Neurology Flashcards
What is the ddx for spinal cord compression?
metastatic cancer
primary tumors
transverse myelitis
epidermal abscess
epidural hematoma
herniated disc
spondylosis
How to work up spinal cord compression with symptoms?
start steroids (dexamethosone)
MRI
neurologic emergency! may need surgery
What are the red flags in back pain (cord compression)?
unremitting back pain
constant pain at night
pain worse with laying down
neuro symptoms
sexual function deficits
age >50
prior cancer hx
unexplained weight loss
pain lasting > 1 month
no improvement following conservative tx
What is the next step when you find cancer in the spine?
CT to look for other cancer (breast, lung, liver)
What is the treatment plan for spinal cord compression with focal neuro findings?
steroids: high dose dexamethasone!!!
if cancer - radiation/chemo depending on cancer
may need sugery if need tissue dx, spinal instability
What is the dx in a pt with evolving paralysis and areflexia and no other systemic manifestations?
Guillain Barre
(demylinating disease)
How do you dx Guillain barre?
LP
Elevated protein, no WBC
dx test is EMG/Nerve conduction velocity
hx of infection (campylobacter), ascending symmetric weakness
How does transverse myelitis present?
clear motor and sensory level loss
hyperreflexia below level
loss of anal sphincter tone
How does Botulism present?
early loss of pupillary reflexes and CN abnormalities
paralysis is descending
How does Charcot-Marie-Tooth disease present?
very slow onset, rarely gets severe
foot drop/weakness or sensory loss stocking distribution
How to manage Guillain Barre?
best to get tx w/in 2 wks onset
tx: plasmapheresis or high dose IVIg (both good)
monitor and provide respiratory support, cardiac arrhythmias, autonomic instability
What is the prognosis in Guillain Barre?
good - most people full recovery with/in weeks to months
need PT
Ddx for dementia?
normal pressure hydrocephalus
chronic subdural hematoma
vit B12 def
hypothyroidism
terytiary syphilis
alzheimer’s dz
psuedodemential of depression
Pick’s dz (frontotemporal dementia)
Lewy body dementia
What is the dx for an elderly pt with dementia, gait ataxia, and urinary incontinence?
normal pressure hydrocephalus
How to work up and dx dementia?
reversible causes w/u: Thyroid function tests, HIV/AIDS (30-50 yo), Vit B12, CBC, VDRL, Drug screen, depression signs
MRI - shows atrophy and degeneration
How to tx alzheimers?
social support (don’t get lost, prevent injury…etc)
Donepezil, rivastigmine, or galantamine (improve memory and slow loss of memory)
Memantine added to cholinesterase inhibitors (above)
How to treat normal pressure hydrocephalus?
LP and remove 30-50ml of CSF and symptoms improve!
Place CSF shunt if caught early
What bleeds in subdural hematomas?
bridging veins, can be chronic and slow
What bleeds in an epidural hematoma?
middle meningeal artery
deteriorate fast after a lucid interval
How to manage subdural hematoma that is symptomatic?
neuro/neurosurg consult
surgical drainage to relieve pressure on the brain
What is the ddx for worst headache of life?
subarachnoid hemorrhage
pituitary apoplexy (during difficulty delivery of baby)
migraine
What is the w/u for worst headache of life?
- noncontrast CT!
- if negative - LP bc CT is negative ~10% of time
*RBCs will not change (stay high) between CSF tube 1 and 4
- could consider CT angiography or MRA (if other 2 are neg and still think it is an SAH, this is the gold standard and will need to be done either way)
How do you figure out the cause of a subarachnoid hemorrhage?
CT angio
or MR angio
*if first image is negative, do a repeat study a little later
What is a significant risk factor for subarachnoid hemorrhage?
1st degree relative with subarachnoid hemorrhage (anuerysm)
How to tx subarachnoid hemorrhage?
ICU, telemetry and electrolyte monitoring, DVT prevention (compression devices, no antithrombotic meds)
- neurosurgical consult
- surgical clipping and coiling with 48-72 hours
- Nimodipine (CCB) for 21 days to prevent post-SAH vasospasma and ischmemia
What are complications of subarachnoid hemorrhage?
re-bleeding
delayed brain ischemia from vasospasm
hydrocephalus
hyponatremia due to SIADH
What is the most common cause of subarachnoid hemorrhages?
aneurysm
less common:
cocaine, arterial dissection, AVM, coagulopathy, trauma
What is meniere’s disease?
chronic vertigo
unilateral hearing loss and tinnitus
comes and goes
What is vestibular neuritis?
labyrinthitis - inflammation of vestibular neuritis
vertigo, acute, severe, unsteadiness
GI sx: N/V, may last hours
How to tx Meniere’s disease?
meclizine
salt reduction and diuretics
What is a Ddx for seizure with focal symptoms?
sz with todd paralysis
stroke w/ sz
AVM w/ sz
brain tumor w/ sz
metabolic cause of sz
cocaine overdose or alcohol/benzo withdrawal
How to work up first time sz?
electrolytes, glucose, ABG, CBC, UA, tox screen
CT with and w/o contrast or MRI w/ contrast
if meningitic s/sx - LP
What is a Todd paralysis?
hemiparesis that resolves within hours of sz
What could a brain enhancing lesion be?
abscess, tumor, lymphoma, toxoplasmosis
How to treat seizures that persist/status?
A, B, C
IV benzo, benzo
IV forsphenytoin/phenytoin
IV phenobarbital
propofol and intubation
How to tx toxoplasmosis?
pyrimethamine and sulfadiazine + folinic acid
if ring enhancing lesion in HIV + pt, start tx, then CT in 2 wks, if lesion isn’t responding - further eval (biopsy)
How to treat a patient for seizures in adults?
phenytoin (load and then daily dose)
levetiracetam, lamotrigine, valproic acid
What is the sz med lamotrigine’s dangerous side effect?
cutaneous hypersensitivity - stevens johnson syndrome
What vitamin must be given if a pregnant woman is on seizure meds?
folic acid!!!
most sz meds deplete folate
What are the major side effects of phenytoin?
cardiac toxciity
hemolytic anemia, nephritis, fever, rash
hirsutism, gingival hyperplasia
How to w/u and tx concern for stroke?
CT non contrast (hemorrhagic or not)
*can take 24 hrs to show up!
tPA if presents within 3 hoursof persistent neuro findings and no active bleeding
aspirin is > 3 hrs and no a-fib
What studies do we need to get for stroke pts while inpt?
repeat CT 3 days later
EKG
ECHO
Carotid doppler
24-hr telemety
Who should be put on heparin if they have a stroke?
only if a-fib present! *be careful, can make the stroke hemorrhagic
Is it more common to have an ischemic stroke or a hemorrhagic stroke?
ischemic (80%)
hemorrhagic (20%)
What are contraindications for TPA in stroke?
previous stroke/head trauma w/in 3 months
BP >185/110
recent surgery w/in 2 wks
abnormal PT/PTT
GI/GU bleeding w/in 21 days
PLTS < 10k
coma or stupor
What aretery is affected in a stroke with symptoms of aphasia/apraxia (can’t do a learned skill that you could before)?
middle cerebral artery
emboli from heart lodge here 80% of time
What is the most common source of emboli for embolic strokes?
HEART!
a fib, mitral stenosis, vegetations
