Neurology Flashcards
1
Q
What is the most common type of HA in clinical practice?
A
Migraine
commonly misdiagnosed
2
Q
What is a hemiplegic migraine?
A
migraine with aura that involves any kind of motor weakness
3
Q
POUND mnemonic for migraines
A
Pulsatile quality
One day duration (4-72 hours…hmm this is longer than a day!)
Unilateral location
Nausea or Vomiting
Disabling intensity (i.e. have to lie down)
4 or more features is 90% predictive of a migraine
4
Q
Patients with a “sinus headache” commonly really have what diagnosis?
A
migraine that will respond to triptans
5
Q
What’s the diagnosis?
Brief paroxysms of unilateral pain in a V2 or V3 distribution?
A
trigeminal neuralgia
Must obtain an MRI to exclude intracranial lesions and MS
6
Q
Tx for trigeminal neuralgia
A
carbamazepine
7
Q
HA in a patient that occurs >10 days a month in patients on pain meds?
A
medication overuse headache
tx: withdraw all pain meds
8
Q
What is the definition of a chronic migraine?
A
HA >15 days a month for >3 months or HA with migraine features >8 days a month
9
Q
Should you ever use opiates or butalbital in headache management?
A
NO
10
Q
Should you use muscle relaxants, benzos or botox for acute or prophylactic treatment of tension type headaches?
A
NO
11
Q
What is a good treatment for rapidy escalating migraines ?
A
nasal triptans or subQ sumatriptan
12
Q
When should a patient be started on migraine prophylaxis?
A
When the headaches
- don’t respond to therapy
- occur more than 10 days a month
- disabling headaches more than 4 days a month
- migraine med use more than 8 days a month
13
Q
is botox indicated for prophylaxis for migraines?
A
only for chronic migraines
14
Q
What are contraindications to triptans?
A
CAD, CVD, brainstem aura and hemiplegic migraine
15
Q
What is a contraindication for women who have migraines with aura?
A
estrogen containing OCPs because of increased stroke risk
16
Q
what medication can be used to prevent cluster headaches?
A
verapamil
17
Q
Should you ever order an EEG for headache disorders?
A
Not according to board basics!
18
Q
Dx?
Woman with a HA, papilledema and neuro findings
A
thrombosis of cerebral vein or dural sinus
tx: LMWH and then warfarin
19
Q
How do you diagnose IIH?
A
CSF pressure >250mm H2O
tx: acetazolamide
20
Q
Do you need to have had a traumatic event to have a subdural hematoma?
A
NO, especially not if you’re old
21
Q
Do single seizures usually require treatment with AEDs
A
no
22
Q
Do absence seizures happen to adults
A
no
23
Q
When should you start AEDs after a first seizure?
A
If the patient is high risk:
- findings on neuroimaging
- focal findings on EEG
- significant risk factor for epilepsy like severe head trauma or after a brain tumor resection
24
Q
What medication is preferred for generalized epilepsy?
A
valproic acid
25
what epilepsy medication is safe during pregnancy?
levetiracetam and lamotrigine
26
What are major possible side effects of all AEDs?
suicidality
drug hypersensitivity syndrome
SJS
27
Who is a candidate for epilepsy surgery?
patient that hasn't responded to 2 AEDs either in sequence or combination
28
When can you safely stop AEDs?
After 2-5 years in patients who have been seizure free
29
What AEDs should be discontinued during pregnancy?
Valproic acid
Topamax
both category D
30
Can you stop AEDs in patients with juvenile myoclonic epilepsy?
NO, need life long treatment
31
What is the only appropriate anticoagulation for AFib associated with valvular heart disease?
Warfarin
32
What medication is contraindicated in dementia with lewy bodies?
haldol!
33
What is the next step in treatment for a patient with Parkinson's who responds well to sinimet but does not have a sustained effect and wears off after a few hours?
Deep brain stimulation is appropriate for patients with Parkinson disease who derive a continued benefit from carbidopa-levodopa but experience medication-related complications.
34
Threshold for stenting or endarterectomy?
Patients with greater than 80% or rapidly progressive stenosis and low cardiac risk
35
What is the threshold for surgical clipping or endovascular coiling of aneurysms?
greater than 7 mm the posterior circulation 12 mm in the anterior circulation
36
Was the definition of a TIA?
