Neurology -Panre Flashcards
No LOC, post traumatic amnesia and other symptoms resolve in < 30 minute when can the athletes return?
7 days
+ LOC , 1 minute or post-traumatic amnesia and other symptoms last > 30 minutes but < 1 week, when can athlete return to sport?
2 weeks if asymptomatic at rest and exertion for at least 7 days
MC cranial neuropathy (facial) nerve palsy associated with lyme dz?
Bell’s Palsy
Bells’s Palsy differentiates from TIA/STroke ?
If upper face is okay(able to wrinkle both sides of forehead ) its NOT bell palsy
How does bell palsy presents?
Sudden onset of ipsilateral hyperacusis 24-48 hours later =unilateral facial paralysis and taste disturbance 2/3
Weakness paralysis only affect’s face?
bell’s palsy
Is treatment need for Bell’s palsy ?
No, will resolve within 1month; but prednisone, artificial tears and acyclovir are used
When is prednisone used with Bell’s palsy
1st 72 hour onset
Idiopathic unilateral CNVII /facial nerve palsy ?
Bell
Bell’s + Zoster
Ramsey Hunt ; same side facial palsy, vertigo, some side hearing loss
Brain injury during perinatal or prenatal period
Cerebral palsy
Muscle tone & postural abnormalities?
Cerebral palsy
What are the 3 types of cerebral palsy?
spastic, syskinetic, ataxia (difficult with movt/speech
Tx for cerebral palsy?
pt, ot, antispasmotic benzondiapenzies, baclofen, cantrolene
Protrusions in the intracranial arteries due to thin or
absent tunica media or internal elastic membrane results in what of type of cerebral aneurysm?
Berry aneurysm, circle of willis
MC type of aneurysm?
Berry aneurysm, circle of willis
Enlargement of entire circumference of vessel results in type of aneurysm?
Fusiform:
Mycotic aneurysm is?
Due to infected emboli from endocarditis
What is Delirium (Level 1)
abrute transient confused state due to identifiable cause
Delirium (Level 1) is common in ?
high suspicion in elderly population,
What is Encephalitis (Level 1)
infection of brain (parenchyma)
Encephalitis (Level 1) Common culprits are?
1 HSV, arboviruses (West Nile, Zika, St Louis); also CMV,
toxoplasmosis, VZV, Borrelia , Rickettsia
Encephalitis (Level 1) s/s?
Altered mental status, fever, HA, seizure, confusion, lethargy, focal neuro
deficits (CN deficits, ↑ DTR)
Dx of encephalitis?
CSF evaluation by LP, CT/MRI may show mass effect
↑lymphocytes, ↑ protein and normal glucose in LP for encephalitis?
viral
Presence of RBC without trauma in LP for encephalitis?
suggesting HSV
tx of encephalitis
HSV encephalitis has ↑ morbidity (70% in untreated), start IV acyclovir at 1st
whiff of suspicion
○ Supportive care: Fluids, pain meds, seizure prophylaxis, airway management
Essential tremor is what type of inherited dz?
autosomal dominant, no genes have been identify
What is the onset age of Essential tremor
> 60
Essential tremor s/s
Postural bilateral tremor common to upper extremities and head
○ Worse with intentional movement and stress
■ Eg, finger to nose testing → tremor ↑ when approaching finger
Temporarily relieved by alcohol
○ No other PE/neuro findings
What is disorder is temporarily relived by alcohol?
essential tremor
Essential disorder presents with other PE/neuro finding true or false?
false
What is Guillain-Barré syndrome (Level 1)
Acquired inflammatory demyelinating polyradiculopathy of peripheral nerves
○ Nerve degeneration slows impulses causing weakness and paresthesias; inflammatory demyelination of many nerve roots in peripheral nerves which was obtained after infection/immunzation etc
What is the #1 cause Guillain-Barré syndrome (Level 1)
Campylobacter jejuni
How does Guillain-Barré syndrome (Level 1) presents?
CM: minimal weakness of legs to total paralysis of all 4 limbs, facial muscles and legs Ascending symmetric weakness/paresthesias
■ May involve muscles of breathing; with loss of reflexes
One critical complication of Guillain-Barré syndrome (Level 1) is?
