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Neurology Flashcards

1
Q

High Risk TIA Score

A

ABCD2
Age >=60
BP >=140/90
Clinical Picture: 2- hemiparesis 1- language, 0 -other
Duration: 2- >=60min, 1 - 10-59min, 0- <10min
DM

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2
Q

ACA Syndrome

A

Contralateral Leg > Arm Hemiparesis and Numbness

Contralateral frontal signs (grasp reflex)

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3
Q

Left Main (M1) MCA Syndrome

A

Global aphasia
Left gaze deviation
Superior: Broca, Right Face/Arm > Leg weakness
Inferior: Wernike, Right cortical sensory loss + Right superior quadransonopia

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4
Q

Left superior MCA Occlusion - Syndrome

A

Expressive (Broca’s) aphasia
Right face/arm > leg weakness
Left gaze deviation

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5
Q

Left inferior MCA Occlusion - Syndrome

A

Receptive (Wernicke’s) aphasia
Right cortical sensory loss
Right superior quadrantonopsia (pie in the sky)

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6
Q

Right Main (M1) MCA Syndrome

A 
Left hemi-NEGLECT
Left cortical sensory loss
Left face/arm > leg weakness
Left superior quadrantonopsia
Right gaze deviation
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7
Q

Left superior MCA occlusion - Syndrome

A

Broca’s Aphasia
Left face/arm > leg weakness
Right gaze deviation

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8
Q

Right inferior MCA occlusion - Syndrome

A

Left hemi-neglect
Left cortical sensory loss
Left superior quadrantonopsia

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9
Q

PCA Stroke (occipital)

A

Contralateral homonymous hemianopsia

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10
Q

Midbrain Stroke (aka Weber’s) from PCA branch occlusion

A

Ipsilateral CNIII Palsy (down and out, ptosis, mydriasis)

Contralateral face/arm/leg hemiparesis

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11
Q

Medial Medullary Stroke due to occlusion anterior spinal artery

A

Ipsilateral tongue weakness (deviates away from lesion)
Contralateral arm/leg hemiparesis
Contralateral arm/leg proprioception/vibration loss

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12
Q

Lateral Medullary Stroke (aka Wallenberg) from PICA/vert occlusion

A

Ipsilateral Horner’s (ptosis, miosis, anhydrosis)
Ipsilateral ataxia/ dysmetria / dysdiadochokinesia
Ipsilateral facial pain/temperature loss
Contralateral arm/leg pain and temperature loss
Vertigo/Nystagmus (away from lesion)
Dysphagia, Hiccups
NO LIMB WEAKNESS

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13
Q

Pons Stroke (due to distal basilar A occlusion)

A

Ipsilateral CN VI and VII palsy
Ataxia/Dysconjugate gaze/Nystagmus
Contralateral hemiparesis and sensory loss

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14
Q

Vertebro-basilar Stroke

A

Posterior circulation = cerebellar signs:

  • Dysmetria/Dysdiadikokinesia
  • Ataxia
  • Nystagmus/Vertigo/Drop attacks
  • Ipsilateral CNs
  • Speech: Dysphagia/Dysarthria
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15
Q

Carotid TIA

A

Contralateral hemiparesis, sensory loss
Contralateral CNs
Language deficits
Loss of coordination

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16
Q

Complete Cord Syndrome Causes

A

Traumatic spinal cord injury
Large disc herniation
Abscess, bleed
Transverse myelitis

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17
Q

Complete Cord Syndrome - Presentation

A

Bilateral UMN pattern weakness below the lesion
Bilateral LMN pattern weakness @ level of lesion
Bilateral complete sensory loss below lesion
Bowel/Bladder dysfunction
If above C3 - diaphragmatic weakness
If above T6 - autonomic dysreflexia

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18
Q

Central Cord Syndrome: Causes

A

Intramedulary tumor

Syringomyelia

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19
Q

Central Cord Syndrome: Presentation

A

Bilateral loss of pain/temperature sensation below lesion
UE more affected than LE motor
Normal proprioception, vibration

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20
Q

Anterior Cord Syndrome: Causes

A

Anterior Spinal Artery infarct

Disc herniation

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21
Q

Anterior Cord Syndrome: Presentation

A

Bilateral weakness (UMN below lesion, LMN @ level)
Bilateral loss of pain/temperature
Bowel and bladder dysfunction
Normal proprioception and vibration

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22
Q

Posterior Cord Syndrome: Causes

A 
B12 deficiency (subacute combined degeneration)
Tabes Dorsalis (syphillis)
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23
Q

Posterior Cord Syndrome: Presentation

A

Bilateral loss of vibration/proprioception sense
+/- weakness
Normal pain/temperature

