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Neurology > Neurology Step Up to Medicine > Flashcards

Neurology Step Up to Medicine Flashcards

1
Q

reversible ischemic neurologic deficit

A

same as TIA but sx last longer than 24 hours, but resolve w/in 2 weeks

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2
Q

evolving stroke

A

stroke with worsening sx

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3
Q

completed stroke

A

stroke in which maximal deficit has occured

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4
Q

TIA

A

transient neurological deficit that lasts from minutes to no more than 24 hours (usually resolves w/in 30 min)

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5
Q

MCC of TIA

A

embolic

- can also be due to transient hypotension in the presence of severe carotid stenosis (> 75%)

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6
Q

what is the relationship between TIA and risk for stroke

A

risk of stroke in pt with previous TIA is about 10% per year with a 30% 5-year stroke risk

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7
Q

most impt RF for stroke

A

age

HTN

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8
Q

RFs for stroke in younger pts,

A

OCP use
hypercoagulable states - protein C/S deficiency, antiphospholipid syndrome
vasoconstrictive drug use - cocaine, amphetamine
polycythemia vera
sickle cell dz

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9
Q

MC origins of embolus in embolic stoke

A

heart - mural thrombus
internal carotid artery
aorta
paradoxical

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10
Q

artery most commonly affected by atherosclerosis in brain

A

middle cerebral artery

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11
Q

what structures does a lacunar stroke affect?

A

basal ganglia
thalamus
internal capsule
brain stem

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12
Q

main predisposing factor for lacunar strokes

A

HTN

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13
Q

how do you evaluate the source of embolic stroke?

A
  1. echo
  2. carotid doppler
  3. ECG/Holter monitoring
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14
Q

Most common location of stroke and assoc. findings

A

MCA

  • contralateral hemiparesis/hemisensory loss
  • aphasia (dom. hemisphere)
  • apraxia, CL body neglect and confusion (non-dom. hemisphere)
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15
Q

signs/symptoms of a TIA of the carotid system

A
  1. temporary loss of speech, paralysis/paresthesias of CL extremity, clumsiness of one limb
  2. amaurosis fugax
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16
Q

amaurosis fugax

A

transient, curtain-like loss of sight in ipsilateral eye due to microemboli to the retina

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17
Q

signs/sx of Vertebrobasilar TIA

A

decreased perfusion of posterior fossa leading to:

  • dizziness, double vision, vertigo
  • numbness of ipsilateral face and CL limbs
  • dysarthria, dysphagia and hoarseness
  • projectile vomiting
  • headaches
  • drop attacks
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18
Q

subclavian steal syndrome

A

caused by stenosis of subclavian artery proximal to origin of vertebral artery - exercise of left arm causes reversal of blood flow down ipsilateral vertebral artery to fill subclavian aa distal to stenosis -> get signs of vertebrobasilar arterial insufficiency

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19
Q

sx. of subclavian steal syndrome

A
  • BP differential in arms (left arm < right arm, decreased pulse in left arm)
  • neuro deficits
  • UE claudication
  • presyncope/syncope
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20
Q

classic presentation of thrombotic stroke

A

pt awakens from sleep with neurological deficits

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21
Q

classic presentation of embolic stroke

A

onset is very rapid (w/in seconds) and deficits are maximal initially

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22
Q

four major syndromes of lacunar stroke

A
  1. pure motor stroke (IC)
  2. pure sensory stroke (thalamus)
  3. ataxis hemiparesis (incoordination ipsilaterally)
  4. clumsy hand dysarthria
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23
Q

deficits seen in ACA stroke

A

contralateral lower extremity
hemiparesis/hemisensory loss
urinary incontinence

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24
Q

deficits seen in MCA stroke

A

aphasia- dominant side
contralateral hemiparesis: upper extremity/face
hemineglect- nondominant
homonymous hemianopia w/ macular sparing

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25
Q

deficits seen in vertebrobasilar stroke

A

ipsilateral: ataxia, diplopia, dysphagia, dysarthria and vertigo
contralateral: homonymous hemianopia (basilar-PCA lesions)

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26
Q

what is the first test you order if pt presents with stroke symptoms

A

non-contrast CT scan

  • R/O hemorrhage
  • ischemic strokes appear darker on CT scan
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27
Q

what is the definitive test for dx. stenosis of vessels of head/neck and aneurysms

A

magnetic resonance arteriogram

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28
Q

what are the uses of head CT in the ED?

