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Medicine Boards > Neurology > Flashcards

Neurology Flashcards

1
Q

<40yo with essential tremor or dystonia, what should you screen for?

A

Wilsons disease – with serum cerrulopasmin + 24-hr urine copper measurements

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2
Q

What is Lhermitte sign?

A

Can be seen in MS

shock like sensation radiating down spine or limbs induced by neck movements

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3
Q

What is Uhthoff phenomenon?

A

Can be seen in MS

transient worsening of baseline neuro symptoms with elevations of body temperature

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4
Q

What is intranuclear opthalmoplegia?

A

Can be seen in MS (brainstem)

  • Inability to adduct one eye
  • Abducting eye has nystagmus
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5
Q

Other than MS, what else can cause white matter lesions on MRI?

A

migraine
head trauma
microvascular ischemic disease

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6
Q

How do you treat acute MS? first attack of isolated syndrome suggesting MS? relapsing-remitting MS?

A

(1) Acute - IV methylpred followed by PO

Both (2) + (3) –> interferon beta OR glatiramer acetate
Also all MS patients should take Vitamin D (if taking interferon beta) - because reduces accumulation of MRI lesions

**interferon contraindicated in liver disease or depression

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7
Q

Treatment for Huntington disease

A

symptomatic tx with tetrabenazine and deutetrabenazine (longer half-life)

(vesicular monoamine transporter 2 (VMAT2) inhibitors).

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8
Q

In addition to PT, what medication can help mobility in MS?

A

Dalfampridine – but can’t use in renal failure b/c will accumulate and increase risk of seizures

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9
Q

When to suspect copper deficiency?

A

mimic B12 def presentation - paresthesias, LE weakness, gait instability, vibration/position loss, sensory ataxia — but may develop AFTER BARIATRIC surgery or from EXCESSIVE ZINC INGESTION

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10
Q

ALS

  • describe clinical picture (classically)
  • treatment
  • Mimics to r/o
A
  1. UMN + LMN signs, but NOT sensory deficits. Muscle weakness starts distally and asymmetrically (20% do have bulbar-onset and have difficulty speaking & swallowing). NOT early cognitive impairment or ocular muscle weakness
    - — UMN = hyperreflexia, hoffman sign, clonus
    - — LMN = atrophy, fasiculation, weakness
  2. Riluzole may increase survival by about 3mo
  3. Hyperthyroidism, hyperaparathyroidism, structural brain and c-spine lesions, Vit B12 and copper deficiency, Lyme disease
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11
Q

Key difference between Myasthenia Gravis and Botulism?

A

Botulism – sluggish or non-reactive pupils
MG – normal pupils

both have diplopia and dysphagia

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12
Q

Lambert-Eaton Syndrome

  1. clinical presentation
  2. difference from MG
  3. Diagnosis
  4. association
A
  1. progressive proximal muscle weakness, diminshed deep tendon reflexes that improve with repetitive movement of affected muscle
  2. LE (presynaptic) MG (postsynaptic). DTR and sensation is normal in MG, also MG has decremental response to repetitive stim on EMG
  3. serum anti-voltage-gated-calcium channel Antibody + EMG with motor response to rapid repetitive stim
  4. undetected malignancy, usually SCLC
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13
Q

What associations do you worry about with MG that you should test for (2)?

A
  1. TSH - autoimmune thyroid disorder

2. Thymoma - get CT chest

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14
Q

Treatment for MG? myasthenia crisis?

A

Initial - pyridostigmine

myasthenia crisis or refractory - plasmapheresis or IVIG

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15
Q

Acute, ascending, areflexic paralysis and paresthesia

  1. diagnosis
  2. association
  3. CSF studies
  4. treatment
A
  1. guillain-barre syndrome (AIDP)
  2. usu preceded by GI illness (campylobacter)
  3. CSF - elevated protein, but normal cell count (albuminocytologic dissociation)
  4. Plasma exchange or IVIG (**NOT steroids)
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16
Q

Progressive proximal motor + sensory neuropathy evolving over months

  1. diagnosis
  2. testing
  3. treatment
A
  1. chronic inflammatory demyelinating polyneuropathy (CIDP) >8wks of progressive or relapsing neuropathy
  2. Initial EMG and CSF findings similar to GBS
  3. prednisone, plasma exchange, or IVIG. Long term steroid sparing agents (azathiorpine, mycophenylate)
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17
Q

What is paraproteinemic neuropathy? What conditions is it associated with? Treament?