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24
Q

Hemicord syndrome: Causes

A

Trauma: knife, bullet

MS (demyelination)

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25
Q

Hemicord syndrome: Presentation

A

Ipsilateral loss of pain/temp @ level of lesion
Contralateral loss of pain/temp below lesion
Ipsilateral loss of vib/proprioception @ level + below
Ipsilateral weakness (LMN @ level, UMN below)

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26
Q

Indications for TPA for acute stroke

A

Last seen normal <=4.5 hrs
NIHSS >=6 or disabling (including aphasia, complete hemianopia, weakness against gravity, vision, disabling for spec person)
>=18 years of age

*can be given even if patient on DAPT

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27
Q

Exclusion criteria for TPA in acute stroke

A

Absolute:

  • ICH on CT Head
  • Any major source of current bleed

Relative:

  • Past ICH
  • Recent major bleed or surgery within 14 days
  • On DOAC (but can do EVT)
  • Stroke within 3 months
  • BP >180/105
  • INR >= 1.7 or plts <100
  • BG very low or high
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28
Q

Indications for EVT

A

Last seen normal <= 6 hrs (up to 24 in some circs)
Age >=18
Disabling stroke
Functionally independent at baseline
Expected survival > 3mo
ASPECTS Score >=6
Proximal large vessel occlusion (eg distal ICA / MCA)

*no evidence in posterior circulation stroke, but can consider for basilar thrombus (bc high morb/mort)

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29
Q

BP Targets in acute stroke

A

If for tPA: <180/<105 x 24hrs
If no tPA: Permissive HTN - only treat if >=220/120 for first 24 hrs (or >160/110 if pregant)
No target for EVT

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30
Q

Timing of ASA in acute stroke

A

If no tPA and no bleed: 160mg ASAP –> 81

If tPA: Rpt CT head @ 24 hrs post and if no bleed –> ASA (no DAPT)

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31
Q

Indications for DAPT in stroke/tia

A
  • Minor stroke (NIH<=3), non cardioembolic (DAPT x21-30 days then SAPT) - within 12-24h
  • High risk TIA (ABCD2 >=4), non-cardioembolic (DAPT x21-30 days then SAPT)
  • Stroke or TIA with severe intracranial atherosclerosis >70% (DAPT x3 mo then SAPT)

*Plavix loading dose 300-600mg
Ticag 180mg loading dose then 90BID

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32
Q

Work-up for all strokes

A

Head/Neck vessel imaging (CTA or MRA)
Holter (2 days, 2 weeks of suspecting cardioembolic)
BW incl A1c/ fasting /75g OGTT, lipids, coags, cbc,
+/- TTE only if suspect embolic or TIA of uncertain cause (+bubble study for PFO if <60yo)

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33
Q

Indications for CEA in carotid stenosis

A
  • Symptomatic carotid 50-99% in men or 70-99% in women (ideal within 48 hrs stroke)
  • Symptomatic carotid 50-59% in women (consider)
  • Asymptomatic or remotely symptomatic (>6mo) + 60-99% stenosis w/ 5+y life expectancy (consider)

*CAS if not CEA candidate (CEA>CAS if age >70)
*Otherwise, medical management with SAPT/DAPT only
Vertebral artery stenosis = medical Mx
*uncertain benefit in mod/severe stroke if brain alrdy lost

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34
Q

Timing of DOAC initiation after stroke due to Afib

A 
TIA - start within 1 day
Minor stroke (NIH < 8): 3 days  (rpt CT 1st)
Moderate stroke (NIH 8-15): 6 days  (rpt CT 1st)
Severe stroke (NIH >15): 12 days (rpt CT 1st)
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35
Q

Indications for PFO closure

A

Age 18-60
Non-lacunar stroke
PFO deemed to be likely cause for stroke

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36
Q

Treatment EXTRA-cranial dissection (carotid or vertebal)

A

Antiplatelet (if asymptomatic) x3-6 mo
Heparin or warfarin (if symptomatic or floating thrombus) x3-6 mo
*no evidence for DOAC

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37
Q

Treatment of intracranial dissection

A

Anti-platelet x3-6 months then re-image

NO evidence for anticoagulation

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38
Q

BP Targets in ICH

A 
SBP <140-160 in 24 hrs (aim to get there asap). 
<140 pref if:
 - Presenting SBP <=220
- Evidence of expanding hematoma
- Onset within 6 hrs of presentation
- On anticoagulation

Long term target: <130/80

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39
Q

Causes of tremors

  • Resting
  • Postural
  • Kinetic/Intention
A

Resting: Parkinsonism (idiopathic, drug induced - symmetrical, LBD, vascular)

