Neurology/ Neurosurgery Flashcards
1
Q
Corticospinal/ corticobulbar tracts control?
A
Voluntary movement
2
Q
Spinothalamic tract is responsible for?
A
Pain and temperature
3
Q
Doral columns are responsible for?
A
Proprioception and vibration
4
Q
Precentral gyrus?
A
Primary motor cortex
5
Q
Post central gyrus?
A
Primary sensory cortex
6
Q
Frontal lobe?
A
movement
executive function
personality
expressive language
7
Q
Temporal lobe?
A
smell
hearing
memory
8
Q
Parietal lobe?
A
sensation
visuospatial
praxias
receptive language
9
Q
Occipital lobe?
A
vision
10
Q
Cerebellum?
A
coordination
11
Q
Brainstem components?
A
midbrain
pons
medulla
12
Q
Where is the relay station?
A
Thalamus
13
Q
Components of basal ganglia?
A
Caudate, putamen, globus pallidus, substantia niagra, subthalamic nucleus
-> motor programming
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
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
16
Q
Thalamus
?sensory loss pattern
? cortical signs
A
Sensory loss - hemi pattern
May have cortical signs
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
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
19
Q
Motor neuron
?UMN/LMN
?sensory sx
?autonomic sx
A
UMN and/or LMN weakness
NO sensory sx
NO autonomic sx
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
21
Q
Root
?LMN
?sensory loss
A
LMN weakness follows myotome pattern
Sensory loss follows dermatome pattern
22
Q
Plexus
?LMN
?sensory changes
A
LMN weakness
Patchy sensory changes
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
24
Q
Neuromuscular junction
?weakness
?sensory sx
A
Fatiguable weakness
NO sensory sx
25
Muscle
?LMN
? sensory
LMN weakness pattern prox>distal
| NO sensory sx
26
LOC
- alert
- confused
- delirious
- lethargic
- obtunded
- stuporous
- comatose
27
Lethargic
Mild decrease in consciousness, easily aroused
28
Obtunded
Cannot be fully aroused
29
Stuporous
Sleep-like state
30
GCS
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
31
CN
```
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
```
32
CN I
olfactory nerve
| - sensation
33
CN II
optic nerve
sensation - visual acuity, visual fields
reflex - pupillary light reflex (afferent = CN II, efferent = CN III)
inspection- ophthalmoscopy
34
CN III
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)
35
Cause of ptosis?
Levator plapebrae superioris lesion (CN III)
36
CN IV
trochlear nerve
| - superior oblique muscle (depression of adducted eye, intorsion of abducted eye)
37
CN V
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)
38
CN VI
abducens nerve
- lateral rectus muscle (abducts eye)
motor - EOM, convergence, nystagmus, saccades
39
CN VII
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
40
CNVIII
vestibulocochlear nerve
| sensation - 512 Hz tuning fork = Weber (lateralization) and Rinne (AC vs. BC); whispered voice test
41
CN IX
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
42
CN X
vagus nerve
| - motor = voice quality and gag
43
CN XI
spinal accessory
| - motor = SCM and trapezius atrophy, fasciculations, strength
44
CN XII
hypoglossial nerve
- motor = tongue atrophy, fasciculations, symmetry on protrusion, strength
lesion = tongue deviates toward side of lesion
45
Chorea
irregular, unpredictable jerky purposeless movements that flow from one body part to another
46
Ballismus
large-amplitude, rapid, violent, flinging movements originating from proximal muscles
47
Dystonia
Sustained muscle contraction causing twisting and repetitive movements or abnormal sustained postures
48
Tics
repetitive, rapid, irregular, patterned, stereotyped movements or vocalizations accompanied by pre-event urge
49
Myoclonus
Rapid, shock-like, sudden larger-amplitude involuntary movements caused by active muscle contraction (positive myoclonus) or inhibition of ongoing muscle contraction (negative myoclonus)
50
What does pronator drift test for?
+ if arm drops and pronates
| assesses cortical weakness
51
Spastic vs. rigidity (hypertonic muscle tone)
spastic - velocity dependent (clasp knife)
| rigidity - not velocity dependent (cog-wheel, lead pipe)
52
Grading scale for strength
```
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
```
53
Deltoid (arm abduction) myotome/ nerve
C5
| axillary n.
