Neurology Clerkship Flashcards
What is the workup for potentially reversible causes of cognitive impairment?
- neuropsychological testing (eg. MOCA)
- lab testing (CBC, Vitamin B12, TSH, CMP)
- neuroimaging
Huntington Disease
1. Motor features
2. Psychiatric features
3. Cognitive
- Chorea
- depression, irritability, psychosis, obsessive compulsive symptoms
- Executive dysfunction
Wallenburg Syndrome
1. Location
2. Presentation
- Lateral medulla
- Ipsilateral CN deficits and contralateral deficits of the body.
– Vestibular nucleus (causes vertigo)
– Spinal trigeminal nucleus (loss of pain and temp in the face)
–Spinothalamic tract (loss of sensation on the contralateral side of the body)
– Descending sympathetic nervous system fibers that travel close to spinothalamic tract (Horner syndrome)
– Inferior cerebellar peduncle (ataxia)
– Nucleus ambiguus (diminished gag reflex, dysphagia, dysphonia)
Cauda Equina Syndrome (CES)
1. What is it?
2. Location in spine
3. Symptoms
4. What is diagnostic?
- medical emergency caused by compression of >= 2 spinal nerve roots in the lumbar cistern
- L2-L5, S1-S5 and the coccygeal nerve
- Severe Radicular pain (in one or both legs) PLUS : motor deficits in affected myotome (classically unilateral but sometimes bilateral) with LMN pattern (diminished reflexes); Patchy sensory loss (saddle anesthesia), Rectal sphincter and bladder dysfunction due to compression of S3-S5
- MRI - then surgical decompression within 24-48 hours
Conus Medullaris Syndrome
1. Presentation
2. Vertebral level
3. Physical exam
- L1-L2
- UMN (tracts of lumbosacral cord), severe low back pain, bowel/bladder dysfunction
- motor weakness symmetric, Hyperreflexia (UMN), symmetric perianal numbness
What is the classic triad of Wernicke encephalopathy (WE)
–How is it treated?
- encephalopathy, ocular dysfunction, and gait ataxia
- Give thiamine along or before glucose. Giving glucose before thiamine can precipitate or worsen WE.
Amyotrophic lateral sclerosis (ALS) results form deterioration of what?
UMN and LMN
- UMN can be cotricospinal neurons located in primary motor cortex
-LMN can be cranial nerves, anterior horn cells
- Early, insidious short-term memory loss
-Language deficits & spatial disorientation
-Later personality changes
What Dementia subtype is this?
Alzheimers
- Stepwise decline
- Early executive dysfunction
- Cerebral infarction &/or deep white matter changes on neuroimaging
What Dementia subtype is this?
Vascular Dementia
- Early personality changes
- Apathy, disinhibition & compulsive behavior
- Frontotemporal atrophy on neuroimaging
What Dementia subtype is this?
Frontotemporal Dementia
- Visual hallucinations
- Spontaneous parkinsonism
- Fluctuating cognition
- Rapid eye movement behavior disorder
What Dementia subtype is this?
Dementia with Lewy Bodies
- Ataxia early in disease
- Urinary incontinence
- Dilated ventricles on neuroimaging
What Dementia subtype is this?
Normal pressure hydrocephalus
- Behavioral changes
- Rapid progression
- Myoclonus with startle &/or seizures
What Dementia subtype is this?
Prion Disease
Real time quaking induced conversion testing of CSF is a test for Creutzfeldt-Jakob disease
L2-L4 Radiculopathy
1. reflex affected
2. sensory loss
3. weakness
- Patellar
- Anteromedial thigh, Medial shin
- Hip flexion (iliopsoas), Hip adduction, Knee extension (quadriceps)
L5 Radiculopathy
1. reflex affected
2. sensory loss
3. weakness
- None
- Lateral shin, Dorsum of the foot
- Foot dorsiflexion & inversion (tibialis anterior), Foot eversion (peroneus), Toe extension (extensor hallucis & digitorum)
S1 Radiculopathy
1. reflex affected
2. sensory loss
3. weakness
- Achilles
- Posterior Calf, Sole and lateral foot
- Hip extension (gluteus maximus), Knee flexion (hamstrings), Foot plantarflexion (gastrocnemius)
S2-S4 Radiculopathy
1. reflex affected
2. sensory loss
3. weakness
- Anocutaneous
- Perineum
- Urinary or fecal incontinence, Sexual dysfunction
Hemorrhagic stroke
-After assessment of the ABCs what steps are taken to reduce risk of brain herniation
- blood pressure control (intravenous nicardipine or labetalol)
- Reversal of anticoagulation: Vitamin K is given for those on warfarin and protamine sulfate to patients on heparin
- Regulation of ICP
Craniopharyngioma
1. age distribution
2. clinical features
- bimodal (5-14 and 50-75)
- optic chiasm compression (bitemporal hemianopsia), pituitary stalk compression which leads to endocrinopathies (Growth failure in children (↓ TSH or ↓ GH); Pubertal delay in children or sexual dysfunction in adults (↓ LH & FSH); Diabetes insipidus (↓ ADH))
What is progressive multifocal leukoencephalopathy?
Reactivation of JC virus especially those immunocompromised (CD4 <200). Reactivated virus spreads to the CNS and lyses oligodendrocytes causing white matter demyelination.
Symptoms include altered mental status, motor deficits, ataxia, and vision abnormalities (eg, diplopia). CT of the brain with contrast usually reveals asymmetric, nonenhancing, hypodense white matter lesions with no surrounding edema. Diagnosis requires lumbar puncture with cerebral spinal fluid evidence of JC virus (by polymerase chain reaction); brain biopsy is rarely required. There is no specific treatment for PML, but initiation of antiretroviral therapy (in patients with AIDS) can sometimes prevent progression and death. However, most patients have long-term neurologic sequalae.
-Action tremor
-Bilateral hands &/or head
- Improves with alcohol
What type of tremor is this?
Essential
-increases as hand reaches target
- Associated ataxia, dysmetria, or gait disorder
What type of tremor is this?
Cerebellar
- Action & rest tremor
- Low amplitude, high frequency (ie, “fine” tremor)
- Not visible under normal circumstances
- Enhanced with sympathetic activation (eg, anxiety, caffeine, hyperthyroidism)
What type of tremor is this?
Physiologic
What is the difference between tremor due to lithium toxicity and lithium-enhanced physiologic tremor
Tremor due to lithium toxicity: an irregular, coarse tremor involving multiple parts of the body (not just the hands) accompanied by gastrointestinal or additional neurologic symptoms. Lithium toxicity requires treatment (eg, hydration, hemodialysis)
Lithium-enhanced physiologic tremor is often managed with watchful waiting and modification of aggravating factors.