Postural: enhanced physiologic (symmetrical, enhanced by stress, coffee, MDMA, cocaine, EtOH wd, hyperT4), essential, dystonic (asymmetric)

Intention: cerebellar (stroke, wilsons, MS), Li tox

*Psychogenic for all

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40
Q

Clinical features of Parkinsonism

A

TRAP
Tremor - rest, asymmetric
Rigidity - cogwheel, asymmetric
Akinesia/Bradykinesia (slow and fatiguing w decreasing size of repetitive movement)
Postural instability - festinating shuffling gait, with reduced arm swing freezing, falls

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41
Q

Diagnosis: Parkinson’s Disease

A 
1) Parkinsonism - must have akinesia / bradykinesia AND one of: Tremor OR Rigidity  
\+ 
2) >=2 supportive criteria: 
-Response to L-dopa +/- L-dopa induced dyskinesias
-Rest tremor of limb, 
-Olfactory loss, 
-Loss of cardiac sympathetic tone on MIBG scintigraphy 
\+ 
3) No mimics or red flags for alternate diagnosis:
-Rapid gait impairment
-Autonomic failure  w/i 5yrs of onset, 
-Pyramidal signs, 
-Early bulbar dysfcn, 
-Stridor, 
-Anterocollis, 
-Severe falls w/i 3y onset, 
-Bilateral symmetric parkinsonism
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42
Q

Meds and S/E for Parkinson’s Disease

A

Levodopa-Carbidopa: +++ motor sx imprv, +++ dyskinesias, ++ impulse control disorder /hallucinations /somnolence /ortho HoTN

Dop-Ag (Pramipexole, Ropinorole): ++ motor Sx improv, ++ dyskinesias, +++ ICD/halluc/somnolence/ortho HoTN

MAOBi (Selegiline, Rasagaline): + motor sx improv, + dyskinesias. minimal other S/E (HTN crisis with tyramine, risk serotonin syndrome)

Other drugs and side effects:

  • Trihexyphenidyl for tremor and amantadine (C/I in sz) for dyskinesia: both are anticholinergic
  • Entacapone (COMT inhibitor so levodopa lasts longer) - same SE as sinemet but orange urine
  • Domperidone for orthostatic HoTN (DA ANT): prolongs QT
  • Botulinum toxin A for drooling
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43
Q

Treatment algorithm Parkinson’s Disease

A

If >60-65: L-dopa
If <60 and concerned re: dyskinesias:
- Mild symptoms: MAOBi
- Moderate-Severe Sx: L-Dopa or Dopamine Agonist

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44
Q

Treatments for REM Sleep Behaviour Disorder

A

Melatonin

Clonazepam

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45
Q

Treatment of drug induced dyskinesias in Parkinson’s

A

Amantadine

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46
Q

Treatment of orthostatic hypotension in Parkinson’s

A

Domperidone
Midodrine
Fludrocortisone

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47
Q

Clues for vascular parkinson’s

A 
Vascular RFs
Lower body predominant
Symmetrical rigidity/bradkinesia 
Pyramidal signs
Falls common 
Tremor uncommon 
Poor L-dopa response
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48
Q

Clues for Multiple Systems Atrophy

A

NO TREMOR
Symmetrical rigidity/bradykinesia
Ataxia, early falls
Predominant orthostatic hypotension, incontinence, ED
Can have pyramidal signs, distal myoclonus, stridor
NO L-dopa response (causes orofacial dyskinesia)

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49
Q

Clues for PSP

A 
NO TREMOR
Symmetrical rigidity/bradykinesia
Axial > Limb predominant symptoms
Vertical gaze palsy and hyperfrontalis 
Dysarthria early in disease course
Poor L-dopa response
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50
Q

Clues for CBD (corticobasal degeneration)

A 
Markedly ASYMMETRIC rigidity/bradykinesia
Apraxia, alien limb
Cortical sensory loss
Aphasia 
Dystonia
Myoclonus (action/tactile stimulated)
No L-dopa response
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51
Q

Clues for LBD

A

Symmetric rigidity/bradykinesia, can hv tremor
Early dementia (precedes/begins within 1y of onset of parkinsonism)
REM Sleep disorder
Visual hallucinations (++sensitive to antipsychotics)
Fluctuating “good and bad days”
Some response to Ldopa but can worsen hallucinations

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52
Q

Features of Horner’s Syndrome (lose sympathetic)

A

Ptosis
Miosis
Anhydrosis (if 1st/2nd order neuron involved)
NO DIPLOPLIA

53
Q

Features of CNIII Palsy

A

(lose parasympathetic)
Ptosis
Diplopia (in oblique gaze, near, looking up/down)
Down and out eye
+/- Mydriasis (Pupil spared in ischemic or partial compressive)