Paralysis of chest muscles/diaphragm =respiratory failure
How is guillan-barre treated
Plasmapheresis, IVIG, respiratory support as needed
● Prognosis: Full recovery in 1 year ~ 60%
What Myasthenia graves?
Autoimmune peripheral nerve dz, 75% have thymic abnormality (hyperplasia or thyoma) or other autoimmune dz. May occur postpartum
Presents with muscle weakness that improve with rest and antibodies are directed against acetycholine receptors
Myasthenia graves
- Ocular weakness (1st presenting symptom) (dipolpia, ptosis, pupils are spared). 2. Follow with generalized muscle weakness and respiratory muscle weakness (may lead to respiratory failure?
Myasthenia graves; muscle weakness least in the am worsen with repeat muscl e use throughout they day, normal sensation/deep tendon reflexes
How to dx Myasthenia graves?
Acetylcholine receptor abx and + MuSK (muscle specific tyrosine kinase ) abx ; Edrophonium (tenilson test)
How to treated Myasthenia graves in non acute settings? in acute settings?
1st line management =Pyriodstigmine or Neostigmine. Plasmapheresis or IVIG for rapid response; Thymectomy if thyme
MOA of Pyridstigmine or Neostigmine?
Increases acetylcholine by decreasing acetylcholine breakdown
s/e of Pyridstigmine or Neostigmine?
abdominal cramps/diarrhea ; cholinergic crisis?
what is cholinergic crisis?
excess acetycholine due to ach-esterase inhibition=weakness, n, v, pallow, sweating, salivation, diarrea, miosis , bradycaria, respiratory failure
To distinguish between cholinergic crisis or myasthenia crisis what test is done?
Tensilon-if flaccid paraylsis improves with test=myasthenic crisis; if worsen with test=cholinergic crisis
What medications need to avoid during myasthenia crisis?
fluoroquinolone and ahminoglycosides
what is Lambert-eaton? How does it differ from MG?
Myasthenic syndrome, MC associated with small cell lung cancer, abs against presynaptic voltage-gated calcium channels prevents acetylcholine release. Difference between MG, weakness IMPROVES WITH REPEATED USE
What is #1 type of dementia?
Alzheimer Disease
Rf of alzheimer dz?
Age, FH, female gender, Down syndrome
Pathology of alzheimer dz?
Neuritic plaques with amyloid deposition and neurofibrillary tangles (tau protein)
What is alzheimer
Loss of brain cells, amyloid deposition (senile plaques) in the brain; Cholinergic deficiency causes memory, language changes, visuospatial changes. Normal reflexes
s/s of alzheimer dz?
1st symptom is memory loss of newly acquired information, progressive along
with disorientation, behavioral and personality changes
what is the 1st symptoms of alzheimer
memory loss
alzheimer is dx?
Clinical features of cognitive decline with no motor impairme. CT-scan: cerebral cortex, atrophy on CT scan
Tx of alzheimer includes?
ACh-esterase inhibitors: Donepezil-reverses cholinergic deficiency and symptoms (does not slow progression); Memantine may slow progression (add in mod-to severe). Anti psychosis for agitation
Memantine#
NMDA antagonist; blocks nmda receptor, slowing ca influx & nerve damage. Glutamate is an excitatory neurotransmitter of the NDMA receptor. Excitotoxicity causes cell death. NMDA antagonists reduces glutamate excitotoxicity. May be adjunctive
2 type of overall dementia after Alzheimer Disease
Vascular
What are the causes of #2 vascular dementia? Rf?
Chronic ischemia and multiple lacunar infarcts; age, HTN, DM2, h/o CVA
s/s of vascular dementia (2 types)
Cortical symptoms: Confusion, amnesia, speech and executive difficulties
○ Subcortical symptoms: Motor deficits, gait difficulties, personality changes
dx of vascular dementia?
Presence of dementia along with focal neurologic signs and symptom onset
either abrupt, stepwise or related to CVA; imaging may show evidence of old infarcts
tx of vascular dementia?
