Neurology Precision & Pearls #1 Flashcards
Describe a tension headache.
What is the treatment for this type (the MC type of primary headache)?
Bilateral, band-like, nonpulsatile steady headache. Worse with stress, fatigue, noise, glare. Not worse with routine activity. No auras.
NSAIDs, local heat
Describe a migraine headache.
Explain what an aura is, what the most common type of aura is, and some things that make migraines worse.
Lateralized, pulsatile headache with nausea/vomiting, photophobia, phonophobia.
Worse with routine activity, alcohol, and hormones.
Auras: focal neurologic symptoms that last < 1 hour. Visual auras are the MC type.
Treatment for migraines (symptomatic AND prophylactic)
Symptomatic (abortive): NSAIDs, Acetominophen, Aspirin. Triptans or Ergotamines.
–Dopamine blockers (Metoclopramide, Promethazine) given with Diphenhydramine to prevent extrapyramidal symptoms. IVF and place patient in a dark/quiet room.
Prophylactic: BB or CCB (first line). TCAs, Anticonvulsants (Valproate, Topiramate), NSAIDs
Explain the MOA of Triptans and some adverse effects of these medications
Triptans, such as Sumatriptan and Zolmiatriptan, are serotonin agonists that cause vasoconstriction and block the pain pathway.
Adverse Effects: chest tightness, nausea, vomiting, malaise
What are cluster headaches? Explain them and what they feel like.
What is it also associated with?
Multiple high intensity headaches with brief duration. Worse at night and with alcohol/stress/foods.
Unilateral, severe periorbital or temporal pain lasting < 2 hours and then resolving. Nasal congestion, rhinorrhea, conjunctivitis.
Horner’s Syndrome: miosis, ptosis, anhidrosis.
Treatment for cluster headaches
What can be given as prophylaxis (specific medication)
100% oxygen
Verapamil for prophylaxis
What imaging, if any, is done for a headache?
CT is first line
If negative, then an LP looking for blood or xanthochromia (SAH)
4-vessel angiography after confirmed SAH
What is the hallmark exam finding of a patient with a postdural puncture headache?
Postural headache that worsens with sitting/standing and improves when supine
Treatment for a postdural puncture headache
Bed rest, hydration, caffeine
Epidural blood patch (headache gone in seconds) if conservative management fails
A subarachnoid hemorrhage is MC due to what? This occurs at what artery?
Name two significant risk factors for a SAH.
a ruptured berry aneurysm at the anterior communicating artery
Smoking and hypertension
Explain the symptoms of a subarachnoid hemorrhage.
What is Kernig Sign?
What is Brudzinski Sign?
Sudden, intense thunderclap headache that is unilateral and described as the “worst headache of my life.”
The patient may also have meningeal signs: nuchal rigidity, etc.
Kernig Sign: extension of knee = neck pain.
Brudzinski Sign: hips/knees flex when neck flexes
Imaging and diagnostics that are done for a subarachnoid hemorrhage?
CT scan without contrast (initial)
If CT negative, do LP to look for blood or xanthochromia (yellow to pink CSF due to breakdown of RBC’s)
Treatment for a SAH
-Supportive: bed rest, stool softeners
-Nimodipine: reduces cerebral vasospasms
-Nicardipine, Labetolol: lower BP
-Decrease ICP: Mannitol, head elevation
-Surgical: endovascular coiling or clipping to prevent rebleeding
Ischemic strokes are the MC type of stroke. What is the MC etiology for this type of stroke? Name the biggest risk factors.
Embolic cause is the MC cause
Hypertension (biggest RF), smoking, makes, DM, A-fib, family history
What are some things you should look for on exam and in the history of a patient with a suspected stroke?
Look for hemiparesis, hemiplegia, gait ataxia, heck vision, check for hemianopsia, urinary incontinence, vertigo, nystagmus, diplopia, focal neuro symptoms, meningeal symptoms
-Neglect to one side of the body, impaired speech, personality changes, confusion, hallucinations, double vision, etc.