A
  • diff ischemic vs. hemorrhagic stroke
  • identifies > 95% of SAH
  • identifies abscesses/tumors
  • identifies epidural and subdural hematomas
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29
Q

who should be screened with a carotid duplex study?

A

patients with:

  • carotid bruit
  • peripheral vascular dz
  • coronary artery dz
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30
Q

what are the tests that should be ordered with pt presents to ED with symptoms of acute stroke?

A
  • non contrast head CT
  • EKG, CXR
  • CBC, platelet count, PT/PTT, electrolytes, glucose
  • bilateral carotid USG
  • ECHO
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31
Q

if a young pt (< 50 yo) presents with stroke, what should you look for?

A

vasculitis, hypercoagulable state and thrombophilia

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32
Q

indications for tPA

A

within 3 hours of symptom onset

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33
Q

contraindications to tPA

A
  • if time is unknown or > 3 hours
  • uncontrolled HTN
  • bleeding disorder
  • tx with anticoagulants
  • hx of recent trauma/surgery
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34
Q

if giving pt tPA, what should be BP level be maintained at?

A

< 185/110 mmHg

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35
Q

if pt presents after 3 hours of sx onset what drug is indicated?

A

Aspirin

- clopidogrel or ticlopidine if pt cannot take aspirin due to allergy or intolerance

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36
Q

role of anticoagulants in stroke tx.

A

heparin/warfarin have not been proven to have efficacy - therefore, not given in acute setting
- unless stroke is due to emboli from a cardiac source

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37
Q

under what conditions do you give anti-hypertensives in stroke pt?

A
  1. BP is > 220/120 or MAP > 130 mmHg
  2. pt has signifcant medical indication for it i.e. acute MI, aortic dissection, CHF, hypertensive encephalopathy
  3. pt is receiving thrombolytic therapy
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38
Q

indications for carotid endarterectomy

A

if pt is symptomatic and has carotid stenosis > 70%

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39
Q

Main causes of intracerebral hemorrhage

A 
HTN - sudden increases
ischemic stroke
amyloid angiopathy
anticoagulant/antithrombolytic drugs
brain tumors
AV malformations
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40
Q

MC locations of intracerebral hemorrhage

A

basal ganglia (MC)
pons
cerebellum
cortex

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41
Q

CF of intracerebral hemorrhage

A

abrupt onset of a focal neuro deficit that worsens steadily over 30-90 min with altered LOC, headache, vomiting and signs of ICP

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42
Q

pupillary findings in ICH and their level of involvement..(3)

A

pinpoint = pons
poorly reactive = thalamus
dilated = putamen

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43
Q

threshold for BP treatment in ICH

A

give antihypertensive if BP is > 160-180/105 mmHg

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44
Q

DOC for BP management in ICH

A

nitroprusside

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45
Q

should you use steroids to reduce ICP in ICH?

A

no..use of steroids can be harmful in hemorrhage

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46
Q

causes of SAH

A
  • ruptured berry aneurysm
  • trauma
  • AVM
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47
Q

common sites of SAH

A
  • junction of anterior comm. aa with ACA
  • junction of posterior comm. aa with ICA
  • bifurcation of MCA
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48
Q

CF of subarachnoid hemorrhage

A

sudden, severe excruciating headache in absence of focal neuro deficits
transient LOC
vomiting
meningeal irritation, nuchal rigidity and photophobia
retinal hemorrhages

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49
Q

diagnostic test of choice for SAH

A

non contrast CT scan of head

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50
Q

if CT scan is non-equivocal in dx of SAH, what test should you do?

