Neurology - Disorders Flashcards
Discuss possible etiology for new onset seizure
- stroke
- intra-cranial hemorrhage
- head trauma
- alcohol withdrawal
- brain tumour
Discuss the definition of status epilepticus
Any of the following
- single epileptic seizure lasting >30 minutes in duration
- series of epileptic seizures during which function is not regained between ictal events in 30 minute period
Clinically any of the following
- >5 minutes of continuous seizure
- >=2 discrete seizures between which there is incomplete recovery of consciousness
Discuss the ABC and initial investigations for seizure
Stabilization - intubation if vomiting or failure to ventilate/oxygenate - supplemental oxygen - initially have hypertension which switch to hypotension post-ictal which may need ephedrine/phenylephrine Investigations - CBC, electrolytes - blood glucose - blood toxicology screen - LFT, creatinine BUN
Discuss the management of seziure
Initial Therapy
- Lorazepam 0.1mg/kg
- Diazepam 0.1mg/kg
- Midazolam 0.05mg/kg (10kg IM if no IV access and >40kg)
- Fosphenytoin 20mg/kg in second IV
- No benefit with benzodiazepine then try second benzodiazepine after 1 minute
Refractory
- require intubation, mechanical ventilation, continuous EEG monitoring
- Midazolam (does not lower BP) 0.2mg/kg IV
- Can infuse at 0.1mg/kg/hr and titrate upward until seizure done
- Propofol 1-2mg/kg loading dose over 5 minutes then titrate to 10-12mg/kg/hr until seizure stops
- Pentobarbital 5mg/kg over 10 minutes and repeat until stops
Discuss the presentation and management of seizure
Presentation
- trigger, prodrome, ictal movements, post-ictal period
Investigation
- ECG for all with loss of consciousness
- EEG for all that do not return to normal level of consciousness
- CT if focal deficit
- headache then lumbar puncture
Management
- should not drive home
- start long-acting anti-convulsant if discharged home
Discuss the presentation and management of meningitis
Etiology
- strep pneumonia
- neisseria meningitidis
- hemophilus influenza
Presentation
- triad of headache, fever, stiff neck
- photophobia
- seizure
- petechial rash in meningitis
- cranial nerve abnormality if involve brainstem
- nuchal rigidity
- positive Kernig (thigh and knee at 90 and pain with resisted knee extension)
- positive Brudzinski (flexion of neck elicits flexion at hips)
Investigation
- Lumbar puncture demonstrating
- High WBC with neutrophils
- low glucose, high protein, high lactate
- Gram stain and culture
Management
- <50 IV ceftriaxone with vancomycin
- >50 and immunocompromised IV ceftriaxone, vancomycin, ampicillin
- Dexamethasone
- Intracranial pressure control
- Elevate head of bed
- control BP
- Glycerol/Mannitol if ICP >20Discuss the differential for Delirium
I WATCH DEATH
- infection (UTI, pneumonia)
- Withdrawal (alcohol, benzodiazepines)
- Acute metabolic disorder (electrolyte imbalance, kidney or renal failure)
- Trauma
- CNS pathology (stroke, hemorrhage, tumour)
- Hypoxia
- Defieciences (thiamine, vitamin B12)
- Endocrinopathies (thyroid, glucose, adrenal)
- Acute vascular
- Toxins, substance use
- Heavy metals
Discuss the diagnostic criteria for delirium
Disturbance in attention or awareness
- change in baseline
- reduced ability to focus, sustain and shift attention
- in awareness with reduced orientation to environment
Disturbance is acute and fluctuates
Cognitive decline in any domain
No other condition or substance
Discuss the management of delirium
History - baseline function - time course of cognitive change - medical conditions - medications (gravol, benzodiazepines, and susbtances) - collateral Investigations - CBC - electrolytes - calcium - magnesium - phosphate - TSH - folate - vitamin B12 - glucose - creatinien, urea - liver enzymes - urinalysis and culture - ECG - CXR Reverse Cause - correct sensory deficits - monitor constipation and urinary retention - fluids and nutrition Control Symptoms - behavioural management - family to visit - mobilize - prefered language with clear and simple communication - haldol 0.5-1mg with max of 3-4mg/24hrs until sedation achieved and then maintenance for 24 hours - atypical antipsychotics (must do ECG where QTc >450 or >25% increase from baseline then discontinue) - Benzodiazepines used in elderly to prevent QTc prolongation
