Neurology Falcon Review 2 Flashcards
What are the types of parenchymal injuries
Concussion
contusion
diffuse axonal injury
Define concussion
Clinical syndrome of altered mental status secondary to head injury typically brought about by a change in momentum of the head
What are some of the symptoms of a concussion
Instantaneous onset of transient neurologic dysfunction, including loss of consciousness, temporary respiratory arrest, and loss of reflexes
Define contusion
Direct parenchymal injury to brain
What are the two types of contusions
Coup injury
Contracoup injury
What is a coup injury
Cerebral injury at point of direct contact
What is a Contracoup injury
damage to brain surface opposite to point of impact
What is a diffuse axonal injury
Injury to white matter due to acceleration and deceleration
– generally located in the corpus callosum, periventricular white matter, and hippocampus
– cerebral and cerebellar peduncle
typically associated with axonal swelling of white matter and is associated with a poor prognosis
What is the most common cause of an epidural hematoma
Trauma to skull causing an epidural artery tear (middle meningeal artery)
– patient may experience a lucid interval lasting upto a few hours
What are the deficits associated with an epidural hematoma
– Contralateral hemiparesis
– ipsilateral pupillary dilation
What is the most common cause of a Subdural hematoma
Tearing of bridging veins
– most common intracerebral lesions and dramatic brain injury
greatest risk is involved with:
– brain atrophy
– coagulopathy (alcoholics)
Do epidural hematomas require drainage
Always
– subdural hematomas to not always require drainage
What are the symptoms of a spinal cord transection
– Upper motor neuron signs below the level of the lesion
– complete sensory loss below the level
– bowel and bladder dysfunction
– may see lower motor neuron signs at the level of the lesion
What is a brown-Sequard syndrome
– Ipsilateral-weakness, joint positions sensory loss
– contralateral-pain and temperature loss
– bowel and bladder dysfunction is rare
What are the causes for central cord syndrome
Tumor
syringomyelia
What is syringomyelia
– Fluid filled cavity within the spinal cord
– most commonly occur in the cervical cord
– can occur after trauma
– can occur in conjunction with chiari malformation
What is the symptoms of a central cord syndrome
– Loss of pain and temperature in a cape like distribution
– lower motor neuron signs and arms
– upper motor neuron signs of lower extremities
– generally spares the dorsal columns
Discuss an anterior spinal artery syndrome
– Rear
– infarction of anterior two thirds of cord
–affects spinothalamic and corticospinal tracts, sparing dorsal columns
– results in spastic paralysis and loss of pain and temperature sensation with intact joint position since and vibration
what cranial nerves are associated with pain sensitive fibers
V
IX
X
Does the brain parenchyma have pain fibers
No
What is the most useful symptom regarding clinical approach to headaches
Time course is the most useful
– quality, severity and location have significant overlap between headache etiologies
What are the signs and symptoms of a subarachnoid hemorrhage
– Thunderclap headache - instantaneous onset, with maximal intensity within minutes
– worst headache of my life
– severe nausea and vomiting is common
– altered level of consciousness is frequent
– may have focal neurologic deficits
Discuss intraparenchymal hemorrhage
Acute onset
focal deficits commonly occur simultaneously
altered level of consciousness is related to the location and size of the bleed
how does a headache associated with meningitis typically present
Bacterial meningitis:
– headache is usually diffuse
– fever and meningismus are typical
viral meningitis
– diffuse headache usually has developed over several days
– associated symptoms of fatigue and myalgias are common
How is the headache associated with temporal arteritis
– headache is typically intermittent, unilateral, and temporal at first, then bilateral temporal, then continuous
– Pain is often throbbing in nature, but also described as aching or burning
– tenderness of the scalp
What is the typical patient presentation for a headache associated with temporal arteritis
Usually women over the age of 60
firm and tender superficial temporal artery
elevated ESR
What is the treatment for temporal arteritis
Steroids until biopsy is negative
– may be continued for years to prevent recurrence
how will a patient with a headache due to hypertensive urgency present
Dull, bilateral ache and pain
no focal deficits
usually seen with BP >170/110
What is RPLS
Reversible posterior leukoencephalopathy
– high blood pressure leading to posterior demyelination in the brain
Discuss cluster headaches
Typically abrupt and onset, peeking over 5 to 10 minutes.
