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MCC Part 1 > Neurology/ Neurosurgery > Flashcards

Neurology/ Neurosurgery Flashcards

1
Q

Corticospinal/ corticobulbar tracts control?

A

Voluntary movement

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2
Q

Spinothalamic tract is responsible for?

A

Pain and temperature

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3
Q

Doral columns are responsible for?

A

Proprioception and vibration

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4
Q

Precentral gyrus?

A

Primary motor cortex

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5
Q

Post central gyrus?

A

Primary sensory cortex

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6
Q

Frontal lobe?

A

movement
executive function
personality
expressive language

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7
Q

Temporal lobe?

A

smell
hearing
memory

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8
Q

Parietal lobe?

A

sensation
visuospatial
praxias
receptive language

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9
Q

Occipital lobe?

A

vision

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10
Q

Cerebellum?

A

coordination

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11
Q

Brainstem components?

A

midbrain
pons
medulla

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12
Q

Where is the relay station?

A

Thalamus

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13
Q

Components of basal ganglia?

A

Caudate, putamen, globus pallidus, substantia niagra, subthalamic nucleus
-> motor programming

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14
Q 
Primary motor/sensory cortex
?UMN weakness pattern
?degrees of weakness re: ACA, MCA
?sensory loss of weakness first
?cortical signs re: dominant vs. nondominant
A 
UMN weakness - hemi pattern
Varying degrees of weakness
- ACA: L > F/A
- MCA: F/A > L
Sensory loss follows weakness
Cortical signs present
- Dom: aphasia
- Nondom: neglect
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15
Q

Corona radiata
?UMN weakness pattern
?weakness/sensory loss
?cortical signs

A

UMN weakness - hemi pattern
Varying degrees of weakness/ sensory loss, as level above
NO cortical signs

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16
Q

Thalamus
?sensory loss pattern
? cortical signs

A

Sensory loss - hemi pattern

May have cortical signs

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17
Q 
Internal capsule
?UMN weakness pattern
?face vs. arm vs. leg
?sensory/weakness pattern
?isolated weakness/sensory loss
A

UMN weakness - hemi pattern
F = A = L
Sensory loss follows similar pattern as weakness
May be isolated weakness, isolated sensory loss, or both

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18
Q 
Spinal cord
?UMN weakness
?sensory level
?autonomic dysfunction
?brown sequard
A

UMN weakness usually bilateral
Look for sensory level
Autonomic dysfunction
Beware Brown Sequard

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19
Q

Motor neuron
?UMN/LMN
?sensory sx
?autonomic sx

A

UMN and/or LMN weakness
NO sensory sx
NO autonomic sx

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20
Q

Brainstem
?UMN
?sensory loss pattern
?CN sx

A

UMN weakness pattern = hemi or bilateral
Sensory loss with variable patterns - look for crossed sensory loss
CN signs/symptoms

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21
Q

Root
?LMN
?sensory loss

A

LMN weakness follows myotome pattern

Sensory loss follows dermatome pattern

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22
Q

Plexus
?LMN
?sensory changes

A

LMN weakness

Patchy sensory changes

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23
Q 
Peripheral nerve
?LMN
?sensory
?3 patterns
?ANS sx
A

LMN weakness
Sensory loss
3 patterns: mononeuropathy, polyneuropathy, mononeuritis multiplex
ANS symptoms can be present

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24
Q

Neuromuscular junction
?weakness
?sensory sx

A

Fatiguable weakness

NO sensory sx

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25
Q

Muscle
?LMN
? sensory

A

LMN weakness pattern prox>distal

NO sensory sx

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26
Q

LOC

A
  • alert
  • confused
  • delirious
  • lethargic
  • obtunded
  • stuporous
  • comatose
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27
Q

Lethargic

A

Mild decrease in consciousness, easily aroused

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28
Q

Obtunded

A

Cannot be fully aroused

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29
Q

Stuporous

A

Sleep-like state

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30
Q

GCS

A

Eyes

  • 4= spontaneous
  • 3= open to voice
  • 2= open to pain
  • 1= do not open

Voice

  • 5= normal
  • 4= confused
  • 3= inappropriate words
  • 2= incomprehensible sounds
  • 1= no response

Motor

  • 6= follows commands
  • 5= localized pain
  • 4= withdraws to pain
  • 3= flexor posturing
  • 2= extensor posturing
  • 1= no movement
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31
Q

CN

A 
I - olfactory nerve
II - optic nerve
III - oculomotor nerve
IV - trochlear nerve
V - trigeminal nerve
VI - abducens nerve
VII - facial nerve
VIII - vestibulocochlear nerve
IX - glossopharyngeal nerve
X - vagus nerve
XI - spinal accessory nerve
XII - hypoglosseal nerve
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32
Q

CN I

A

olfactory nerve

- sensation

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33
Q

CN II

A

optic nerve
sensation - visual acuity, visual fields
reflex - pupillary light reflex (afferent = CN II, efferent = CN III)
inspection- ophthalmoscopy

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34
Q

CN III

A

oculomotor nerve

  • superior rectus (elevates), inferior rectus (depresses), medial rectus (adducts), inferior oblique (elevates adducted eye, extorts abducted eye), elevator palpebral superioris (raises eyelid - lesion = ptosis)
  • parasympathetic innervation to pupillary sphincter (constricts pupil) and ciliary muscles (accommodation)
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35
Q

Cause of ptosis?

