Neurology Flashcards by Michael Montesano

Q

sudden onset weakness on ONE side of body
weakness of half of face
aphasia
+/- partial/total loss of vision

A

stroke, or TIA (transient ischemic attack)

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Q

stroke SPARES what part of face?

A

UPPER THIRD OF FACE

from the eyes up

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Q

80% of strokes are

A

ischemic (d/t thrombosis, or embolism)

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Q

20% of strokes are

A

hemorrhagic

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Q

symptoms last

A

TIA (transient ischemic attack)

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Q

transient loss of vision in one eye

A

amaurosis fugax

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Q

TIAs are ALWAYS caused by what? and are NEVER caused by?

A

emboli, or thrombosis

- never hemorrhage

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Q

best INITIAL test for stroke or TIA

A

head CT WITHOUT contrast

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Q

how many days are needed to achieve > 95% sensitivity in detection of nonhemorrhagic stroke?

A

3-5 days

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Q

achieves 99% sensitivity for nonhemorrhagic stroke w/i 24 hours

A

MRI

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Q

can be positive for nonhemorrhagic stroke w/i 1 hour

A

MRA

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Q

treatment for stroke w/i 3 HOURS of onset of symptoms

A

thrombolytics

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Q

ABSOLUTE CI to thrombolytic therapy in a stroke pt (8)

A

h/o hemorrhagic stroke
intracranial mass
active bleeding/surgery w/i 6 weeks
bleeding d/o
CPR w/i 3 weeks
suspicion of aortic dissection
stroke w/i 1 year
cerebral trauma/brain surgery w/i 6 months

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Q

best INITIAL treatment for pts coming too late for thrombolytics, and AFTER use of thrombolytics

A

aspirin

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Q

treatment if pt develops stroke while already on aspirin

A

switch to clopidogrel, or

- add dipyridamole to aspirin

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Q

should be added to ALL nonhemorrhagic strokes

A

statin

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Q

arterial lesions and symptoms:

C/L PROFOUND LOWER extremity weakness
mild upper extremity weakness
personality changes, or psychiatric disturbance
urinary incontinence

A

anterior cerebral artery

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Q

arterial lesions and symptoms:

C/L PROFOUND UPPER extremity weakness
APHASIA (can’t speak)
apraxia/neglect (inability to carry out purposeful movements)
eyes deviate TOWARDS the lesion
C/L homonymous hemianopsia

A

middle cerebral artery

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Q

arterial lesions and symptoms:

prosopagnosia (inability to recognize faces)

A

posterior cerebral artery

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Q

arterial lesions and symptoms:

vertigo
N/V
“drop attack,” LOC
VERTICAL nystagmus
dysarthria (difficulty pronouncing words), and dystonia
sensory changes in face and scalp
ATAXIA
B/L FINDINGS

A

vertebrobasilar artery

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Q

arterial lesions and symptoms:

I/L FACE
C/L body
VERTIGO
Horner’s syndrome (doesn’t have to be all 4 signs: miosis, ptosis, anhydrosis, and enophthalmos)

A

posterior inferior CEREBELLAR artery

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Q

arterial lesions and symptoms:

MUST BE AN ABSENCE OF CORTICAL DEFICITS
ataxia
Parkinsonian signs
sensory deficits
hemiparesis (most notable in face)
possible bulbar signs (impairment of CNs 9, 10, 11, 12)

A

lacunar infarct

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Q

arterial lesions and symptoms:

amaurosis fugax

A

ophthalmic artery

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Q

after initial treatment of stroke/TIA, most important issue is to?

A

determine origin of stroke

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the following are indicated in ALL pts with stroke/TIA

- echocardiogram - carotid dopplers/duplex - EKG/Holter monitor

the following are indicated in young pts (

- ESR - VDRL, or RPR - ANA - ds-DNA Ab - protein C - protein S - factor V Leiden mutation - antiphospholipid syndrome

the younger the pt, the more likely the cause of stroke is from

vasculitis, or hypercoagulable state

treatment for status epilepticus

benzodiazepine

treatment for status epilepticus if seizure PERSISTS after use of benzodiazepine

add fosphenytoin

treatment for status epilepticus if seizure PERSISTS after use of benzodiazepine, and fosphenytoin

add phenobarbital

treatment for status epilepticus if seizure PERSISTS after use of benzodiazepine, fosphenytoin, and phenobarbital

general anesthesia (pentobarbital, thiopental, midazolam, propofol)

the following tests should be ordered on a pt having a seizure

- sodium, calcium, magnesium, glucose, O2 - stat head CT (MRI if CT is negative) - urine toxicology screening - liver and renal function

if INITIAL tests do not reveal etiology of seizure, next step in mangement

EEG (electroencephalogram)

generally, should you treat with chronic antiepileptic drug therapy after a SINGLE seizure?