With a stroke, the patient can have anterior circulation symptoms or posterior circulation symptoms. Describe them both.
Anterior: contralateral arm/leg weakness and sensory deficits. Contralateral homonymous hemianopsia. Facial drooping, slurred speech, etc.
Posterior (V’s): vertigo, visual changes, vomiting. Nystagmus, nausea, coma.
What’s the best initial diagnostic to rule out hemorrhagic cause of stroke?
However, what is the most accurate diagnostic?
CT head without contrast (may be negative in the first 6-24 hours)
MRI brain = most accurate
Immediate management of a patient with a stroke
-If within 3 hours of symptom onset: Alteplase (if no bleeding disorder)
-Mechanical thrombectomy within 24 hours of symptom onset and if anterior circulation affected.
However, if the symptom onset of a stroke is 3-4.5 hours ago, what is the treatment?
Aspirin and long-term management
Long-term management: Antiplatelet therapy (Aspirin, Clopidogrel, Dipyridamole)
-Also initiate statin therapy regardless of LDL level
The Middle Cerebral Artery is the MC artery involved in a stroke.
Name the symptoms of this artery being involved.
-Contralateral sensory/motor deficits greater in the face and arm
-Involves lower half of face (can raise forehead)
-Contralateral homonymous hemianopsia.
-Gaze preference toward side of lesion
-Dominant hemisphere (left MC): aphasia (Broca - expressive or Wernicke- sensory), math comprehension
-Nondominant hemisphere (right MC): flat affect, impulsivity, impaired judgment, no insight, neglect of other side
With an anterior cerebral artery (ACA) stroke, what symptoms would you expect?
-Contralateral sensory/motor deficits greater in the leg/foot.
-Face is usually spared.
-urinary incontinence
-Contralateral homonymous hemianopsia
-Personality and cognitive deficits
With a posterior cerebral artery (PCA) stroke, what symptoms would you expect?
Think of V’s for vertebral
-Vertigo with nystagmus
-Vomiting
-Vision changes
With a vertebrobasillar artery stroke, what symptoms would you expect?
-“Crossed symptoms”
–Ipsilateral cranial nerve deficits with contralateral motor/sensory deficits
–Diplopia, dizziness, vomiting, ataxia
–Asymmetric but bilateral deficits!!!!
Remember, one side face, other side body.
What’s the pneumonic to remember the order of the cranial nerves?
Name them.
Only one of the two athletes felt very good victorious and healthy
I (Olfactory), II (Optic), III (Oculomotor), IV (Trochlear), V (Trigeminal), VI (Abducens), VII (Facial), VIII (Vestibulocochlear), IX (Glossopharyngeal), X (Vagus), XI (Accessory), XII (Hypoglossal)
What is the pneumonic to remember motor/sensory in the cranial nerves?
Describe the sensory and motor functions of each nerve.
Some say money matters but my brother says big butts matter more
-Olfactory: smell
-Optic: pupillary light reflex, VA, VF
-Oculomotor: inferior rectus muscle
-Trochlear: superior oblique rectus
-Trigeminal: muscles of mastication, light touch to three divisions of nerve
-Abducens: lateral rectus muscle
-Facial: muscles of facial expression, taste (anterior 2/3 of tongue) and external ear
-Vestibulocochlear: hearing, balance, proprioception
-Glossopharyngeal: swallow/gag reflex, taste (posterior 1/3 of tongue)
-Vagus: voice/gag reflex, relays to brain about organs
-Accessory: shoulder shrug, turn head
-Hypoglossal: tongue (inspect for asymmetry)
What is a transient ischemic attack (TIA)?
What are some symptoms of this condition, including Amaurosis Fugax?
Transient neurologic symptoms lasting < 24 hours without acute infarction
Symptoms resemble a stroke: carotid bruits, most resolve within 1 hour.
Amaurosis Fugax: transient monocular vision loss
What diagnostic is done initially for a TIA?
What other imaging studies are done for a TIA?
