has memory deficits
Mesial temporal or mesial thalamus
Pt has loss of anger and fear, hypersexuality
amygdala
Pt has facial recognition problems
Fusiform cortex
Reading disorder kid (dyslexia) is problem where?
Planum temporale
Risk factors for early cognitive impairment in Parkinsons?
REM sleep disorder, hyposmia (loss of smell) , and gait dysfunction
Parkinson’s Fatigue: What treats it, and what is NOT helpful?
Treats: methylphenidate, amantadine
NOT helpful: modafinil
What toxic exposures can mimic parkinsonian symptoms?
Carbon monoxide, Fe deposition, and manganese in basal ganglia can cause these symptoms.
Olfactory dysfunction in Parkinson
Hyposmia or anosmia happens in 90% of PD. Asosciated with lewy bodies in lower medulla nd decreased cholinergic denervation. Strongly associated with cognitive decline and dementia.
Postural tremor (drug) vs Parkinsonian Resting
Postural tremor usually will be bilateral whereas Parkinson is going to be unilateral.
DaTSCAN and Drug Induced Parkinsonism
Should normalize after discontinuing the offending agent. h
Does levodopa speed up the progression of parkinsons?
No , but it can wear off. ‘off periods’ happen where it is not effective.
At what point is DBS given in parkinson’s?
Late stage
What does the carbidopa do?
it is a peripheral decarboxylase inhibitor to reduce side effects.
What is the major side effect of dopamine agonists? (bromocriptine, ropinirole, pramipexole, rotigotine, apomorphine)
More impulsive/compulsive behavior like gambling, hypersexuality, eating, money
What do COMT inhibitors (entacapone, tolcapone) do in parkinsons?
Prolongs effectiveness of levodopa, decreases dyskinesia. But may increase levodopa side effects (orthostatis hypotension, dyskinesia, hallucinations, nausea, orange urine. )
What drug causes orange urine?
The Al Capones (COMT inhibitors). Entacapone and Tolcapone
Progressive Supranuclear Palsy
Can be levodopa resistant, so don’t keep giving it. It is a ‘Parkinson’s Plus’ Diagnosis
Essential tremor: what makes it better?
alcohol and benzos suppress the essential tremor. In ET, head movements may happen too. ET is autosomal dominant. Worsened with caffeine.
What is the new TPA window?
4.5 hours for IV, 6 hours for intraarterial right in the artery from interventional neuro.
Aspirin plus clopidogrel
Not indicated bc it increases risk of brain hemorrhage.
Heparin in non-embolic stroke
(other than with venous thrombosis) is NOT INDICATED and may be harmful.
How long does a seizure need to be in order to be in status?
10 minutes OR 2 back to back seizures without full recovery.
What antiseizure medicine also treats anxiety?
clobazam
Which antiepileptic med is good for Alzheimer’s and epilepsy?
Levetiracetam is more tolerated.
Mechanism of gabapentin and pregabalin?
Calcium channel blockers. They actually don’t work on gaba.
Risk factors for post-ictal psychosis
Prolonged seizure or cluster of seizures. Also happens more in FRONTAL vs temporal.
Worst headache of my life
SAH
Headache that is worse lying flat or awakening during the night?
Concern for increased intracranial pressure. May also see vomiting preceding a headache, or ifHA is induced by bending, lifting, coughing.
Headache in pregnancy or dehydration
concern for cerebral venous thrombosis
Which mood stabilizer is given for migraines via infusion?
depakote (and topiramate)
How long must one have a migraine to be in status migrainosis?
3 days
What is SUNCT?
Short-lasting, Unilateral, Nueralgiform headache with Conjunctival Injection and Tearing. Usually men who are older than 50. Happen durin gthe day and last seconds/minuttes. Can have multiple attacks in an hour and are treated via IV lidocaine or topiramate or depakote(not o2). VERY RARE.
NSAID overuse syndrome
Can happen if one takes NSAIDS chronically. It’s a headache.
Diagnosing brain death
Temperature must be above 36.5. ie, pt cannot be hypothermic.
Brain stem reflexes needed to diagnose brain death
No pupillary response to light, no corneal reflex, no oculocephalic reflex , no vestibular cochlear refelx (cold caloric), no gag, apnea test is positive.
How does locked in syndrome happen?
Usually by paralysis of lower brain stem-innervated musculature. They can answer questions by eye movement.