A
  1. symmetric distal sensory neuropathy
  2. MGUS, multiple myeloma, amyloidosis, cyroglobulinemia
  3. treat underlying disorder
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18
Q

Name this dementia

– early dementia within first year of appearance of parkinsonism

A

Lewy body dementia (*also hallucinations)

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19
Q

Hallmark of Multiple system Atrophy

A

severe orthostatic hypotension also ataxia and MRI showing “necrosis” of putamen and cerebellar atrophy

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20
Q

What are the 3 parkinsons plus syndromes?

A
  1. Multiple system atrophy - severe orthostatic hypoTN, ataxia, urinary sx, anosmia, acting out of dreams during sleep
  2. Progressive supranuclear palsy - inability to move eyes vertically, unexplained falls (backwards)
  3. Corticobasilar degeneration (CBD) - alien hand phenomenon, cortical sensory loss, dystonia, myoclonus
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21
Q

Which AED(s) cause hyponatremia and pancytopenia?

A

carbamazepine and oxycarbazepine

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22
Q

Which AED causes gingival hypertrophy, chronic ataxia, osteoporosis?

A

Phenytoin

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23
Q

Which AED causes weight gain, hypercholesterolemia, hepatotox, thrombocytopenia, hyperammonemia, teratogenic?

A

Valproic Acid

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24
Q

Which AED(s) increase risk of kidney stone? also can have weight loss, paresthesias, and word finding difficulties

A

Topiramate and zonisamide

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25
Q

Which AEDs can be used in pregnancy

A 
Levetiracetam 
Lamotrigine (req dose increase in pregnancy)
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26
Q

Which AED is preferred in generalized epilepsy? focal epilepsy?

A
  1. valproic acid (superior)

2. carbamazepine (cheap)

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27
Q

Which 5 AEDs can treat both focal and generalized epilepsy?

A 
lamotrigine
levetiracetam
topiramate
valropic acid 
zonisamide
28
Q

What are key features of PNES (psychogenic nonepileptic spells)?

A

forced eye closure
long duration
hypermotor activity that starts and stops
pelvic thrusting

29
Q

How do you treat trigeminal neuralgia? drug monitoring? what diagnostic workup must you get?

A
  1. carbamazepine
  2. BMP, CBC - hyponatremia and agranulocytosis
  3. MRI brain to exclude intracranial lesions and MS
30
Q

What can you use for migraine prophylaxis?

A

(Level A evidence)
1. B-blockers (3) - propranolol, timolol, metoprolol
2. Antiepileptics (2) - divalproex, topiramate
(Level B evidence)
1. B-blocker - atenolol
2. Antidepressants - amitriptyline, venlafaxine

For chronic migraine (>15days/mo x 3 mo) can use Onabotulinum Toxin A

31
Q

Cluster headaches

  1. acute treatment
  2. long term prevention
A
  1. triptan or oxygen

2. verapamil

32
Q

Clinical pattern of cluster headache

A
  • location: periorbital
  • duration: 15 min - 3 hr
  • frequency: several times per day, repeating over weeks, then disappearing for months-years
  • autonomic sx: unilateral tearing, nasal congestion, rhinorrhea, eyelid edema, miosis, ptosis
33
Q

Clinically describe Huntingtons disease

A
  • autosomal dominant
  • psychiatric disease, impulsivity, executive dysfunction, dysarthria, incoordination, and ataxia (wide based); chorea is a major manifestation.
34
Q

describe classic presentation of MG with negative ach-r, what should you test for? treatment?

A
  • Order MuSK (muscle specific kinase) Ab!
  • Hallmark = weakness of neck extension, worse in evening. also more likely to cause focal or severe bulbar, cervical, or respiratory weakness.
  • Tx = plasmapheresis and glucocorticoids + aggressive maintenance immunosuppression (off label ritux). Thymectoy and pyridostigmine = not helpful
35
Q

What is POEMS syndrome?

A
  • Polyneuropathy – peripheral neuropathy
  • Organomegaly - ie. splenomegaly
  • Endocrinopathy - ie. thyroid issue
  • Monoclonal gammopathy - monoclonal plasma cell disorder
  • Skin changes - ie. hyperpigmentation, angiomas

AND at least 1 of the following: osteosclerotic myeloma, castleman disease (angiofollicular lymph node hyperplasia), or elevated serum VEGF

Typically 2/2 underlying Cancer

36
Q

What is idiopathic brachial plexopathy? what are the other two names for it?

