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Neurology Flashcards

1
Q

What is the most common type of HA in clinical practice?

A

Migraine

commonly misdiagnosed

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2
Q

What is a hemiplegic migraine?

A

migraine with aura that involves any kind of motor weakness

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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

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4
Q

Patients with a “sinus headache” commonly really have what diagnosis?

A

migraine that will respond to triptans

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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

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6
Q

Tx for trigeminal neuralgia

A

carbamazepine

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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

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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

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9
Q

Should you ever use opiates or butalbital in headache management?

A

NO

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10
Q

Should you use muscle relaxants, benzos or botox for acute or prophylactic treatment of tension type headaches?

A

NO

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11
Q

What is a good treatment for rapidy escalating migraines ?

A

nasal triptans or subQ sumatriptan

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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
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13
Q

is botox indicated for prophylaxis for migraines?

A

only for chronic migraines

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14
Q

What are contraindications to triptans?

A

CAD, CVD, brainstem aura and hemiplegic migraine

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15
Q

What is a contraindication for women who have migraines with aura?

A

estrogen containing OCPs because of increased stroke risk

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16
Q

what medication can be used to prevent cluster headaches?

A

verapamil

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17
Q

Should you ever order an EEG for headache disorders?

A

Not according to board basics!

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18
Q

Dx?

Woman with a HA, papilledema and neuro findings

A

thrombosis of cerebral vein or dural sinus

tx: LMWH and then warfarin

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19
Q

How do you diagnose IIH?

A

CSF pressure >250mm H2O

tx: acetazolamide

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20
Q

Do you need to have had a traumatic event to have a subdural hematoma?

A

NO, especially not if you’re old

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21
Q

Do single seizures usually require treatment with AEDs

A

no

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22
Q

Do absence seizures happen to adults

A

no

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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
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24
Q

What medication is preferred for generalized epilepsy?

A

valproic acid

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25
Q

what epilepsy medication is safe during pregnancy?

A

levetiracetam and lamotrigine

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26
Q

What are major possible side effects of all AEDs?

A

suicidality
drug hypersensitivity syndrome
SJS

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27
Q

Who is a candidate for epilepsy surgery?

A

patient that hasn’t responded to 2 AEDs either in sequence or combination

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28
Q

When can you safely stop AEDs?

A

After 2-5 years in patients who have been seizure free

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29
Q

What AEDs should be discontinued during pregnancy?

A

Valproic acid
Topamax

both category D

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30
Q

Can you stop AEDs in patients with juvenile myoclonic epilepsy?

A

NO, need life long treatment

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31
Q

What is the only appropriate anticoagulation for AFib associated with valvular heart disease?

A

Warfarin

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32
Q

What medication is contraindicated in dementia with lewy bodies?

A

haldol!

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33
Q

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?

A

Deep brain stimulation is appropriate for patients with Parkinson disease who derive a continued benefit from carbidopa-levodopa but experience medication-related complications.

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34
Q

Threshold for stenting or endarterectomy?

A

Patients with greater than 80% or rapidly progressive stenosis and low cardiac risk

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35
Q

What is the threshold for surgical clipping or endovascular coiling of aneurysms?

A

greater than 7 mm the posterior circulation 12 mm in the anterior circulation

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36
Q

Was the definition of a TIA?

A

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

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37
Q

What is the workup for all patients with stroke or TIA

A
  • 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
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38
Q

Patients with a TIA have an elevated risk of stroke for how long?

A

48 hours

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39
Q

Dx for an older patients with persistent, acute onset vertigo?

A

vertebral- basilar stroke

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40
Q

What is the time window for giving rtPA to a patient with an ischemic stroke?

A

3 hours since stroke onset or last seen well time

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41
Q

Threshold for starting antihypertensive medication post stroke?

A
  • SBP > 220, DBP > 120, MAP >140
  • SBP >185 if thryombolytic therapy planned, DBP > 110
  • ACS, aortic dissection or end organ damage present
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42
Q

Outpatient anti-plt tx for strokes?

A

ASA + dipyridamole (better than ASA alone)

Clopidogrel is equivalent

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43
Q

resvascularization post stroke?