54
Biceps (elbow flexion) myotome/ nerve
C5/6/7
| musculocutaneous n.
55
Triceps (elbow extension) myotome/ nerve
C6/7/8
| radial n.
56
Extensor carpi ulnaris/ radialis (wrist extension) myotome/ nerve
C5/6/7/8
| radial n
57
Flexor carpi ulnaris/ radialis (wrist flexion) myotome/ nerve
C6/7/8 T1
| ulnar/median .
58
Hand intrinsic myotome/ nerve
C8/T1
| ulnar n. except LOAF = median n.
59
Iliopsoas (hip flexion) myotome/ nerve
L1/2/3
| femoral n.
60
Adductors (hip adduction) myotome/ nerve
L2/3/4
| Obtruator n.
61
Gluteus maximus (hip extension) myotome/ nerve
L5, S1/2
| inferior gluteal n.
62
Quadriceps (knee extension) myotome/ nerve
L2/3/4
| femoral n.
63
Hamstrings (knee flexion) myotome/ nerve
L5/S1/2
| sciatic n.
64
Gastrocnemius (plantar flex ankle) myotome/ nerve
S1/2
| tibial n.
65
Tibialis anterior (dorsi flex ankle) myotome/ nerve
L4/5
| deep peroneal n.
66
Grading reflexes
```
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
```
67
Deep tendon reflexes segmental level and peripheral nerve
```
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.
```
68
Levels of principle dermatomes
```
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
```
69
How do you test for dysdiadochokinesia?
Rapid alternating movements
70
How to test for dysmetria?
Point to point movement
71
What gait will you see ataxia?
Tandem gait
72
How do you bring out gastrocnemius muscle weakness (S1)?
Walk on tip toes
73
How do you bring out anterior tibialis weakness (L5)?
Walk on heels
74
Rhomberg tests integration of what?
Visual, vestibular and proprioceptive function
| - remove visual pathway when close eyes (balance if proprioception and vestibular pathways intact)
75
How many levels does the nervous system have?
10
76
UMN/CNS (level 1-6)
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
77
LMN/PNS (level 7-10)
7. Motor neuron weakness, atrophy, fasciculations, no sensory sx
8. Root/plexus/nerves - variable motor/sensory sx, areflexia
9. Neuromusclar junction - fatiguability, diplopia, ptosis, dysphagia, no sensory sx
10. Muscle - proximal weakness, no sensory sx
78
UMN lesion
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
LMN lesion
- forehead involving facial droop, fasciculations of tongue
- decreased bulk
- decreased tone
- pattern of strength re: localization of lesion
- reflexes decreased, plantar downgoing
80
Sensory patterns re: lesions
```
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
Weakness
Loss of power/strength
- partial = paresis
- full = paralysis
- > corticospinal tract
ddx re: 10 levels of NS
82
How does anterior horn cell weakness present?
Progressive dysphagia and dysarthria with both UMN and LMN signs
- no sensory and no bowel/ bladder sx
83
Weakness muscle workup
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
Weakness NMJ workup
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
Weakness peripheral nerve workup
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
Weakness plexus workup
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
Weakness root workup
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
Weakness anterior horn cell workup
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
Weakness spinal cord workup
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
Weakness brainstem workup
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
Weakness subcortical workup
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
Weakness cortical workup
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
Stroke
Ischemic - thrombic vs. embolic
vs.
Hemorrhagic - ICH vs. SAH
94
Time for tPA
less than 4.5h from sx onset
95
RF hemorrhagic stroke
```
HTN
smoking
increased age
FHx
atherosclerosis
bleeding disorder
increased EtOH
cocaine, amphetamines
trauma
vasculitis
aneurysm
AVM
tumor
amyloid angiopathy
```
96
RF ischemic stroke
```
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
CNS vascular anatomy
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
Oslar nodes, Janeway lesions, Roth spots, splinter hemorrgahes, petechia are signs of what?
Endocarditis
99
Stroke investigations
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
BP target stroke
<220/120 in pt without tPA
| <180/105 in pt with tPA
101
Stroke management
- 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
Hemorrhagic stroke tx
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
ICP management
- 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
CI tPA
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
Positive sensory complaints
paresthesia/dysesthesia = tingling, pins and needles, burning, neuropathic pain
106
Negative sensory complaints
hypoesthesia/anesthesia = numbness, diminution/ absence of feeling
107
Which tracts essential for sensory lesions?