NO

treat seizures chronically under the following circumstances:

- strong family history - abnormal EEG - status epilepticus requiring a benzodiazepine - non-correctable precipitating cause (brain tumor)

first-line treatments for long-term management of seizures

- valproic acid - carbamazepine - phenytoin - levetiracetam - lamotrigine (all equal in efficacy)

adverse effect of lamotrigine

- Stevens-Johnson syndrome

second-line treatments for long-term management of seizures

- gabapentin | - phenobarbital

best treatment for absence seizures (petit mal)

ethosuximide

- tremulous pt w/ slow, abnormal "festinating" gait - predominantly a gait d/o - orthostasis

Parkinson's disease

PE findings of Parkinson's disease

- cogwheel rigidity - resting tremor - hypomimia (masklike/underreactive face) - micrographia - orthostasis - INTACT cognition and memory

diagnostic test for Parkinson's disease

NONE, clinical diagnosis

treatment for Parkinson's disease: - mild symptoms - under age 60

anticholinergic agent (benztropine, hydroxyzine)

treatment for Parkinson's disease: - mild symptoms - over age 60

amantadine

treatment for Parkinson's disease: - severe symptoms

- levodopa/carbidopa - COMT inhibitors (tolCAPONE, entaCAPONE) - MAO inhibitors (seleGILINE, rasaGILINE)

definition of severe symptoms in Parkinson's disease

inability to perform ADL

resting tremor - diagnosis - treatment

- Parkinson's disease | - amantadine

intention tremor - diagnosis - treatment

- cerebellar d/o | - treat etiology

resting AND intention tremor - diagnosis - treatment

- essential tremor | - propranolol

- abnormalities of ANY part of CNS - optic neuritis - MOTOR and SENSORY problems - bladder defect - fatigue - hyperreflexia - spasticity - depression

multiple sclerosis

MC abnormality of multiple sclerosis

optic neuritis

best INITIAL test for multiple sclerosis

MRI

MOST ACCURATE test for multiple sclerosis

MRI

when is CSF tap indicated in multiple sclerosis?

if MRI is nondiagnostic | check for presence of oligoclonal bands

best INITIAL treatment for acute exacerbation of multiple sclerosis

steroids

disease-modifying treatment for multiple sclerosis

- beta interferon - glatiramer - mitoxantrone - natalizumab - fingolimod - dalfampridine

adverse effect of natalizumab

PML

treatment for fatigue in multiple sclerosis

amantadine

treatment for spasticity in multiple sclerosis

- baclofen | - tizanidine

- slowly progressive loss of memory EXCLUSIVELY in older pts (> 65 yoa) - NO focal deficits - diagnosis of exclusion

Alzheimer's disease

for ALL pts w/ memory loss, you must order the following:

- head CT - B12 level - TSH/T4 - VDRL, or RPR

only abnormal test in Alzheimer's disease will be

head CT showing DIFFUSE, SYMMETRICAL ATROPHY

standard of care treatment for Alzheimer's disease

anticholinesterase inhibitors - donepezil - rivastigmine - galantamine

- PERSONALITY and BEHAVIOR become abnormal FIRST | - memory loss afterwards

frontotemporal dementia (Pick's disease)

head CT, or MRI shows what in frontotemporal dementia (Pick's disease)?

FOCAL atrophy of FRONTAL and TEMPORAL lobes

treatment for frontotemporal dementia (Pick's disease)

same as Alzheimer's disease: anticholinesterase inhibitors - donepezil - rivastigmine - galantamine

- caused by prions - RAPIDLY progressive dementia - MYOCLONUS

Creutzfeldt-Jakob disease (CJD)

MOST ACCURATE test for Creutzfeldt-Jakob disease (CJD)

brain biopsy

CSF shows what in Creutzfeldt-Jakob disease (CJD)?

14-3-3 protein | if found, spares pt from needing brain biopsy

- Parkinson's disease PLUS dementia | - very vivid, detailed hallucinations

lewy body dementia

- wet: urinary incontinence - weird: dementia - wobbly: wide-based gait/ataxia

normal pressure hydrocephalus (NPH)

diagnostic tests for normal pressure hydrocephalus (NPH)

- head CT | - lumbar puncture showing NORMAL pressure

treatment for normal pressure hydrocephalus (NPH)

shunt placement

- young pt (30's) - family history - dementia - psychiatric disturbance w/ personality changes - chorea/movement d/o

huntington's disease/chorea

diagnosis for huntington's disease/chorea

genetic testing | autosomal dominant

treatment for movement d/o in huntington's disease/chorea

tetrabenazine

symptomatic control of huntington's disease/chorea

antipsychotics

what percentage of migraine headaches are unilateral vs bilateral?