ACh-esterase inhibitors along with Memantine may be helpful
○ Risk factor management
What is Frontotemporal dementia
FTD; has been known as Pick’s disease; Group of neurodegenerative disorders characterized by changes in behavior,
personality, speech along with atrophy of frontal and temporal lobes
MC variant of Frontotemporal dementia
Behavioral variant FTD
s/s of Frontotemporal dementia
Disinhibition, significant behavioral and personality changes
early in disease, lack of empathy, apathy (PRESERVES VISUOSPATIAL)
DX & TX Frontotemporal dementia? RISKS?
Dx: Clinical, MRI/CT showing atrophy
● Tx: Symptomatic
FAMILY HX
What IS A common cause of early onset dementia onset 50-60’s ?
Pick’s dz
2nd most common cause of degenerative dementia after Alzheimer disease
Lewy Body Dementia
Risks of Lewy Body dementia?
Risks: Male gender, age
s/s of lewy body dementia?
- Physical and cognitive symptoms present around the same time
○ Parkinsonism: Bradykinesia, rigidity, tremor, shuffling gait
○ Visual hallucinations, attention and visuospatial deficits, REM sleep
behavior disorder, and memory loss
dx and tx of lewy dementia?
Dx: Clinical, imaging to r/o other causes, definitive dx on autopsy/brain biopsy
○ Diffuse abnormal neuronal protein deposits (Lewy bodies)
● Tx: Symptomatic, can try levodopa for parkinsonisms
normal CSF values
Opening pressure 5-20 cm H2O, protein 15-45 mg/dL,
glucose 50-80 mg/dL, WBC 0-5, RBC < 10
Bacterial Meningitis common culprits by age: <6 month, 6mo-60 yr; >60 y/o
<6 mo: Group B strep, Listeria monocytogenes
○ 6mo-60yr: Neisseria meningitidis (#1 in teens) (aka meningococcal
meningitis), Streptococcus pneumoniae (aka pneumococcal meningitis)
○ >60yr: S. pneumo, Listeria monocytogenes
Group B strep, Listeria monocytogenes meningitis is common in what age group
<6 mon
Neisseria meningitidis (aka meningococcal meningitis), Streptococcus pneumoniae (aka pneumococcal meningitis) is common in what age group?
6 mo-60 y/o
S. pneumo, Listeria monocytogene is common in what age group?
> 60 yr
RF of Bacterial meningitis?
Recent otitis media, sinusitis, crowded living conditions, sick contacts,
immunodeficiencies
s/s Bacterial meningitis?
Meningeal signs (headache, nuchal rigidity), fever/chills, nausea/vomiting, photosensitivity, altered mental status, seizure
PE of Bacterial meningitis?
PE: Positive Kernig’s sign → inability to straighten knee with flexed hip;
positive Brudzinski’s sign → passive flexion of neck causes active hip/knee
flexion
○ N. meningitidis associated with petechial rash esp <18yr
Bacterial meningitis is dx?
LP for CSF studies definitive diagnosis
■ Typical findings: ↑ WBC (100-100,000), > 80% PMNs, ↓ glucose
<40, ↑ total protein >100, ↑ CSF pressure, gram stain;
Head CT before LP to rule out mass effect if high risk (start empiric
antibiotics before scan)
tx of Bacterial meningitis
empiric antibiotics (up to 2 hours before LP); *nothing delays antibiotics; Age < 1 mo Ampicillin + (Cefotaxime or Gentamicin)
○ Age 1mo-60yr (Ceftriaxone or Cefotaxime) + Vancomycin to cover N.
meningitidis, S. pneumo
○ Age > 60yr Ampicillin + (Ceftriaxone or Cefotaxime) + Vancomycin
(Ampicillin to cover Listeria monocytogenes )
○ Dexamethasone ↓ hearing loss, mortality, neuro(15-20 mins prior of abs)
In bacterial menignitis, if dexamethasone is given, when it should be given?
Administer 15-20 min prior or with first dose antibiotics
■ No efficacy if antibiotics have already been administered
■ Discontinue if S. pneumo is determined not to be culprit
Should close contact of pt’s infected with meningococcal meningitis be given treatment?
