Neurology IV Flashcards
Wernicke encephalopathy typically manifests as a triad of […], oculomotor dysfunction, and gait ataxia.
Wernicke encephalopathy typically manifests as a triad of encephalopathy, oculomotor dysfunction, and gait ataxia.
typically occurs in an alcoholic (most common) or severely malnourished patient (e.g. anorexia nervosa), but may also be seen in pregnant patients with hyperemesis gravidarum; may be induced iatrogenically by administration of glucose without thiamine
Wernicke encephalopathy typically manifests as a triad of encephalopathy, […], and gait ataxia.
Wernicke encephalopathy typically manifests as a triad of encephalopathy, oculomotor dysfunction, and gait ataxia.
typically occurs in an alcoholic (most common) or severely malnourished patient (e.g. anorexia nervosa), but may also be seen in pregnant patients with hyperemesis gravidarum; may be induced iatrogenically by administration of glucose without thiamine
Wernicke encephalopathy typically manifests as a triad of encephalopathy, oculomotor dysfunction, and […].
Wernicke encephalopathy typically manifests as a triad of encephalopathy, oculomotor dysfunction, and gait ataxia.
typically occurs in an alcoholic (most common) or severely malnourished patient (e.g. anorexia nervosa), but may also be seen in pregnant patients with hyperemesis gravidarum; may be induced iatrogenically by administration of glucose without thiamine
What CNS pathology is characterized by “multiple lesions in time and space”?
Multiple sclerosis
i.e. relapsing neurologic deficits with periods of remission
What cranial nerve pathology causes repetitive, unilateral, shooting pain in a distribution of CN V2 and V3 lasting < 1 minute?
Trigeminal neuralgia (tic douloureux)
What CSF analysis finding is useful for diagnosis of multiple sclerosis?
Oligoclonal bands of IgG
other CSF findings include increased myelin basic protein and lymphocytes
What CSF findings are associated with HSV encephalitis?
Protein: […]
Glucose: […]
WBC: […]
RBC: […]
What CSF findings are associated with HSV encephalitis?
Protein: high
Glucose: normal
WBC: high lymphocytes
RBC: high
increased RBCs due to hemorrhagic destruction of temporal lobes
What CT finding may be found in patient’s with late-stage Alzheimer’s disease?
Diffuse cortical and subcortical atrophy
imaging should primarily be used to exclude alternative causes of dementia
What demographic (age, gender) is most commonly affected by multiple sclerosis?
Women age 15 - 50
What demographic is classically affected by pseudotumor cerebri?
Young, obese women
What form of hydrocephalus is a reversible cause of dementia?
Normal pressure hydrocephalus
What funduscopic finding is likely present in a patient with multiple episodes of transient vision loss associated with changes in head position?
Papilledema
What funduscopy finding is often found in patients with pseudotumor cerebri?
papilledema
due to increased intracranial pressure
What hematologic pathology is associated with restless leg syndrome?
Iron deficiency anemia
other possible causes of RLS include uremia, diabetes mellitus, Parkinson disease, and pregnancy
What imaging modality is the gold standard for diagnosis of multiple sclerosis?
MRI (T2-weighted)
What is a worrisome sequelae of pseudotumor cerebri if left untreated?
Blindness
What is first-line treatment for essential tremor?
non-selective β-blockers (e.g. propanolol)
also may use primidone (a barbituate) or topiramate
What is the diagnostic test of choice for spinal epidural abscess?
MRI of the spine
What is the first-line pharmacologic treatment for pseudotumor cerebri?
acetazolamide +/- furosemide
topiramate is sometimes used as an alternative treatment
What is the first-line pharmacotherapy for restless leg syndrome?
Dopamine receptor agonists (ropinirole, pramipexole)
an alternative pharmacotherapy is alpha-2-delta Ca2+ channel ligands (e.g. gabapentin enacarbil)
What is the first-line pharmacotherapy for tabes dorsalis?
IV penicillin
penicillin-allergic patients may be treated with IV ceftriaxone
What is the gold standard for diagnosis of HSV encephalitis?
HSV PCR analysis of CSF
What is the greatest risk factor for both ischemic and hemorrhagic stroke?