54
Q

Indications to obtain head imaging in CN3 Palsy

A

1) CNIII Palsy with mydriasis +/- pain (hints at compressive)
2) Incomplete CN III palsy without mydriasis

*r/o PCOM aneurysm

55
Q

Causes of Horner’s Syndrome & Ix

A

Lesion in 1st order neuron (from brain down spinal cord):

  • Stroke/Bleed
  • Tumor
  • Demyelination
  • MRI brain

Lesion in 2nd order (out @ SC, up in vessels along SC)

  • T1 radiculopathy
  • Pancoast tumor
  • MRI Cspine/CT chest

Lesion in 3rd order neuron (from sup symp ganglion up carotids into face)

  • Carotid dissection
  • Carotid aneurysm
  • CTA neck/brain
56
Q

HINTS Exam - Results demonstrating peripheral lesion

A

Unidirectional horizontal nystagmus
Positive head impulse test (corrective saccade w/ rotation)
Negative test of skew (vertical misalignment of eyes)

57
Q

HINTS Exam - demonstrating central lesion

A

Direction changing or vertical/torsional nystagmus
Negative head horizontal test (no corrective saccade)
Positive test of skew (vertical misalignment of eyes)

58
Q

Clues of Polyneuropathy (dz of 2+ nerves)

A

Symmetric, Length dependent peripheral neuropathy
Sensory >motor
Large fibre sensory > small fibre sensory
Tingling precedes numbness
Cramps precedes weakness (eg toe flexor/extensor weakness)
Loss of ankle reflexes
Axonal (can be determined by NCS/EMG)

Red flags for alt dx: asymmetry, acute onset, early motor loss, significant autonomic involvement

59
Q

Causes of polyneuropathy

A

Metabolic: DM, B12 deficiency (can be assoc’d w/ metformin), Hypothyroidism, CKD, Cirrhosis
Drugs: Chemo (Vincristine), EtOH, heavy metals
Idiopathic sensory neuropathy of the elderly (ISNE)
Charcot marie tooth

60
Q

Causes of mononeuropathy multiplex (dz of multiple, individual, named nerves) and polyradiculopathy (dz of nerve roots)

A

Inflammatory: Small/med vessel vasculitis (GPA, eGPA, PAN), SLE, Sjogren’s, RA, Sarcoid
Infectious: HepC, HIV
Cancer: Myeloma, Lymphoma, leukemia, amyloid

61
Q

Foot Drop (weak dorsiflexion): L5 vs Peroneal Nerve

A

L5: All muscle groups sitting cross-legged weak

  • Weak hip abduction
  • Weak knee flexion
  • Weak Ankle inversion
  • Weak ankle eversion and dorsiflexion *Both

Peroneal:

  • Hip abduction, knee flexion, ankle inversion normal
  • Weak ankle eversion and doriflexion *Both
62
Q

Finger Abduction Weakness: Ulnar vs C8/T1

A

C8/T1

  • Weak EIP (2nd finger extension)
  • Weak APB (thumb abduction)
  • Weak FPL (thumb flexion)
  • Weak finger abduction*

Ulnar

  • Weak finger abduction only* Both
  • Sensation to 5th finger deficit
63
Q

Finger/Wrist Extension weakness: C7 vs radial

A

C7:

  • Strong brachioradialis
  • weak pronator teres and triceps
  • abn triceps reflex, normal brachioradialis
  • *weak finger and wrist extension - both
  • sensation to 3rd finger abn, back of hand normal

Radial: (drinker)

  • Weak brachioradialis
  • Strong pronator teres and triceps
  • normal triceps reflex, abn brachioradialis
  • *weak finger and wrist extension - both
  • sensation to 3rd finger normal, back of hand abn
64
Q

LP landmarks:

  • Spinal cord ends at what level (ie conus medullaris)
  • Cauda equina
  • Iliac crests
A

Conus medullaris L1/2
Cauda equina S2 (PSIS)
Iliac crests L3/L4

65
Q

Diagnosis of epilepsy

A

> =2 unprovoked seizures >24 hrs apart OR
1 unprovoked seizure with epileptiform EEG/abn MRI OR
Epilepsy Syndrome

66
Q

Tx for generalized seizures

A 
Valproate
Keppra (eg levetiracetam)
Lamotrigine
Clonazepam
Clobazam
Topiramate

*other tx: vagal nerve stimulator, ketogenic diet

67
Q

Tx for myoclonic seizures

A

Valproate
Keppra (eg levetiracetam)
(Avoid dilantin - can exacerbate myoclonus)

68
Q

Tx for absence seizures

A

Valproate

Ethosuxamide

69
Q

Tx for focal seizures

A 
NO valproate or Keppra
Oxcarbazepine/Carbemazepine
Dilantin (eg Phenytoin) 
Gabapentin/Pregabalin
Lacosamide