A

Levator plapebrae superioris lesion (CN III)

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36
Q

CN IV

A

trochlear nerve

- superior oblique muscle (depression of adducted eye, intorsion of abducted eye)

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37
Q

CN V

A

trigeminal nerve
sensation - pain, temp, light touch of ophthalmic, maxillary and mandibular regions
motor - strength of master and temporalis, pterygoids
reflexes - corneal (afferent = CNV, efferent = CNVII); jaw jerk (afferent = CNV, efferent = CNV)

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38
Q

CN VI

A

abducens nerve
- lateral rectus muscle (abducts eye)
motor - EOM, convergence, nystagmus, saccades

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39
Q

CN VII

A

facial nerve
motor - facial movements; ask about hyperacusis (nerve to stapedius m.)
sensory - taste anterior 2/3 tongue

lesion = UMN forehead spared; LMN forehead involved

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40
Q

CNVIII

A

vestibulocochlear nerve

sensation - 512 Hz tuning fork = Weber (lateralization) and Rinne (AC vs. BC); whispered voice test

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41
Q

CN IX

A

glossopharyngeal nerve

  • motor = palatal elevation
  • reflex = gag (afferent = CN IX, efferent = CN X)
  • sensory = taste posterior 1/3 tongue

lesion = palate deviates away from side of lesion

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42
Q

CN X

A

vagus nerve

- motor = voice quality and gag

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43
Q

CN XI

A

spinal accessory

- motor = SCM and trapezius atrophy, fasciculations, strength

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44
Q

CN XII

A

hypoglossial nerve
- motor = tongue atrophy, fasciculations, symmetry on protrusion, strength

lesion = tongue deviates toward side of lesion

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45
Q

Chorea

A

irregular, unpredictable jerky purposeless movements that flow from one body part to another

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46
Q

Ballismus

A

large-amplitude, rapid, violent, flinging movements originating from proximal muscles

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47
Q

Dystonia

A

Sustained muscle contraction causing twisting and repetitive movements or abnormal sustained postures

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48
Q

Tics

A

repetitive, rapid, irregular, patterned, stereotyped movements or vocalizations accompanied by pre-event urge

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49
Q

Myoclonus

A

Rapid, shock-like, sudden larger-amplitude involuntary movements caused by active muscle contraction (positive myoclonus) or inhibition of ongoing muscle contraction (negative myoclonus)

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50
Q

What does pronator drift test for?

A

+ if arm drops and pronates

assesses cortical weakness

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51
Q

Spastic vs. rigidity (hypertonic muscle tone)

A

spastic - velocity dependent (clasp knife)

rigidity - not velocity dependent (cog-wheel, lead pipe)

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52
Q

Grading scale for strength

A 
0 = no muscle movement
1 = trace contraction/ flicker
2 = movement with gravity removed
3 = movement against gravity
4 = movement against partial resistance
5 = movement against full resistance
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53
Q

Deltoid (arm abduction) myotome/ nerve

A

C5

axillary n.

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54
Q

Biceps (elbow flexion) myotome/ nerve

A

C5/6/7

musculocutaneous n.

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55
Q

Triceps (elbow extension) myotome/ nerve

A

C6/7/8

radial n.

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56
Q

Extensor carpi ulnaris/ radialis (wrist extension) myotome/ nerve

A

C5/6/7/8

radial n

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57
Q

Flexor carpi ulnaris/ radialis (wrist flexion) myotome/ nerve

A

C6/7/8 T1

ulnar/median .

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58
Q

Hand intrinsic myotome/ nerve

A

C8/T1

ulnar n. except LOAF = median n.

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59
Q

Iliopsoas (hip flexion) myotome/ nerve

A

L1/2/3

femoral n.

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60
Q

Adductors (hip adduction) myotome/ nerve

A

L2/3/4

Obtruator n.

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61
Q

Gluteus maximus (hip extension) myotome/ nerve

A

L5, S1/2

inferior gluteal n.

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62
Q

Quadriceps (knee extension) myotome/ nerve

A

L2/3/4

femoral n.

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63
Q

Hamstrings (knee flexion) myotome/ nerve

A

L5/S1/2

sciatic n.

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64
Q

Gastrocnemius (plantar flex ankle) myotome/ nerve

A

S1/2

tibial n.

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65
Q

Tibialis anterior (dorsi flex ankle) myotome/ nerve

A

L4/5

deep peroneal n.

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66
Q

Grading reflexes

A 
deep tendon
0 = no response
1+ = requires reinforcement (Jendrassik maneuver)
2+ = normal
3+ = associated with spread of reflex
4+ = associated with clonus
cutaneous
- abdominal -> above umbilicus (T8/9/10), below umbilicus (T10/11/12)
- plantar reflex (L5, S1/2)
other
- primitive reflexes (grasp, root, etc)
- Hoffman
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67
Q

Deep tendon reflexes segmental level and peripheral nerve

A 
Bicep = C5/6, musculocutaneous n.
Tricep = C7/8, radial n.
Brachioradialis = C5/6, radial n.
Knee jerk = L2/3/4, femoral n.
Ankle jerk = S1/2, sciatic n.
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68
Q

Levels of principle dermatomes

A 
C5 = clavical
C6 = thumb
C7 = middle finger
C8 = ring and little finger
T4 = nipples
T10 = umbillicus
T12 = suprapubic
L1 = inguinal area
L2 = knee 
L4 = medial side first toe
L5 = dorsum of foot
S1 = lateral foot
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69
Q

How do you test for dysdiadochokinesia?

A

Rapid alternating movements

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70
Q

How to test for dysmetria?

A

Point to point movement

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71
Q

What gait will you see ataxia?

A

Tandem gait

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72
Q

How do you bring out gastrocnemius muscle weakness (S1)?

A

Walk on tip toes

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73
Q

How do you bring out anterior tibialis weakness (L5)?

A

Walk on heels

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74
Q

Rhomberg tests integration of what?

A

Visual, vestibular and proprioceptive function

- remove visual pathway when close eyes (balance if proprioception and vestibular pathways intact)

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75
Q

How many levels does the nervous system have?