Spinothalamic and dorsal column pathways
108
Sensory cortical/subcortical and brainstem - ddx and workup
Ddx
- vascular (CVA, ICH, SAH)
- inflammatory (MS)
- neoplasm
- infection
Inv - CT head, MRI brain (brainstem suspected)
+/- LP
Tx - underlying cause
109
Sensory spinal cord - ddx and workup
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
Sensory polyneuropathy ddx and workup
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
Sensory mononeuropathy ddx and workup
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
Neuropathic pain
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
Somatic vs. visceral nociceptive pain (tissue damage)
Somatic = well localized, sharp, short lasting
Visceral = originates from organ/cavity lining; poorly localized, crampy, diffuse
114
Neuropathic pain ddx
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
Seddon categories of peripheral nerve injuries
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
Complex regional pain syndrome (CRPS)
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
Dysarthria
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
Aphasia
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
Brocas area
motor patterns - fluency
120
Wernicke's area
autitory centre - comprehension
121
Articulation re: CN
```
mama = CN VII
gaga/caca = CN IX, X
lala = CN XII
```
122
Global aphasia sx
fluency
naming
comprehension
repetition
123
Brocas aphasia sx
fluency
naming
repetition
124
Wernickes aphasia sx
naming
comprehension
repetition
125
Conduction aphasia sx
naming
| repetition
126
Transcortical motor aphasia sx
fluency
| naming
127
Transcortical sensory aphasia sx
naming
| comprehension
128
Transcortical mixed aphasia sx
fluency
naming
comprehension
129
Timeline of ddx aphasia
```
sec-min = vascular
hr-d = infection
d= inflammation
wk-mo = neoplasn
mo-yr = degenerative
```
130
Aphasia investigation
neuroimaging - Cat or MRI brain +/- LP, EEG, etc
131
Aphasia management
Underlying etiology tx
| supportive care - modified diet, SLP
132
```
Dysarthria based on localization - workup, tx
cerebral cortex
basal ganglion (hypophonation)
cerebellum (scanning speech)
brainstem (brainstem findings)
```
inv - neuroimaging (CT head, MRI brain)
+/- LP, serum tests
Tx re: cause
133
```
Dysarthria based on localization - workup, tx
isolated CN palsies
- CN VII
- CN IX/X (structural)
- CN CII (structural)
```
Inv - MRI brain, EMG/NCS
| Tx re: cause
134
Dysarthria based on localization - workup, tx
Motor neuron
(spastic/ hyper nasal), degenerative
Inv - diagnostic criteria and r/o other cause
Supportive care
135
Dysarthria based on localization - workup, tx
| NMJ (fatiguable) - MG
Tensilon/ice pack test, Anti-AchR antibody, etc.
- NCS with repetitive stimulation
- Single fiber EMG
MG management
136
Dysarthria based on localization - workup, tx
| Muscle - inflammatory, metabolic, drug/toxin induced, genetic
Inv - EMG/NCS, CK, etc
| Supportive care and tx curable cause
137
Dysarthria based on localization - workup, tx
| larynx/respiratory (hypo phonic)- structural
Inv - laryngoscopy, CXR, PFT, etc.
| consult ENT/pulmonary prn
138
Location of disease in movement disorders?