Persist for 45 minutes to 2 hours
clusters over days two weeks
consistently unilateral, orbital location
Nausea and vomiting are atypical
Who is generally affected by cluster headaches
Typically young adult men onsets in the third decade
male-female ratio 5:1
What is a treatment for cluster headache
Abortive therapy is often ineffective but can use: – sumatriptan – DHE – oxygen – intranasal lidocaine
Prophylactic therapy
– lithium
– valproic acid
– amitriptyline
Describe the headache that is associated with a venous sinus thrombosis
An abrupt onset headache that lingers
often diffuse, may localize near the vertex
What is the diagnosis and management of venous sinus thrombus
MRI to define
IV heparin followed by oral anticoagulation
What is the major difference between a classic migraine in common migraine
A classic migraine has a preceding neurologic symptom (aura)
common migraines or more likely to be bilateral
What is the treatment for migraine
Abortive therapy – triptans – IV ergotamine (status migrainnosis) – caffeine – NSAIDs
Preventive therapy
– avoid triggers
– treat attacks early
– tricyclic antidepressants
What is the mechanism of triptan’s
Serotonin 5 HT-1D antagonists
– may cause chest pain and facial flushing
What is the pseudotumor cerebi
A.k.a. idiopathic intracranial hypertension
– headache is described as a diffuse, dull, ache or pressure sensation
– onset is gradual but often progressive
– worsened by laying down in my physical activity
– horizontal diplopia is occasionally seen
Discuss the epidemiology of pseudotumor cerebri
75% of patients are female
20 to 40 years of age
majority are obese
can be associated with drugs (steroid, vitamin A toxicity, tetracycline)
How’s a diagnosis pseudotumor cerebri made
Imaging to rule out mass lesion
LP to document opening pressure (elevated)
What is the treatment for pseudotumor cerebri
Lumbar puncture
weight loss
carbonic anhydrase inhibitor
shunts
How do carbonic anhydrase inhibitors (acetazolamide) benefit pseudotumor cerebri
Decreased CSF production
how are headaches associated with brain tumors
No classic headache syndrome defines a tumor
usually insidious onset
worse in the morning or wakens patient at night due to raised ICP
Discuss tension headaches
Most common variant of headaches
– May limits, but not prohibit activities
– usually bilateral, within a occipital-temporal-frontal “band like” distribution
– tenderness in the cervical paraspinals and temporalis muscles
– typically respond to OTC analgesics
Was the prophylactic treatment for tension headaches
Tricyclic antidepressants arefirst line
What is chronic daily headaches
Typically involves out of tension type headaches associated with analgesic abuse
– cessation of analgesic use as first line treatment followed by tricyclic antidepressants
What is trigeminal neuralgia
Tic doulaureaux
– electric, shooting pain lasting seconds
– neuralgia of cranial nerve V
– triggered by non-noxious sensory stimuli to the affected face
What headaches are associated with an increased risk of suicide
Cluster headaches
trigeminal neuralgia
What is the treatment for trigeminal neuralgia
Carbamazepine or oxcarbamazepine
– may be combined with baclofen
surgical intervention
– decompression of trigeminal nerve
What are the AHS guidelines for imaging for headaches
– New onset headache inpatient over 40
– headache with abnormal neurologic exam
– reassure and anxious patient
CT useful only in ER situations suspected of SAH
MRI brain is the study of choice to rule out tumor
What is epilepsy
Tendency to experience recurrent unprovoked seizures
– 10% of the population will have a seizure in their lifetime. 30% chance of a future second seizure
– 1% have epilepsy
What are generalized seizures
A seizure which affects the entire brain at once
– primary generalization
– secondary generalization (begins locally then spreads to entire brain)
What is a partial seizures
A seizure which originates in one area of the brain. May secondarily generalized
What differentiates a simple partial seizure from a complex partial seizure
Simple partial seizures have no loss of consciousness. Associated with positive neurologic symptoms
Complex partial seizures has impaired consciousness. Associated with automatism’s
What is a generalized tonic clonic seizure
Grand mal seizure
– tonic extension of all four extremities followed by chronic jerking
– Todd’s paralysis is common
What is an absence seizure
Generalized seizure characterized by unresponsive staring lasting several seconds followed by immediate recovery
– typically seen in childhood
Discuss febrile seizures
Most common cause of new onset seizures in children
– six months to five years of age
– occur in the setting of a febrile illness without evidence of intracranial infection
– typically generalized at onset
– generally are benign
What is done in the workup for a first non-febrile seizure
History and physical