A

Lumbar puncture

- unless there is papilledema in which case repeat the CT scan

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51
Q

gold standard for diagnosis of SAH

A

xanthochromia on LP

- results from RBC lysis; implies blood has been in CSF for several hours and that it is not due to traumatic tap

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52
Q

once SAH is diagnosed, what test do you order?

A

cerebral angiogram

- definitive study for detecting site of bleeding and for surgical clipping

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53
Q

complications of SAH

A
  1. rebleeding
  2. vasospasm
  3. seizures
  4. communicating hydrocephalus
  5. SIADH
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54
Q

what drug is used to reduce incidence/infarction due to vasospasm in SAH?

A

CCB - nifedipine

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55
Q

medical therapy of SAH

A
  • bed rest in quiet dark room
  • stool softeners
  • analgesics
  • IVF for hydration
  • BP meds (lower gradually)
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56
Q

major pathophys of Parkinsons dz

A

loss of DA-containing neurons located in the pigmented substantia nigra and the locus ceruleus in the midbrain

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57
Q

CF of Parkinson’s dz

A
  1. pill rolling tremor at rest (worse w/ emotional stress)
  2. cogwheel rigidity
  3. bradykinesia
  4. postural instability
  5. masked facies, decreased blinking
  6. dysarthria and dysphagia, micrographia
  7. dementia later in dz
  8. autonomic dysfunction - orthostatic hypotension, increased sweating
  9. personality changes
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58
Q

Shy-Drager syndrome

A

Parkinsonian symptoms AND autonomic insufficiency

widespread neurological signs (cerebellar, pyramidal, LMN)

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59
Q

most effective drug for tx of parkinsonian symptoms

A

carbidopa-levodopa (Sinemet)

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60
Q

side effects of sinemet

A
  • dyskinesias (involuntary, choreic movements) can occur after 5-7 years of therapy
  • NV, anorexia
  • HTN
  • Hallucinations
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61
Q

what DA-R agonists are used in tx of Parkinsons?

A

bromocriptine

pramipexole - MC used

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62
Q

what are DA-R agonists esp. useful for in tx of PD?

A
  • sudden episodes of hesitancy or immobility (“freezing”)

- can control initial symptoms and delay need for levodopa for many years

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63
Q

Selegeline

A

MOA-B inhibitor (increases DA activity and reduced levodopa metabolism); used as an adjunctive agent in tx of PD, usually in early dz

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64
Q

amantadine

A

antiviral agent used to tx. early or mild parkinsons disease

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65
Q

what anticholinergic drugs can be used in tx of Parkinsons

A

trihexiphenidyl

benztropine

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66
Q

what is the major benefit of anticholinergic drugs as tx of PD?

A

mostly help with tremor symptoms

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67
Q

what antidepressant can be used to tx both Parkinsonian symptoms and depressive symptoms of PD?

A

amitryptiline

- both anticholinergic and antidepressant

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68
Q

what are indications for deep brain stimulation as tx of PD?

A

if pt is unresponsive to medications OR pt develops severe dz before age of 40

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69
Q

progressive supranuclear palsy

A

degenerative condition of brain stem, basal ganglia and cerebellum that causes bradykinesia, rigidity, cognitive decline and opthalmoplegia; it does not cause tremor

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70
Q

does tremor or bradykinesia as the major symptom impart better prognosis in PD

A

tremor

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71
Q

what medications cause parkinsonian side effects

A
  1. neuroleptics - chlorpromazine, haloperidol, perphenazine
  2. metoclopramide
  3. reserpine
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72
Q

pathophys of Huntingtons chorea

A

AD mutation on Xm4 causing extended triple repeat (CAG) leads to loss of GABA-producing neurons in striatum

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73
Q

what should you always keep in mind in a young patient who develops a movement disorder?

