Neurology Flashcards
What are examples of a migraine with aura?
visual loss, hallucinations, flashing lights, numbness, tingling, aphasia, confusion
Brainstem aura: ataxia, vertigo, dysarthria, diplopia, tinnitus, hyperacusis, alteration in consciousness
Hemiplegic
Differential diagnosis of a migraine (4)
1) tension type headache
2) trigeminal neuralgia
3) medication overuse headache
4) chronic migraine headache
What can be used as prophylaxis for tension type headache vs trigeminal neuralgia?
Tension type: TCAs
trigeminal neuralgia: carbamezapine
What types of migraines are best treated by nasal triptans or subcutaneous sumatriptan? (3)
1) migraine present when awakening
2) migraine with vomiting
3) escalates quickly
Which antiemetic can be used for migraine-associated nausea and enahnace efficacy of abortive medication?
metaclopramide
When to use migraine prophylaxis?
Headache occurs more than ___ per month
disabling headache occurs ___ per month
use of acute migraine meds more than ___ per month
Headache occurs more than 10 days per month
disabling headache occurs 4 per month
use of acute migraine meds more than 8 per month
What are 5 migraine prophylaxis meds that can be used?
amytripyline, topiramate, valproic acid, metoprolol, propranolol, venlafaxine
What are 4 types of trigeminal autononic cephalgias?
1) cluster headache
2) chronic paroxysmal hemicranias
3) SUNCCT
4) hemicrania continua
What is this headache?
periobital, 20-60min several times a day
repeats over weeks then dormant
sx: nilateral tearing, nasal congestion, rhinorrhea
What is the treatment?
cluster headache
tx: oxygen, triptan
prophylaxis: verapamil
What is this headache?
> 5x daily lasting 3-20 min
What is treatment?
chronic paroxysmal hemicranias
tx: indomethacin
What is this headache?
dozens to hundreds x a day lasting 1-600 seconds, unilateral periocular, see in men in 50s
What is treatment?
SUNCT(Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing)
tx: resistant to treatment
What is this headache?
persistent unilateral headache that responds to indomethacin
hemicrania continua
What is 4 differentials for a thunderclap headache?
1) subarachnoid hemorrhage
2) cerebral/vertebral dissection
3) thrombosis of cerebral vein or dural sinus
4) reversible cerebral vasoconstriction syndrome
What are 4 clinical features of a seizure that suggest it was a partial seizure that turned into a generalized seizure?
1) head turning to one side
2) aura
3) focal weakness
4) unilateral shaking
What are 4 comorbidities with epilepsy?
1) sleep disorders
2) mood disorders
3) metabolic bone disease
4) hyperlipidemia
What are 6 situations that would convince you to start AED after a first time unprovoked seizure?
1) age >65
2) h/o partial seizure
3) h/o significant head trauma
4) h/o postictal weakness/paralysis
5) focal findings on EEG
6) focal findings on imaging
What is the best AED for generalized epilepsy?
valproic acid
What is the cheapest AED for focal epilepsy?
carbamezapine
Which AED interacts with other hepatically metabolized drug and increases risk for osteoporosis and hypercholesterolemia?
carbamezapine
Which AED can cause weight gain, hypercholesterolemia, PCOS, teratogenicity?
valproic acid
Which AEDs cause risk of kidney stones? (2)
topiramate and zonisamide
which AEDs cause hyponatremia? (2)
carbamazepine and oxcarbazepine
Which 2 AEDs can be continued through pregnancy?
Keppra and lamotrigine
True/False:
carbamazepine, oxcarbazepine, phenytoin, topiramate, clobazam, felbamate, phenobarbital causes decrease in efficacy of hormonal contraception
True
Surgical intervention of aneurysms are indicatd when aneurysms are bigger than
___ for posterior communicating and basilar arteries
___ for anterior circulation
> 7 in posterior/basilar arteries
>12 in anterior circulation
What is the only approved drug for AF with valvular heart disease?
