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Pedia > Neurology > Flashcards

Neurology Flashcards

1
Q

At least 1 unprovoked epileptic seizure with either a second one or EEG convincingly demonstrating enduring predisposition to develop recurrences

2 or more unprovoked seizures occuring in a time frame longer than 24 hours

A

Epilepsy

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2
Q

6 months to 6 years
Normal neurologic exam
Occurs with fever (not due to CNS infection or metabolic imbalance)
Most commonly due to viral URTI, OM, Roseola, UTI
Normal EEG

A

Febrile seizure

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3
Q

Few seconds to 15 minutes
Generalized
Only once in 24 hours

A

Simple febrile seizure

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4
Q

Focal
More than 15 minutes
Recurrent more than 2 in 24 hours

or

3 seizures in 3 days

A

Complex febrile seizure

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5
Q

Major risk factor for seizure recurrence

A

Age <1 year (most important)
Duration of fever <24 h
Fever 38-39 before onset, low

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6
Q

Management of febrile seizures

A 
In actively convulsing:
Do not put anything in mouth (except when biting the tongue)
Time the event
Do not restrain
Do not give anything to drink 
Turn to the side to prevent choking
Put something under head 
O2 not needed

LP in <18 months not fully immunized to r/o meningitis

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7
Q

Seizure >5 minutes or recurrent seizure tx

A

Diazepam 0.2-0.4 rectal, IV

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8
Q

Antiepileptic drugs that prevent recurrence of febrile seizure

A

Phenobarbital - dec cognitive function

Valproate - hepatotoxicity

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9
Q

Antibodies target NR1 subunit of NMDA

Encephalitis due to antibodies against neuronal cell surface proteins and synaptic receptors in synaptic transmission

A

Anti-N-Methyl-D-Aspartate Receptor Encephalitis

NMDAR Encephalitis

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10
Q

Glutamate receptor and ion channel

Activated when glutamine and glycine bind to it

Important for controlling synaptic plasticity and memory

A

NMDAR

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11
Q

Glutamate exerts toxic acitivity through 3 receptor subtypes

A

NMDAR
AMPA (amino-3-hydroxy-5-methyl-4-isoxazol-proprionic acid)
KA (kainic acid)

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12
Q

NMDAR Tx

A

Methylprednisone IV 5 days

IVIG

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13
Q

More common etiology of CNS infection

A

viral

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14
Q

Most common acute viral encephalitis in the Philippines

A

Japanese encephalitis

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15
Q

Most common acute viral encephalitis in the worle

A

Enterovirus

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16
Q

Chronic meningitis

A

Subacute Sclerosing Panencephalitis

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17
Q 
Hypothermia
Fever (ominous or severe)
Seizure (late)
Lethargy or irritability 
Poor feeding
Respiratory distess
Diarrhea

Are all symptoms of CNS infection in

A

Neonates (0-28 days)

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18
Q 
Fever (50%)
Seizure (40%)
Poor feeding
Abdominal distention
Bulging anterior fontanel 
Altered sensorium

Are all symptoms of CNS infection in

A

Infants (1 mo-2 years)

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19
Q

Fever
Headache
Nuchal rigidity

Are all symptoms of CNS infection in

A

Older children and adult

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20
Q

The most common cause of bacterial meningitis in 0-2 months old

Philippines

West

A 
E coli (Gram negative)
Pseudomonas
Klebsiella
Listeria
Salmonella

Group B streptococcus pneumoniae

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21
Q

The most common cause of bacterial meningitis in 3 months to 6 years

A

H influenzae
Streptococcus pneumoniae

Can be prevented through vaccines given as early as 6 weeks

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22
Q

The most common cause of early to late childhood bacterial meningitis

A 
Streptococcus pneumoniae
Neisseria meningitidis (Meningococcus)
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23
Q

Meningitis mode of transmission

A

Respiratory droplet

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24
Q

Bacterial meningitis pathophysiology

A

Nasopharyngeal colonization
Local invasion
Bacteremia
Bacterial replication
Subarachnoid space inflammation (seizures and fever)
TNF and inflammatory enzymes (reaction to infection)
Increased BBB permeability and ICP
3 types of edema: vasogenic, cytotoxic and interstitial