A

10

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76
Q

UMN/CNS (level 1-6)

A
  1. Cortical - hemiplegia/ hemianesthsia + cortical findings (aphasia, neglect, apraxia), seizures, loss of consciousness
  2. Subcortical - hemiplegia/ hemianesthsia, visual field cut, no cortical findings
  3. Basal ganglia - rigidity, involuntary movement, no sensory sx
  4. Cerebellum - ataxia, no sensory sx
  5. Brainstem - CN findings with (often contralateral) motor and sensory findings, loss of consciousness
  6. Spinal cord - sensory level, bowel and bladder sx
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77
Q

LMN/PNS (level 7-10)

A
  1. Motor neuron weakness, atrophy, fasciculations, no sensory sx
  2. Root/plexus/nerves - variable motor/sensory sx, areflexia
  3. Neuromusclar junction - fatiguability, diplopia, ptosis, dysphagia, no sensory sx
  4. Muscle - proximal weakness, no sensory sx
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78
Q

UMN lesion

A

UMN

  • forehead sparing, CN reflexes absent, hyperactive jaw reflex
  • normal bulk
  • increased tone
  • distal weaker than proximal strength; arm extensors weaker than flexors, leg flexors weaker than extensors
  • increased reflexes, plantar upping, +ve Hoffman
79
Q

LMN lesion

A
  • forehead involving facial droop, fasciculations of tongue
  • decreased bulk
  • decreased tone
  • pattern of strength re: localization of lesion
  • reflexes decreased, plantar downgoing
80
Q

Sensory patterns re: lesions

A 
Hemianesthesia (all one side of body) = cortical or subcortical 
Ipsilateral face contralateral body loss of pain and temperature = brainstem
Sensory level (bilateral below certain level) loss of pain, temp, vibration, proprioception) = spinal cord
Stocking glove pattern = polyneuropathy
Loss of sensation in distribution innervated by affected nerve = CN/ peripheral nerve/ plexus
81
Q

Weakness

A

Loss of power/strength

  • partial = paresis
  • full = paralysis
  • > corticospinal tract

ddx re: 10 levels of NS

82
Q

How does anterior horn cell weakness present?

A

Progressive dysphagia and dysarthria with both UMN and LMN signs
- no sensory and no bowel/ bladder sx

83
Q

Weakness muscle workup

A

Sx - proximal muscle weakness +/- muscle pain, no sensory sx

Inv
- ESR, CRP, muscle enzymes, EMG/NCS, muscle biopsy

Ddx/tx

  • Myositis -> immunosuppression
  • Myopathy -> correct metabolic derangement
  • Rabdo -> supportive hydration +/- dyalysis
  • Muscular dystrophy -> nil
84
Q

Weakness NMJ workup

A

Sx - fatiguable weakness in small muscles causing ptosis, diploplia, dysphagia, dysarthria, progressing to proximal > distal weakness and no sensory sx

Inv - EMG/ NCS, repetitive stimulation, single fiber EMG, Tension test, ice pack test, anti-Ach receptor antibodies, CXR/CT chest (r/o thymoma for MG)

Ddx/tx

  • Myasthenia gravis -> ABC, admit and monitor resp status, swelling assessment, steroids, IVIG or plasmapheresis, Mestinon, PT/OT
  • Lambert-Eton syndrome -> steroids, IVIG, plasmapheresis, chemotherapy (if cancer), Mestinon, Amigampridine
  • Botulism toxin -> anti-toxin if early, otherwise botulism immunoglobulin and supportive tx
85
Q

Weakness peripheral nerve workup

A

Sx - variable distribution based mononeuropathy (focal weakness) vs. polyneuritis (symmetric distal > proximal weakness)

Inv - EMG/NCS, LP, medication review, social history, FBS, TSH, Vit B12, LFT, Cr, BUN, infectious, vasculitic, nutritional workup pro
MRI L spine if presumed cause equina

Ddx/tx

  • AIDP = GBS -> ABC, admit and monitor resp status, plasmapheresis or IVIG, PT/OT
  • CIDP -> corticosteroids, plasmapheresis of IVIG
  • Medication/drug induced
  • DM -> glycemic control
  • Thyroid -> correct
  • Vit B12 deficiency -> B12
  • Vasculitis -> immunosuppression
  • Infections (Lyme, diphtheria) -> tx re: infection
  • Trauma -> surgery, rehab
  • Cauda equina secondary compression -> urgent neurosurgery/ radiation (tumor)
86
Q

Weakness plexus workup

A

Sx - weakness involving multiple myotomes/ dermatomes and peripheral nerve distributions

Inv - MRI plexus, EMG/NCS, FBS

Ddx/tx

  • Bracial neuritis -> supportive
  • Trauma -> supportive
  • DM -> glycemic control
87
Q

Weakness root workup

A

Sx - weakness affecting specific myotome with sensory sx distributed along same dermatome, often with neck/ back pain with neuropathic radiation along dermatome

Inv - x-ray/ CT/ MRI spine, EMG/NCS

Ddx/tx
- Herniated disc
- OA/ degenerative disc disease
- Avulsion
- Tumor 
tx - supportive, PT/OT, consult NSx/ortho
88
Q

Weakness anterior horn cell workup

A

Sx - classic diseases causing progressive dysphagia, dysarthria, with UMN and LMN signs, no sensory sx, no bladder/ bowel sx

Inv - El Escorial criteria
- r/o other possible localizations/ disorders

Ddx/tx

  • Amyotrophic lateral sclerosis
  • Primary lateral sclerosis
  • Primary muscular atrophy
  • Progressive bulbar palsy
  • Pseudobulbar palsy
  • > supportive tx
89
Q

Weakness spinal cord workup

A

Sx - para or quadra-plegia/ paresis with sensory level, bowel and bladder sx +/- back pain

Inv - MRI + gadolinium of spinal cord; LP (cell count, cytology, flow cytometry, infx)
Infx workup - syphilis, CMV, HTLV, mycoplasma, HSV, VZV, HIV, etc.
Paraneoplastic antibodies

Ddx/tx

  • Trauma -> consult NSx
  • MS -> steroids +/- disease modifying tx
  • Transverse myelitis -> steroids
  • Neoplasms/ metastasis -> consult NSx, med/rad onc
  • Vascular -> optimize risk factors
90
Q

Weakness brainstem workup

A

Sx - hemiplegia/ paresis associated with CN findings (+/- asymmetric/ symmetric bilateral weakness)

Inv - MRI brain, other inv. re: results MRI

Ddx/tx

  • Stroke (ischemic/ hemorrhagic) -> stroke tx
  • Vascular (AVM, aneurysm, etc) -> consult NSx
  • Mass lesion - consult NSx/ oncology
  • Infection (abscess) - abx, antifungal, antiparasitic; consult ID
  • MS -> steroids +/- disease modifying tx
91
Q

Weakness subcortical workup

A

Sx - hemiplegia/paresis involving face, arm and leg equally +/- visual sx, sensory sx, etc.