Warfarin only
What is clinical presentation of the stroke in the following areas:
1) anterior cerebral artery
2) middle cerebral artery
3) posterior cerebral artery
4) deep/lacunar
5) basilar artery
6) vertebral artery
1) contralateral leg weakness
2) contralateral face and arm weakness > leg weakness; sensory loss, visual field cut, aphasia, neglect
3) contralateral visual field cut
4) contralateral motor/sensory deficit without cortical signs, clumsy hand-dysarthria syndrome, ataxic hemiparesis
5) oculomotor deficits with/or ataxia with crossed sensory/motor deficits
6) lower cranial nerve deficits (vertigo, nystagmus, dysphagia, dysarthria, tongue/palate deviation) and/or ataxia with crossed sensory deficits
TIA ABCD2 scoring system
What merits admission?
What merits dual antiplatelet therapy?
ABCD2= age >60, BP >140/90, clinical symptoms (1 point for speech impairment, 2 points for focal weakness), Diabetes, duration of TIA (1 pt for 10-59 min, 2 pts >60 min)
Admission=3
dual antiplatelet=4 (21 day DAPT then clopidegrel for total 90 days)
When to give TPA for stroke?
<3 hours
<4.5 hours IF not >80 yo, severe stroke, DM with previous infarct, anticoagulation
What are reasons to not give TPA for a stroke?
1) h/o ICH
2) ischemic stroke or head trauma during previous 3 months
3) GI/GU bleed during past 3 weeks
4) major surgery/trauma over past 14 days
5) arterial puncture over noncompressible site over past 7 days
6) heparin therapy within past 48 hours with elevated PTT
7) hyper/hypo glycemia, INR >1.7, plt <100k
8) BP >185/110
9) seizure at stroke onset
When do you treat hypertension in stroke?
When do you treat HTN if thrombolysis is planned?
> 220/120
> 185/110 (use labetolol or nicardipine)
What % of carotid stenosis do you do revascularlization after stroke?
within 2 weeks for >70% occlusion
In a subarachnoid hemorrhage, what is the BP to maintain?
<140/80
Why is a cerebral angiography indicated for <45 yo when there is an intracranial hemorrhage with cocaine use?
association with vascular anomalies
What are 3 ways to decrease intracranial pressure from an intracranial hemorrhage?
What is the BP range to maintain?
1) mannitol
2) hyperventilation
3) phenobarb coma
BP 140-160 (do NOT use nitrates because it can increase ICP)
What is the MMSE score to diagnose dementia?
<24
What are two types of frontotemporal dementia?
1) behavioral varient (early and prominent personality changes, <60 yo
2) prominent and early changes in language function
What two characteristics separates early frontaltemporal dementia from Alzheimer?
Sparing of memory and visuospatial function
What are side effects of cholinesterase inhibitors?
diarrhea, nausea, vomiting, bradycardia, syncope, heart block (cholinesterase inhib: donepezil, rivastigmine, galantamine)
What two types of dementia can cholinesterase inhibitors be used for?
1) mild to moderate alzheimers
2) dementia with lewy bodies
What 3 symptoms can precede parkinsons?
1) constipation
2) acting out dreams
3) diminished sense of smell
What is the hallmark of dementia with lewy bodies vs parkinsons?
early dementia within first year of motor parkinsonism
What dermatologic finding is seen with parkinsons?
seborrheic dermatitis
What is treatment for parkinsons?
levodopa and/or dopamine agonist
Differentials for Parkinsons
1) severe orthostatic hypotension and ataxia with MRI showing “necrosis” of putamen and cerebellar atrophy
2) unexplained falls backward, inability to move eyes vertically, parkinsonian features
3) asymmetic parkinosnisum and dystonia, myclonia, cortical sensory deficits, congnitive deficits
4) early dementia, parkinsonism, hallucinations
5) use of prochloperazine, reglan, haldol, lithium, methyldopa
1) multiple system atrophy (Shy Drager syndrome)
2) progressive supranuclear palsy
3) corticobasal degeneration
4) dementia with lewy body
5) medication induced parkinsonism
Levodopa is used for Parkinsions but is associated with motor fluctuations such as what 2 examples?