A

Wilson’s disease

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74
Q

CF of Huntington’s chorea

A
  1. chorea
  2. altered behavior - irritability, personality changes, antisocial behavior, depression, psychosis
  3. progressive dementia
  4. unsteady and irregular gait
  5. incontinence
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75
Q

diagnosis of Huntington’s

A

MRI will show atrophy of head of caudate; DNA testing confirms the diagnosis

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76
Q

Tx of Huntington’s

A

supportive

  • DA blockers may improve psychosis and chorea
  • anxiolytics/antidepressants may be necessary
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77
Q

coarse, action tremor aka intention tremor is due to lesion in…

A

cerebellum

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78
Q

features of essential tremor

A

fine tremor that occurs with certain postures (arms outstretched) or certain tasks (handwriting); improved by alcohol consumption

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79
Q

assoc. features with a cerebellar tremor

A

ataxia
nystagmus
dysarthria

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80
Q

assoc. features with an essential tremor

A

vocal tremulousness

head tremor

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81
Q

characteristic tremor seen in Parkinsons

A

resting, pill-rolling tremor that is improved by actions

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82
Q

tx for essential tremor

A

propranolol

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83
Q

general characteristics of ataxia

A

gait instability
loss of balance
impaired limb coordination

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84
Q

acquired causes of ataxia

A 
alcohol intoxication
vit B12 or thiamine deficiency
cerebellar infarction/neoplasm
demyelinating disease
tertiary syphillis (tabes dorsalis)
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85
Q

Friedrich’s ataxia

A

AR dz that presents in young adulthood with ataxia, nystagmus, impaired vibratory sense and proprioception

86
Q

ataxia telengiectasia

A

AR dz that presents by childhood with ataxia, nystagmus, impaired vibratory and position sense as well as telengiectasias; pts have increased risk of cancer

87
Q

potentially reversible causes of dementia

A 
hypothyroidism
neurosyphillis
vit B12/folate/thiamine deficiency
medications
normal-pressure hydrocephalus
depression
subdural hematoma
88
Q

Binswanger’s dz

A

insiduous onset dementia due to diffuse subcortical degeneration, MC in pt with long standing HTN and atherosclerosis

89
Q

cortical dementia

A

Cortical dementia is atrophy of the cortex which affects ‘higher’ functions such as memory, language, and semantic knowledge

90
Q

subcortical dementia

A

subcortical dementia affects mental manipulation, forgetfulness, and personality/emotional changes.

91
Q

CF of normal pressure hydrocephalus

A

triad of dementia, gait ataxia and urinary incontinence; normal CSF pressure with dilated ventricles

92
Q

risk factors for Alzheimer’s dementia

A
  1. increased age
  2. family history
  3. Down Syndrome
  4. genes - Xm 21, 14 and 19 involved
93
Q

senile plaque

A

focal collection of dilated, tortuous neuritic processes surrounding a central amyloid core (amyloid beta protein)

94
Q

neurofibrillary tangle

A

bundles of neurofilaments in cytoplasm of neurons; denote neuronal degeneration

95
Q

how do you diagnose Alzheimer’s disease?

A

CLINICAL diagnosis

- CT or MRI showing cortical atrophy with enlarged ventricles supports the diagnosis

96
Q

first line tx of Alzheimer’s dementia

A

cholinesterase inhibitors i.e. donepezil, galantamine, rivastigmine

97
Q

relationship between vitamin E intake and Alzheimers

A

study showed that megadoses of vitamin E (2000 IU/day) slowed disease progression and preserved function in pts with moderately severe dementia

98
Q

relationship between hormone replacement therapy and Alzheimers

A

hormone replacement therapy is associated with lower risk of developing Alzheimers

99
Q

CF of Lewy Body Dementia

A

visual hallucinations
Parkinsonian symptoms
fluctuating mental status
pts are sensitive to adverse effects of neuroleptic agents

100
Q

anticholinesterase medications are indicated only for what two kinds of dementia?

A

Alzheimers and Lewy Body dementia

101
Q

arousal relies on…

A

intact reticular activating system in BS

102
Q

cognition relies on…

A

intact cerebral hemispheres

103
Q

which medications/drugs can precipitate delirium?