Hypertension (4x risk of CVA compared to normotensive individuals)
elevated shearing force on intracerebral vascular endothelium accelerates the atherosclerotic process
What is the initial diagnostic test of choice in a patient with suspected stroke?
Non-contrast CT scan of the head
critical for evaluation of ischemic versus hemorrhagic stroke, which determines further management
What is the initial drug of choice for symptomatic treatment of myasthenia gravis?
Pyridostigmine (long-acting acetylcholinesterase inhibitor)
if symptomatic despite pyridostigmine, chronic immunosuppressive therapy (e.g. corticosteroids) may be warranted
What is the initial imaging study of choice in a patient that presents to the ED after an unprovoked first seizure?
CT head without contrast
must rule out acute neurologic problems (e.g. bleed); MRI is more sensitive for identifying structural causes of epilepsy and the imaging modality of choice in elective situations
What is the likely diagnosis in a diabetic patient that presents with ptosis and a “down and out” pupil that is normal-sized and reactive?
Ischemic CN III palsy
the inner somatic fibers are more prone to ischemia compared to the outer parasympathetic fibers
What is the likely diagnosis in a patient that develops persistent headache, confusion, difficulty concentrating, and poor sleep for the past month after hitting their head?
Post-concussive syndrome
other manifestations include amnesia, vertigo, and mood alterations; symptoms typically resolve with symptomatic treatment within a few weeks to months following the TBI
What is the likely diagnosis in a patient that develops rapidly progressing asymmetric lower extremity weakness and diminished lower extremity DTRs with a normal CSF examination after returning from a hiking trip in the Northeast?
Tick-borne paralysis
due to neurotoxin release, which requires 4-7 days of feeding; removal of the tick results in spontaneous improvement in most patients
differentiation from GBS: GBS typically causes symmetric LE weakness over days to weeks with autonomic dysfunction following a prodromal viral illness; CSF analysis typically reveals albuminocytolic dissociation
What is the likely diagnosis in a patient that experiences multiple episodes of transient, monocular vision loss described as a “curtain falling over the eye”?
Amaurosis fugax
most commonly due to atherosclerotic emboli from the ipsilateral carotid artery
What is the likely diagnosis in a patient that presents with bilateral lower extremity weakness and loss of pain/temperature sensation with preserved proprioception and vibratory sense following a motor vehicle accident?
Anterior cord syndrome
proprioception, vibratory sensation, and light touch (dorsal column) are unaffected
What is the likely diagnosis in a patient that presents with monocular vision loss accompanied by “washed-out” color vision, afferent pupillary defect, and painful eye movements?
Optic neuritis
What is the likely diagnosis in a patient that presents with muscle cramps/weakness and hyporeflexia with broad, flat T waves on EKG?
Hypokalemia
What is the likely diagnosis in a patient that presents with painless, proximal muscle weakness of the lower extremities? The patient has a history of giant cell arteritis that is medically managed. ESR and CK levels are normal.
Drug-induced myopathy (due to corticosteroids)
in contrast, polymyalgia rheumatica responds rapidly to glucocorticoids and is associated with muscle pain and no weakness
What is the likely diagnosis in a patient that presents with rapidly progressive dementia with prominent myoclonus?
Creutzfeldt-Jakob disease (CJD)
diagnosis is typically confirmed on postpartem brain biopsy (gold standard), however genetic testing for the prion protein (PRNP) is now being used
What is the likely diagnosis in a patient that presents with severe eye pain and a sensation of a foreign body in the eye with a corneal staining defect on fluorescein examination?
Corneal abrasion
What is the likely diagnosis in a patient that presents with signs of increased intracranial pressure one day after a large ischemic stroke?
Hemorrhagic transformation
usually occurs within 48 hours of the stroke and manifests with detiorating mental status
What is the likely diagnosis in a patient that presents with worsening back pain, especially at night, and bilateral lower extremity weakness/sensory loss, and gait ataxia for the past week?
Spinal cord compression
bowel and bladder disturbances are late findings
What is the likely diagnosis in a patient with a head CT revealing numerous small punctate hemorrhages at the gray-white junction?