Focal neurological deficit resulting from ischemia rather than infarction. Defined by the absence of infarction on neuroimaging, independent of symptom duration, which typically lasts 5 to 60 minutes
37
What is the workup for all patients with stroke or TIA
- emergency non con head CT
- EKG, telemetry or event monitoring
- vascular studies: cerebrovascular ultrasound, MRI or CT
- echo to rule out LV or valvular thrombus
38
Patients with a TIA have an elevated risk of stroke for how long?
48 hours
39
Dx for an older patients with persistent, acute onset vertigo?
vertebral- basilar stroke
40
What is the time window for giving rtPA to a patient with an ischemic stroke?
3 hours since stroke onset or last seen well time
41
Threshold for starting antihypertensive medication post stroke?
- SBP > 220, DBP > 120, MAP >140
- SBP >185 if thryombolytic therapy planned, DBP > 110
- ACS, aortic dissection or end organ damage present
42
Outpatient anti-plt tx for strokes?
ASA + dipyridamole (better than ASA alone)
| Clopidogrel is equivalent
43
resvascularization post stroke?
endarterectomy or stent within 2 weeks of a nondisbaling stroke/TIA if ipsilateral carotid stenosis is >70% and patient should live 5 years longer
44
Should you choose endarterecomty for a patient with 100% stenosis?
no
45
If you are concerned for a SAH and the imaging is negative what's the next step?
LP to look for blood!
46
Treatment for patient with SAH?
- treat ruptured aneurysms with clips or coiling within 48-72 hours
- maintain BP <140/80
- oral nimodipine for 21 days to prevent vasospasm and improve neuro outcomes
47
How diagnose ICH due to cocaine use?
cerebral angiography
48
tx for ICH?
mannitol
barbiturate coma
hyperventilation
-- all above to decrease intracranial pressure
nicardipine or labetalol gtt to maintain BNP between 140-160
if associated with warfarin, give vit K and PCC
49
Why should you not use nitroglycerin or nitroprusside to lower BP in ICH?
can increase intracranial pressure
50
Should you give steroids or platelets for ICH?
NO
51
How distinguish dementia from mild cognitive impairment?
MCI doesn't interfere with daily functioning
52
Is there a test that can determine likelihood of an individual to going and developing dementia?
no!
don't be tricked
53
Do any treatments delay the onset of alzheimer's in patients with MCI?
no!
don't be tricked!
54
what mini mental score with compatible with dementia?
24
55
Most common cause of rapidly progressive dementia?
Creutzfeldt-Jacob
56
What is the diagnosis?
patient with mild parkinsonism, postural instability and gait difficulty, fluctuating cognition, delusions and visual hallucinations
Dementia with Lewy bodies
57
Dementia with personality changes and behavioral disturbances
frontotemporal dementia
58
What is the diagnosis?
75M with frequent falls, apathy, parkinsonism who isn't responding to sinimet and has vertical gaze palsy
progressive supranuclear palsy
59
Should you order Apo E genotyping in a patient with suspected Alzheimer's
no, don't do it!
60
How can you differentiate Alzheimer's and frontotemporal dementia?
frontotemporal classically spares memory and visuospatial function (don't get lost)
61
What are some of the side effects of acetylcholinesterse inhibitors?
```
bradycardia
diarrhea
heart block
nausea and vomiting
syncope
```
62
what medication can you use to delay cognitive decline in patients with moderate to advanced Alzheimers
memantine
63
what is the treatment for dementia with lewy bodies?
acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine
64
What is the treatment for vascular dementia?
acetylcholinesterase inhibitors
| risk factor modification
65
What is the treatment for normal pressure hydrocephalus
large volume LP
66
Is memantine plus acetylcholinesterase inhibitors more effective than one alone
No, no more effective than acetylcholinesterase inhibitors alone
don't be tricked!
67
is any medication effective for frontotemporal dementia?
no
don't be tricked!
68
Should you use benzos for behavioral symptoms in patients with dementia?
no
don't be tricked!
69
How should you treat depression in dementia?
SSRIs
not TCAs because they can make confusion worse
don't be tricked!
70
Should you use benzos for delirium?
No, even if the CCU nurses ask
they can worsen delirium
only use if patient also has etoh withdrawal
don't be tricked!