basal ganglia and/or cerebellum
139
Hyperkinetic movement disorder
abnormal movement disorders
| - dystonia, chorea, myoclonus, ballismus, tremor, tics
140
Hypokinetic movement disorder
lack/paucity of normal movement disorders
| - Parkinsonism
141
Tremor
rhythmic oscillation of a body part secondary to alternating or synchronous contraction of reciprocally innervated antagonistic muscles
142
Classification of tremors
- 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
Parkinsonism
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
Red flags re: Parkinsonism
symmetric symptoms
early postural instability or falls
impaired up gaze
poor response to Sinemet (carbidopa- levodopa)
145
Treatment hyperkinetic movement disorders
trial propranolol
lifestyle (less caffeine, EtOH)
Neurologist referral
146
Treatment hyperkinetic movement disorders
Parkinson disease = trial L-dopa
| neurologist referral if red flags
147
Wilson disease
- 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
Gait
manner of walking
| - coordination of vision, vestibular function, cerebellar function, sensory perception, and motor capabilities
149
Ataxia
impaired ability to coordinate muscular movements (axial and/or appendicular muscles involved)
150
Ddx gait dysfunction
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
Headache
pain anywhere in the head or neck
- > brain has NO nociceptors so does not feel pain
- > dura mater has nociceptors
152
Headache red flags
- 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
Secondary causes of headache - ddx, workup, management
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
Primary headache ddx
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
Transient loss of consciousness (TLOC)
transient loss of awareness and/or responsiveness caused by various mechanisms
156
Syncope
TLOC caused by reduced blood flow and O2 and glucose to the brain
157
Seizure
paroxysmal, abnormal and synchronous discharge of cortical neutrons, resulting in various semiologies
158
Epilepsy
chronic condition characterized by >2 unprovoked seizures
159
Inhibitory and excitatory neurotransmitters in seizures
```
inhibitory = GABA (decreased in seizures)
excitatory = glutamate (increased in seizures)
```
160
Ddx syncope
Hypovolemia
Hypotensive - vasovagal, drugs, dysautonomia
Cardiac - arrhythmia, contractility issue, inflow/ outflow obstruction
Metabolic - hypoglycaemia, anemia
Cerebrovascular - vertebrovascular disease, vasospasm
Multifactorial
161
Ddx seizure
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
Status epilepticus
- 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
Convulsive seizure
episode of abnormal muscle contraction, usually bilateral
164
Myoclonic seizure
sudden, brief (<100ms), involuntary contractions of muscles
165
Clonic seizure
prolonged, regular, repetitive movement, involving same muscle group, 2-3Hz
166
Tonic seizure
sustained muscle contraction lasting seconds to minutes
167
Tonic-clonic seizure
tonic phase followed by clonic phase
168
Atonic seizure
sudden loss of muscle tone lasting approx 1-2sec
169
Typical absence seizure
brief (sec) loss of consciousness without convulsions, with generalized 3Hz smile and slow waves on EEG
170
Atypical absence seizure
brief LOC without convulsions, abnormality of tone, 2Hz spike and slow waves on EEG
171
Seizure investigations
CBC, lytes, Ca, Mg, Cr, BUN, liver enzymes, TSH
- LP if suspicious of infection
- CT/MRI
- EEG
-> provoked vs. unprovoked
172
Seizure management
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
Mental status
Attention and arousal, as well as cognition and executive function
174
Altered mental status ddx
True altered mental status - dementia or delirium
| Mimic - depression, mania, psychosis, conversion, malingering
175
Delirium
acute change from baseline in attention and arousal and one or more cognitive domain that fluctuates
- organic cause
176
Coma
pathologic state of unarousable unconsciousness (symptom not diagnosis)
177
Ddx coma
- 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
Coma Workup
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
Concussion (mild traumatic brain injury)
immediate and transient loss of consciousness without macroscopic structural damage
180
Categorization head injury severity
- mild = GCS 13-15 with brief LOC or impaired cognition
- moderate = GCS 9-12 or LOC >5min
- severe = GCS 3-8
181
CPP equation
CPP = MAP - ICP
normal CPP >50mmHg
normal ICP <20mmHg
182
Signs of herniation
posturing, dilated and unreactive pupil
183
What CN palsy is common with increased ICP?
CNVI
184
Workup head trauma
trauma blood workup
CXR, lateral c-spine xr +/- pelvic xr
CT head if GCS <13 and re: CT head rules
185
Canadian CT Head Rule
| - adults with minor head injury who are not anticoagulated
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
Epidural hematoma
Hyperdense biconvex extra axial collection on CT
- no crossing suture lines
- often arterial (middle meningeal artery)
- LOC then lucid interval
- NSx
187
Subdural hematoma
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
Intraparenchymal hemorrhage/ contusion
patchy, ill-defined hyper density within brain parenchyma within edematous background; often in anterioinferior frontal or temporal lobes
- NSx
189
Traumatic subarachnoid hemorrhage
- hyper dense blood layer in sulci often adjacent to contusions or extra axial hemorrhages
- asymmetric (vs. aneurysmal SAH)
- NSx
190
Skull fracture
- irregular hypodense lines that are thin without branching (vs. vessels) and not along known sutures (coronal, sagittal)
- bone windowed CT
- NSx
191
Brain death
irreversible loss of function of brain, including brainstem
192
Brian death criteria
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
Organ donation
- 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