Diffuse axonal injury
due to sudden acceleration-deceleration injury (e.g. motor vehicle accident)
What is the likely diagnosis in a patient with unilateral arm pain and dizziness while exercising? Physical exam reveals blood pressure discrepancy between the left and right arm.
Subclavian steal syndrome
due to stenosis of the proximal subclavian artery, which causes reversal of blood flow in the ipsilateral vertebral artery
What is the likely diagnosis in an elderly patient that presents with marked weakness in the upper extremities compared to the lower following a motor vehicle accident?
Central cord syndrome
may be accompanied by localized deficit in pain and temperature sensation; typically occurs with hyperextension injuries in elderly patients with pre-existing degenerative changes in the cervical spine
What is the likely location of hemorrhage in a patient that presents with occipital headache, neck stiffness, nausea/vomiting, and ipsilateral hemiataxia without hemiparesis?
Cerebellum
What is the major cause of death within the first 24 hours of presentation of a subarachnoid hemorrhage?
Rebleeding
What is the major cause of delayed morbidity and death after 3 - 10 days of presentation of a subarachnoid hemorrhage?
Vasospasm
What is the most common cause of intraparenchymal hemorrhage in children?
AV malformation
What is the most common cause of spontaneous lobar/cortical (intraparenchymal) hemorrhage in the elderly?
Cerebral amyloid angiopathy
typically manifests as recurrent lobar hemorrhagic strokes in an elderly patient
What is the most common primary malignant CNS tumor in adults?
Glioblastoma multiforme (GBM)
What is the most common subtype of Guillain-Barre syndrome?
Acute inflammatory demyelinating polyradiculopathy (AIDP)
What is the next step in management for a patient developing respiratory failure due to myasthenic crisis?
Intubation
What is the next step in management for a patient that develops a cardioembolic stroke secondary to bacterial endocarditis?
IV antibiotics and observation
surgery can be considered in patients with significant valvular dysfunction, persistent/difficult to treat infection, or recurrent embolism
What is the next step in management for a patient that presents one day after an ischemic stroke with signs of hemorrhagic transformation?
Non-contrast CT scan of the head
required to confirm diagnosis of HT before urgent surgical decompression
What is the next step in management for a patient that presents with bifrontal headaches upon awakening with associated nausea, vomiting, and blurry vision for the past month?
MRI of the brain
warning signs that warrant early imaging include:
What is the next step in management for a patient that presents with warfarin-associated intracerebral hemorrhage?
IV vitamin K and prothrombin complex concentrate (PCC)
PCC results in rapid reversal of warfarin; fresh frozen plasma can be considered if PCC is not available
What is the pharmacotherapy of choice for the treatment of acute agitation in elderly patients (e.g. delirium)?
typical or atypical antipsychotics (e.g. low dose haloperidol)
benzodiazepines are relatively contraindicated in older patients
What is the recommended initial pain management for a cancer patient with severe pain refractory to NSAIDs?
Short-acting opioids (e.g. morphine, hydromorphone)
if the pain requires frequent dosing or bedtime dosing doesn’t provide relief through the night, a long-acting opioid may be added (e.g. oxycodone, fentanyl patch)
What is the recommended pharmacotherapy for Alzheimer’s dementia?
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
may provide moderate symptom relief and temporarily improve functioning, however, long-term disease course remains unaltered
What is the recommended treatment for foodborne botulism in adults?
Horse-derived antitoxin
What is the recommended treatment for Wernicke encephalopathy?
Thiamine prior to or along with glucose administration
What is the treatment for normal pressure hydrocephalus?
Serial large volume lumbar punctures; if symptoms are relieved, then a ventriculoperitoneal shunt is placed
What is the treatment of choice for acute exacerbations of multiple sclerosis with disabling neurologic symptoms?
Corticosteroids
plasmapheresis may be considered in patients refractory to corticosteroids
What is the underlying pathophysiologic cause of Wernicke encephalopathy?
Thiamine (B1) deficiency
What malignancy is associated with Lambert-Eaton syndrome?
Small cell lung cancer
Lambert-Eaton syndrome resolves with resection of the cancer
What malignancy is associated with myasthenia gravis?
Thymoma (also may have thymic hyperplasia)
symptoms improve with removal of the thymus