Discuss the diagnostic algorithm for vertigo
Ask about migraines
- if present then migranous vertigo
Ask about hearing loss
- present then ask about episodic
- present then meniere disease
- absent then labyrinthitis
- no hearing loss ask about episodic
- present the benign paroxysmal positional vertigo
- absent then vestibular neuritisDiscuss diagnostic algorithm for dysequilibrium
Underlying condition - peripheral neuropathy - Parkinson's - medications Older Individuals Evaluate - gait - vision - Romberg test - neuropathy screen
Discuss the diagnostic algorithm for presyncope
Cardiovascular history
- arrhythmia
- myocardial infarction
- medication
- orthostatic hypotension
Discuss the diagnostic algorithm for lightheadedness
- history of depression or anxiety
- hyperventilation provocation test
Differentiate between upper and lower motor neuron disease
Upper Motor Neuron - Minimal muscle atrophy - increased tone, spasticity - hyperreflexia - upgoing plantar response Lower Motor Neuron Disease - weakness, muscle atrophy - decreased tone - hyporeflexia - downgoing plantar reflex (normal)
Differentiate between motor, sensory and autonomic neuropathy
Motor - muscle weakness - atrophy - cramps Sensory - numbness - loss of feeling - tingling paresthesia - small fibers have more burning pain, large then loss of proprioception Autonomic - sweating - gastroparesis - bowel/bladder dysfunction - erectile dysfunction - orthostatic hypotension
Discuss causes of mononeuropathy
Compressive Neuropathy - carpal tunnel syndrome - ulnar neuropathy - radial nerve (saturday night palsy) - lateral femoral cutaneous nerve - peroneal neuropathy Mononeuropathy Multiplex - diabetes mellitus - rheumatoid arthritis - SLE - vasculitis
Discuss causes of polyneuropathy
Axonal Polyneuropathy
- diabetes
- renal failure
- vitamin B12 deficiency
- alcohol
Demyelinating Polyneuropathy
- Guillain-Barre syndrome
- acute progressive symmetric muscle weakness with hyporeflexia
- Chronic Inflammatory Demyelinating polyneuropathyDifferentiate between different types of focal seizures
Focal with Intact Awareness
- Jacksonian march where spreading to adjacent muscle groups
- Unusual sensations
Focal with Impaired Awareness
- may appear awake but impairement of awareness
- automastims: chewing, swallowing, lip-smacking
Discuss the pathophysiology, presentation and management of Parkinson’s
Pathophysiology
- loss of dopaminergic neurons in pars compacta of substantia nigra leads to decreased dopamine in striatum and disinhibition of indirect pathway and decreased activation of the direct pathway
- Results in increased inhibition of cortical motor areas
Presentation (TRAP)
- Tremor, resting pill-rolling
- Rigidity: lead-pipe, cogwheeling
- Akinesia/bradykinesia: slow, small amplitude movements, fatigue of rapid alternating movements
- Postural instability: shuffling gait, freezing of gait
Management
- Levodopa/carbidopa where levodopa is dopamine precursor and carbidopa decreases peripheral metabolism of levodopa decreasing side effects and increasing half-life
Discuss the pathophysiology, presentation and management of Huntingtons Disease
Pathophysiology
- autosomal dominant CAG repeats on Huntington gene on chromosome 4
- have global cerebral atrophy, worse in striatum leading to increased activity of direct pathway and decreased indirect pathway
Presentation
- clumsiness, fidgetiness, irribility to major NCD, psychosis and chorea
- Chorea: begins with movement of eyebrows and forehead to dance-like or ballism to rigidity and dystonia
Investigation
- MRI: enlarged ventricles, atrophy
Management
- no disease altering treatment
Discuss the pathophysiology, presentation and management of dystonia
Presentation
- sustained twitching movements caused by co-contraction of agonist and antagonist
- worsened with fatigue, stress, and emotions
Management
- Botox
- anticholinergics, muscle relexants
Discuss the pathophysiology, presentation and management of amyotrophic lateral sclerosis
- progressive neurodegenerative disease of UMN and LMN
Pathophysiology - anterior horn cells, cranial nerve nuclei and corticospinal tract affected
Presentation - Limb motor movements: segmental and asymmetrical UMN and LMN
- Bulbar: dysarthria, dysphagia, tongue atrophy and fasciculations
- Frontotemporal dementia