CT scan initially to rule out intracranial hemorrhage
Carotid doppler, CT angiography. Echocardiogram, Coagulation studies.
Angiography is definitive.
Treatment for TIA
(Noncardiogenic vs cardiogenic)
-Supine position
-Do NOT lower BP unless > 220/110
-Antiplatelet therapy if noncardiogenic in nature (Aspirin, Clopidogrel)
-Oral anticoagulation if cardiogenic
When should a carotid endarterectomy be done for a TIA?
If stenosis is 50-99%
How do you test for a Cranial Nerve XI (Accessory Nerve) disorder?
Tested with head rotation and shoulder elevation against resistance.
-Patient may be unable to turn head from lateral to neutral against resistance from either side and inability to raise shoulders against resistance if damage to accessory nerve)
What percentage of patients with a TIA will have a CVA within the first 24-48 hours afterwards?
50%
What is a Bell Palsy? Although idiopathic, what MAY it be related to?
Unilateral cranial nerve VII (Facial nerve) palsy leading to hemifacial weakness and paralysis.
May be related to HSV reactivation.
Symptoms of a Bell Palsy
-Sudden onset of ipsilateral hyperacusis (ear pain), unilateral facial weakness or paralysis INVOLVING the forehead
-Taste disturbance
-Inability to fully close eyelid
-Weakness/paralysis that only affects the face
Treatment for Bell Palsy
-Supportive: artificial tears. May tape the eye shut at night
-Prednisone: if within 72 hours of symptom onset reduces time of recovery
-Acyclovir +/- steroids in severe cases
What should you tell a patient with a Bell Palsy in regards to recovery and expectations?
-Function returns in 2 weeks with significant improvement within 4 weeks with or without treatment
-May want to tape eye shut at night and use eye drops for dry eyes
When is a bilateral Bell Palsy found?
if related to Lyme disease!
Symptoms of diabetic peripheral neuropathy
-Progressive distal sensory loss in a stocking glove pattern (involving distal lower extremity first) and progressing to hands
-Decreased ankle reflexes
-Gait abnormalities
-Foot ulcer formation
-Autonomic complications (gastroparesis, sexual dysfunction, orthostatic hypotension)
Treatment for diabetic peripheral neuropathy
-Glucose control!
-Pregabalin and Duloxetine are first line!
Explain the pathophysiology of Guillain-Barre’ Syndrome
Autoantibody attacks the myelin sheath of nerves after an infection
What are some common etiologies and things you should remember that can cause Guillain-Barre Syndrome?
-Increased incidence with Campylobacter Jejuni or other GI or respiratory infections
-Immunizations!
-HIV
Symptoms of Guillan-Barre Syndrome (Remember GBS)
Ground to brain symptoms (ascending weakness), usually symmetric. Pain and paresthesias.
May develop weakness of respiratory muscles and bulbar muscles (swallowing difficulty)
Lower motor neuron signs: Decreased DTR’s, flaccid paralysis, sensory deficits, autonomic dysfunction
What diagnostics should be done for GBS?
Which is the most specific?
Nerve conduction/EMG (most specific)
CSF analysis: high protein, normal WBC
PFT
Treatment for Guillan-Barre Syndrome?
Plasmapheresis or IVIG
Mechanical ventilation if respiratory failure
What is the pathophysiology of Myasthenia Gravis?
75% of patients with this condition have an abnormal ______.
It occurs in who?
Autoantibodies against acetylcholine receptors on the muscles, leading to weakness at the neuromuscular junction
Abnormal thymus gland
Occurs in young women and older men
Symptoms of Myasthenia Gravis
“Strongest in morning, weakest at night”
–Generalized weakness worse with use and better with rest
–Ocular weakness (diplopia, ptosis)
–Pupils of the eyes are spared
–Bulbar weakness
–Respiratory muscles weakness –> failure
What diagnostics are done for Myasthenia gravis (including the antibody testing, imaging, etc.)