*other tx: epilepsy surg

70
Q

Side effects of AEDs

  • interactions with other meds
  • what to avoid in idiopathic generalized epilepsy
A

SCARED-P
Sedation (eg clobazam, phenobarb)
Cytopenia/ Cog impairment (eg topramate, clobazam)
Ataxia
Rash (SJS risk with phenytoin, lamotrigine, carbemaz)
Emesis/GI upset
Diplopia
Pregnancy risk (eg do not start valproate, lamotrigine, levetiracetam) - monitor levels in T3

Others: OP, hypoNa (-bazepines), PR prolong (lacosamide), weight gain (valproate), weight loss (topiramate)

  • interactions with antibiotics, OCP, anticoag
  • avoid phenytoin in idiopathic generalized epilepsy (juvenile myoclonic epilepsy)
71
Q

Definition of status epilepticus

A

Clinical/subclinical seizures for >=5 minutes or

>=2 seizures without recovery in between

72
Q

Definition of refractory status

A

Ongoing status despite 1 abortive tx and 1 AED

73
Q

Abortive Treatments for seizures

A

Lorazepam 4mg IV
Midazolam 10 mg IM/buccal
Diazepam 20mg PR

74
Q

AEDs for status

A

Dilantin (phenytoin)
Keppra (levetiracetam)
Valproate

75
Q

Treatment for refractory status

A

Midazolam/Propofol/Phenobarb infusion
Target burst suppression for >24hrs before tapering
-Monitor for nonconvulsive status w/ continuous EEG (esp if paralyzed or intubation)

76
Q

Causes of seizure

A

Metabolic: Hypoglycemia, hypoPO4, hypoCa, hypo Mg, hypoNa
Vascular: Stroke, Bleed, Sinus venous thrombosis, PRES
Infectious: Meningoencephalitis, Tb, crypto, toxo, sepsis (Febrile sz)
Neoplastic: Primary brain CA, Mets
Drugs: Cocaine, TCAs, ASA, bupropion, imipenem, penicillin, clozapine, missed AED
Withdrawal: EtOH, Benzos, barbiturate

77
Q

Clinical features of Guillian-Barre Syndrome

A

Ascending motor and sensory loss with NO REFLEXES
Dysautonomia: labile BP/HR, urinary retention, ileus
Respiratory failure: as disease progresses
*Triggered often by antecedent GI/Resp infection (eg campylobacter, influenza, HIV, Zika, flu vaccine)

78
Q

Indications for intubation in GBS and Myasthenia

A

20-30-40

  1. FVC <20ml/kg
  2. MIP 0 to -30 cm H2O
  3. MEP <40 cm H2O
79
Q

Treatment of GBS

A

If nonambulatory within 4 weeks of symptoms:

  • IVIG 2g/kg over 2-5 days (no role for repeat IVIG)
  • 2nd line = PLEX
  • SLP for oropharyngeal weakness, PT/OT, bladder/bowel care
  • ETT rf: onset to admission <7d, FVC<60% predicted, can’t cough/ stand/ lift head or arms, facial weakness

NO STEROIDS for GBS, only CIDP

80
Q

Treatment of CIDP (>2mo)

A

IVIG q3 weeks or SCIG

Pred 1mg/kg

81
Q

Clinical presentation Myasthenia Gravis (AI destruction of post-synaptic NMJ)

A

Fatiguable weakness of:

  • ocular muscles: ptosis, binocular diplopia, pupil sparing
  • bulbar muscles: dysarthria, dysphonia, dysphagia, chewing fatigue, head drop
  • resp muscles: orthopnea
  • extremities (prox >distal)
82
Q

Investigations in Myasthenia Gravis

A

Antibodies: AcHrAb, MUSK, LRP4
FVC/PFTs
CT chest to r/o thymoma
EMG/NCS: single fiber EMG of frontalis; repetitive nerve stim for decrement

83
Q

Treatment Myasthenia Crisis

A

PLEX
2nd line: IVIG 2g/kg over 2-5d

  • hold pyridostigmine when intubated (manage airway secretions)
  • caution with high dose pred (can worsen resp status)
84
Q

Maintenance treatment for Myasthenia Gravis

A

Pyridostigmine (for symptoms) - S/E: GI, bronchorrhea, cholinergic crisis

DMARDS:

  • Pred (lowest dose),
  • Aza (S/E: leukopenia, transaminitis)
  • PLEX (S/E hypogamma, hypoCa, arrhythmia)
  • IVIG,
  • Eculizumab (S/E: meningococcal infxn)