“wearing off” effect and dyskinesia
What medication is started in parkinsons <65 vs >65?
dopamine agonists (pramipexole, ropinirole) <65 levodopa/carbidopa >65yo
What are side effects of dopamine agonists?
sedation, increase in compulsive behaviors
Avoid cabergoline and bromocriptine due to what association?
valvular heart disease
What are treatments for drug induced dystonia?
clonazepam, tetrabenazine, anticholinergic agents, clozapine
What are the treatments for essential tremor?
propranolol and primidone
What are the treatments for restless legs?
ropinorole and pramipexole and rotigotine patch
What is treatment for REM sleep behavior disorder?
melatonin, clonazepam
What are treatment for neuroleptic malignant syndrome?
dantrolene and bromocriptine
What other diagnosis to consider in a <40 yo with “essential tremor” or dystonia?
Willson disease
What can occur with rapid withdrwawal from chronic dopaminergic treatment? (like in parkinson’s patient in hospital?)
neuroleptic malignant syndrome
MS is not associated with cortical syndromes such as what two symptoms?
aphasia and neglect
What 3 processes can also cause white matter lesions on MRI besides MS?
migraines, head trauma, microvascular ischemic disease
What are the 9 symptoms in MS?
1) optic neuritis
2) afferent pupils (unaffected pupil will dilated when light moves to affected pupil)
3) papillitis (flared appearance of optic disc)
4) myelitis
5) Lhermitte sign
6) increase in urinary frequency, urge
7) cerebellum with ataxia and vertigo
8) brainstem–inability to adduct one eye and nystagmus in abducting eye
9) uhthoff phenomenon-transietn worsening of neuro symptoms with elevation in body temp
What are treatments in MS?
- interferon beta (contraindicated for liver disease and depression) or glatiramer for relapse/remitting MS
- natalizumab for refractory disease (side effect is progressive multifocal leukoencephalopathy)
- mitoxantrone (SE: cardiac toxicity and secondary leukemia)
- fingolimod (SE: bradycardia)
- teriflunomide
- dimethyl fumarate
- vit D for all
- if IV steroids don’t help, can do plasmapheresis
What medication can help with mobility in MS?
dalfampridine
What disease inclues recurrent episodes of myelitis and optic neuritis without brain lesions in MS; NMO-IgG autoantibody may be present
neuromyelitis optica (Devic disease)
What are 2 etiologies of copper deficiency? What is the presentation?
1) excessive zinc
2) s/p bariatric surgery
looks like vit B 12 deficiency with paresthesia, lower extremity weakness and gait instability
What is the pattern of MMA and homocysteine in Vit B deficiency vs folate?
vit B: increase MMA and homocystine
folate: increased homocystine, normal MMA
Motoneuron diseases
1) cortical motoneurons in the frontal lobe
2) anterior horn cells in spinal cord
3) cortical motoneurons and anterior horn cells
1) primary lateral sclerosis
2) progressive muscular atrophy
3) ALS
What symptoms is nonexistent in ALS?
sensory issues
What is a myasthenic crisis? What can precipitate it?
rapidly progressive respiratory failure
triggers: natural history of myashtenia, infection, surery, meds (aminoglycosides, quinolones, magnesium, BB, CCB)
What are symptoms of myasthenia gravis?
fatigue, exertion, increased body temperature, stress, intercurrent infections
What are some concurrent diseases with myasthenia gravis?
hypothyroidism, elevated serum TSH levels, thymoma
What symptoms differentiate botulism from myasthenia?
botulism as cranial nerve involvement with sluggish/nonreactive pupils. MG doesn’t have pupil involvement
What symptoms differentiate Eaton Lambert mysasthenic syndrome from myasthenia gravis?
progressive proximal weakness and diminished tendon reflexes that improve with repetitive movement
How do you diagnose Eaton Lambert myasthenic syndrome?
serum anti-voltage-gated calcium channel antibodies and EMG of facilitation of motor response to rapid repetitive stimulation
What is the most common malignancy with Eaton Lambert myasthenic syndrome?
SCLC
What is the treatment for myasthenia gravis and when do you decrease the dose?
pyridostigmine, if severe, then use immunosuppressive therapy
(decrease if increased salivation, respiratory secretions, sweating, bradycardia)
thymectomy if see thymoma
When do you intubate a patient with myasthenia gravis?
VC <15mL/kg and begin plasmapharesis
How do you treat a myasthenic crisis or refractory disease?
plasmapharesis or IVIG; avoid pyridostigmine monotherapy as it increases secretion!