71
how do you diagnose parkinson's
need two of four:
- bradykinesia
- rigidity
- resting tremor
- postural reflex abnormality (falling)
neuro sx often present asymmetrically
if the patient has early onset dementia think of lewy body dementia
72
How do you diagnose parkinsons
clinically
73
What is the diagnosis?
severe orthostatic hypotension and ataxia
MRI with necrosis of the putamen and cerebellar atrophy
multiple system atrophy
74
What is the diagnosis?
unexplained falls (often backwards), inability to move eyes vertically and parkinsonian features
progressive supranuclear palsy
75
What is the diagnosis?
early dementia, parkinsonism and hallucinations
dementia with lewy bodies
76
What medications can induce parkinsonism?
```
reglan
compazine
haldol
reserpine
lithium
methyldopa
```
77
What is the best treatment approach for Parkinsons in a young patient
If younger than 65 start with a dopamine agonist like pramipexole or ropinerole to avoid the wearing off effect seen with levodopa
78
what are side effects of dopamine agonists?
sedation
| increase in compulsive behaviors like gambling, shopping and hypersexuality
79
how do you treat the wearing off symptoms of dopamine therapy?
increase the dose or frequency of levodopa or using a sustained release formulation
80
When do you start treatment for parkinsonism?
When symptoms begin to interfere with function
don't be tricked!
81
What is the most important red flag for atypical parkinsonism
failure to respond to dopamine therapy
don't be tricked!
82
What is the diagnosis?
bilateral or postural tremor that improves with Etoh
Essential tremor
treat with propranolol, primidone or topiramate
83
What is the treatment for:
Cervical dystonia
botox is first line
84
What is the treatment for:
Tourette's
CBT or reassurance
if interfere with daily function then:
clonidine, guanfacine, topiramate, and tetrabenazine.
85
Are rigidity and resting tremor features of essential tremor?
NO
don't be tricked!
86
Patients < 40 yo with essential tremor or dystonia should be screened for what?
Wilson's dz with serum ceruloplasmin and 24 urine copper measurements
87
Oligoclonal IgG bands in CSF suggests what diagnosis?
MS
88
Aside from MS what else can cause white matter lesions on MRI?
migraine
microvascular ischemic disease
head trauma
don't be tricked!
89
What is the treatment for: MS in the acute setting
IV methylprednisolone followed by oral glucocorticoids for acute exacerbations, especially optic neuritis
**fever can worsen MS, so want to exclude infection first
90
First long term treatment for MS
interferon beta or glatiramer. can also use teriflunomide
91
how treat MS relapses that have no or minimal impact on function
observe
92
what should be added to interferon beta for MS patients?
Vit D, reduces the accumulation of MRI lesions and is recommended for all patients with MS
93
What is the treatment for urinary retention in MS?
manual pelvic pressure, intermittent self cath, no meds
94
Which MS patients should receive interferon?
liver disease
| depression
95
Does pregnancy further disable patients with MS?
No
96
Is there a benefit to MS patients of adding interferon beta to glatiramer acetate?
no
97
What is the diagnosis?
recurrent episodes of myelitis and optic neuritis without brain lesions seen in MS
neuromyelitis optica (devic disease)
98
What is the diagnosis?
| subacute onset of weakness, sensory changes and bowel and bladder dysfunction
idiopathic transverse myelitis
99
Should you check methylmalonic acid and homocysteine measurements for patients with borderline vitamin b12 values?
no
don't be tricked!
100
What is the treatment for: transverse myelitis
iv methylpred
101
What is the treatment for: spinal cord compression from metastatic dz?
high dose glucocorticoids and surgical decompression and then radiation
102
Spinal cord compression from what cancers should be treated urgently with radiation and not surgery?
leukemia
lymphoma
myeloma
germ cell tumors
don't be tricked!
103
Do patients with ALS typically have sensory deficits?
No, usually upper and lower motor neuron signs though
104
What is the workup for a patient you suspect of ALS?
EMG and MRI of anatomic area
PFTs if pulmonary signs
Swallow test if dysphagia
105
Are fasciculations in the absence of associated muscle atrophy or weakness a feature of ALS?
No
| don't be tricked!
106
What is the only approved medication for ALS?