Inv - CT/MRI brain, inv. re: findings

Ddx/tx

  • Stroke (ischemic/hemorrhagic) -> stroke tx
  • Vascular (AVM, aneurysm, etc) -> consult NSx
  • Mass lesion - consult NSx/ oncology
  • Infection (abscess) - abx, antifungal, antiparasitic; consult ID
  • MS -> steroids +/- disease modifying tx
  • Trauma (contusion) -> consult NSx/ supportive
92
Q

Weakness cortical workup

A

Sx - hemiplegia/paresis
ACA - mostly leg
MCA - face and arm >leg
+ cortical sx (aphasia if dominant hemisphere; apraxia and neglect if non dominant hemisphere)

Inv - CT/MRI brain; inv. re: imaging

Ddx/tx

  • Stroke (ischemic/hemorrhagic) -> stroke tx
  • Vascular (AVM, aneurysm, etc) -> consult NSx
  • Mass lesion - consult NSx/ oncology
  • Infection (abscess) - abx, antifungal, antiparasitic; consult ID
  • MS -> steroids +/- disease modifying tx
  • Trauma (contusion, SDH, etc.) -> consult NSx/ supportive
  • Other causes with no imaging findings (Todd paralysis, hemispheric migraine, hypoglycaemia) -> tx re: cause
93
Q

Stroke

A

Ischemic - thrombic vs. embolic
vs.
Hemorrhagic - ICH vs. SAH

94
Q

Time for tPA

A

less than 4.5h from sx onset

95
Q

RF hemorrhagic stroke

A 
HTN
smoking
increased age
FHx
atherosclerosis
bleeding disorder
increased EtOH
cocaine, amphetamines
trauma
vasculitis
aneurysm
AVM
tumor
amyloid angiopathy
96
Q

RF ischemic stroke

A 
increased age
smoking
DM
hyperlipidemia
HTN
Afib
prev. stroke/ TIA
FHx
cardiac source
atherosclerosis
obesity/ physical inactivity
OCP/HRT
OSA
elevated homocysteine
ethnicity
hypercoaguable state
hypo perfusion
97
Q

CNS vascular anatomy

A

ACA = contralateral leg> face/arm involvement
MCA = contralateral face/arm >leg involvement
- dominant = aphasia
- nondominant = apraxia, neglect
PCA = contralateral vision
Basilar = variable sx involving weakness, CN (diplopia, dysphagia, dysarthria) and cerebellar (ataxia) sx

98
Q

Oslar nodes, Janeway lesions, Roth spots, splinter hemorrgahes, petechia are signs of what?

A

Endocarditis

99
Q

Stroke investigations

A

Dx and type of stroke

  • Noncontrast CT head - hemorrhagic vs. ischemic
  • LP - suspicious SAH and CT negative (RBC, xanthochromia)
  • MRI - type and localization (esp. acute ischemic infarcts, posterior fossa strokes)

Etiology stroke

  • carotid doppler US (carotid stenosis)
  • CT angiography (atherosclerosis, dissection, aneurysms, intracranial vascular lesions)
  • MRI angiography (AVMs, aneurysms, carotid)
  • conventional angiography - gold standard for AVMs and aneurysms (invasive)
  • TTE (cardiac emboli)
  • TEE (atrial thrombi, atheromatous aortic disease, valve disease, PFO)
  • holder
  • hyper coagulable work up

Stroke factors/ secondary prevention

  • fasting blood glucose
  • fasting lipids
  • BP
  • smoking/ EtOH/ drugs
  • CBC, INR, PTT, bytes, Cr, BUN
  • LFT, CK (prior to statins)
100
Q

BP target stroke

A

<220/120 in pt without tPA

<180/105 in pt with tPA

101
Q

Stroke management

A
  • tPA if indicated (<4.5hr, no CI)
  • BP (<220/120, <180/105)
  • ASA 160mg chewed or 650mg PR
  • rehab (SLP, OT, PT)
    secondary prevention
  • anti platelet (ASA, placid, Aggrenox)
  • DM tight glycemic control
  • lipids (statins)
  • BP (ACEI/ARB or diuretic -> <140/90; if DM <130/80)
  • lifestyle
  • Surgery (endarterectomy/ stunting)
    complication prevention
  • DVT prophylaxis
  • Mobilization/ positioning re: pressure ulcers
  • swallowing screen/ diet appropriate
102
Q

Hemorrhagic stroke tx

A

ICH - ABC, reverse coagulation, supportive, NSx consult, ICP management

SAH - ABC, reverse coagulation, aggressive BP control (SBP <160), urgent angiographic imaging, SAH precautions, nimodipine, NSx consult, definitive management of underlying cause

103
Q

ICP management

A
  • HOB >30 (increase venous outflow)
  • neutral neck - avoid neck compression
  • avoid hypotension
  • normal to mild hypercarbia (only hyperventilate if signs of herniation or as bridge to surgery)
  • sedation (opioids, versed, propofol)
  • intracranial pressure monitoring (external ventricular drain, intraparenchymal monitor)
  • osmotic (mannitol, hypertonic saline)
  • paralytics
  • surgical options (clot evacuation, decompressive craniotomy)
104
Q

CI tPA

A

absolute

  • intracranial hemorrhage
  • severe uncontrolled HTN
  • head trauma/stroke last 3mo
  • thrombocytopenia/ coagulopathy
  • therapeutic anticoagulation (LMWH last 24h)

relative

  • age >75-80
  • improving stroke sx
  • coma/severe stroke (higher risk hemorrhagic transformation)
  • recent major surgery
  • recent gi/gu bleed (within 3wk)
  • seizures
  • recent MI
  • CNS structural lesions (neoplasm, AVM, aneurysm)
105
Q

Positive sensory complaints

A

paresthesia/dysesthesia = tingling, pins and needles, burning, neuropathic pain

106
Q

Negative sensory complaints

A

hypoesthesia/anesthesia = numbness, diminution/ absence of feeling

107
Q

Which tracts essential for sensory lesions?