A 
TCAs
corticosteroids
anticholinergics
hallucinogens
cocaine
benzodiazepines
narcotics
104
Q

what test should be performed in any febrile, delirious patient unless contraindications?

A

lumbar puncture

105
Q

if asymmetry is noted on motor exam in a comatose patient….

A

mass lesion is likely the cause

- metabolic of systemic causes would not cause asymmetric motor abnormalities

106
Q

what can cause an abnormal pupillary light reflex in comatose patient?

A

structural intracranial lesions
drugs - morphine, atropine
anoxic encephalopathy
recent eye drops

107
Q

what can cause bilateral fixed, dilated pupils in a comatose pt?

A

severe anoxia

108
Q

what can cause unilateral, fixed and dilated pupil in comatose pt?

A

CN III palsy (uncal herniation)

109
Q

what can cause pinpoint pupils in a comatose pt?

A

narcotics

intracerebral hemorrhage

110
Q

if pupils are round and symmetrically reactive to light in comatose pt…

A

midbrain is intact and not cause of coma

111
Q

anisocoria (asymmetric) pupils in comatose pt is a sign of

A

uncal herniation

112
Q

locked in syndrome

A

mimics coma bc pt is completely paralyzed (muscles for blinking, vertical eye movements and breathing intact); pt is fully aware of their surroundings and pain

113
Q

lesion that causes locked in syndrome

A

infarction or hemorrhage of ventral pons

114
Q

criteria for dx of brain death

A
  1. irreversible absence of brain/brainstem function - unresponsiveness, apnea despite oxygenation/ventilation and no brainstem reflexes
  2. no drug intoxication or metabolic condition
  3. core body temp > 32 C
  4. clinical evidence or imaging study to suggest reason
  5. repeat exams or EEG shows isoelectric activity
115
Q

classic location of plaques in MS

A

angles of lateral ventricles

116
Q

commonly involved tracts in MS

A

pyramidal and cerebellar pathways
medial longitudinal fasciculus
optic nerve
posterior columns

117
Q

clinically definite MS

A

two episodes of symptoms

two lesions on imaging

118
Q

lab-supported definite MS

A

two episodes of sx
atleast one white matter lesion on imaging
oligoclonal bands in CSF

119
Q

probable MS

A

two episodes of sx and either one white matter lesions OR oligoclonal bands

120
Q

MC initial presentation of MS

A

transient sensory deficits - decreased sensation or paresthesias in upper or lower limbs

121
Q

MC complaint of MS pts

A

fatigue

122
Q

what kinds of motor sx are seen in MS

A

weakness - pyramidal tract involvement

spasticity - leg stiffness (may affect pts ability to walk / balance)

123
Q

CF of optic neuritis as seen in MS

A

monocular vision loss with pain on movement of eyes; central scotoma and decreased pupillary light reflex

124
Q

internuclear opthalmoplegia

A

lesion in MLF resulting in ipsilateral medial rectus palsy on attempted lateral gaze (Adduction defect) and horizontal nystagmus of abducting eye

125
Q

what factors increase the chance of severe disability in MS pt

A
  • frequent attacks early in dz
  • onset at older age
  • progressive course
  • early cerebellar or pyramidal involvement
126
Q

diagnostic test of choice for MS

A

MRI

- the number of lesions is not proportional to disease severity or progression

127
Q

LP finding in MS

A

oligoclonal bands of IgG

128
Q

how can evoked potentials be applied to MS diagnosis

A

measure speed of nerve conduction w/in the brain; newly remyelinated axons will conduct sensory impulses more slowly

129
Q

Tx of acute MS attack

A

high dose IV steroids

  • oral steroids dont work
  • dont affect MS course or outcome
130
Q

tx option for steroid-refractory acute demyelinating attacks

A

therapeutic plasma exchange

131
Q

what drug has shown to reduce relapse rates in MS?