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25
Q

Causes neurologic problems seizure and fever

A

Subarachnoid Space inflammation

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26
Q

Frequent sequelae of bacterial meningitis

A

Cerebral infarction from vascular occlusion bec of inflammation, vasospasm and thrombosis

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27
Q

Common acute complication of bacterial meningitis

A

Inc ICP (tentorial herniation -> temporal lobe and CN III palsy)

Communicating hydrocephalus by adhesive thickening of arachnoid around basal cistern
Non obstructive from fibrosis is chronic

Inc CSF protein From inc vascular permeability of BBB and loss of albumin-rich fluid

Hypoglycorrachia (dec CSF glucose) dec glucose transport by cerebral tissue

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28
Q

Pathogenesis of bacterial meningitis most commonly results from

A

Hematogenous dissemination from a distant site (nasopharyngeal colonization)

N meningitides and Hib attach to mucosal epithelium via Vili and breaches mucosa to enter circulation

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29
Q

2 patterns of acute meningitis

A

Fever with URTI/GIT -> Meningitis -> Non-specific signs of CNS (lethargy and irritability)

Less common but more dramatic: sudden onset rapid manifestation of shock, purpura, DIC and reduced levels of consciousness progressing to coma and death within 24 h

+ Kernig and Brudzinski
Seizure

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30
Q

Seizure occuring within first 4 days

Seizure persisting after 4th day

A

No significance

Poor prognosis

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31
Q

Elicited by stroking the skin with blunt object and observing raised red streak within 30-60 seconds

A

Tache cerebrale

Photophobia

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32
Q

LP is done at this level of the child

A

22 gauge at L3-L4

23 gauge at L4-L5 (newborn)

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33
Q

LP contraindications

A

Cardiorespiratory compromise or shock -dyspnea, tachycardia, coma or respirator

Increased ICP or impending herniation

Bulging fontanel, CN 3/6 palsy with depressed level of consciousness, hypertension and bradycardia with respiratory abnormalities

Space occupying lesions - focal neurologic signs

Obstructive hydrocephalus

Local infection, epidural abscess

Bleeding dyscrasias

Thrombocytopenia (PC <20)

Imaging to rule out CI

Infection of skin overlying LP site

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34
Q 
Normal/high opening pressure
WBC: 1,000 - 10,000 (PMN >80)
Slight increase in RBC
VERY HIGH PROTEIN (100-500)
Glucose <40?
Gram stain 60-90% Positive
Culture % positive: 70-85
A

Bacterial Meningitis

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35
Q 
Normal opening pressure
WBC: <300 (PMN <20) BECAUSE MONONUCLEAR LYMPHOCYTES
RBC count Normal 
Protein Normal
Glucose Normal
Gram stain Negative
Culture % positive: 25
A

Viral

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36
Q 
Normal/high opening pressure
WBC: 20-500 (PMN <50)
Normal RBC
High protein
Glucose <40
Gram stain Negative
Culture % positive: 25-50
A

Fungal

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37
Q 
Opening pressure usually high 
WBC 50-500 (PMN <20)
RBC Count Normal
Protein High
Glucose <40
Gram stain 40-80% positive
Culture % positive: 50-80
A

Tuberculous meningitis

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38
Q

Basal enhancement on CT Scan

A

TB Meningitis

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39
Q

Subdural effusion on CT Scan

A

H influenzae
S pneumoniae
N meningitides (Meninggococcal)

Edema of brain is seen only in infancy from 6
mo to 2 years which resolves spontaneously until it gets infected becoming empyema.