EEG
lab work
neuroimaging
What is benign Rolandic epilepsy
– childhood onset
– Simple partial seizure involving mouth and face, maybe generalized tonic clinic
– Nocturnal preponderance of seizures
– EEG findings: Centrotemporal spikes
– Treatment: generally no treatment needed, carbamazepine if necessary
What is Lennox-Gastaut syndrome
– childhood to early adolescence
– All types of seizures
– Associated with mental retardation
– EEG findings: slow (1 to 2 Hz spike and wave), proximal fast activity, multifocal spikes
– All anti-epileptic drugs
What is Absence Epilepsy
– childhood and adolescence
– Absence, may generalized tonic clonic
– Hyperventilation’s often a trigger. May outgrow seizures
– EEG findings: 3 Hz spike-and-wave
– Treatment ethosuximide; valproate if it generalizes
What is juvenile myoclonic epilepsy (JME)
– adolescents and young adults
– Myoclonic, absence, generalized tonic clonic seizures
– Early-morning predominance of seizures. Triggers include sleep deprivation and alcohol use
– EEG findings: 4 to 6 Hz spike-and-wave. Frequent photo paroxysmal response (strobe light activation of seizures)
Was the most common cause of adult epilepsy
Adults
– idiopathic is most common
– medial temporal lobe sclerosis
– tumors are more common cause in adults than in children
Elderly
– stroke is the most common
– metabolic disturbances (calcium, sodium, magnesium)
– UTI
– medication related (benzodiazepine withdrawal)
When this treatment indicated for seizures
After the second unprovoked seizure
Were the common anti-epileptic drugs
Phenytoin carbamazepine valproic acid phenobarbital ethosuximide gabapentin lamotrigine tiagabine topiramate zonisamide felbamate levetiracetam
Discuss phenytoin
– Na channel blocker
– Used for partial, generalized seizures
– Side effects: gingival hyperplasia, coarsening of facial features
Discuss carbamazepine
– Na channel blocker
– used for Partial, generalized seizures. May worsen myoclonus and absence seizures
– Side effects: hyponatremia, agranulocytosis
discuss valproic acid
– Na channel blocker, GABA receptor agonist
– Used for partial, generalized, absence
– Side effects: weight gain, tremor, hair loss, hepatotoxicity, thrombocytopenia
Discuss phenobarbital
– GABA receptor agonist
– Used for partial, generalized seizures
– Side effects: sedation, mild addiction potential
Discussed ethosuximide
– T type Ca channel blocker
– Used for absence seizures
– Side effects: G.I. symptoms
Discuss gabapentin
– manipulates GABA pathway
– Used for partial seizures
– Side effects: sedation, ataxia, weight gain at high doses
Discuss lamotrigine
– Na channel blocker, glutamate receptor antagonist
– Use for partial, generalized seizures
– Side effects: Stevens-Johnson’s syndrome with rapid titration
Discuss tiagabine
– GABA reuptake inhibitor
– Used for partial seizures
– Side effects: sedation
Discuss topiramate
– mechanism unknown
– Used for partial, generalized seizures
– Side effects: weight loss, cognitive difficulty, renal stones (skinny and stupid)
Discuss zonisamide
– T-type Ca channel blocker, inhibits glutamate release
– Used for partial, generalized seizures
– Side effects: weight loss, drowsiness, ataxia at high doses, renal stones
Discuss felbamate
– unknown mechanism
– Used for partial, generalized seizures
– Side effects: weight loss, insomnia, aplastic anemia, liver failure
Discuss levetiracetam
– Unknown mechanism
– Used for partial, generalized seizures
– Side effects: somnolence, asthenia, dizziness, akasthesia
What is the problem with epilepsy in pregnancy
Untreated women have a higher risk of birth defects
All AED’s are potentially teratogenic. Risk can be minimized by taking 1 mg folate PO Q day
What is the treatment for status epilepticus
- ABCs, ABG, IV access
- Benzodiazepines
- Phenytoin if status continues
- Intubate, phenobarbital 20 MG/KG IV to induce a coma
What is meningitis
Inflammation of the leptomeninges and cerebrospinal fluid within subarachnoid space
What is meningoencephalitis
Inflammation of the meninges and the brain parenchyma
What are the causes of meningitis
- Infectious
– bacterial, viral, mycobacterial, spirochete, fungal, parasitic - Chemical
- Neoplastic
With the CSF findings for acute bacterial meningitis
Wbc’s >1000
neutrophils >50
glucose 100
Where the CSF findings for acute fungal or viral meningitis
Wbc’s 100-500
neutrophils <50
glucose normal (40)
protein 50-100
What a CSF findings for acute HSV encephalopathy
Wbc’s 10-1000
neutrophils 30
protein >75
What are the common bacterial pathogens for meningitis in a patient less than one month
Group B strep
E. coli
Listeria
Klebsiella
What is the treatment for bacterial meningitis in a patient less than one month
Ampicillin + cefotaximine
Were the common bacterial pathogens for meningitis in a patient 1 month to 23 months of age
Strep pneumonia N. meningitidis group B strep H influenza E. coli