- 60% U/L | - 40% B/L

triggers for migraines

- cheese - caffeine - menstruation - OCPs

symptoms that may proceed migraine headache

- aura of bright flashing lights - scotomata - abnormal smells

when should head CT or MRI be done for migraines?

- sudden and/or severe - onset of headaches AFTER age 40 - FNDs

best INITIAL (abortive) treatment for migraines

sumatriptan, or ergotamine

prophylactic treatment for migraines (requires several weeks to take effect)

- BB - CCB - TCA - SSRI

when should a pt be placed on prophylactic treatment for migraines?

4 or more headaches per month

- 10x more frequent in men than women - EXCLUSIVELY unilateral - redness/tearing of eye - rhinorrhea

cluster headache

best INITIAL (abortive) treatment for cluster headache

triptans, or 100% oxygen

best INITIAL prophylactic treatment for cluster headache

CCB

- tenderness of temporal area | - jaw claudication

temporal arteritis

diagnostic test for temporal arteritis

ESR

MOST ACCURATE test for temporal arteritis

temporal artery biopsy

most important treatment for temporal arteritis

STEROIDS | a delay may result in permanent vision loss

- obese, young woman w/ headache and double vision - papilledema - normal CT/MRI - +/- vitamin A use - 6th CN palsy - pulsatile tinnitus

pseudotumor cerebri

MOST ACCURATE test for pseudotumor cerebri

LP w/ OPENING PRESSURE MEASUREMENT (markedly elevated)

treatment for pseudotumor cerebri

- weight loss - acetazolamide - surgery if those fail

- room spinning - N/V - HORIZONTAL nystagmus

vertigo

ALL pts w/ vertigo should have what?

MRI of internal auditory canal

causes of vertigo: - changes w/ position - NO hearing loss

benign positional vertigo (BPPV)

causes of vertigo: - does NOT change w/ position - NO hearing loss

vestibular neuritis

causes of vertigo: - acute - hearing loss

labyrinthitis

causes of vertigo: - chronic - hearing loss

Meniere's disease

causes of vertigo: - ATAXIA - hearing loss

acoustic neuroma

causes of vertigo: - h/o trauma - hearing loss

perilymph fistula

PE finding in BPPV

Dix-Hallpike maneuver

treatment for BPPV

meclizine

treatment for vestibular neuritis

meclizine

treatment for labyrinthitis

meclizine and steroids

treatment for Meniere's disease

salt restriction and diuretics

diagnosis for acoustic neuroma (8th CN tumor related to neurofibromatosis)

MRI of internal auditory canal

treatment for acoustic neuroma (8th CN tumor related to neurofibromatosis)

surgical resection

- h/o chronic heavy alcohol abuse - confusion w/ confabulation - ataxia - memory loss - gaze palsy/ophthalmoplegia - nystagmus

Wernicke-Korsakoff syndrome

diagnostic tests for Wernicke-Korsakoff syndrome

- head CT - B12 level - TSH/T4 - VDRL, or RPR

treatment for Wernicke-Korsakoff syndrome

THIAMINE FIRST, then glucose

if a CNS infection is suspected, when should you do a head CT before doing an LP?

- h/o CNS disease - FND - PAPILLEDEMA - seizures - altered consciousness - significant delay in ability to perform LP

if CNS infection is suspected, next steps in management

- LP - blood cultures - empiric antibiotics

does a negative blood culture exclude meningitis?

NO, only 50-60% sensitive

gram + diplococci

Pneumococcus

gram - diplococci

Neisseria

gram - pleomorphic, coccobacillary organisms

Haemophilus

gram + bacilli

Listeria

CSF glucose below 60 is consistent w/

bacterial meningitis

best INITIAL test for meningitis

CSF cell count

if thousands of neutrophils are present in CSF, next step in management

start IV ceftriaxone, vancomycin, and steroids

MOST IMPORTANT criterion to determine need to treat pt w/ suspected meningitis

CSF cell count | thousands of neutrophils is meningitis until proven otherwise

- HIV-positive pt w/ CD4 count

Cryptococcus

best INITIAL test for Cryptococcal meningitis

India ink

MOST ACCURATE test for Cryptococcal meningitis

Cryptococcal Ag

best INITIAL treatment for Cryptococcal meningitis

amphotericin and 5-flucytosine (5FC), followed by fluconazole PO until CD4 count is > 100