- Sparing of sensation, ocular muscles, bowel/bladder sphincters
Investigations - EMG: chronic denervation and reinnervation, fasciculations
Management - riluzole
- BiPAP
- spasticity: baclofen, tizanidine
Discuss the pathophysiology, presentation and management of Guillain-Barre Syndrome
Pathophysiology
- acute rapidly evolving inflammatory polyradiculopathy that starts distal lower limbs and ascends
- autoimmune attack of myelin following viral/bacterial infection
Presentation
- Distal symmetric paresthesias, loss of proprioception
- weakness and areflexia
- autonomic: blood pressure dysfunction
Investigations
- CSF: albuminocytologic dissociation (high protein, normal WBC)
Management
- IVIG or plasmaphoresis
Discuss the pathophysiology, presentation and management of myasthenia gravis
Pathophysiology
- progressive autoimmune disorder due to anti-ACh or anti-MuSK anitbodies resulting in early saturation of the neuromuscular junction and inadequate muscle activation with increasing nerve stimulation
- increase risk of thymic neoplasia
Presentation
- Fatigable, weakness without reflex changes, sensory changes or coordination abnormalities
- diplopia or ptosis
- dysphagia or dysarthria (bulbar muscles)
- proximal limb weakness
Investigations
- Edrophonium test: improvement over 2min following injection
- ECG: decremental response with increased stimulation
- Anti-ACh antibody assay
- CT/MRI for thymic dysplasia
Management
- acetylcholinesterase inhibitors (pyridostigmine)
- steroids
Discuss the pathophysiology, presentation and management of Lambert-Eaton Myasthenic Syndrome
Pathophysiology
- autoimmune disorder due to antibodies against presynaptic voltage-gated calcium channels, causing decreased ACh at the NMJ
- associated with small-cell carcinoma of the lung
Presentation
- Weakness of skeletal muscle without sensory or coordination abnormalities
- reflexes diminished or absent
- dry mouth, impotence, constipation, blurred vision
Investigations
- no response with edrophonium test
- EMG: incremental response with rapid stimulation
Management
- ACh modulation
Discuss the pathophysiology, presentation and management of botulism
Pathophysiology - clostridium botulinum bacteria enter through wounds or ingestion PResentation - 6-48hr following ingestion - GI symptoms to EOM weakness to dysphagia to limbs and respiratory involvement - dry mouth Investigation - blood test for toxin Treatment - botulinum anti-toxin
Discuss the pathophysiology, presentation and management of myotonic dystrophy
Pathophysiology
- unstable trinucleotide CTG repeat in myotonic dystrophy kinase gene
Presentation
- ptosis, bifacial weakness, frontal baldness and triangular faces
- distal muscle weakness worse
- delayed relaxation of muscles after exertion
- heart block and atrial arrthymias
- hypoventilation
Discuss the pathophysiology, presentation and management of complex regional pain syndrome
Pathophysiology
- minor injury to limb or lesions in remote body area precede symptoms
Presentation
- continuing pain with allodynia and hyperalgesia
- edema, changes in skin blood flow, or abnormal vasomotor activity
Management
- early mobilization
- topical capsaicin
- TCA
Discuss the clinical patterns and diagnosis of multiple sclerosis
- chronic inflammatory disease of CNS characterized by relapsing and remitting neurological symptoms due to inflammation, demyelination and axonal degeneration
Clinical Pattern - relapsing remitting
- primary progressive
- progressive relapsing
- secondary progressive
Diagnosis - Dissemination in time: 2 or more attacks with presence of gadolinium enhancing and non-enhancing MRI lesions at any time
- Dissemination in space: >=1 T2 lesions in MRI in at least 2 of 4 CNS regions (periventricular, juxtacortical, infratentorial, spinal cord)
Discuss the presentation and management of multiple sclerosis
Presentation
- numbness, optic neuritis, weakness, spasticity, weakness
- Lhermitte’s sign
- Uhthoff’s phenomenom
Investigation
- MRI: demyelinating plaques appear hyperintense on TW
- dawson’s fingers with periventricular lesions heading into corpus callosum
- CSF: oligoclonal bands
- evoked potentials delayed
Management
- Acute: methyprednisolone 1000mg IV x3-7d
- Disease modifying: teriflunomide, interferon B
- Symptomatic: baclofen, oxybutynin for bladder dysfunction, TCA