A
  • AKA neuralgic amyotrophy OR Parsonage-Turner syndrome
  • Subacute severe pain followed by resolution of pain and progressive weakness and atrophy involving the shoulder girdle and upper extremity muscles
  • Triggered by a preceding event, such an infection or surgery (anywhere)
37
Q

Treatment of Tourette Syndrome (tics)

A
  1. reassurance if mild
  2. CBT
  3. If daily disruptive can use meds: clonidine, guanfacine, topiramate, levetiracetam, and tetrabenazine
  4. If refractory can use antipsychotics but risk of tarditive dyskinesia
  5. severe + refractory + focal - botulinum toxin
38
Q

Young healthy pt + new-onset status epilepticus + progressive confusion suggest diagnosis of _____

A

autoimmune limbic encephalitis

    • classically - hyponatremia, myoclonus, and limbic encephalitis (amnesia, temporal lobe seizures, and confusion)
    • usu associated with paraneoplastic syndromes (find the cancer!)
39
Q

When is Surgical clipping or endovascular coiling of aneurysm indicated?

A 
>/= 7mm in posterior circulation
>/= 12mm in anterior circulation
40
Q

Treatment of Parkinsons Psychosis (hallucinations, etc)

A
  1. d/c any meds that are not carbidopa-levadopa (ie. pramipexole)
  2. Pimavanserin (only FDA approved) - a nondopaminergic atypical antipsychotic agent and selective serotonin 5-hydroxytryptamine receptor 2A inverse agonist
  3. Can also use Quetiapine and clozapine, but not atypical antipsychotics
41
Q

Primary Central Nervous System Lymphoma (PCNSL)

  1. location
  2. clinical picture
  3. diagnosis
  4. treatment
A
  1. non-hodgkin lymphoma, focal supratentorial lesion often involving optic radiations and vitreous or retina (20%)
  2. visual symptoms, headache, nausea, CN palsies
  3. brain biopsy req for diagnosis, but can do slit lamp + vitreal biopsy/fluid sampling if difficult for brain bx. (LP with CSF cytology only 10% diagnostic)
  4. NOT resection (worsen outcomes), sensitive to whole brain radiation and chemotherapy
42
Q

What is McArdle disease?

A
  • Metabolic Myopathy - glycogen storage disease V
  • Exercise intolerance with MYOGLOBINURIA therefore elevated Cr (CKD), cramping, myalgia, mild weakness, “second wind” phenomenon after they take brief break, better with carb loading
43
Q

Blood pressure goal in ICH? What med do you use?

A
  1. SBP 140

2. Nicardipine, not nitroprusside b/c could increase ICP

44
Q

What Sx would make you consider vertebral-basilar stroke in older adults?

A

persistent, acute-onset vertigo

45
Q

rtPA for CVA

  1. time frame
  2. exclusion criteria
  3. BP goals before give TPA
A
  1. 3hr (up to 4.5)
  2. > 80yo, DM with previous CVA, severe CVA, anticoagulant use
  3. SBP <185, DBP <110 (105?) with IV labetalol or IV nicardipine
46
Q

How long to do you allow permissive HTN in CVA? What are exceptions?

A
  1. 48hr
  2. Exceptions:
    - BP >220/120 (MAP 1>140)
    - planned thrombolytic therapy with BP >185/110
    - ACS
    - Aortic dissection
    - End organ damage
47
Q

Indications for endarterectomy post CVA

A
  • ipsilateral carotid stenosis >70%
  • Life expectancy at least 5yr
  • non disability CVA or TIA
  • within 2 weeks of event
48
Q

How to prevent vasospasm (neuro complication) in subarachnoid hemorrhage?

A

PO nimodipine for 21 days

49
Q

When to get CTA in ICH?

A

<45 yo with cocaine use b/c assoc with high incidence of vascular anomalies

50
Q

What score on Mini-Mental test indicates dementia?

A

<24

51
Q

Name disease ___

  • prominent myoclonus
  • EEG with triphasic sharp waves
  • CSF protein 14-3-3
  • rapidly progressive early age
A

CJD - crutzfeldt-jakob disease

52
Q

What types of dementia can you use acetylcholinesterase inhibitors to slow down? Name these drugs

A
  1. mild-moderate alzheimers (for mod-adv (MMSE 3-14) can use memantine)
  2. Dementia with lewey bodies
  3. vascular cognitive impairment
    (no drug for frontrotemporal dementia)

Donepezil, rivastigmine, galantamine

53
Q

Describe clinical and EMG findings for familial Amyloidosis. How to diagnose?