- recent camping/hiking trip - tick exposure only remembered by 20% of pts - joint pain - 7th CN palsy - rash w/ central clearing (target lesion)

lyme disease

MOST ACCURATE tests for CNS lyme disease

serology and Western blot of CSF

treatment for CNS lyme disease

IV ceftriaxone, or IV PCN

- camper/hiker - rash that STARTS on WRISTS and ANKLES, and moves centripetally toward center - fever, headache, and malaise PRECEDE rash - only 60% will remember tick bite

rocky mountain spotted fever

- extremely difficult diagnosis - look for immigrant w/ h/o lung TB - presentation is very slow over weeks to months - if case describes fever, headache, and neck stiffness over HOURS then it is not TB

TB meningitis

CSF protein level in TB meningitis

very high

acid fast stain is positive in what percentage of TB meningitis?

10%

treatment for TB meningitis

rifampin, isoniazid, pyrazinamide, ethambutol, and steroids

- diagnosis of exclusion | - lymphocytic pleocytosis (elevated WBCs)

viral meningitis

treatment for viral meningitis

no specific treatment

treatment for Listeria monocytogenes meningitis

IV ampicillin

- elderly pt - neonatal pt - HIV-positive pt - asplenic pt - immunocompromised w/ leukemia/lymphoma - elevated neutrophils in CSF

Listeria monocytogenes meningitis

- adolescent pt - pt in the military - asplenic pt - pt w/ TERMINAL COMPLEMENT DEFICIENCY

Neisseria meningitidis

treatment for Neisseria meningitidis meningitis

- respiratory isolation | - IV ceftriaxone

isolation type for Neisseria meningitidis meningitis

droplet precautions

Neisseria meningitidis meningitis: prophylactic treatment for close contacts

rifampin, ciprofloxacin, or ceftriaxone

fever + confusion over a few hours =

encephalitis

best INITIAL test for encephalitis

head CT scan

MOST ACCURATE test for encephalitis

PCR of CSF

best INITIAL treatment for encephalitis

acyclovir (MCC of encephalitis in USA is HSV)

treatment for acyclovir-resistant pts for encephalitis

foscarnet

- fever, headache, FND | - "ring," or contrast-enhancing lesion

brain abscess

next step in management of brain abscess is based on?

HIV status

if HIV-negative, next step in management of brain abscess

brain biopsy

if HIV-positive, next step in management of brain abscess

treat for toxoplasmosis w/ pyrimethamine/sulfadiazine x 2 weeks and repeat head CT

- NON-enhancing brain lesions in HIV-positive pt | - no mass effect

progressive multifocal leukoencephalopathy (PML)

treatment for progressive multifocal leukoencephalopathy (PML)

raise CD4 count w/ ART

- Mexican pt w/ seizure | - multiple 1cm CYSTIC lesions (calcify over time)

neurocysticercosis

diagnosis for neurocysticercosis

serology

treatment for neurocysticercosis if still active and uncalcified

albendazole and steroids

treatment for neurocysticercosis if there's only calcifications

antiepileptics only

head trauma and intracranial hemorrhage: focal deficits: never head CT: normal

concussion

head trauma and intracranial hemorrhage: focal deficits: rarely head CT: ecchymosis

contusion

head trauma and intracranial hemorrhage: focal deficits: +/- head CT: crescent-shaped collection

subdural hemorrhage

head trauma and intracranial hemorrhage: focal deficits: +/- head CT: lens-shaped collection

epidural hemorrhage

best initial test for head trauma and LOC

head CT scan

treatment for concussion

none

treatment for contusion

admit for observation

treatment for subdural and epidural hemorrhage

- leave small ones alone | - drain large ones

treatment for large intracranial hemorrhage w/ mass effect

- intubation/hyperventilation to decrease ICP (decrease pCO2 to 28-32 to constrict cerebral blood vessels) - mannitol to decrease ICP - surgical evacuation

which pts should receive stress ulcer prophylaxis

- head trauma - burns - endotracheal intubation w/ mechanical ventilation

- sudden, severe headache - stiff neck - photophobia - LOC (in 50% of pts) - FND (in 30% of pts)

subarachnoid hemorrhage (SAH)

best INITIAL test for subarachnoid hemorrhage (SAH)

head CT w/o contrast

MOST ACCURATE test for subarachnoid hemorrhage (SAH)

lumbar puncture

normal WBC to RBC ratio in CSF

1:500

treatment for subarachnoid hemorrhage (SAH)