A

Interferon

- should be started early in course of disease before disability becomes irreversible

132
Q

what kind of tx can be used for rapidly progressive disease in MS?

A

non-specific immunosuppressive therapy with cyclophosphamide

133
Q

symptomatic tx of muscle spasticity in MS

A

baclofen or dantrolene

134
Q

symptomatic tx. of neuropathic pain in MS

A

carbamazepine or gabapentin

135
Q

main CF of Guillain-Barre syndrome

A

rapidly ascending symmetric weakness/paralysis of all 4 extremities that frequently progresses to involve facial, bulbar and respiratory muscles; sphincter control and mentation are generally preserved

136
Q

CSF analysis in pt with Guillain-Barre syndrome

A

elevated protein, but normal cell count

137
Q

nerve conduction studies in Guillain-Barre syndrome

A

decreased motor nerve conduction velocity

138
Q

Tx of Guillain-Barre syndrome

A
  1. monitor pulmonary function
  2. IV immunoglobulin - if pt has sig weakness
  3. plasmapheresis - may reduce severity
  4. do NOT give steroids
139
Q

what is Guillain Barre syndrome

A

inflammatory demyelinating polyneuropathy that affects motor nerves; usually preceded by viral or mycoplasmal infection of upper respiratory or GI tracts

140
Q

what common infections lead to Guillain Barre

A

camplyobacter jejuni, CMV, hepatitis, HIV

141
Q

non infectious causes of Guillain Barre

A

Hodgkins disease
lupus
after surgery
after HIV seroconversion

142
Q

pathomechanism of Myasthenia Gravis

A

autoantibodies directed against the nAch-R of NMJ leading to reduced post-synaptic response to Ach, resulting in significant muscle fatigue

143
Q

what muscles are most affected in Myasthenia Gravis

A

skeletal mm that are stimulated repeatedly i.e. extraocular mm

144
Q

MC initial symptoms of Myasthenia

A

ptosis, diplopia and blurred vision

145
Q

which cranial muscles are involved in Myasthenia

A

extraocular mm
eyelids (ptosis)
facial muscles (diff chewing, weakness, slurred speech)

146
Q

main CF in Myasthenia gravisi

A

skeletal mm weakness that gets worse with activity (worse at end of day) and improved with rest; sensation and reflexes are preserved

147
Q

myasthenic crisis

A

acute exacerbation of MG; medical emergency with diaphragmatic and intercostal mm fatigue leading to respiratory failure; usually starts with bulbar weakness, which can lead to dysphagia or upper airway obstruction

148
Q

causes of myasthenic crisis

A

concurrent infections
surgery
pregnancy/childbirth
medications: antibiotics (aminoglycosidies, erythromycin, azithromycin), cardiac drugs (BB, procainamide, quinidine, Mg2+)

149
Q

indications for elective intubation in myasthenic crisis

A

if VC is < 20 ml/kg or maximal inspiratory force (MIF) is less than - 30 cmH20

150
Q

Tx of myasthenic crisis

A

withdrawal of anticholinesterases for few days
mechanical ventilation
plasmaphoresis&raquo_space; IVIG

151
Q

diagnostic test of choice for Myasthenia

A

Ach-R antibody test

152
Q

what does EMG show in Myasthenia

A

decremental response to repetitive stimulation of motor nerves

153
Q

Edrophonium (Tensilon) test

A

AchE medications cause marked improvement of symptoms

154
Q

Tx. approach to Myasthenia gravis

A
  1. AchE inhibitors - pyridostigmine (symptomatic benefit)
    - use steroids if pt has poor response
    - third line: azathioprine and cyclosporine
  2. Thymectomy
    - symptomatic and complete remission in many pts
  3. Plasmaphoresis or IVIG in acute exacerbations
155
Q

medications that exacerbate Myasthenia Gravis

A

antibiotics - aminoglycosides, tetracyclines, macrolides
B-blockers
antiarrhythmics - procainamide, quinidine, lidocaine

