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.
Cocaine use can precipitate intracranial hemorrhage and should be suspected when stroke occurs in a subcortical location (like thalamus) and/or young patients.
- what indications can tell you cocaine use might be the cause of stroke?
- young age, absence of typical risk factors, sympathetic activation, subcortical location of strokes
What is the most common brain tumor in children?
- low grade astrocytoma (e.g. pilocytic astrocytoma at cerebellum) - are benign and slow growing causing symptoms to develop over many months.
** High grade astrocytomas (eg. glioblastomas) - malignant and much less common. This would cause symptoms over days to weeks.
Medulloblastoma
1. where does it arise
2. symptoms it causes
- posterior fossa at the cerebellar vermis
- ataxia
What drug types can induce symptoms of parkinsonism?
- antipsychotics (haloperidol, risperidone)
- antiemetics (metoclopramide, prochlorperazine)
Ankylosing spondylitis
1. age of onset
2. relieved with what?
3. symptoms
4. exam findings and complications
5. associated with what HLA
6. imaging you would want
- <40
- exercise but not rest
- noturnal pain, reduced range of motion
- Arthritis (sacroiliitis), Reduced chest expansion & spinal mobility, Enthesitis (tenderness at tendon insertion sites), Dactylitis (swelling of fingers & toes), Uveitis
–complications: Osteoporosis/vertebral fractures, Aortic regurgitation, Cauda equina syndrome - HLA-B27
- Xray of sacroiliac joints or MRI
saccular aneurysm at the posterior communicating artery induces what type of palsy?
- Oculomotor N (CN III) palsy - pupillary dilation due to loss of parasympathetic innervation, ptosis and down and out eye positioning due to loss of somatic innervation
saccular aneurysm at the internal carotid or anterior communicating artery induces what type of palsy?
- Optic nerve (CN II) palsy - unilateral vision loss and bitemporal hemianopsia
saccular aneurysm at the superior cerebellar artery induces what type of palsy?
saccular aneurysm at the AICA induces what type of palsy?
- trochlear nerve (CN IV) palsy
- abducens nerve (CN VI) palsy
Alcoholic cerebellar degeneration
1. what are the manifestations in this?
- wide based gait and postural instability (inability to tandem gait, abnormal heel-knee shin testing)
*relatively preserved limb coordination.
Friedreich Ataxia (FA)
1. inheritance pattern
2. symptoms
3. comorbidities
4. genetic mutation
- autosomal recessive
- progressive ataxia in adolescence, dysarthria, limb weakness, loss of deep tendon reflexes, loss of position and vibratory senses (deterioration of dorsal spinal column)
- kyphoscoliosis, pes cavus, hypertrophic cardiomyopathy, increased risk of arrhythmia and heart failure, death by age 40
- repeat GAA in frataxin gene
- What is amaurosis fugax?
- what is the cause
- What testing/imaging should be done?
- painless, rapid, and transient (<10 minutes) monocular vision loss. Description of a curtain descending over the visual field is highly suggestive of this.
- retinal ischemia due to atherosclerotic emboli originating from the ipsilateral carotid artery
- duplex ultrasound of the neck
When a pt comes in for eval of headache what warning signs should lead to consideration of early imaging?
- neurologic findings: seizure, changes in consciousness, specific deficits
- differences compared to prior headaches
- other: new at age >40, sudden onset, trauma, present on awakening.
What vitamin do newborns need to avoid ICH
Newborns who do not receive intramuscular vitamin K are at risk of vitamin K deficiency bleeding, which presents with easy bruising or bleeding, including intracranial hemorrhage (ICH). ICH can cause obstructive hydrocephalus, leading to a bulging fontanelle, upward gaze impairment, and signs of increased intracranial pressure (eg, irritability, vomiting, bradycardia, hypertension).
What triad is in normal pressure hydrocephalus?
what is the treatment?
- urinary incontinence, cognitive impairment, gait abnormalities - all 3 are not required for dx, only gait dysfunction. UMN signs may also occur
- high volume lumbar puncture - confirms dx. then shunt can be put in place.
Fluoxetine, paroxetine, sertraline, fluvoxamine, escitalopram and citalopram
- what drugs are these?