A
  • predominantly sensory + motor peripheral neuropathy and/or autonomic neuropathy
  • multiorgan involvement (eye [glaucoma] and the neurologic, gastrointestinal, cardiac, and urinary (ED) systems
  • Dx by mutation of the transthyretin gene
  • EMG diffuse axonal sensorimotor polyneuropathy.
54
Q

Name 3 AEDs that can be associated with bone loss and osteoporosis

A
  1. Carbamazepine
  2. Phenytoin
  3. Phenobarbital
  4. Valproic acid
55
Q

What test evaluates risk of falling backwards? (ex. in a parkinsons patient)

A
  1. PULL TEST
    test of postural stability, the examiner throws the patient off base by pulling backward on the shoulders; the test is considered positive if the patient topples into the examiner’s arms or takes more than two corrective steps. Backward falls are often related to loss of postural reflexes and resultant postural instability.
56
Q

What is a primary stabbing headache? (“ice-pick” headache)

A

transient local stabs of head pain (sparing face) lasts seconds, no organic disease, common in pt with history of migraine. May linger 1-2 min with dull ache or soreness. Can happen multiple times per day (series) or <1 per day, no autonaumic sx. Can use indomethacin during repeat occurrences but rarely necessary (usu self resolves)

57
Q

Name a few major meds/medication classes that lower seizure threshold

A 
tramadol 
meperidine
bupropion
fluoroquinolones, carbapenems
cefepime
58
Q

Diagnostic criteria of Migraine

A
  • at least five episodes lasting 4-72 hours when untreated
  • Two of the following
    1. Throbbing
    2. Unilateral
    3. Moderate-severe intensity
    4. worsening with physical activity

Must include either N/V OR photo + phonophovia

Think of “POUND” - pulsatile, One day duration(4-72hr), Unilateral, Nausea of vomiting, Disabling

59
Q

Intracranial hypotension

  • clinical presentation
  • etiology
  • MRI findings
  • Treatment
A
  1. orthostatic headache with postural change. yet if has headache weeks-months the orthostatic component may fade. May have thunderclap headache
  2. CSF leak (LP, surgery, trauma, spontaneous) can evaluate with CT myelography
  3. MRI (abn 80%) diffuse nonnodular pachymeningeal enhancement, cerebellar tonsillar abnormalities, subdural fluid collections
  4. Tx - epidural blood patch
60
Q

Relative contraindications to cholinesterase inhibitors (ie. donepezil for dementia)

A
  • SSS
  • LBBB
  • uncontrolled asthma
  • angle-closure glaucoma
  • ulcer disease.
61
Q

Bells Palsy

  • Clinical presentation
  • Treatment
A
  1. unilateral facial weakness involving BOTH upper +lower parts of face (CN VII involvement), alteration in taste (involvment of chorda tympani), and hyperacusis (intolerance of loud noise 2/2 stapedius muscle involvement)
  2. PO prednisone within 72hr expedites rate of full recovery
62
Q

How do you treat transverse myelitis that is refractory to high dose IV glucocorticoids?

A

Plasma exchange

63
Q

In a pt with MCI, what can you test to determine if it is secondary to Alzheimer disease?

A

LP –> CSF measure levels of soluble Aβ42 peptide and soluble tau protein - specific pattern consistent with a diagnosis of Alzheimer disease (low Aβ42 and high tau and p-tau levels)
- In a patient with MCI, these levels have a greater than 80% sensitivity and specificity

64
Q

Reversible Cerebral Vasoconstriction Syndrome (RCVS)

  • type of HA
  • how to Dx
  • predisposing factors (drugs)
  • triggers
  • treatment
A
  • most freq source of thunderclap headache
  • dx by CTA or MRA documenting multifocal constriction of intracranial vessels that normalizes w/in 3 mo of onset
  • predisposing factors: vasoactive drugs (sympathomimetic agents, triptans, cocaine, cannabis) and antidepressants (sertraline)
  • Triggers: exertion, valsalva, emotion, showering/bathing
  • Tx: CCB - verapamil and nimodipine
65
Q

Name this tremor ____

At rest and with action, resolves by changing position of limb (arm), worse with scissors, but no issue with handwriting

A

Dystonic Tremor

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