- angiography to locate site of bleeding | - embolize site of bleeding (superior to surgical clipping)

treatment for subarachnoid hemorrhage (SAH) if hydrocephalus develops

ventriculoperitoneal shunt (VP shunt)

treatment to prevent stroke in subarachnoid hemorrhage (SAH)

nimodipine (CCB)

50% chance of what if pt rebleeds in SAH?

pt will die

spine d/o's: nontender

lumbosacral strain

spine d/o's: tender

cord compression

spine d/o's: tender and fever

epidural abscess

spine d/o's: pain on walking downhill

spinal stenosis

- defective fluid cavity in center of spinal cord caused by trauma, tumor, or congenital defect - loss of sensation of pain and temperature in UE's B/L in cape-like distribution over neck, shoulders, and down both arms

syringomyelia

diagnosis of syringomyelia

MRI

treatment for syringomyelia

surgery

diagnosis of cord compression

MRI

MOST ACCURATE test for cord compression if diagnosis is unclear from history

biopsy

MOST URGENT step in cases of cord compression

steroids to reduce swelling

diagnosis of spinal epidural abscess

MRI

treatment for spinal epidural abscess

treat against Staphylococcus - oxacillin - nafcillin

treatment for spinal epidural abscess w/ large accumulations

surgical decompression

diagnosis of spinal stenosis

MRI

treatment for spinal stenosis

surgical decompression

- ALL SENSATION is lost except position and vibratory sense

anterior spinal artery infarction

treatment for anterior spinal artery infarction

no specific treatment

- traumatic injury to spine (e.g. knife wound) - loss of I/L position and vibratory sense - loss of C/L pain and temperature

Brown-Sequard syndrome

idiopathic d/o of BOTH upper and lower motor neurons ``` - upper motor neuron signs: = hyperreflexia = + Babinski = spasticity = weakness ``` - lower motor neuron signs: = wasting = fasciculations = weakness

amyotrophic lateral sclerosis (ALS)

treatment for amyotrophic lateral sclerosis (ALS)

riluzole (blocks glutamate accumulation)

MCC of peripheral neuropathy

DM

treatment for peripheral neuropathy

gabapentin, or pregabalin

- pain and weakness of 1st 3 digits of hand | - symptoms worsen w/ repetitive use

carpal tunnel syndrome

treatment for carpal tunnel syndrome

- splint | - steroids

- results from falling asleep w/ pressure on arms underneath body, or - outstretched arm, draped over back of chair - WRIST DROP

radial nerve palsy

- results from high boot pressing on back of knee | - FOOT DROP, and inability to Evert foot

peroneal nerve palsy

- hemifacial paralysis of BOTH UPPER and lower halves of face - loss of taste on ANTERIOR 2/3 of tongue - hyperacusis - inability to close eye at night

7th cranial nerve palsy (Bell's palsy)

treatment for 7th cranial nerve palsy (Bell's palsy)

steroids

- occurs in pt w/ previous injury to extremity | - light touch results in extreme pain ("burning")

reflex sympathetic dystrophy

treatment for reflex sympathetic dystrophy

- NSAIDs - gabapentin - nerve block

- bed partner c/o pain and bruises in legs - pt experiences uncomfortable feeling in legs relieved by movement - associated w/ iron deficiency

restless leg syndrome (RLS)

treatment for restless leg syndrome (RLS)

pramipexole, or ropinirole

- ASCENDING weakness - LOSS OF DTRs - URI 2-4 weeks may precede - paresthesia is common, but true sensory deficits are rare

Guillain-Barre syndrome

MOST URGENT step in Guillain-Barre syndrome

peak inspiratory pressure

most important factor in determining need for therapy w/ either IVIG, or plasmapheresis

peak inspiratory pressure

- weakness in muscles of mastication - blurry vision d/t diplopia - drooping of eyelids as day progresses

myasthenia gravis

best INITIAL test for myasthenia gravis

anti-acetylcholine receptor Abs (ACHR Abs)

MOST ACCURATE test for myasthenia gravis

clinical presentation AND ACHR Abs

best INITIAL treatment for myasthenia gravis

pyridostigmine, or neostigmine

treatment for myasthenia gravis in pts

thymectomy

treatment for myasthenia gravis if thymectomy does NOT work, or no response to pyridostigmine, or neostigmine

steroids

treatment for myasthenia gravis to keep pts off of long-term steroids

azathioprine, or cyclosporine