Yes, prophylaxis ASAP with
Ciprofloxacin or Rifampin
Bacterial meningitis can be prevented with ?
Two vaccines
○ Quadrivalent covers serogroup A, C, Y, W135 given between 11-18yr
○ Serogroup B conjugate vaccine covers B given between 16-23y
What are the complications of bacterial meningitis?
Sensorineural hearing loss, seizures, brain abscess, focal neuro
deficits, coma, death
CSF: High IgG (oligoclonal bands)
Multiple sclerosis
CSF: Guillan Barre Syndrome
High protein with normal WBC/cell count
CSF:High protein with increased WBC (primarily polymorphnuclear neutrophils) decreased sugar
Bacterial meningitis
CSF: Normal glucose, increased WBCs (lymphocytes)
Aspectic meningitis (viral)
CSF: Decreased glucose, increased WBCs (lypmh)
fungal or TB meningitis
CSF: increased CSF pressure otherwise normal
Idiopathic intracranial htn
xanthocromia, blood in CSF
subarachnoid hemorrhage
What is Aseptic Meningitis
aka (viral )Clinical and lab evidence of meningeal inflammation with negative bacterial
cultures
Common causes of Aseptic Meningitis
1 viruses but also fungal ( cryptococcus, coccidiomycosis )
spirochetes (syphilis, Lyme), TB, medications (NSAIDs, TMP-SMX, IVIG,
antiepileptic drugs)
which meds result in Aseptic Meningitis
NSAIDs, TMP-SMX, IVIG,
antiepileptic drugs)
What viruses are Aseptic Meningitis
Enteroviruses (Echovirus, Coxsackie), Arboviruses (St. Louis,
West Nile), Mumps, HSV, HIV
Symptoms and signs of Aseptic Meningitis? How to differential from encephalitis
Headache, fever, lethargy, N/V meningeal signs but may not be as intense as
bacterial meningitis, normal cerebral function (differentiates from encephalitis
Aseptic Meningitis labs(csf opening pressure, glucose, protein,wbc)
Normal opening pressure, protein mildly elevated but
<100, Glucose normal, ↑ WBC(10-300) >50% lymphocytes, negative gram
stain
○ CT to r/o mass effect similar criteria to bacterial meningitis
tx of aseptic Meningitis
Tx: If unclear cause of meningitis, begin empiric antibiotics
○ Once confirmed viral, supportive care, IV fluids, antipyretics
○ Treat other causes as directed by ID specialist
● Viral meningitis usually self-limited course of 7-10 days
True or false is ascetic meningitis is self limited course?
true
What is a Migraine Headaches (Level 3)? common in men or women or more often?
Women > men, Vasodilation of blood vessels innervated by trigeminal nerve
sub types of Migraine Headaches (Level 3)
Migraine without aura and migraine with aura
s/s of Migraine Headaches (Level 3)? Possible auras?
Pain described as pulsatile/throbbing
○ + N/V
○ + photo/phonophobia
○ Worse with activity, sleep disturbances, alcohol, OCPs/menstruation
Usually last <60m before HA onset
■ Visual: Flashes, zig zags, scotomas (blind spots)
■ Verbal: Aphasia
tx of Migraine Headaches (Level 3)
- Symptomatic
■ Triptans (sumatriptan
Dopamine blockers (metoclopramide, promethazine)
IV fluids
■ Dark, quiet room - Prophylactic
■ 𝛃blockers, CCB, TCAs, anticonvulsants, NSAIDS
Triptans (sumatriptan) MOA? s/e? CI?
Serotonin agonists causing vasoconstriction
○ Adverse effects: Chest tightness, N/V
○ Contraindications: PVD/CAD, uncontrolled HTN,
pregnancy
Dopamine blockers should be given with?
Give with diphenhydramine to prevent EPS, dystonic reactions
What is MS? More common in male/female? Onset age? Incidence occurs in what population of the world?