-Acetylcholine receptor antibodies (AChR-Ab) = initially
-MuSK Ab if acetylcholine negative
-EMG most accurate
-CXR, CT, MRI to check thymus gland
-Edrophonium (Tensilon) Test: brief improvement after IV edrophonium given.
-Ice pack test: ocular symptoms are improved when ice pack is placed on eye for 10 minutes.
Treatment or Myasthenia Gravis
1) Acetylcholinesterase Inhibitors: Pyridostigmine or Neostigmine (first line)
2) Immunosuppression or myasthenic crisis (trouble breathing): Plasmapheresis or IVIG
3) Thymectomy if thymoma
What classes of medications should be avoided in a patient with Myasthenia Gravis because they can exacerbate symptoms?
Beta Blockers
Aminoglycosides (-mycin)
Fluoroquinolones (-oxacin)
What is the pathophysiology of Lambert-Eaton Syndrome?
What is this condition COMMONLY associated with?
Antibodies against presynaptic voltage-gated calcium channels to prevent acetylcholine release –> muscle weakness
Small cell lung cancer!
Symptoms of Lambert-Eaton Syndrome
-Proximal muscle weakness that improves with use (unlike MG)
-Autonomic symptoms (dry mouth, ED, ortho hypotension)
-Hyporeflexia, sluggish pupillary response (unlike MG)
What diagnostics are done for Lambert-Eaton Syndrome (think of the pathophysiology)
-Voltage-gated Calcium channel antibody assay
-EMG confirmatory
-CT scan to assess for lung malignancy due to high association
Treatment for Lambert-Eaton Syndrome
-Treat malignancy
-Pyridostigmine (initial)
-Plasmapheresis or IVIG if severe or refractory to first-line medication
Aseptic (Viral) Meningitis is MCC by what?
What are the symptoms of this condition and what does it NOT include?
Enteroviruses (Coxsackievirus and Echovirus)
H/a, fever, stiffness, photosensitivity, nuchal rigidity, positive Kernig and Brudzinski signs
-No focal neurologic deficits
What does CSF examination after LP show for aseptic (viral) meningitis?
Normal glucose
Lymphocyte Predominance
Protein < 200
Treatment for aseptic (viral) meningitis?
Supportive
What are the common etiologies/bacteria of bacterial meningitis for the following age groups?
-In adults, and in general
-In older kids (ages 10-19)
-In Neonates < 1 mos & infants < 3 mos
-Neonates, > 50, immunocompromised
-Strep Pneumo (in general, and MCC in adults)
-In older kids: Neisseria Meningitidis
-Group B Strep
-Listeria Monocytogenes
Symptoms of bacterial meningitis and what DOES it include?
-Meningeal signs
-Focal neuro symptoms: AMS, seizures, etc.
A LP and CSF examination is the definitive diagnostic for bacterial meningitis. What should you expect to see in regards to this test?
-Low glucose, increased neutrophils, increased protein, increased pressure
When should you perform a head CT scan prior to an LP with bacterial meningitis?
-Only if you need to rule out mass if they have seizures, confusion, papilledema, > 60 years old, history of CNS disease, or are immunocompromised
Management for bacterial meningitis. You should give ABX + Dexamethasone. What ABX should you give for the following age groups?
1) Neonates up to 1 month old
2) > 1 month - 50 years old
3) > 50 years old
1) Ampicillin + Gentamicin/Cefotaxime
2) Vancomycin + Ceftriaxone
3) Vancomycin + Ceftriaxone + Ampicillin (to cover for Listeria)
Furthermore, what advice should be given to those with Neisseria Meningitidis? What kind of bacteria is this bacteria?
-Droplet precaution for 24 hours
-Rifampin or Ciprofloxacin for close contacts for prophylaxis
-Gram negative diplococci
With Fungal or TB Meningitis, what should you expect to see on LP/CSF exam?
-Low glucose, mostly lymphocytes, high protein, +/- high pressure
What three vaccines can help prevent meningitis?
When is the meningitis vaccine given?
Hib, Pneumo vaccine, Meningitis vaccine (> 55 years old or asplenia)