Mild TBI
Lasts shorter than 30 minutes. No neurological deficits. Sequelae of migraines may happen. Headaches are common and may go away after a few months or switch to chronic.
A-Delta Fibers vs C fibers
A-D : myelinated quick pain, small field of innervation. “1st pain.”
C: unmyelinated, aching, “2nd pain”, polymodal, less than 1 cm2 field of innervation. Chronic.
Mewtwo (Mu2) vs Mu 1
Mu 1 involved in analgesia
Mewtwo: Respiratory depression
Opioid receptors: Delta vs Kappa vs Mu
Delta: bind enkephalins. Less analgesia than mu receptors. DE
Kappa: Bind dynorphine and contributes to dysphoria. Spinal anesthesia. KD
Mu: Bind enkephalins and beta endorphin. Greatest concentration in periaqueductal grey. . Mu1, Mu2, mu3
Opioid mechanism of action
Activates G couple proteins, leads to increase K+ chanell and decreased voltage gated Calcium channel activity, leads to hyperpolarization, leads to decreased neuronal excitability which leads to decreased intracellular cAMP, ultimately leading to decreased substance P.
COX1 vs COX 2 inhibitors: which has lower risk of GI bleed plus higher risk of MI and CVA?
COX 2 inhibitors have lower GI but higher risk of MI and CVA.
Which drug irreversible inhibits COX?
Aspirin
Which analgesics are FDA approved for fibromyalgia?
gabapentin and pregabalin.
Small Fiber Neuropathy (SFN)
Rare cause of peripheral neuropathy seen in stocking/glove distribution. Typically beings in feet first. Rarely non-length dependant. “Wooden” feeling or “walking on pebbles, and.”
What condition may cause numbness in hands first as opposed to feet?
B12 or lead deficiency
First line prn therapy for small fiber neuropathic pain
Long term treatment?
Tramadol for prn. Amitripyptiline, nortrip, Duloxetine, gabapentin, pregabalin all for long term.
Foot drop comes from damage to what nerve?
L5 will involve the big toe. S1 involves the small toe.
When is surgical decompression done for bulged disc?
When pain is unbearable or functional problem like foot drop . otherwise don’t do surgery.
Thalamic Pain: where in the body is it felt?
Face/arm/torso/leg. May have decreaesd sensation (temp/pin prick) , +/- hemiplegia . Increased to emotional stress. Often due to the posterior thalamus. Can happen after a stroke.
What increases the risk of phantom limb pain?
If there was significant pre-amputation pain.
Surgical options in phantom limb
Minimal evidence. Can hit dorsal root entry zone lesions, thalamic lesions. Can revise the stump.
What is Complex Regional Pain Syndrome?
Acute onset of pain after acute tissue trauma or surgery. Pain can be burning, hyperalgesia (with cold), allodynia. Severe, seen in arm or leg most often and does not follow a dermatomal distribution. Autonomic changes seen in the area. Can be boggy/acute or chronic.
Nonmedical tx for lower back pain?
TENS (transcutaneous electrical nerve stimulation)
Carbamezepine side effect to be aware of
Blurry vision, grab a level
Age of onset with Duchenne vs Becker MD
Duchenne : age 2-6
Becker: can be later in life (13+) and less severe
Steroids in Guillain Barre or AIDP?
Not useful
Conversion Disorder and pupillary reflexes
Conversion Disorder (functional neurological disorder) patients will have pupillary reflex while an anatomical neuro trauma with blindness will have no pupillary reflex.
What is Foster-Kennedy Syndrome?
Tumor that compresses 1 optic nerve leading to visual field loss, puts pressure on CN1 (anosmia), and increases intracranial pressure which leads to papilledema seen in opposite eye.
What is Horner Syndrome? “PAM”
Ptosis, Anhydrosis, Miosis. Usually due to a pancoast lung tumor or dissection of internal carotid artery. Get an MRI of head and neck which covers the dissection.
Normal brainstem function and doll’s eye
Doll’s eye (vision fixed on one point in space when moving head side to side) is NORMAL whereas a lesion would cause a loss of doll’s eye.
What is normal vestibular functioning?
Cold calorics. In normal situation, eyes will shoot quickly to the opposite ear from where cold water was put. It will then gradually work it’s way back towards the cold ear.
If abnormal, brainstem is messed up.
Upper motor neuron vs lower motor neuron deficits
If UMN damaged, will have spasticity and brisk reflexes.