Thymectomy

85
Q

Indications for thymectomy in Myasthenia

A

1) MG with thymoma on CT chest
2) No thymoma but elective if:
- Age <60 +
- Positive AChRAb +
- Disease duration <5 years

86
Q

Drugs that can trigger myasthenia crisis

A 
Neuromuscular blockade
PD-1 inhibitors (eg pembro, nivolumab)
Antibiotics: FQs, macrolides, aminoglycosides
CV: BB, procainamide
Plaquenil
botox
Mg
Lithium
Glucocorticoids
87
Q

Clues to sinus venous thrombosis as cause of headache

A

Hypercoagulable (OCP, pregnancy, CA)
Female
Seizures
Signs of high ICP on exam

88
Q

Clues to carotid or vertebral dissection as cause for headache

A

Headache with neck pain + horner’s

89
Q

Clues to RCVS (reversible cerebral vasoconstriction syndrome) as cause for headache

A 
Recurrent thunderclap headache
Pregnancy
Decongestant or cannabinoid use
Vasoactive meds (eg triptans)
Intracranial vessel beading
90
Q

Clues to PRES as cause for headache

A

Hypertensive
On cyclosporine or tacrolimus
MRI: vasogenic edema in parietal/occipital

RF: AKI, CKD, HUS, TTP, Sickle cell, Eclampsia, vasculitis, porphyria, HyperCa, hypoMg, sepsis, transplantation, exposure to iodine contrast
Drugs: VEGFi, cisplatin, chemo, IFNa, IVIG, MTX, Ritux, TKI

91
Q

Clues to pituitary apoplexy as cause for headache

A

Pregnant/post-partum
Diplopia or vision changes
Hypotension

92
Q

Idiopathic intracranial HTN (IIH):

-Pt, Dx, Tx

A

Young fat female on birth control
Signs of high ICP with positional changes (H/A, vision changes, papilledema)
CN6 palsy (diploplia)
Pulsatile tinnitus

Ix: LP opening pressure >200-250
Tx: weight loss, NSAIDs, acetazolamide +/- lasix, +/- surgery if vision loss

93
Q

Diagnosis Migraine

A

> =5 episodes of HA lasting 4-72 hrs w/o better explanation:
=2 of: Unilateral, pulsating, moderate-severe, aggravated by routine activity, causing avoidance of routine activity
PLUS
= 1 of: Nausea, vomiting, photophobia, phonophobia

94
Q

Diagnosis Multiple Sclerosis

A
  1. MS Most likely diagnosis +
  2. > =1 clinical attack (CIS) +
  3. Dissemination in space (>=2 clinical attacks, >=2 clinical syndromes at 1 time, >=2 lesions on imaging) +
  4. Dissemination in time (>= 2 clinical attacks, + oligoclonal bands, lesions of differing ages on MRI)
95
Q

Treatment of acute MS Attack

A

If functionally disabling (optic neuritis, weakness):

Methylpred 1g IV x3-7 days then taper
2nd line: PLEX (if poor steroid response)

96
Q

Chronic treatment of MS to decrease relapse and lesion accumulation

A

Injections: B-interferon, glatiramer
Oral: dimethyl fumarate, teriflunomide, fingolimod, siponimod, cladribine
Infusions: - mabs
HSCT

*nonpharm: exercise, smoking cessation, vitamin D

97
Q

Treatment of Migraines

A

-Nonpharm: sleep, stress, avoid trigger, check medication over use (NSAID<15, triptan<10/mo)

-Pharm:
NSAID: ASA, diclofenac, ibuprofen, naproxen, tylenol
Triptans: Suma-, Riza-, Zolmi-
IV: ketorolac, metoclopramide, domperidone, Mg (aura), Dex, dihydroergotamine

  • Peripheral neve block
  • Neuro stimulation

*Do not use: opioids, barbituates, dex, haldol, tylenol, magnesium, opiates, diclofenac, VPA,

98
Q

Contra-indications to Triptan therapy for migraines

A

History of CAD, Stroke, TIA, PVD
Uncontrolled HTN
History of hemiplegic or basilar migraines

99
Q

Presentation of pseudobulbar palsy

A

1) UMN CN 5, 6, 9, 10, 11, 12 palsies
2) Dysphagia
3) Dysarthria
4) Hyperreflexic jaw jerk
5) Pseudobulbar affect (emotional lability)

100
Q

Causes of pseudobulbar palsy

A

1) ALS
2) Parkinson’s Disease
3) PSP
4) Tumor/Stroke
5) TBI
6) MS

101
Q

Lacunar stroke syndrome

A

Pure Motor - contralat face, arm, leg weakness

Pure Sensory - contralat face, arm, leg sensory sx

102
Q

Secondary Stroke Prevention Targets: HTN, Lipids, DM

A

HTN:
<140/90 or past stroke/TIA
<130 for small subcortical stroke
<130/80 for diabetic w stroke