156
Q

main CF of Duchenne Muscular dystrophy

A

progressive muscle weakness that is symmetric and begins in childhood; promixal muscles are primarily affected (pelvic girdle)

157
Q

Gower’s manuever

A

patient uses hands to get up from floor because the weakness in the proximal LE mm makes it difficult to rise w/o support

158
Q

dx of Duchenne muscular dystrophy

A

serum CPK elevated

DNA testing has replaced muscle biopsy

159
Q

tx of Duchenne muscular dystrophy

A
  1. Prednisone - can increase mm strength and function; use in boys > 5 yo whose motor skills are declining
  2. Surgery to prevent progressive scoliosis
160
Q

central cavitation of cervical cord due to abnormal collection of fluid w/in spinal parenchyma

A

syringomyelia

161
Q

what is syringomyelia associated with

A

Arnold Chiari malformation

- other causes: trauma, infection, tethered cord, intramedullary tumors

162
Q

CF of syringomyelia

A

bilateral loss of pain and temp over shoulders (cape like distribution), preservation of touch, thoracic scoliosis and mm atrophy of hands

163
Q

causes of spinal hemisection

A

crush injury to one side
trauma - stab, fracture
tumors
abscesses

164
Q

CF of Brown Sequard syndrome

A

C/L loss of pain and temp (spinothalamic)
I/L hemiparesis (corticospinal)
I/L loss of position/vibration (DCML)

165
Q

what is transverse myelitis

A

rare condition affecting tracts across the horizontal aspect of spinal cord at a given level, most commonly thoracic spine

166
Q

CF of transverse myelitis

A

LE weakness/paralysis
sensory loss below lesion
back pain
sphincter disturbance

167
Q

diagnostic study of choice for tranverse myelitis

A

MRI with contrast

168
Q

tx of transverse myelitis

A

high dose steroids

- evidence supporting its use is equivocal

169
Q

Horner’s syndrome results from…

A

interuption of cervical SNS nerves; can be either PRE (central lesions) or POST (distal to superior cervical ganglion)

170
Q

CF of Horner’s syndrome

A

ipsilateral ptosis, miosis and anhydrosis

171
Q

causes of Horner’s syndrome

A 
idiopathic
Pancoasts tumor
internal carotid dissection
brainstem stroke
neck trauma (cervical spinal injury)
172
Q

what does poliovirus affect

A

anterior horn cells and motor neurons of spinal cord and brain stem; LMN involvement

173
Q

CF of poliomyelitis

A
  • asymmetric mm weakness (leg&raquo_space; arm)
  • absent DTRs
  • flaccid, atrophic mm
  • normal sensation
174
Q

vertigo

A

disturbance of vestibular system characterized by sensation of spinning or hallucination of movement

175
Q

features of central vertigo

A
  • gradual onset
  • concurrent neuro findings (brainstem)
  • look for CV risk factors in pt
  • accompanying nystagmus
  • no refractoriness
176
Q

features of peripheral vertgio

A
  • acute onset
  • head position has strong effect
  • NV
  • tinnitus/hearing loss
177
Q

benign positional vertigo

A

vertigo is experienced in certain positions/positional changes; lasts a few moments and is more common among pts > 60 yo

178
Q

tx of benign positional vertigo

A

meclizine

- usually resolves w/in 6 months

179
Q

Meniere’s disease

A

triad of vertigo, tinnitus and hearing loss

180
Q

tx. of Meniere’s disease

A

sodium restriction

diuretics

181
Q

what CF can be seen with an acoustic neuroma

A

ataxia, gait unsteadiness, nystagmus, hearing loss and tinnitus

182
Q

causes of central vertigo

A

MS - demyelination of vestibular pathways
vertebrobasilar insufficiency
migraine-associated vertigo