A

endarterectomy or stent within 2 weeks of a nondisbaling stroke/TIA if ipsilateral carotid stenosis is >70% and patient should live 5 years longer

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44
Q

Should you choose endarterecomty for a patient with 100% stenosis?

A

no

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45
Q

If you are concerned for a SAH and the imaging is negative what’s the next step?

A

LP to look for blood!

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46
Q

Treatment for patient with SAH?

A
  • 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
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47
Q

How diagnose ICH due to cocaine use?

A

cerebral angiography

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48
Q

tx for ICH?

A

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

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49
Q

Why should you not use nitroglycerin or nitroprusside to lower BP in ICH?

A

can increase intracranial pressure

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50
Q

Should you give steroids or platelets for ICH?

A

NO

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51
Q

How distinguish dementia from mild cognitive impairment?

A

MCI doesn’t interfere with daily functioning

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52
Q

Is there a test that can determine likelihood of an individual to going and developing dementia?

A

no!

don’t be tricked

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53
Q

Do any treatments delay the onset of alzheimer’s in patients with MCI?

A

no!

don’t be tricked!

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54
Q

what mini mental score with compatible with dementia?

A

24

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55
Q

Most common cause of rapidly progressive dementia?

A

Creutzfeldt-Jacob

56
Q

What is the diagnosis?

patient with mild parkinsonism, postural instability and gait difficulty, fluctuating cognition, delusions and visual hallucinations

A

Dementia with Lewy bodies

57
Q

Dementia with personality changes and behavioral disturbances

A

frontotemporal dementia

58
Q

What is the diagnosis?

75M with frequent falls, apathy, parkinsonism who isn’t responding to sinimet and has vertical gaze palsy

A

progressive supranuclear palsy

59
Q

Should you order Apo E genotyping in a patient with suspected Alzheimer’s

A

no, don’t do it!

60
Q

How can you differentiate Alzheimer’s and frontotemporal dementia?

A

frontotemporal classically spares memory and visuospatial function (don’t get lost)

61
Q

What are some of the side effects of acetylcholinesterse inhibitors?

A 
bradycardia
diarrhea
heart block
nausea and vomiting
syncope
62
Q

what medication can you use to delay cognitive decline in patients with moderate to advanced Alzheimers

A

memantine

63
Q

what is the treatment for dementia with lewy bodies?

A

acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine

64
Q

What is the treatment for vascular dementia?

A

acetylcholinesterase inhibitors

risk factor modification

65
Q

What is the treatment for normal pressure hydrocephalus

A

large volume LP

66
Q

Is memantine plus acetylcholinesterase inhibitors more effective than one alone

A

No, no more effective than acetylcholinesterase inhibitors alone

don’t be tricked!

67
Q

is any medication effective for frontotemporal dementia?

A

no

don’t be tricked!

68
Q

Should you use benzos for behavioral symptoms in patients with dementia?

A

no

don’t be tricked!

69
Q

How should you treat depression in dementia?

A

SSRIs

not TCAs because they can make confusion worse

don’t be tricked!

70
Q

Should you use benzos for delirium?

A

No, even if the CCU nurses ask

they can worsen delirium

only use if patient also has etoh withdrawal

don’t be tricked!

71
Q

how do you diagnose parkinson’s

A

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
Q

How do you diagnose parkinsons

A

clinically

73
Q

What is the diagnosis?

severe orthostatic hypotension and ataxia

MRI with necrosis of the putamen and cerebellar atrophy

A

multiple system atrophy

74
Q

What is the diagnosis?

unexplained falls (often backwards), inability to move eyes vertically and parkinsonian features

A

progressive supranuclear palsy

75
Q

What is the diagnosis?

early dementia, parkinsonism and hallucinations

A

dementia with lewy bodies

76
Q

What medications can induce parkinsonism?

A 
reglan
compazine
haldol
reserpine
lithium
methyldopa
77
Q

What is the best treatment approach for Parkinsons in a young patient

A

If younger than 65 start with a dopamine agonist like pramipexole or ropinerole to avoid the wearing off effect seen with levodopa

78
Q

what are side effects of dopamine agonists?