A

Spinothalamic and dorsal column pathways

108
Q

Sensory cortical/subcortical and brainstem - ddx and workup

A

Ddx

  • vascular (CVA, ICH, SAH)
  • inflammatory (MS)
  • neoplasm
  • infection

Inv - CT head, MRI brain (brainstem suspected)
+/- LP

Tx - underlying cause

109
Q

Sensory spinal cord - ddx and workup

A

Ddx

  • vascular (cord infarction)
  • neoplasm
  • inflammatory (MS)
  • infection (syphilis)
  • nutritional (B12 deficiency)
  • trauma
  • syringomyelia
  • paraneoplastic

Inv - MRI cord +/- LP
- serology, vit B12, paraneoplastic antibodies

tx

  • optimize vascular rf
  • consult NSx/ rad onc if mass
  • steroids for inflammation
  • ABx for infection
  • replace deficiencies
  • steroids/PLEX and rx underlying cancer if paraneoplastic
110
Q

Sensory polyneuropathy ddx and workup

A

Ddx

  • metabolic (DM, uraemia)
  • drug (chemo, EtOH)
  • infection (HIV, Lyme)
  • paraneoplastic
  • inflammatory (amyloid, sarcoid, vasculitis)
  • heritable
  • idiopathic

Inv - EMG/NCS
- FBS, Cr, BUN, TSH, AST, ALT, serology re: infection, CD4 count, inflammatory workup (ESR, CRP), paraneoplastic antibodies

Tx

  • optimize DM, kidney function, liver function
  • d/c drug if cause
  • Rx infection
  • steroids/PLEX and rx underlying cancer if paraneoplastic
  • steroids, etc for inflammatory causes
111
Q

Sensory mononeuropathy ddx and workup

A

Ddx

  • stretch
  • compression (CTS)
  • contusion
  • laceration
    note: peripheral nerve injury often occurs as part of more extensive injury and tend to go unrecognized

Inv - EMG/NCS
+/- imaging
FBS, Cr, BUN, TSH, AST, ALT, serology re: infection, CD4, inflammatory workup (ESR, CRP), paraneoplastic antibodies

Tx

  • task modification, splints, PT/OT, ergonomics
  • severe/axonal loss on EMG/NCS consider surgical release
  • consult plastic surgery re: nerve injuries
112
Q

Neuropathic pain

A

Pain from dysfunctional/disruption of either central or peripheral nervous system

  • allodynia (painful response to non-painful stimulus), hyperalgesia (increase pain in response to painful stimulus), constant pain (burning, sharp, stabbing, shooting, electrical)
  • worse at rest, constant pain
113
Q

Somatic vs. visceral nociceptive pain (tissue damage)

A

Somatic = well localized, sharp, short lasting

Visceral = originates from organ/cavity lining; poorly localized, crampy, diffuse

114
Q

Neuropathic pain ddx

A

Abnormal neural activity
Sympathetic - CRPS
Central (abnormal CNS activity) - phantom limb, post-stroke, post-spinal injury, MS pain
Peripheral (nerve damage/pressure) - post herpetic neuralgia, trigeminal neuralgia, diabetic neuropathy, nerve entrapment, HIV sensory neuropathy

115
Q

Seddon categories of peripheral nerve injuries

A

Neuraprazia

  • focal demyelination
  • temporary conduction block/ paralysis
  • complete recovery typical

Axonotmesis

  • axonal destruction with preservation of myelin
  • prolonged conduction block/ paralysis
  • recovering axon can follow intact myelin base to reestablish connectivity
  • complete recover possible

Neurotmesis

  • complete transection
  • prolonged/ permanent conduction block/ paralysis
  • loss of myelin base to guide axon
  • neuroma formation results
  • unlikely to have complete recovery without surgery
116
Q

Complex regional pain syndrome (CRPS)

A

chronic neuropathic pain developing over months which affects an extremity and cannot be localized to a peripheral nerve or root territory

  • all tissue types in vicinity affected (deem, thickened skin, muscle wasting, patchy demineralized bone)
  • severe/permanent changes within 1yr

type 1 = no definable lesion/insult
type 2 = definable lesion/insult (e.g. trauma, head injury, stroke, infection, idiopathic, MI, etc)

regional sympathetic nerve block can be diagnostic and therapeutic

117
Q

Dysarthria

A

abnormality of speech

  • articulation problem re: lesion in motor pathways controlling speech
  • any speech subsystems can be affected (respiration, phonation, resonance, prosody, articulation)
  • often with oropharyngeal dysphagia
118
Q

Aphasia

A

abnormality of language

  • lesion in dominant hemisphere
  • paraphasic errors (mispronunciation or inappropriate substituted words), including semantic (based on meaning) or phonemic (based on sounds) errors and neologisms (creation of new words)
119
Q