40
Q

Subdural empyema is a complication of this population

A

Childhood
not seen in adults

Low sugar content
Higher protein content than CSF

41
Q

Uncommon complication of bacterial meningitis usually from H influenzae

A

Brain abscess

Contiguous focus of infection (otitis media, mastoiditis)
Hematogenous spread from distant focus
Cranial trauma

42
Q

Complication of N meningitides meninggococci

A

Pericarditis

Arthritis

43
Q

most severe, Long term sequelae of Meningitis in infancy

A

Sensorineural hearing loss (15-20%) bec of cochlear nerve affectation

Tx: Cochlear nerve implant

44
Q

Highest mortality of bacterial meningitis

A

Pneumococcal meningitis

Poorest prognosis in infants <6 mo

45
Q

Bacterial meningitis Tx in 0-2 months

A

Cefotaxime (3rd gen) + Aminoglycoside
Gram Neg
Group B Strep

46
Q

Bacterial meningitis in >2 months - 5 years

A

Ceftriaxone
Cefotaxime + Vancomycin

H influenzae
Strep pneumoniae
Meningitidis

47
Q

Bacterial meningitis in >5-18

A

Ceftriazone

Pen G

48
Q

For Hib causing meningitis, also give

A

IV Dexamethasone 2 days

49
Q

N meningitidis chemoprophylaxis is given

A

all close contacts of patients with meningococcal meningitis regardless of age or immunization

(direct exposure to oral secretions mouth to mouth, suctioning, intubation)

50
Q

N meningitidis chemoprophylaxis

A

Rifampicin 10 mg/kg/dose every 12h for 2 DAYS

51
Q

Routine administration of Meningococcal vaccine is recommended for

A

11-12 years old adolescents

High risk children >2 years with anatomic or functional asplenia or deficiency of terminal complement proteins

College freshmen

Adjunct with chemoprophylaxis for exposed contacts and epidemic

52
Q

Meningitis vaccine

A

Quadrivalent (A, C, Y, W-135 Conjugated vaccine MCV 4; Menactra)

53
Q

H influenzae Rifampicin 20 mg/kg/h OD for 4 DAYS prophylaxis

is given in

A

All household contacts of patients (spent minimum 4 hours, at least 5/7 days preceding hosp)

Close family member younger than 3-4 years without immunization

Immunocompromised

54
Q

Strep pneumoniae meningitis prophylaxis is through

A

Routine administration of Pneumococcal conjugate vaccine PCV 13

for children younger than 2 (2, 4, 6 months)
Functional or anatomical asplenia
Immunodeficiency

55
Q

Most common form of CNS infection in Philippines

A

TB Meningitis

56
Q

Inflammation of leptomeninges
Tuberculoma

Basal exudates

Hydrocephalus due to thick exudates (Communicating hydrocephalus)
CN palsies due to basal location
Vasculitis

A

TB Meningitis

57
Q

Period of highest risk of development of TB infection

A

1-3 months post primary TB infection

58
Q

Metastatic TB foci lodge in

A

Meninges
Cerebral or spinal tissue
Choroid plexus

59
Q

Arises from primary hematogenous seeding or secondary spread from extracranial focus

Rupture of these foci cause spread into subarachnoid space

A

Rich focus: Subependymal or tuberculid

60
Q

Neuropathologic findings in TB Meningitis

A

Basal exudates

Encephalitis Border Zone

61
Q

Radiologic triad of TB Meningitis

A

Basal meningitis
Cerebral infarction/arteritis
Hydrocephalus

62
Q

CSF analysis of TB Meningitis shows

A

Pellicle formation

Cobweb like clot

63
Q

TB Meningitis earliest age of onset

A

4 months

bec of 2-3 months incubation period from primary infection

Flat sulci
Hydrocephalus

on UTZ

64
Q

TB Meningitis Tx

A

2 months HRZE (anti-Koch’s)

10 months HR (double therapy)