What is the treatment for bacterial meningitis in a patient’s 1 month to 23 months of age
Vancomycin and a third-generation cephalosporin
Were the common bacterial pathogens for bacterial meningitis in a patient 2-50 years old
N. Meningitidis
strep pneumoniae
What is the treatment for bacterial meningitis in a patient’s 2-50 years old
Vancomycin plus a third-generation cephalosporins
What are the common bacterial pathogens for meningitis in a patient >50 years old
Strep pneumoniae
N. Meningitidis
Listeria
aerobic gram-negative bacilli
What is the treatment for bacterial meningitis in a patient’s >50 years old
Vancomycin plus third-generation cephalosporin plus ampicillin
What are the etiologies associated with acute viral meningitis
Non-polio enteroviruses (85%)
– Echovirus
– coxsackievirus
Arboviruses (5%)
– Eastern equine encephalitis
– Western equine encephalitis
– St. Louis encephalitis
Herpes family viruses (4%)
For the spirochetes that can cause meningitis
Treponema
Borrelia
Leptospira
What is the Argyle-Robertson pupil
No direct or consensual light response, but pupils constrict with accommodation
What diagnostic testing is done for neurosyphilis
Non-Treponema antigen test
– R PR or VDRL
Treponema antigen test
– FTA-ABS
What diseases caused by the spirochete Borrelia burgdorferi
Lyme disease
What is the treatment for Lyme disease
Amoxicillin or doxycycline
Were the common fungal organisms associated with meningoencephalitis
Cryptococcus neoformans coccidoides immitis Candida albicans Mucor Aspergillus fumigatus Histoplasma capsulatum Blastomyces dermatiitidis
What is the most common fungal infection of the CNS
Cryptococcus meningoencephalitis
Discuss Cryptococcus meningoencephalitis
– typically in the immuno compromised
– inhalation of spores from soil and pigeon excrement
– increased intracranial pressure leading to a protean headache
– CSF: very low glucose, elevated protein
What is the treatment for Cryptococcus meningoencephalitis
Amphotericin B, flucytosine, fluconazole
Were the common parasitic organisms that lead to meningoencephalitis
Toxoplasmosis Cysticercosis and echinococcosis malaria amebiasis trypanosomiasis
What was CT and MRI demonstrate for a patient with cerebral toxoplasmosis
Multiple ring enhancing lesions
– similar findings with CNS lymphoma, tuberculosis, or fungal infections
Toxois the most common calls for a cerebral mass lesion in a patient with AIDS
What is the treatment for toxoplasmosis
Pyrimethamine, sulfadiazine and folinic acid
What is the most common parasitic infection of the CNS worldwide
Neuro-cysticercosis
– caused by the pork tapeworm Taenia solum
– brain involvement in 50 to 70% of cases
What will imaging demonstrated for Neuro cysticercosis
Ring enhancing cystic lesions (active cyst)
Parenchymal calcifications (old cyst)
Vasogenic edema
What is the treatment for Neuro cysticercosis
Albendazole to kill the parasite
What is leptomeningeal carcinomatosis
Diffuse seating of leptomeninges with metastatic tumor cells
Occurs in breast cancer, small cell lung cancer, melanoma, medulloblastoma, PNET tumors (primary Neuro ectodermal tumors)
What is encephalitis
Infection of the brain parenchyma
– leads to confusion, delirium, focal neurologic deficits, seizures and coma
What are the common etiologies to encephalitis
Arboviruses
Enteroviruses
herpes simplex virus
CMV, EBV, VZV
Discuss HSV encephalitis
Most common in children and young adults
– presents with alteration in mood, memory, and behavior
– involves inferior and medial regions of temporal lobes and orbital gyri of frontal lobes
– often hemorrhagic
– Cowdrey intra-nuclear viral inclusion bodies
What is the most accurate diagnostic procedure for HSV encephalitis
CSF HSV PCR
What is progressive multifocal leukoencephalopathy
A viral encephalitis caused by polyomavirus (JC virus)
– virus preferentially infects oligodendrocytes which leads to demyelination
– PML does not enhance on MRI
What are the transmissible spongiform encephalopathies
Creuzfeldt-Jakob disease – new variant CJD (mad cow) Gerstmann-Straussler-Scheinker syndrome fatal familial insomnia Kuru
All associated with abnormal forms of a specific protein (prion protein) which is infectious and transmissible
Discuss the pathogenesis of prion diseases
– Prion protein is usually a normal protein in neurons.
– The prion protein undergoes conformational change from Alpha helix to beta pleated sheet
– prion protein acquires relative resistance to digestion with proteases
– infectious nature comes from ability to corrupt the integrity of normal cellular components
– leads to a buildup in neurons
What are the clinical features of Creufeldt-Jakob disease
– Rapidly progressive dementia
– peak incidence in seventh decade
– iatrogenic transmission possible with transplants
– subtle changes in memory and behavior followed by rapidly progressive dementia with involuntary jerking muscle contractions (myoclonus)