If LMN damaged, will have flaccidity and decreased reflexes.
Vitamin B12 deficiency symptoms
Large beefy tongue, sensory deficits, motor deficits. Enlarged liver.
Dorsal Columns “PV2”
Position of joints, vibration, and 2 point touch.
Brown sequard: contralateral PTL , ispilateral PV2 (position, vibration 2 touch)
Spinothalamic Tract “Praise The Lord”
Pain, temperature, light touch.
Brown sequard: contralateral PTL , ispilateral PV2 (position, vibration 2 touch)
Subarachnoid hemorrhage on CT
will be seen where the CSF lives. INTRACEREBRAL hemorrhage is its own type. Blood in the middle of the brain.
Lower extremity only stroke including bilateral
Think anterior cerebral artery stroke.
Medication for fatigue seen in MS
Modafinil
Periventricular white matter spots seen on T2?
MS.
What blood marker is elevated in ADEM (acute disseminating encephalomyelitis) in children?
Platelets.
Most likely risk factors of recurrence after a single tonic-clonic szr?
- abnormal neurologic findings
- intellectual disability
- abnormal electroencephalographic findings
- myoclonic jerks, absences
- atonic seizures
- structural brain lesions
- family history of epilepsy
- elderly individuals
What condition? triphasic sharp wave complexes in the context of a slow background on EEG and 14-3-3 proteins in cerebrospinal fluid
Creutzfeldt-jakob
Risk factors for MS
- Family hx
- Young age
- Female sex
- European ethnicity
- Living further from the equator
- Smoking
- Other autoimmune disease
MS is the MCC of neurologic disability in young adults.
Which cells get targeted in MS?
oligodendrocytes.
MS symptoms possible
- Decreased color vision in one eye
- Legs tingle when neck bent forward
- Severe fatigue
- Transverse myelitis
- depression and cognitive slowing
Timeline of MS exacerbation
hours to days, not sudden like strokes.
Giving contrast in MS
If areas enhance with contrast in MS patients, more indicative of acute lesions. T2 flair is nonspecific and will have scars.
What to monitor if MS patient is on natalizumab
reactivation of the JC virus.
Herpes Simplex on EEG
Periodic lateralizing epileptiform discharges (PLEDS)
What lab is extremely important to give prior to TPA administration?
blood glucose . Make sure it isnt less than 50.
If stroke pt took rivaroxiban within the last ___ hours, they can’t receive TPA.
48
If pt gets a headache during TPA infusion, what do you do?
Stop the infusion and get another CT head to check for a bleed.
What test do you order if pt describes 10 min monocular vision loss?
This is amaurosis fugax where the shade goes over the eye. Get a carotid doppler.
What percentage occlusion does one need to have for carotid artererctomy?
70-99% on that side . Don’t operate if it is fully occluded.
Face+ Arm+ leg weakness on same side
Subcortical stroke, probably lacunar. Think lenticulostriate arteies, posterior limb of internal capsule.
Things to know about watershed strokes
Generally bilateral, and generally due to hypotension
Where do most SAH happen?
Saccular berry aneurysm at the circle of willis. Usually anterior portion.
When does an aneurysm need surgery? (what size?)
> 10 mm risk of rupture is high.
Locked in syndrome happens at what artery?
Basilar artery. Bilateral corticobulbar and corticospinal tracts.
Dysfunction of the operculum
swallowing, salivation, mastication, epigastric aura, and speech arrest frequently associated with clonic facial movements; and gustatory hallucinations also may occur.
Epileptic Myocluonus
progressive degeneration disorders of the nervous system in which myoclonus may occur in association with cognitive impairment, ataxia, and multiple seizure types. Examples include myoclonic absence, infantile spasms, and Lennox-Gastaut syndrome.
Lambert-Eaton Myasthenic syndrome
usually middle aged men; proximal weakness of limbs, especially in the legs which may improve with exercise; reduced or absent reflexes; cranial nerve tend to be spared (vs. myasthenia gravis) except mild ptosis; often autonomic impairment-impotence, urinary dysfunction, dry mouth, orthostasis; repetitive stimulation study reveals a decremental response at low rates of nerve stimulation and an incremental response at high rates; often associated with small cell lung cancer; and due to presence of antibodies directed against presynaptic voltage-gated P/Q-type calcium channels that can be measured clinically.