Riluzole can incrase survival by 3 months
107
What malignancy is associated with Lambert Eaton
SCLC
108
What are the characteristic findings of myasthenia gravis?
ptosis or diplopia
muscle weakness
postiive anti-acetylcholinesterase receptor antibody titers
normal DTRs and sensation
decremental response to repetitive stimulation on EMG
109
What is the workup for myasthenia gravis?
EMG
elevated TSH since associated with autoimmune thryoid disorders
CT chest to look for thymoma
110
What is the treatment for: myasthenia gravis
pyridostigmine, thymectomy if a thymoma is found
111
What is the treatment for myasthenia crisis?
plasmapheresis or IVIG
avoid pyridostigmine monotherapy because the drug increases respiratory secretions
112
Most common diagnosis for a mononeuropathy?
compression or nerve entrapment
113
what is the definition of polyneuropathy?
diffuse, generalized and usually symmetric peripheral neuropathy, often the manifestation of a systemic disease or exposure to a toxin like EtOH or medication like chemo
114
Routine tests for peripheral neuropathies?
```
EMG
B12
SPEP
UPEP
ESR
blood glucose level
```
115
What is the diagnosis?
isolated anterolateral thigh numbness without weakness
meralgia paresthetica, compressive neuropathy of the lateral femoral cutaneous nerve
tx: locate and relieve pressure (clothes, weight)
116
What is the diagnosis?
sensory loss over palmar surface of the first 3 digits and weakness with thumb abduction and opposition
median neuropathy aka carpal tunnel
splints, steroid injections, surgery if severe
117
What is the diagnosis?
numbness of 4th and 5th fingers and weakness of interosseous muscles
ulnar neuropathy
elbow splint, surgical release if severe
118
What is the diagnosis?
pain, tingling and numbness in the great toe along medial foot
tarsal tunnel syndrome
tx: steroid injection, surgery if severe
119
What is the diagnosis?
multiple, noncontiguous nerve deficits
mononeuritis multiplex
consider vasculitis, lyme, lymphoma, amyloid, sarcoid, HIV, leprosy, diabetes and treat underlying disorder
120
What is the diagnosis?
acute, ascending, areflexic paralysis andparestehsias preceded by GI illness
Guillain Barre
CSf shows elevated protein and normal cell count
Tx: plasma exchange or IVIG
121
What is the diagnosis?
progressive proximal motor and sensory neuropathy that evolves over months
initial EMG and CSf similar to Guillain Barre
dx is chronic inflammatory demyelinating polyneuropathy
tx: prednisone, plasma exchange or IVIG
122
What is the diagnosis?
symmetirc distal sensory neuropathy in the setting of MGUS, multiple myeloma, amyloid or cryoglobulinemia
paraproteinemic neuropathy
treat underlying disorder
123
Do you need additional neuro imaging for a patient with Bells Palsy who has no additional neuro deficits?
no
don't be tricked!
124
Are steroids useful in Guillain--Barre?
No, can slow recovery
don't be tricked!
125
How can you differentiate a myopathy from a neuropathy?
myopathy has a normal sensory and reflex exam
126
What is the common presentation of a myopathy?
symmetric weakness of proximal muscles
- elevated CK, falls with treatment
- EMG confirms myopathic changes (ow amplitude, short duration, polyphasic motor unit potentials)
127
What is the treatment for: primary CNS lymphoma
chemo and whole brain radiation
128
How do meningiomas appear on CT scan
partially calcified, homogeneously enhancing with a dural tail
129
What is the treatment for: meningiomas
surgical resection if symptomatic or enlarging, observation if small and asymptomatic
130
Is there a role for chemo in meningiomas?
no
don't be tricked!
131
If a metastatic brain tumor is the first indication of malignancy in a patient what is the next step?
evaluate the patient for lung, breast cancer and melanoma
132
What is the treatment for: patients with leptomeningeal mets from leukemia or lymphoma?
chemo: MTX and cytarabine
133
What is the treatment for: patients with brain parenchymal tumors leptomeningeal mets (not from leukemia or lymphoma)?
steroids
don't be tricked! chemo is not indicated
134
What is the most appropriate study for unprovoked first time seizure?
head CT
high value care
135
what is the first line antiplatelet regimen for secondary stroke prevention
aspirin monotherapy
high value care