Brocas area

A

motor patterns - fluency

120
Q

Wernicke’s area

A

autitory centre - comprehension

121
Q

Articulation re: CN

A 
mama = CN VII
gaga/caca = CN IX, X
lala = CN XII
122
Q

Global aphasia sx

A

fluency
naming
comprehension
repetition

123
Q

Brocas aphasia sx

A

fluency
naming
repetition

124
Q

Wernickes aphasia sx

A

naming
comprehension
repetition

125
Q

Conduction aphasia sx

A

naming

repetition

126
Q

Transcortical motor aphasia sx

A

fluency

naming

127
Q

Transcortical sensory aphasia sx

A

naming

comprehension

128
Q

Transcortical mixed aphasia sx

A

fluency
naming
comprehension

129
Q

Timeline of ddx aphasia

A 
sec-min = vascular
hr-d = infection
d= inflammation
wk-mo = neoplasn
mo-yr = degenerative
130
Q

Aphasia investigation

A

neuroimaging - Cat or MRI brain +/- LP, EEG, etc

131
Q

Aphasia management

A

Underlying etiology tx

supportive care - modified diet, SLP

132
Q 
Dysarthria based on localization - workup, tx
cerebral cortex
basal ganglion (hypophonation)
cerebellum (scanning speech) 
brainstem (brainstem findings)
A

inv - neuroimaging (CT head, MRI brain)
+/- LP, serum tests
Tx re: cause

133
Q 
Dysarthria based on localization - workup, tx
isolated CN palsies
- CN VII
- CN IX/X (structural)
- CN CII (structural)
A

Inv - MRI brain, EMG/NCS

Tx re: cause

134
Q

Dysarthria based on localization - workup, tx
Motor neuron
(spastic/ hyper nasal), degenerative

A

Inv - diagnostic criteria and r/o other cause

Supportive care

135
Q

Dysarthria based on localization - workup, tx

NMJ (fatiguable) - MG

A

Tensilon/ice pack test, Anti-AchR antibody, etc.

  • NCS with repetitive stimulation
  • Single fiber EMG

MG management

136
Q

Dysarthria based on localization - workup, tx

Muscle - inflammatory, metabolic, drug/toxin induced, genetic

A

Inv - EMG/NCS, CK, etc

Supportive care and tx curable cause

137
Q

Dysarthria based on localization - workup, tx

larynx/respiratory (hypo phonic)- structural

A

Inv - laryngoscopy, CXR, PFT, etc.

consult ENT/pulmonary prn

138
Q

Location of disease in movement disorders?

A

basal ganglia and/or cerebellum

139
Q

Hyperkinetic movement disorder

A

abnormal movement disorders

- dystonia, chorea, myoclonus, ballismus, tremor, tics

140
Q

Hypokinetic movement disorder

A

lack/paucity of normal movement disorders

- Parkinsonism

141
Q

Tremor

A

rhythmic oscillation of a body part secondary to alternating or synchronous contraction of reciprocally innervated antagonistic muscles

142
Q

Classification of tremors

A
  • based on when it is most prominent
    Rest - patient quietly resting (Parkinson disease)
    Action - during voluntary muscle movement (cerebellar disease, MS)
    Postural - patient maintaining a posture against gravity (enhanced physiologic tremor, essential tremor)
143
Q

Parkinsonism

A

syndrome characterized by tremor (predominantly rest tremor), rigidity, bradykinesia, postural instability, classic gait
classic gait - decreased initiation, bradykinetic, shuffling, stooped posture, decreased arm swing, destinations, en bloc turning
Parkinsonism does not equal Parkinson disease

144
Q

Red flags re: Parkinsonism

A

symmetric symptoms
early postural instability or falls
impaired up gaze
poor response to Sinemet (carbidopa- levodopa)

145
Q

Treatment hyperkinetic movement disorders

A

trial propranolol
lifestyle (less caffeine, EtOH)
Neurologist referral

146
Q

Treatment hyperkinetic movement disorders

A

Parkinson disease = trial L-dopa

neurologist referral if red flags

147
Q

Wilson disease

A
  • autosomal recessive disease of copper metabolism
  • mutation in ATP7B on chrm 13 -> encodes Cu transporting ATPase in liver -> Cu not incorporated into ceruloplasm to excrete in bile -> Cu accumulation in liver, brain, and other tissues
    sx
  • liver cirrhosis -> failure
  • dysarthria, dystonia, asymmetrical tremor
  • arthropathy, osteopenia
  • hemolytic anemia
  • Fanconi syndrome, urolithiasis, hematuria
    Kayser-Fleischer rings in eyes
    Inv - serum ceruloplasmin, 24h urine for supper, slit lamp exam, neuroimaging, liver biopsy
    tx - diet modifications, chelation (e.g. zinc)
148
Q

Gait

A

manner of walking

- coordination of vision, vestibular function, cerebellar function, sensory perception, and motor capabilities

149
Q

Ataxia

A

impaired ability to coordinate muscular movements (axial and/or appendicular muscles involved)

150
Q

Ddx gait dysfunction

A

Vision - cataracts, glaucoma, macular degeneration, etc.
- ophthalmology consult

Vestibular system (vertigo, n/v, nystagmus) -> central vs. peripheral - vascular, tumor, abscess, BPPV, labyrinthitis, etc.

  • MRI, Dix-Hallpike, Fukuda stepping test, etc
  • Neuro referral; Epley; symptomatic tx, etc.