Neurogenic claudication gets better when:
- rest
- flexion at the waist
- sitting,
thought to be due to intermittent cauda equina ischemia brought on by the increased blood flow demand with exercise
Proximal neuropathy
Proximal neuropathy tends to cause pain in the thighs, hips, or buttocks, and can lead to weakness in the legs.
Pellagra
Vitamin B3 deficiency. Niacin, deficiency is the most common cause of pellagra. In addition to diarrhea, dermatitis, and dementia, it may involve photosensitivity, glossitis, ataxia, and dilated cardiomyopathy
Main reason for ishcemic infarcts?
atherosclerosis
What is stiff person syndrome and how is it caused?
Anti- glutamic acid decarboxylase (GAD) antibodies. Stiff person syndrome is characterized by progressive fluctuating muscular rigidity..
mesial temporal epilepsy syndrome (MTLE) is often caused by what?
Hippocampal sclerosis. Mesial temporal lobe epilepsy syndrome (MTLE) is the most common epilepsy syndrome associated with complex partial seizures.
Which test to diagnose toxoplasmosis after seeing ring-enhancing lesions on brain?
SPECT , will tell you if it is this or lymphoma.
Progressive Supranuchlear Palsy
progressive supranuclear palsy (PSP), a degenerative neurologic disorder characterized by a combination of cognitive, behavioral, balance, and visual symptoms. Among the most common signs are difficulty in the voluntary movement of the eyes in the vertical plane and impairment in voluntary eye saccades.
Cerebral salt wasting
Generally resolves within a few weeks
Severe headache that wakes one from sleep
Hypnic headaches
5-6 yo with parkinson like features?
Dopa-responsive dystonia, give levodopa
What other disorder must one consider if Huntington’s is on the differential?
Wilson’s disease
How do you treat hemicrania continua?
Indomethacin
Small fiber neuropathy has increased or decreased nerve density?
Decreased intraepidermal nerve fiber density
Which bacterial infections can result in Guillan Barre?
Bacterial infections include Campylobacter jejuni, Haemophilus influenzae, Mycoplasma pneumoniae, and Borrelia burgdorferi.
What deficiency can happen after bariatric surgery ?
Copper deficiency. mild weakness and decreased sensation in all extremities. The neurological examination demonstrates decreased proprioception and vibration sensation, hyperreflexia, and mild weakness, but normal tone, in all extremities.
Where is downbeat nystagumus happenign?
Downbeat nystagmus may occur with cervicomedullary junction disease, midline medullary lesions, posterior midline cerebellar lesions, or diffuse cerebellar disease. Chiari malformation can do it.
Loss of vision in one eye with light is inicative of what?
carotid occlusive disease
Which drugs are FDA indicated to treat diabetic neuropathy?
Medications used to help relieve diabetic nerve pain include tricyclic antidepressants, (amitriptyline, imipramine, and desipramine), other types of antidepressants (duloxetine, venlafaxine, bupropion, paroxetine, and citalopram), anticonvulsants (pregabalin, gabapentin, carbamazepine, and lamotrigine), and opioids and opioid-like drugs (controlled-release oxycodone, tramadol). Duloxetine and pregabalin are approved by the FDA specifically for treating painful diabetic peripheral neuropathy.
One weird way to get a blown pupil?
ipratropium bromide leaking from the mask on one side.
Other drug other than riluzole for ALS?
In 2017, edaravone, the second-drug for ALS treatment, was approved by the US FDA. It can also be used concomitantly with riluzole, for ALS.
What is a pallitodomy and what does it treat?
Pallidotomy is carried out for advanced Parkinson’s disease by ligating the anterior choroidal artery. Anterior choroidal is a terminal branch of the internal carotid artery and supplies the globus pallidus and caudate nucleus. The infarction of the globus pallidus is considered the therapeutic mechanism behind pallidotomy. Pallidotomy is not used for Alzheimer’s. It is primarily used for Parkinson’s and sometimes for hemiballismus and dystonia.
What virus can happen with Natalizumab?
JC virus. Natalie prays to Jesus Christ
What imaging study do you get for shaken baby syndrome?
Diffusion tensor MRI
What antibody seen in Neuromyelitis optica?
Aquaporin 4. These patients won’t get better with MS treatments.
What types of cells form the myelin sheath?
Oligodendrocytes form the myelin sheaths around nerves in the spinal cord.
Conus medularis syndrome
. Conus medullaris syndrome typically involves variable motor loss in the lower extremities with loss of bowel and bladder function and is the correct answer.