SSRIs
What can SSRIs be used for?
- major depression
- anxiety
- OCD
- eating disorders
- motor recovery after stroke
- premenstrual dysmorphic disorder
Venlafaxine, desvenlafaxine, duloxetine, milnacipran, and levomilnacipram
- what drugs are these?
SNRIs
What can SNRIs be used for?
- Depression
- Generalized anxiety disorder
- Duloxetine can be used to treat diabetic neuropathy
- Venlafaxine can be used for panic disorder and social anxiety disorder
Lithium clinical uses
- bipolar disorder
- in combination with other meds it can treat schizoaffective disorder, schizophrenia, refractory depression, and other mood disorders with psychotic features
Lithium typical side effects?
- fine hand tremor
- hypothyroidism
- nephrogenic diabetes insipidus caused by ADH antagonism
What are TCAs MOA?
- block reuptake of NE and 5HT
What are clinical uses of TCAs?
- major depression
- panic disorder
- enuresis
- fibromyalgia
- chronic pain disorders
- neuropathic pain
Despiramine, Nortriptyline, imipramine, clomipramine, amitriptyline, amoxapine, and doxepin
What drug type are these?
tricyclic anti depressants
Tranylcypromine, phenelzine, selegiline, and isocarboxazid
- what drug type are these?
Monoamine Oxidase Inhibitors (MAOIs)
- to increase seretonin, dopamine, and NE
Clinical uses of MAOIs?
- Atypical depression
- Depression resistant to first and second line medication
- specific phobias
- panic disorders
Haloperidol, trifluoperazine, loxapine, perphenazine, pimozide, thiothixene, fluphenazine, chlorpromazine, and thioridazine
- what drug type are these?
1st generation antipsychotics (Typical anti-psychotic agents)
1st generation antipsychotics (Typical anti-psychotic agents)
- mechanism of action?
Blocking postsynaptic dopamine D2 receptor in the limbic system of brain - to decrease response of postsynaptic membrane to dopamine excitation.
1st generation antipsychotics (Typical anti-psychotic agents)
- Clinical uses?
- Used to treat positive symptoms of schizophrenia (e.g. delusions, hallucinations)
- bipolar disorder
- and tourette syndrome
—Haloperidol is used to delirium and agitation
1st generation antipsychotics (Typical anti-psychotic agents)
- Side effects?
- Sedation (due to histamine blockade)
- Anti-cholinergic side effects (dry mouth, urinary retention, blurry vision)
- Extrapyramidal system side effects (acute dystonia/muscle spasms, akinesia, akathisia/motor restlessness, and tardive dyskinesia/involuntary oral facial movements)
- Galactorrhea
- Amenorrhea
- Hyperprolactinemia
*some patients can develop neuroleptic malignant syndrome - muscle rigidity, change in mental status, elevated temp, and autonomic instability
Clozapine, risperidone, olanzapine, ziprasidone, aripiprazole, quetiapine, asenapine, ilioperidone, lurasidone, and paliperidone
- What drug type is this?
2nd generation antipsychotics (Atypical anti-psychotic agents)
2nd generation antipsychotics (Atypical anti-psychotic agents)
- mechanism of action?
block both 5HT and dopamine receptors but less affinity to dopamine receptors compared to 1st gen
2nd generation antipsychotics (Atypical anti-psychotic agents)
- clinical uses?
- Treat positive and negative symptoms of schizophrenia
- Bipolar disorder and other psychotic disorders
Mirtazapine
-mechanism of action
alpha2, 5HT2, and 5HT3 receptor antagonist thereby increasing sympathetic tone and increasing the release of serotonin and norepinephrine
Mirtazapine
-clinical uses
- Depressive disorders
- Generalized anxiety disorder, especially in underweight patients
Trazadone
- mechanism of action?
- inhibits reuptake of seretonin, also blocks 5-HT, alpha1, and H1 receptors
Trazadone
- clinical uses?
- insomnia
- major depressive disorder
Triazolam, midazolam, lorazepam, temazepam, oxazepam, alprazolam, chlordiazepoxide, diazepam, clonazepam, flurazepam
what type of drugs are these?
Benzodiazepines
Benzodiazepines
What is the mechanism of action?