65
Q

Streptomycin side effect

A

Irreversible deafness

66
Q

Ethambutol side effect

A

Optic neurotis

Color blindness

67
Q

Steroids Dexamethasone and Oral Prednisone given for stage

A

2 and 3 for 1-2 months

68
Q

Tx on Multidrug resistant TB

A

Fluoroquinolone

69
Q

Most common fungal infection causing meningitis more common in immunocompromised

A

Cryptococcus neoformans

70
Q

Exposure for cryptococcus neoformans

A

Pigeons

71
Q

Cryptococcus neoformans is essily diagnosed by

A

Fungal on India ink smear and CALAS

72
Q

Cryptococcus neoformans Tx

A

Amphotericin B 4-6 weeks

73
Q

Opacity of basal leptomeninges

A

Cryptococcal meningitis

74
Q

Collection of pus surrounded by well vascularized capsule usually from gram negative meningitis:

Citrobacter diversus (neonates)?
Proteus
Serratia

Polymicrobial

A

Brain abscess

75
Q

Brain abscess predisposing factors

A

Embolus from CHD Right to left shunt (TOF)
Penetrating injury
Hematogenous spread
ENT infection

76
Q

Large multiloculated abscess with hyperdense ring enhancement on CT Scan

A

Brain abscess

77
Q

CI in brain abscess

A

Lumbar tap may cause herniation

78
Q

Diagnostic test of choice in brain abscess

A

MRI

on CT hypodense center

79
Q

Brain abscess Tx

A

Ceftriaxone + Metronidazole
Cefotaxime + Metronidazole

If unknown
Cefotaxime/Ceftriaxone + Metronidazole + Vancomycin

Known CHD
Ampi-Sul or Ceftriaxone/Cefotaxime + Metronidazole

4-6 weeks IV

80
Q

Surgical indication brain abscess

A 
> 2.5 in diameter
Gas present in abscess
Multiloculated lesion
Abscess in posterior fossa
Fungus
81
Q

Most common cause of encephalitis in the Philippines

A

Japanese encephalitis

Immunization required

82
Q

HSV encephalitis affects this part of the brain

A

Temporal lobe
Subfrontal regions
Hippocampus

83
Q

Arbovirus (Japanese) encephalitis affects this part of brain

A

Entire brain

84
Q

Rabies affects this part of the brain

A

Basal structures

85
Q

HSV Encephalitis EEG

A

Paroxysmal lateralized epileptiform discharges
PLEDS (frontal or temporal)

EEG in meningitis will always be normal

86
Q

Most common vaccine-preventable cause of encephalitis in Asia and Pacific region

A

Japanese Encephalitis

87
Q

Yellow virus
Arbovirus transmitted by

Culex

Single stranded RNA Flavivirus with enveloped glycoproteins

Mostly seen in rice fields, temperate and tropical areas

A

Jap encephalitis

88
Q

Japanese encephalitis incubation period

A

6-16 days

89
Q

Jap encephalitis enters blood stream -> peripheral tissue -> cortex especially the

A

Basal Ganglia

90
Q

Within 3 days from fever

Altered sensorium
Convulsion
Neck stiffness, muscular rigidity
Mask-like facies, involuntary movement

Splitting, shouting, cursing, mild personality change but NO VIOLENT BEHAVIOR

Abulia (inability to act decisively), wide unblinking eyes, bizarre posturing, papilledema, dysphagia, asymetric irregular distribution of motor and tone abnormalities

A

Japanese encephalitis

91
Q

Gold standard for Diagnosis of Japanese Encephalitis

A

IgM and IgG capture ELISA

Repeated if initially negative

92
Q

High intensity/hyperintense T2 weighted imaging of Thalamus, cerebral hemispheres, and cerebellum on MRI

Diffuse theta and delta waves on EEG

A

Japanese Encephalitis

93
Q

Live attenuated recombinant

0.5 ml single injection for >1 year

Booster for 18 years and above but not needed until 5 years after primary administration

A

JEV vaccine

94
Q

Long term consequence of neurologic impairment in JEV

A

Limb contracture

Bed sore

95
Q 
Psychiatric symptoms
Emotional and behavioral disturbances
Seizures
Autonomic instability
Automatisms 
Extrapyramidal signs
Speech dysfunction

Ovarian teratomas in <18

A

Anti-NMDAR Encephalitis

Do UTZ

96
Q

NMDAR Confirmatory diagnostic study

A

Detection of antibodies to NR1 subunits of NMDAR

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