What is the workup for neuropathy? (6)
EMG, vit B12, SPEP, UPEP, ESR, blood glucose level
What is the differential diagnosis of bells palsy? What is treatment? (6)
diabetes, vasculitis, Lyme, sarcoidosis, HIV, compression or infiltrative malignancies
tx: prednisone if within 72 hours
What is the differential diagnosis of mononeuritis multiples (multiple noncontinguous nerve deficits)? (8)
vasculitis (especially if painful), lymphoma, amyloidosis, sarcoidosis, Lyme, HIV, leprosy, diabetes
What is the differential diagnosis of distal and symmetric (stocking-glove) sensory or sensorimotor deficit? (2)
Axonal polymeuropathies, DM, alcohol
What is progressive proximal motor and sensory neuropathy that evolves over months?
Chronic inflammatory demyelinating polyneuropathy
What is symmetric distal sensory neuropathy in the setting of MGUS, multiple myeloma, amyloidosis, cryoglobulinemia and other hematologic malignancies?
paraproteinemic neuropathy
What are 3 medications that are FDA approved for painful neuropathy?
pregabalin, duloxetine, tapentadol ER
How do you work up bells palsy?
If it is classic presentation without neurologic deficits, then no need for work up. If symptoms continue after 2 months, then get MRI and lab tests
What two things differentiates a myopathy from neuropathy?
Myopathies have normal sensation and reflexes
What type of myopathy?
1) diffuse myalgia, proximal muscle weakness, elevated CK, myoedema (transient edematous lump in muslce in response to external percussion)
2) myopathy, brisk reflexes, fasiculation, ophthalmoplegia
3) proximal muscle weakness, myalgia, fatigue, osteomalacia-related bone pain
1) hypothyroid myopathy
2) hyperthyroid
3) vit D deficiency
What type of myopathy? part 2
1) proximal weakness and myalgia, normal CK levels, normal EMG
2) prfound painless generalized wekaness with elevated CK levels
3) subacute toxic myopathy associated with rhabdo
4) myotonia (delayed hand-grip release) and distal weakness
1) glucocorticoid myopathy
2) critical illness
3) statin myopathy
4) myotonic dystrophies
Which statins have a higher propensity to cause statin myopathies? (3)
lipophilic statins (simvastatin, atorvastatin, lovastatin) (better ones are hydrophilic statins--pravastatin, rosuvastatin, fluvastatin)
What is a non-Hodgkin lymphoma that presents as a focal supratentorial lesion? What is the most common symptom?
Primary central nervous system lymphoma
Visual symptoms
What is the treatment for primary central nervous system lymphoma and HIV?
What is the treatment w/o HIV?
What is treatment with organ transplantation?
1) ART
2) whole brain radiation and chemo
3) stop immunosuppresion
DO NOT RESECT
Which neuro tumor is benign?
meningioma
What are symptoms of meningioma?
Usually indolent, but if symptomatic, then is progressive headache with focal neurologic lesions
What is the CT scan finding for meninioma?
partially calcified, homogenously enhancing extra-axial mass adherent to the dura na dan enhancing dural “tail”
What is treatment for meningioma?
surgical resection for symptomatic or enlarging
If small, asymptomatic, then can watch and wait
NO CHEMO
1) What are 3 cancers with parenchymal brain mets?
2) What causes leptomeningeal mets?
1) lung, breast, melanoma
2) lymphoma, leukemia
1) What are symptoms of patient with leptomeningeal tumor?
2) What do you do if it is suspected but MRI is negative?
1) headache, spinal pain, CN or spinal radicular pain, weakness, mental status pain, communicating hydrocephalus
2) CSF for elevated protein and reduced glucose levels and positive cytologic findings
What is treatment for all brain mets?
glucocorticoids first, then can do palliaite whole brain radiation if mets are from known solid tumor or resection for controlled extracranial disease and a solitary accessible brain met
What is chemotherapy for patients with leptomeningeal mets from leukemia/lymphoma?
methotrexate and cytarabine
Where is the infarct for “locked-in” state?
pontine
Subacute progression of symptoms of personality change, psychosis, and seizures is most consistent with what process?
antibody-mediated paraneoplastic Ab syndrome
What is paraneoplastic limbic encephalitis associated with?
lung tumors (SCLC), breast cancer, thymoma, germ cell tumors, Hodgkin lymphoma