Enhanced GABA A receptor activation results in increased flow of chloride ion thereby leading to hyperpolarization.
-Decreased activity of the neurons of the limbic, thalamic, and hypothalamic regions of CNS
Benzodiazepines
What is the clinical use?
- acute anxiety
- seizures
- status epilepticus
- alcohol withdrawal
- Midazolam and diazepam are also used as anesthetics
Phenobarbital, thiopental, secobarbital, amobarbital, and pentobarbital
-Type of drug?
Barbiturates
Barbiturates
- mechanism of action?
Potentiate GABA A receptor activity in the brain, which leads to cell membrane hyperpolarization and decreased activity of CNS neurons
Barbiturates
- clinical uses?
- sedative (anxiety and insomnia)
- thiopental has been used for induction of anesthesia
-phenobarbital is used for management of seizures
Phenytoin
1. mechanism of action
2. clinical uses
- decrease flow of sodium and calcium ions - thereby resulting in decreased polarization of the cells of the NS
- simple and complex partial seizures
- generalized tonic-clonic seizures (grand mal)
-status epilepticus
Phenytoin
1. side effects?
- Cerebellar dysfunction: Nystagmus (Horizontal), ataxia, dysmetria
- slurred speech
- n/v
- Hyperreflexia
- altered mental status, coma, paradoxical seizures, and death
- Gingival hyperplasia
- Drug induced lupus
- Folic acid deficiency - impairs folic acid absorption in the jejunum
Pancytopenia
Arrhythmia
Liver injury
Teratogen
Induce of CYP 450
Lamotrigine
1. Mechanism of action
2. Clinical uses
- Block fast voltage activated sodium channels at the presynaptic neuron - thereby decreasing the release of glutamate and aspartate at the neuronal synapse
- Epilepsy (simple and complex partial seizures and generalized tonic-clonic seizures)
Valproic Acid
1. clinical uses
- Generalized tonic-clonic seizures
- Myoclonic seizures
- Absence seizures
- Treatment of mania
Ethosuximide
1. clinical uses
- treatment of absence seizures
Carbamazepine
1. Mechanism of action
2. Clinical uses
- Inhibiting the flow of sodium ions through sodium channels on neural cell membranes - thereby causing hyperpolarization and decreased activity of the neuron
- Simple seizures, complex partial seizures, trigeminal neuralgia, and generalized tonic clonic seizures
Topiramate
1. Mechanism of action
2. Clinical use
- Block the flow of sodium ions through voltage gated sodium channels - causing hyperpolarization
- Epilepsy and prophylaxis for migraine
Tiagabine
1. Mechanism of action
2. clinical uses
- Inhibit the reuptake of GABA - thereby potentiating effect of GABA (inhibitory)
- partial seizures (in combination with other drugs)
Vigabatrin
1. clinical uses
- Infantile spasms in children -
- Refractory complex partial seizures
Levetiracetam
1. clinical uses
- partial seizures
- myoclonic seizures
- tonic clonic seizures
Halothane, isoflurane, desflurane, sevoflurane, enflurane, and methoxyflurane
- what type of drug?
- clinical use?
- General Inhaled Anesthetic Agents
- General anesthetic induction and maintenance
Butorphanol
1. mechanism of action
2. clinical use
- partial agonist at opioid mu receptors and agonist activity at opioid k receptors
- pain, especially in management of migraines, labor pain, post op pain
Tramadol
1. mechanism of action
2. clinical use
- weak mu opioid receptor agonist (hyperpolarization and decreased activity of neural cells)
- moderate to moderately severe chronic pain
Dantrolene
1. mechanism of action
2. Clinical use
- inhibit calcium release for SR of myocytes by binding to ryanodine receptor - leads to muscle relaxation
- malignant hyperthermia and neuroleptic malignant syndrome
Tetrabenazine
1. mechanism of action
2. clinical use
- inhibit uptake of catecholamines (NE, Epi, Dopamine) as well as 5HT into synaptic vesicles
- To tx choreiform movements seen in Huntington’s
Memantine
1. mechanism of action
2. clinical use
- NMDA receptor antagonist - thought to decrease neuronal excitation by glutamate
- Alzheimers disease