Cerebellar system (ataxia) - structural, toxins, inborn error of metabolism, degenerative

  • MRI, EtOH hx, tox screen, Vit E, Vit B12, genetics
  • neuro referral, PT/OT
Motor system (weakness) - UMN, LMN
- weakness/movement disorder workup/tx
Sensory system (decreased proprioception/ joint position +/- pain and temperature; positive Rhomberg) - cortical, subcortical, brainstem, spinal cord (posterior columns), radiculopathy, polyneuropathy, etc
- sensory workup/tx
151
Q

Headache

A

pain anywhere in the head or neck

  • > brain has NO nociceptors so does not feel pain
  • > dura mater has nociceptors
152
Q

Headache red flags

A
  • first/different
  • worst
  • thunderclap hx/acute
  • persistent
  • > 50yo
  • worse in recumbency/ with Valsalva
  • worse in AM
  • hx trauma, cancer
  • abnormality on neuro exam
  • fever
  • meningismus
  • papilledema, retinal hemorrhage
  • severe HTN
  • hypercoaguable state/ bleeding disorder
  • taking anticoagulants
  • pregnancy
  • CO exposure
  • jaw claudication/scalp tenderness/ tenderness over TA/ PMR/ monocular blurred vision
  • cocaine/amphetamine use
153
Q

Secondary causes of headache - ddx, workup, management

A

SAH

  • thunderclap onset
  • CT: acute blood in subarachnoid space
  • LP: high RBC + xanthochromia
  • refer NSx

Temporal arteritis

  • > 50yo, monocular blurred vision, tender over temporal artery, jaw claudication, scalp tenderness, PMR
  • increased ESR, temporal artery biopsy
  • high-dose corticosteroid

Venous thrombosis

  • diffuse h/a, hx clots, OCP/HRT, hyper coagulable state, low flow state, dehydration, sepsis
  • MRV: thrombsis +/- venous infarcts
  • abnormal hyper coagulable workup (INR/PTT/Pro C/ Pro S/ ATT etc)
  • anticoagulate

Intracranial hematoma

  • hx trauma, bleeding disorder
  • acute = rapidly progressive neurologic deficits
  • chronic = h/a may be only sx
  • CT: EDH, SDH, ICH, IVH
  • refer NSx

Severe arterial HTN
- HTN, encephalopathic, papilledema, Hx cocaine, amphetamine, MAOI
- positive drug screen, urine metanephrines
+/- CT head
- treat HTN; manage underlying condition

Idiopathic intracranial HTN (pseudotumor cerebri)

  • worse in AM/ recumbent. Valsalva, papilledema, worsening VA/VF
  • CT = no mass; LP = high opening pressure
  • Diamox, Topamax, Lasix
  • Ophth/NSx consults

Intracranial infection
- febrile, septic, meningismus, rash, encephalopathic, decreased LOC
- LP (check opening pressure)
- bacterial = increased protein, decreased glucose, increased WBC
- viral = increased protein, n glucose, increased WBC (lymphocytes)
tx- antibiotics/ antivirals

Mass lesion (abscess, tumor, etc.)

  • gradually progressive h/a with focal neurologic findings
  • CT - ring enhancing lesion
  • NSx referral
154
Q

Primary headache ddx

A

Migraine

  • aura, mod-severe throbbing, worse with activity, n/v, photophobia, phonophobia
  • NSAIDs, triptans, DHE
  • prophylactic = propranolol, TCAs, AEDs

Tension

  • later in day, no associated sx, mild-mod dull, aching, band-like
  • NSAIDs, tylenol
  • prophylactic = TCAs, AEDs

Cluster

  • M>F, severe stabbing unilateral/ periorbital pain with ipsilateral autonomic signs (tearing, miosis, hydrous, conjunctival injection), seasonal recurrence of multiple episodes with intermittent remission
  • tx O2, triptans, DHE
  • prophylactic = steroids (short term), verapamil, methysergide, lithium

Medication overuse

  • worsening chronic h/a >15d/mo of OTC analgesia and >10d/mo triptans, ergots, combination analgesia
  • drug holiday
155
Q

Transient loss of consciousness (TLOC)

A

transient loss of awareness and/or responsiveness caused by various mechanisms

156
Q

Syncope

A

TLOC caused by reduced blood flow and O2 and glucose to the brain

157
Q

Seizure

A

paroxysmal, abnormal and synchronous discharge of cortical neutrons, resulting in various semiologies

158
Q

Epilepsy

A

chronic condition characterized by >2 unprovoked seizures

159
Q

Inhibitory and excitatory neurotransmitters in seizures

A 
inhibitory = GABA (decreased in seizures)
excitatory = glutamate (increased in seizures)
160
Q

Ddx syncope

A

Hypovolemia
Hypotensive - vasovagal, drugs, dysautonomia
Cardiac - arrhythmia, contractility issue, inflow/ outflow obstruction
Metabolic - hypoglycaemia, anemia
Cerebrovascular - vertebrovascular disease, vasospasm
Multifactorial

161
Q

Ddx seizure

A

Focal vs. generalized
focal (activation localized area within one hemisphere)
- simple (focal without impairment of consciousness)
- complex (focal with impaired consciousness)

generalized (activation bilateral cerebral hemisphere; always associated with LOC; focal sx may evolve to bilateral convulsive sx)

  • convulsive = tonic, clonic, tonic-clonic, atonic, myoclonic
  • non-convulsive = typical absence, atypical absence
162
Q

Status epilepticus

A
  • life threatening condition
  • one continuous seizure or recurrent seizures without regaining consciousness between seizures
  • > 30min
    management:
  • O2, IV
  • thiamine and dextrose
  • IV lorazepam 0.1mg/kg
  • IV phenytoin (incompatible with glucose-containing solutions)
    -30-50min if seizure persisting intubate and IV phenobarbital or propofol infusion (burst suppression on EEG)
  • urgent EEG if necessary
163
Q

Convulsive seizure

A

episode of abnormal muscle contraction, usually bilateral

164
Q

Myoclonic seizure

A

sudden, brief (<100ms), involuntary contractions of muscles

165
Q

Clonic seizure

A

prolonged, regular, repetitive movement, involving same muscle group, 2-3Hz

166
Q

Tonic seizure

A

sustained muscle contraction lasting seconds to minutes

167
Q

Tonic-clonic seizure

A

tonic phase followed by clonic phase

168
Q

Atonic seizure

A

sudden loss of muscle tone lasting approx 1-2sec

169
Q

Typical absence seizure

A

brief (sec) loss of consciousness without convulsions, with generalized 3Hz smile and slow waves on EEG

170
Q

Atypical absence seizure

A

brief LOC without convulsions, abnormality of tone, 2Hz spike and slow waves on EEG