Lipid
Start statin
LDL <1.8
Add ezetimibe to max statin dose if LDL>1.8
Add PCSK9i (evolocumab) if LDL>1.8 & CV dz
Add icosapent ethyl 2g BID if TG >1.5 & DM or CV dz on statin

DM:
Target A1C <7%
Add SGLT2 or GLP1-R Ag if above 7% on meds

103
Q

Lifestyle Mx after stroke for 2ndary prevention

A 
Diet: plant protein, low trans/sat fat, low cholesterol <200mg/d (Mediterranean)
Na<2g/d
Exercise 4-7d/wk
BMI 18.5-25
Waist <88cm (F), <102 (M)
EtOH <10 (F), <15 (M)
Smoking cessation
104
Q

Embolic stroke undetermined source (ESUS) 2ndary prevention

A

ASA 81g

NO evidence for anticoagulation if no afib

105
Q

Stroke in young (<55yo) risk factors (most important and MC)

A

Most important rf: HTN, DLPD, Smoking

MC: Cardioembolic and Dissection

106
Q

ICH workup & care (VTE ppx, sz, steroids)

A
  • CTA (or MRA) to assess for underlying lesion during admission
  • Consider MRI for cerebral amyloid angiopathy, mass, AVM, AVF
  • External ventricular drain if dec LOC and hydrocephalus
  • VTE ppx w/ IPC then LMWH at 48h once hematoma stable
  • Sz does not need AEDs
  • ICP: steroids can cause harm
107
Q

Features of essential tremor

A 
Symmetric
Postural / action
Fam Hx
Response to EtOH
Signif level of impairment
108
Q

Parkinsonism Ddx

A

Idiopathic
Parkinson plus disorders: LBD, PSP (vertical gaze palzy or saccades), MSA, CBD
Vascular (lower extremity parkinsonism)
Drug-induced (DA R ANT): antipsychotics, metoclopramide
Genetic: Wilson’s
Toxins: Manganese

109
Q

Idiopathic PD course

A

Preceding: anosmia, REM behavior sleep, constipation
Early: asymmetric tremor/ rigidity/ bradykinesia
Late: postural instability/falls, dementia, hallucinations, autonomic dyscn

110
Q

Vasculopath with sudden complete painless unilateral vision loss

A

Central retinal artery occlusion with cherry red spot

111
Q

Unilateral eye pain and vision loss

-pale disk?

A

Acute optic neuritis

Pale disk = prior optic neuritis

112
Q

Poor peripheral vision, painless,
Elevated eye pressure
Large cup to disk ratio and pale disk

A

Glaucoma

113
Q

Ophthalmoscope findings in DM and HTN

A

DM:
Micro-aneurysm
Neo-vascularization

HTN:
AV nicking, copper wiring, disk edema
Cotton wool spots, Hard exudates, Flame hemorrhages

114
Q

Diploplia Anatomy + Fcn (CN, sympathetic, cavernous sinus)

A

LR6SO4

CN3: MR, IR, SR, IO

  • Elevates eyelid (via levator palpebrae superioris)
  • Pupil constriction (via parasympathetic)

Sympathetics

  • Eyelid elevation (via Muller’s)
  • Pupil dilation

Cavernous sinus: CN3, 4, V1/V2 (facial sensation), sympathetics

115
Q 
Diploplia Q's:
Monocoular vs binocular
Horizontal vs vertical vs oblique
Worse with near vs far
Looking L/R vs up/down
A

Monocular (psych, optho)
Binocular (EoM eg thyroid, NMJ eg MG, CN3/4/6, nucleus 3/4/6 in brainstem eg stroke/MS, INO eg stroke/MS)

Horiz (CN6), Vertical (CN4), Oblique (CN3)
Near (CN3/4), Far (CN6)
Worse L/R (CN6), up/down (CN3/4)

116
Q

CN6 palsy DDx and Ix

A

Ddx:

  • Brainstem: stroke, demyelination, tumor
  • Cavernous sinus: fistula, aneurysm, dissection, tumor, inflamm, infxn
  • False localizing: increased ICP from tumor, IIH, venous sinus thrombosis, trauma

Ix:
CT/CTA intracranial vessels for cavernous sinus pathology
MRI brain with GAD (for tumor, inflamm, infxn)
MRI brain w/ MRV or CTV (for VST), then LP (for IIH)

117
Q

LP Contraindications and Pre-imaging contraindications

A

C/I:

  • INR>1.7
  • Plt<50
  • Papilledema, raised ICP secondary to mass
  • Cannot safely undergo