Demyelinating inflammatory autoimmune disorder of the CNS
● Female to male 3:2
● Onset: 20-40yr
● Incidence ↑ with distance from equator
MS subtypes? Which has the best prognosis?
Subtypes:
○ Relapsing-remitting #1
■ Best prognosis
○ 1º progressive
■ Progressive decline without exacerbations
○ 2º progressive
■ Relapsing-remitting that becomes progressive
What is visual problems are common with MS?
Optic neuritis with unilateral diplopia, vision loss,
weakness/paralysis of eye muscles, Marcus-Gunn pupil
MS s/s ? Are symptoms worsen or decrease with pregnancy? How often do individuals relapse ?
Multiple neuro complaints separate in time and cannot be explained by a single
lesion. Affects motor, sensory and visual. Symptoms ↓ commonly with pregnancy
○ Relapses occur spontaneously q 1.5yr on average lasting for a few weeks
Sensory symptoms of MS? 2 signs?
Sensory symptoms in limbs/face, Uhthoff’s phenomenon
(symptoms transiently worsen with heat: showers, exercise, hot tubs),
Lhermitte’s sign (lightning shock type pain from spine down leg caused by
neck flexion)
Motor problems in MS?
Limb weakness, + Babinski, spasticity
How is MS dx? Imaging? Labs?
Clinical, MRI with gadolinium shows asymmetric, multiple white matter lesions
(Dawson fingers), ↑ oligoclonal IgG bands in CSF
MRI with gadolinium shows asymmetric, multiple white matter lesions
MS
Tx of MS? acute?
Acute exacerbations: IV steroids
○ Immunomodulators: 𝛃-interferon
○ Symptomatic
C5 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Shoulder abduction, elbow flexion with open palm
● Sensory: Lateral arm above elbow but below deltoid, axillary nerve
● Muscles: Deltoid, biceps
● Reflex: Biceps
C6 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Wrist extension
● Sensory: Thumb, radial side of hand
● Muscles: Brachioradialis, extensor carpi radialis
● Reflex: Brachioradiali
C7 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Elbow extension, wrist flexion
● Sensory: Radial side of fingers, digits 2-4
● Muscles: Triceps, flexor carpi radialis
● Reflex: Triceps
C8 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Finger flexion
● Sensory: Median nerve distribution
● Muscles: Flexor digitorum superficialis
L4 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Foot dorsiflexion
● Sensory: Medial aspect of lower leg
● Muscles: Tibialis anterior
● Reflex: Patellar
L5 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Big toe dorsiflexion, foot eversion
● Sensory: Dorsum of foot and lateral aspect of lower leg
● Muscles: Extensor hallucis longus, peroneus
s1 nerve roots affect what motor, sensory, muscle and reflex ?
Motor: Plantar flexion, hip extension
● Sensory: Plantar and lateral aspects of the foot
● Muscles: Gastrocnemius, soleus, gluteus maximus
● Reflex: Achilles
what is Radiculopathy (Level 2)
Disease of the nerve root
Symptoms on corresponding dermatome and myotome, most likely due to nerve
root compression
s/s Radiculopathy (Level 2)? common in part of the spine?
Pain, reflex changes, motor/sensory symptoms
● Common in cervical and lumbar spine
dx and tx radiculopathy (Level 2)
: Clinical, MRI, EMG
● Tx: NSAIDs, PT, address underlying process, possible surgery
what is Post-concussion syndrome (Level 2)
Common sequelae after mild TBI
○ May occur in up to 80% with mild TBI
s/s of Post-concussion syndrome (Level 2)
Headache, dizziness, fatigue, irritability, noise sensitivity, cognitive impairment
with concentration/memory, psych symptoms
dx of Post-concussion syndrome (Level 2)
Clinical, MRI if persistent disabling symptoms
tx of Post-concussion syndrome (Level 2)
Symptomatic; medications for headache (amitriptyline), counseling,
reassurance
Recovering typically within a few weeks to few months
what is Parkinson disease (Level 1)
Onset common 45-65yr
● Caused by idiopathic dopamine depletion
Lewy bodies are abnormal aggregates of protein inside nerve cells
○ Contributes to Parkinson dementia
s/s of Parkinson disease (Level 1)
Resting tremor: often #1 symptom
Pill rolling”
■ Worse at rest
■ Better with intentional movement (differentiates it from essential
tremor)
■ Starts on one side/one limb and may take years to progress
○ Bradykinesia: slowness of voluntary movements
■ Shuffling gait and lack of swinging arms with walking
○ Cogwheel rigidity: ↑ resistance to passive movements
○ Facial involvement: Fixed facial expressions, Myerson’s sign (tapping on
bridge of nose causes sustained blink)
○ Postural instability: Late finding, + pull test (stand behind patient and pull
arms → they will fall or step back)
○ Dementia: Late finding, 50%
treatment of Parkinson disease (Level 1)? which #1 tx for efficacy?