A

sedation

increase in compulsive behaviors like gambling, shopping and hypersexuality

79
Q

how do you treat the wearing off symptoms of dopamine therapy?

A

increase the dose or frequency of levodopa or using a sustained release formulation

80
Q

When do you start treatment for parkinsonism?

A

When symptoms begin to interfere with function

don’t be tricked!

81
Q

What is the most important red flag for atypical parkinsonism

A

failure to respond to dopamine therapy

don’t be tricked!

82
Q

What is the diagnosis?

bilateral or postural tremor that improves with Etoh

A

Essential tremor

treat with propranolol, primidone or topiramate

83
Q

What is the treatment for:

Cervical dystonia

A

botox is first line

84
Q

What is the treatment for:

Tourette’s

A

CBT or reassurance

if interfere with daily function then:
clonidine, guanfacine, topiramate, and tetrabenazine.

85
Q

Are rigidity and resting tremor features of essential tremor?

A

NO

don’t be tricked!

86
Q

Patients < 40 yo with essential tremor or dystonia should be screened for what?

A

Wilson’s dz with serum ceruloplasmin and 24 urine copper measurements

87
Q

Oligoclonal IgG bands in CSF suggests what diagnosis?

A

MS

88
Q

Aside from MS what else can cause white matter lesions on MRI?

A

migraine
microvascular ischemic disease
head trauma

don’t be tricked!

89
Q

What is the treatment for: MS in the acute setting

A

IV methylprednisolone followed by oral glucocorticoids for acute exacerbations, especially optic neuritis

**fever can worsen MS, so want to exclude infection first

90
Q

First long term treatment for MS

A

interferon beta or glatiramer. can also use teriflunomide

91
Q

how treat MS relapses that have no or minimal impact on function

A

observe

92
Q

what should be added to interferon beta for MS patients?

A

Vit D, reduces the accumulation of MRI lesions and is recommended for all patients with MS

93
Q

What is the treatment for urinary retention in MS?

A

manual pelvic pressure, intermittent self cath, no meds

94
Q

Which MS patients should receive interferon?

A

liver disease

depression

95
Q

Does pregnancy further disable patients with MS?

A

No

96
Q

Is there a benefit to MS patients of adding interferon beta to glatiramer acetate?

A

no

97
Q

What is the diagnosis?

recurrent episodes of myelitis and optic neuritis without brain lesions seen in MS

A

neuromyelitis optica (devic disease)

98
Q

What is the diagnosis?

subacute onset of weakness, sensory changes and bowel and bladder dysfunction

A

idiopathic transverse myelitis

99
Q

Should you check methylmalonic acid and homocysteine measurements for patients with borderline vitamin b12 values?

A

no

don’t be tricked!

100
Q

What is the treatment for: transverse myelitis

A

iv methylpred

101
Q

What is the treatment for: spinal cord compression from metastatic dz?

A

high dose glucocorticoids and surgical decompression and then radiation

102
Q

Spinal cord compression from what cancers should be treated urgently with radiation and not surgery?

A

leukemia
lymphoma
myeloma
germ cell tumors

don’t be tricked!

103
Q

Do patients with ALS typically have sensory deficits?

A

No, usually upper and lower motor neuron signs though

104
Q

What is the workup for a patient you suspect of ALS?

A

EMG and MRI of anatomic area

PFTs if pulmonary signs

Swallow test if dysphagia

105
Q

Are fasciculations in the absence of associated muscle atrophy or weakness a feature of ALS?

A

No

don’t be tricked!

106
Q

What is the only approved medication for ALS?

A

Riluzole can incrase survival by 3 months

107
Q

What malignancy is associated with Lambert Eaton

A

SCLC

108
Q

What are the characteristic findings of myasthenia gravis?

A

ptosis or diplopia
muscle weakness
postiive anti-acetylcholinesterase receptor antibody titers
normal DTRs and sensation
decremental response to repetitive stimulation on EMG

109
Q

What is the workup for myasthenia gravis?