171
Q

Seizure investigations

A

CBC, lytes, Ca, Mg, Cr, BUN, liver enzymes, TSH

  • LP if suspicious of infection
  • CT/MRI
  • EEG

-> provoked vs. unprovoked

172
Q

Seizure management

A

Antiepileptic drugs
- affect voltage gate Na channels, GABA metabolism, Ca currents

Valproate - increases GABA
- generalized or partial/focal seizures

Carbamazepine - Na channel antagonist
- partial/focal onset seizures

Lamotrigine - Na channel antagonist, decreases glutamate
- generalized and focal seizures

Topiramate - Na/Ca channel modulation causing decreased glutamate
- generalized and focal seizures

Dilantin - Na channel antagonist
- generalized and focal seizures

173
Q

Mental status

A

Attention and arousal, as well as cognition and executive function

174
Q

Altered mental status ddx

A

True altered mental status - dementia or delirium

Mimic - depression, mania, psychosis, conversion, malingering

175
Q

Delirium

A

acute change from baseline in attention and arousal and one or more cognitive domain that fluctuates
- organic cause

176
Q

Coma

A

pathologic state of unarousable unconsciousness (symptom not diagnosis)

177
Q

Ddx coma

A
  • locked-in syndrome - pt paralyzed but alert and aware
  • akinetic mutism - pt lacks impulse to move
  • malingering
  • persistent vegetative state (pt barely emerged from coma or progressed to profound dementia)
  • brain death
    Coma
    Focal - neurologic, bilateral hemisphere or brainstem (hemorhagge, infarction, neoplasm, abscess, trauma, herniation)
    Diffuse - systemic deficiencies- hypoexmia, hypercarbia, etc.;
    excesses - ureic, hepatic encephalitis, metabolic acidosis, DKA, thyroid storm, etc.
178
Q

Coma Workup

A

ABC, IV, O2, monitors, STAT investigations
- thiamine, glucose and/or Narcan
Neuro exam - CN, motor tone, deep tendon reflexes, plantar reflex
Inv - CT/MRI
- ABG, CBC-D, bytes, Ca, Mg, Cr, BUN, urinalysis, ALT, AST, PTT, INR, NH3, albumin, TSH, etc.

Herniation tx - mannitol, HOB >30, normocarbia/ normothermic, NSx consult
Treat underlying causes

179
Q

Concussion (mild traumatic brain injury)

A

immediate and transient loss of consciousness without macroscopic structural damage

180
Q

Categorization head injury severity

A
  • mild = GCS 13-15 with brief LOC or impaired cognition
  • moderate = GCS 9-12 or LOC >5min
  • severe = GCS 3-8
181
Q

CPP equation

A

CPP = MAP - ICP
normal CPP >50mmHg
normal ICP <20mmHg

182
Q

Signs of herniation

A

posturing, dilated and unreactive pupil

183
Q

What CN palsy is common with increased ICP?

A

CNVI

184
Q

Workup head trauma

A

trauma blood workup
CXR, lateral c-spine xr +/- pelvic xr
CT head if GCS <13 and re: CT head rules

185
Q

Canadian CT Head Rule

- adults with minor head injury who are not anticoagulated

A

Order CT head if
high risk - GCS <15 at 2hr post-injury; suspected open or depressed skull #; sign basal skull #; vomiting x2; age >65
medium risk - amnesia for events 30min before; dangerous mechanism (pedestrian struck, ejection MVC, fall 3ft/ 5stairs)

186
Q

Epidural hematoma

A

Hyperdense biconvex extra axial collection on CT

  • no crossing suture lines
  • often arterial (middle meningeal artery)
  • LOC then lucid interval
  • NSx
187
Q

Subdural hematoma

A

Crescentic hyper dense extra axial collection crossing suture lines, often along supratentorial convexity

  • subacute >4d old = isodense
  • chronic >2wk old = hypodense
  • often venous (bridging veins)
  • uncal herniation (ipsilateral fixed and dilated pupil, contralateral hemiparesis, declining LOC)
  • NSx
188
Q

Intraparenchymal hemorrhage/ contusion

A

patchy, ill-defined hyper density within brain parenchyma within edematous background; often in anterioinferior frontal or temporal lobes
- NSx

189
Q

Traumatic subarachnoid hemorrhage

A
  • hyper dense blood layer in sulci often adjacent to contusions or extra axial hemorrhages
  • asymmetric (vs. aneurysmal SAH)
  • NSx
190
Q

Skull fracture

A
  • irregular hypodense lines that are thin without branching (vs. vessels) and not along known sutures (coronal, sagittal)
  • bone windowed CT
  • NSx
191
Q

Brain death

A

irreversible loss of function of brain, including brainstem

192
Q

Brian death criteria

A

Prerequisites

  • evidence (clinical or neuroimaging) of acute CNS catastrophe compatible with brain death
  • no complicating factors
  • no intoxications or poisonings (time of drugs to leave system)
  • normothermic

Requirements

  • coma or unresponsive - no cerebral motor response to pain in ANY extremities (beware spinal reflex)
  • no brainstem reflexes - pupils fixed and dilated; ocular movements (no oculocephalic or vestibuloocular reflexes); no facial movements/reflexes; no pharyngeal movements (gag, cough); positive apnea test (no resp effort with ventilator off and increase PaCO2 >60mmHg or 20 above baseline; as long as PO2 >200mmHgm SB >90mmHg, normothermic and euvolemic)

Confirmatory investigations

  • conventional (catheter) angiography
  • EEG
  • trancranial US
  • technetium-99m hexameethylpropylene amine oxide brain scan
  • somatosensory evoked potential
193
Q

Organ donation

A
  • brain death or donation after cardiac death

absolute CI

  • age >80yr
  • HIV infection (relative CI HBV, HCV)
  • active metastatic cancer
  • prolonged hypotension or hypothermia
  • DIC
  • sickle cel anemia or hemoglobinopathy
    note: sepsis not CI

MCC Part 1 (22 decks)

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