Medical management not used early when symptoms are mild
○ Levodopa/carbidopa: #1 treatment for efficacy
■ Levodopa converts to dopamine
]Bromocriptine, Ropinirole
Levodopa/carbidopa
Levodopa/carbidopa:
#1 treatment for efficacy. Levodopa converts to dopamine ■ S/E: N/V, dyskinesia
Dopamine agonist: Bromocriptine, Ropinirole
Stimulates dopamine receptors
■ Used for younger patients to delay use of Levodopa/carbidopa
What is Peripheral neuropathy (Level 2)? Dx? Tx?
Disorder of peripheral nervous symptoms
● Dx: Clinical, nerve conduction studies
● Tx: Treat underlying cause
what is Distal sensory polyneuropathy? Peripheral neuropathy
● “Stocking glove pattern” refers to symmetric sensory loss affecting distal UE and
LE
● Axonal neuropathies
○ Affect longest axons first so symptoms distal and move proximal
■ Usually does not affect hands until symptoms have progressed to
knees
Common causes of Peripheral neuropathy (Level 2)?
Diabetes Vitamin B12 deficiency ○ Syphilis ○ HIV ○ Lyme disease ○ Alcohol Abuse Chemotherapy
Diabetes neruopathy s/s? tx?
S/S: Symmetric polyneuropathy leading to burning pain, foot trauma,
ulcers and infections, “stocking glove pattern”
■ Tx: Amitriptyline, gabapentin
■ Preventive foot care
Radial nerve damage results motor and sensory deficit? common cause? Clinical feature?
Motor deficit: Wrist extension
○ Sensory deficit: Dorsal forearm and first 3 fingers
○ Common cause: Humeral fracture, Saturday night palsy
○ Clinical feature: Wrist drop
Median nerve damage results motor and sensory deficit? common cause? Clinical feature?
Motor deficit: Pronation, thumb opposition
○ Sensory deficit: Palmar surface of first 3 fingers
○ Common cause: Carpal Tunnel syndrome
○ Clinical feature: Flat thenar eminence
Ulnar nerve damage results motor and sensory deficit? common cause? Clinical feature?
Motor deficit: Finger abduction
○ Sensory deficit: Palmar and dorsal surfaces of last 2 fingers
○ Common cause: Elbow dislocation
○ Clinical feature: Claw hand
peroneal nerve damage results motor and sensory deficit? common cause? Clinical feature?
Motor deficit: Dorsiflexion, eversion
○ Sensory deficit: Dorsal foot and lateral leg
○ Common cause: Knee dislocation, fibular trauma
○ Clinical features: Foot drop
axillary nerve damage results motor and sensory deficit? common cause? Clinical feature?
Motor deficit: Arm abduction
○ Sensory deficit: ↓ sensation over the deltoid
○ Common cause: Anterior shoulder dislocation
Muscles innervated Oculomotor nerve (CN III)
(motor) 1. Extraocular muscles innervated by CN III are superior rectus (SR), inferior rectus (IR), medial rectus (MR), and inferior oblique (IO) 2. Levator palpebrae superioris 3. Ciliary muscle 4. Sphincter pupillae
Deficit of Oculomotor nerve (CN III) lesion is seen how?