183
Q

syncope

A

transient LOC/postural tone secondary to acute decrease in cerebral blood flow

184
Q

cardinal features of syncope due to cardiac cause

A

sudden syncope without any prodromal symptoms i.e. the pt hits the floor

185
Q

causes of cardiac syncope

A

arrhythmias
obstruction of blood flow
massive MI

186
Q

characteristic features of vasogenic syncope

A

preciipitating factors including emotional stress, pain,fear, extreme fatigue or claustrophobic situations with premonitory sx such as pallor, diaphoresis, lightheadedness, nausea, dimming of vision, roaring in ears

187
Q

what test can reproduce the sx of vasogenic syncope

A

tilt table test

188
Q

tx of vasogenic syncope

A

assume supine position, elevate legs
B-Blockers
Disopyramide

189
Q

causes of orthostatic hypotension syncope

A 
ganglionic blocking agents
diabetes
old age
prolonged bed rest
vasodilators/diuretic use
190
Q

what are you worried about if syncope happens with exertion

A

assess for potentially life threatening hypertrophic cardiomyopathy or aortic stenosis

191
Q

tx of orthostatic hypotension syncope

A

increased sodium intake and fluids

fludrocortisone

192
Q

what type of stroke can cause syncope

A

if it involves vertebrobasilar system “drop attacks”

193
Q

San Francisco syncope rule

A

high risk of adverse outcomes due to syncope if:

  • hx of dyspnea or CHF
  • sys. BP < 90
  • decreased hematocrit
  • abnormal ECG
194
Q

who should be admitted with syncope?

A
  • older pt > 60-70 yo
  • sig cardiac RFs
  • recurrent syncope
  • serious underlying illness
195
Q

metabolic causes of seizure

A 
hyponatremia, water intoxication
hypo/hyperglycemia
hypocalcemia
uremia
thyroid storm
hyperthermia
196
Q

mass lesions that can cause seizures

A

tumors - primary and mets

hemorrhage

197
Q

what “missing drugs” can cause seizures

A

noncompliance w/ anticonvulsants

acute w/d from alcohol, BDZs and barbiturates

198
Q

misc causes of seizures not covered by 4 M’s and Is

A

pseudoseizures
eclampsia
hypertensive encephalopathy

199
Q

Intoxications with what substances can cause seizure

A 
cocaine
lithium
lidocaine
theophylline
metal poisoning - lead, mercury
CO poisoning
200
Q

4 I’s that cause seizures

A

Intoxications
Infections
Ischemia
Increased ICP

201
Q

simple partial seizure

A

consciousness remains INTACT, seizure remains localized, may involve transient unilateral tonic-clonic movement

202
Q

complex partial seizure

A

consciousness is impaired with postictal confusion; automatisms are common, pt may become aggressive if restrained and olfcatory/gustatory hallucinations present

203
Q

generalized seizure

A

loss of consciousness and involve disruption of electrical activity in entire brain

204
Q

DOC for partial seizures

A

phenytoin and carbamazepine

205
Q

typical course of grand-mal seizure

A

bilaterally, symmetric w/o focal onset

  • sudden LOC, pt drops
  • tonic: rigid with extension of all 4 extremities
  • clonic: musculature jerking (30 sec)
  • pt becomes flaccid and comatose before regaining consciousness
  • usually postictal confusion and drowsiness
206
Q

typical features of petit-mal (absence) seizure

A

usually in school aged children; pts disengage from current activity and stare into space - impaired consciousness but no loss of postural tone or continence and no postictal confusion

207
Q

lab values to check immediately in unfamiliar, seizing patient

A

serum calcium
serum sodium
serum glucose
BUN

208
Q

what is most impt test for pt with known epilepsy who has a seizure

A

anticonvulsant levels

209
Q

what is status epilepticus

A

prolonged, sustained LOC with persistent convulsive activity in seizing pt; medical emergency with high mortality

210
Q

causes of status epilepticus

A 
poor compliance w/ meds
alcohol withdrawal
neoplasm
metabolic disorder
drug overdose
211
Q

management of status epilepticus

A 
establish airway
IV diazepam
IV phenytoin
50 mg dextrose
- resistant cases: IV phenobarbital

Neurology (15 decks)

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