A

EMG
elevated TSH since associated with autoimmune thryoid disorders
CT chest to look for thymoma

110
Q

What is the treatment for: myasthenia gravis

A

pyridostigmine, thymectomy if a thymoma is found

111
Q

What is the treatment for myasthenia crisis?

A

plasmapheresis or IVIG

avoid pyridostigmine monotherapy because the drug increases respiratory secretions

112
Q

Most common diagnosis for a mononeuropathy?

A

compression or nerve entrapment

113
Q

what is the definition of polyneuropathy?

A

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
Q

Routine tests for peripheral neuropathies?

A 
EMG
B12
SPEP
UPEP
ESR
blood glucose level
115
Q

What is the diagnosis?

isolated anterolateral thigh numbness without weakness

A

meralgia paresthetica, compressive neuropathy of the lateral femoral cutaneous nerve

tx: locate and relieve pressure (clothes, weight)

116
Q

What is the diagnosis?

sensory loss over palmar surface of the first 3 digits and weakness with thumb abduction and opposition

A

median neuropathy aka carpal tunnel

splints, steroid injections, surgery if severe

117
Q

What is the diagnosis?

numbness of 4th and 5th fingers and weakness of interosseous muscles

A

ulnar neuropathy

elbow splint, surgical release if severe

118
Q

What is the diagnosis?

pain, tingling and numbness in the great toe along medial foot

A

tarsal tunnel syndrome

tx: steroid injection, surgery if severe

119
Q

What is the diagnosis?

multiple, noncontiguous nerve deficits

A

mononeuritis multiplex

consider vasculitis, lyme, lymphoma, amyloid, sarcoid, HIV, leprosy, diabetes and treat underlying disorder

120
Q

What is the diagnosis?

acute, ascending, areflexic paralysis andparestehsias preceded by GI illness

A

Guillain Barre

CSf shows elevated protein and normal cell count

Tx: plasma exchange or IVIG

121
Q

What is the diagnosis?

progressive proximal motor and sensory neuropathy that evolves over months

A

initial EMG and CSf similar to Guillain Barre

dx is chronic inflammatory demyelinating polyneuropathy

tx: prednisone, plasma exchange or IVIG

122
Q

What is the diagnosis?

symmetirc distal sensory neuropathy in the setting of MGUS, multiple myeloma, amyloid or cryoglobulinemia

A

paraproteinemic neuropathy

treat underlying disorder

123
Q

Do you need additional neuro imaging for a patient with Bells Palsy who has no additional neuro deficits?

A

no

don’t be tricked!

124
Q

Are steroids useful in Guillain–Barre?

A

No, can slow recovery

don’t be tricked!

125
Q

How can you differentiate a myopathy from a neuropathy?

A

myopathy has a normal sensory and reflex exam

126
Q

What is the common presentation of a myopathy?

A

symmetric weakness of proximal muscles

  • elevated CK, falls with treatment
  • EMG confirms myopathic changes (ow amplitude, short duration, polyphasic motor unit potentials)
127
Q

What is the treatment for: primary CNS lymphoma

A

chemo and whole brain radiation

128
Q

How do meningiomas appear on CT scan

A

partially calcified, homogeneously enhancing with a dural tail

129
Q

What is the treatment for: meningiomas

A

surgical resection if symptomatic or enlarging, observation if small and asymptomatic

130
Q

Is there a role for chemo in meningiomas?

A

no

don’t be tricked!

131
Q

If a metastatic brain tumor is the first indication of malignancy in a patient what is the next step?

A

evaluate the patient for lung, breast cancer and melanoma

132
Q

What is the treatment for: patients with leptomeningeal mets from leukemia or lymphoma?

A

chemo: MTX and cytarabine

133
Q

What is the treatment for: patients with brain parenchymal tumors leptomeningeal mets (not from leukemia or lymphoma)?

A

steroids

don’t be tricked! chemo is not indicated

134
Q

What is the most appropriate study for unprovoked first time seizure?

A

head CT

high value care

135
Q

what is the first line antiplatelet regimen for secondary stroke prevention

A

aspirin monotherapy

high value care

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