- Diplopia
- Ptosis
- Loss of accommodation (Outward and downward deviation)
- Pupillary involvement
in: a. compressive lesions the pupil becomes dilated and non-reactive
b. in ischemic lesions (e.g., diabetes mellitus) the pupil is spared
Deficit of Cranial Nerve II
(sensory) partial or complete blindeness-optic nerve
Deficit of Cranial Nerve 1
(sensory)Loss of smell - CN I = Olfactory nerve
Muscles innervated cranial nerve IV
Trochlear nerve -Superior oblique
Deficit of cranial nerve IV
Difficulty looking down
Head tilt away from the side of the lesion
Muscles innervated cranial nerve V3
(Both) Trigeminal.
1. Muscles of mastication include masseter, temporalis
lateral and medial pterygoid
2. Anterior belly of the digastric muscle
3. Mylohyoid muscle
4. Tensor palati
5. Tensor tympani
Deficit of cranial nerve V3
Jaw deviation towards the side of the lesion
Muscles innervated (CN VI)
Abducens nerve-Lateral rectus
Deficit of cranial nerve (CN VI)
Abducens nerve-Horizontal diplopia
Muscles innervated CN VII
- Muscles of facial expression
- Posterior belly of digastric muscle
- Stylohyoid muscle
- Stapedius muscle
Deficit of CN VII
Bell’s palsy
Loss of blink reflex
Hyperacusis (when the stapedius is involved)
CT head without contrast based on clinical criteria for concussion?
Based on 3 validated criteria: Canadian CT head rules (CCHR), New
Orleans criteria (NOC), National Emergency X-Radiography
Utilization Study II (NEXUS II) combined for following list
GCS < 15, 2 hours post injury
● Suspected skull fracture (scalp lacs, bony step off)
● Suspected basilar skull fracture (hemotympanum, raccoon
eyes/periorbital bruising, battle sign/retroauricular bruising,
otorrhea/rhinorrhea
● > 2 episodes of emesis
● New neuro deficit
● Known anticoagulation use or bleeding disorder
● Age > 60yr
● Retrograde amnesia >30 min before event
● High impact mechanism of injury (ped vs car, fall ≥ 3 ft/down ≥
5 stairs, MVC)
● Intoxication
Seizure disorder (Level 1)-Subtypes
Partial (focal): Confined to small brain area; can progress to general
○ Generalized: Diffuse brain involvement, both hemispheres
● R/o systemic causes with complete labs
Partial seizures(2 kinds)
Simple partial and complex partial
What is Simple partial?
Uncontrollable twitch in thumb that
patient is fully conscious of
Simple partial presents?
CONSCIOUSNESS NOT IMPAIRED
○ Symptoms are FOCAL SENSORY, MOTOR OR AUTONOMIC
■ Sensory: Numbness, heat, cold, olfactory, paresthesias
■ Motor: Jerky, rhythmic movements in affected area, spread is called
“Jacksonian March”
■ Autonomic: Sinus tachy, abd pain/N/V
Postictal focal neuro deficit: Todd’s paralysis, resolves w/in 24hrs
what is Complex partial?
Lip smacking with impaired
consciousness followed by confusion
How does complex partial presents?
Consciousness impaired
○ Temporal lobe involvement 70-80%
○ Aura common
○ EEG: Interictal spikes with waves in temporal area
○ Postictal confusion, amnesia, disorientation common
EEG results for partial ?
Focal
EEG results for complex partial ?
Interictal spikes with waves in temporal area
Complex partial dx? Tx?
May need CT/MRI to r/o focal lesion
● Tx: Same as Tonic-Clonic
Levetiracetam, phenytoin, carbamazepine, phenobarbital, valproic acid
■ Phenobarbital in kids
■ Phenytoin testable SE: Gingival hyperplasia, SJS, hirsutism
CVA-2 types
Ischemic-interruption of blood supply
Hemorrhagic : rupture of blood vessel or ban vascular structure
Risk factors
Age + 3 amigos (htn, dm , hld)+ smoking + afib + hx of prior stroke or TIA
Hemorraghic stroke
“HA-most common symptom” vs ischemic, other symptoms typical-slurred speech, face drooping, arm weakness