Pre-imaging C/I:

  • FND
  • New seizure
  • GCS<10 or ALOC
  • Immunocompromised
  • Anatomical issues: instrumentation, tethered cord, chiari malformation, local skin infxn
118
Q

ALS Features

A
  • LMN (atrophy, fasciculations, weakness) at level of lesion
  • UMN (spasticity, hyperreflexia, brisk jaw jerk, upgoing toes) below lesion
  • Progressive asymmetric limb weakness
  • Bulbar symptoms: pseudobulbar affect, dysphagia, dysarthria, tongue wasting,
  • Frontotemporal degen: cog / behav decline
  • Fam Hx
119
Q

ALS Tx

A
  • Riluzole (survival benefit)
  • Edaravone (decrease functional decline)
  • Mulitdisplinary clinics

Symptom based:

  • Drooling: anticholinergic, oral suction, botox
  • Spasticity: baclofen, botoz, BZD, CBD, tizanidine, PT
  • Cramps: tonic water, gabapentin, baclofen
  • Depression/anxiety: SSRI/SNRI
  • Respiratory, home NIV if: orthopnea, MIP<40, FVC <65% (upright) or <80% (seated/supine), CO2>45, or abN nocturnal oximetry and sleep disordered breathing
  • Nutrition: high calorie and carbs
  • Early enteral tube if aspiration, bulbar sx, dysphagia, 5-10% wt loss, >1 point BMI drop or BMI<18.5, FVC dropping below 50%
120
Q

Driving restrictions: seizure

A

First unprovoked = 3 mo
Epilepsy: 6mo sz free on meds
Med change: 3 mo

121
Q

GBS/CIDP Ix

A

MRI spine + GAD (nerve roots and cauda equina may enhance) to r/o acute myelopathy (mimic)
FVC
PVR
LP: albuminocytologic dissoc (high prot, low WBC)
EMG/NCS shows absent F waves and conduction blocks (CIDP shows acquired demyelination)
+/- Anti Gq1b AB
Nerve US in CIDP shows focal enlargement

122
Q

Headache red flags

A

SNOOP4
Systemic: fevers, weight loss, immunosuppression (HIV, steroids, cancer, preg)
Neuro symptoms: meningismus, encephalopathy, papilledema
Onset: thunderclap - peaks <1min
Older >50y
Pattern change, positional , pulsatile tinnitus, precipitated by cough or valsalva

123
Q

Headache differential

A

Primary:

  • Migraine,
  • Tension,
  • Trigeminal autonomic cephalalgia (cluster, paroxysmas hemicrania, short lasting unilateral neuralgiform/cranial autonomic eg SUNCT/SUNA, hemicrania

Secondary (red flags)

  • Vascular: stroke, venous thrombosis, hemorrhage, dissection, GCA, RCVS, PRES, pituitary apoplexy, AVM
  • Space occupying: tumor, IIH, hydrocephalus
  • Infectious: meningitis, encephalitis, abscess, sinusitis, otitis
  • Opthalmologic: acute glaucoma, iritis, optic neuritis
124
Q

Clues for Spontaneous intracranial hypotension

A

Worse standing

125
Q

MS syndromes

A

Optic neuritis: painful eye movements, RAPD, monocular vision/color loss, 33% mild disk swelling

Brainstem/cerebellar syndrome:

  • Bilateral INO, diploplia, gaze evoked nystagmus, vertigo
  • Dysarthria, ataxia,
  • Facial numbness, 6th nerve palsy

Incomplete transverse myelitis

  • Sensory loss
  • Asymmetric limb weakness
  • Urge incontinence
  • ED
  • Lhermitte

-Uhthoff (worsening with heat)

126
Q

MS Ddx

A

Demyelinating: ADEM, NMO, MOG
Inflamm: Sarcoid, SLE, Sjogren’s, GPA, Behcet
Infectious: post-infectious demyelinating, HIV, PML, HTLV, syphilis, Lyme, Bartonella, TB
Metabolic: B12/Cu deficiency
Neoplastic: lymphoma
Pysch: somatization
Vascular: vasculitis, migraine, vascular malformation

127
Q

B12 vs Neurosyphilis

A

Pupils: B12 normal vs/ Argyle Robertson
Both hv dementia and altered mental status
Both have loss of vibration and proprioception

B12: UMN weakness, increased tone in legs, hyperreflexia, clonus
Syphilis: NO reflexes in LE, normal tone/power

128
Q

Pinpoint pupils

A 
PinPoint Pupils (think 4Ps)
Pontine hemorrhage
Phosphate (organophosphate)
Pain killer (Opioid)
Pilocarpine (glaucoma eye drops)

RCE (18 decks)

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