Neuromedicine Flashcards
Types Of Gait
Remember GCS PV
G Gait Apraxia
C cerebellar
S Steppage
P Parkinsonian
V Vestibular
What are the Causes of Gait Apraxia?
Frontal lobe Degeneration
NPH
Triad Of Gait Apraxia
Magnetic gait with incontinence and Dementia
Strength, Co ordination and sensory functions are intact
Imaging shows dilated ventricle on CT/MRI
T/m of Gait Apraxia
Serial Lumber puncture
Definitive t/m is ventriculoperitoneal shunts
How cerebellar gait disorder present?
Wide based staggering gait with ataxia
Impairment of which part of cerebellum cause truncal ataxia
Vermis
Impairment of which part of cerebellum cause limb ataxia
Cerebellar hemispheres
How Parkinson gait disorder present?
Short steps with shuffling
Causes of Steppage Gait (Foot drop)
L5 radiculopathy Or
common peroneal nerve neuropathy
- Associated with motor neuropathy
How patient avoid foot drop?
Foot drop due to weakness in dorsiflexion
Flexes hip and knee to raise foot
Avoid dragging the toe with each step
How Common Peroneal nerve neuropathy occurs?
Due to compression of nerve on lateral aspect of fibula (eg due to prolonged crossing of legs or squatting)
How to d/f Steppage Gait due to L5 Radiculopathy and Common Peroneal nerve Neuropathy?
Both present with foot drop.
L5 Radiculopathy:
Radiating pain with weakness of foot eversion
Common Peroneal nerve Neuropathy:
Limited to foot only
Associated with paresthesias and sensory loss of Dorsum of the foot
No loss of inversion and planter flexion (tibial nerve)
How Vestibular gait disorder presents?
Unsteady and falling to one side
Associated with Normal sensation, reflexes and motor strength
Nausea and vertigo
Causes of Vestibular gait disorder
Meniere disease
Acute Labyrinthitis
How spastic gait disorder present?
The gait appears stiff or rigid with circumduction (the spastic leg is abducted and advanced while in extension and internal rotation) and plantar flexion of the affected limb
Cause of spastic gait disorder
Pyramidal tract or corticospinal tract (CST) lesions can cause spastic ataxia.
Causes of Peripheral Facial nerve palsy
Bells palsy usually after HSV reactivation
Lyme disease
Herpes zoster (Ramsay hunt syndrome) Sarcodosis
Parotid gland tumor
Diabetes mellitus
Important information
U/L Peripheral bell palsy is a clinical diagnosis
Need no test to dx it
Important information of UMN Or Corticospinal lesion
UMN lesion causes more weakness in supinator than pronator muscles of upper limbs arm drifts downwards and palm turns (pronates) towards the floor
What are the causes of Spinal Cord Compression?
Remember SIM
Spinal Injury viz motor vehicle accident
Infection viz epidural abscess
Malignancy
Triad of Spinal Cord Compression
Gradual worsening Lower back pain esp at night
Early signs are symmetric lower limb weakness with depress deep tendon reflex
Late signs are lower limb weakness with b/l babinski positive, low rectal tone with increased DTR
How to d/f back pain due to spinal cord compression and degenerative joint disease?
Pain is usually worse in the recumbent position (due to distension of the epidural venous plexus when lying down)
In contrast to back pain from degenerative joint disease, which improves with recumbency
Which level of spine mostly affected due to spinal cord compression?
Thoracic spine is most frequently involved level (60%) followed by lumbar spine
How central cord syndrome occurs?
Occur with hyperextension injuries in elderly pt with pre-existing degenerative changes in cervical spine
What tracts damaged in Central Cord Syndrome?
specifically central portion of corticospinal tracts and decussating fibres of lateral spinothalamic tract
SxS of Central cord Syndrome
Loss of pain and temperature sensation
Motor Weakness more in upper extremities than lower
Why Motor Weakness more in upper extremities than lower in central cord syndrome?
motor fibers serving arms are closer to the central part of corticospinal tract
What is the cause of Anterior Cord syndrome?
Due to occlusion of Anterior spinal artery (Aortic dissection/surgery)
What are the causes of posterior cord syndrome?
Multiple sclerosis and vascular disruption (eg vertebral artery dissection) are most common
Impairment of what part cause Cauda Equina Syndrome?
Compression of spinal nerve roots by disk herniation or rupture, tumor, spinal stenosis, infection, hemorrhage, or iatrogenic injury
Important information
A sensory level at the umbilical excluded cauda equina syndrome
What are the SxS of Cauda Equina Syndrome?
Severe b/L Radicular pain with depress reflexes of lower limb
Asymmetric motor weakness with saddle
Anaesthesia
Late onset bowel and bladder Dysfunction
What part of Body innervated by Cauda Equina?
Sensory innervation to saddle area
Motor innervation to sphincters (anal and urethera)
Parasympathetic innervation to bladder and lower bowel
What are the SxS of Conus Medullaris Syndrome?
Sudden onset severe back pain with hyperreflexia
Symmetric motor weakness with perianal anesthesia
Early onset bowel and bladder Dysfunction
ARP in Tabes Dorsalis
ARP accomodation reflex present
PRA Pupillary reflex absent
T/m of Tabes Dorsalis
IV penicillin for couple of weeks
SxS of Weber Syndrome
Ipsilateral CN 3 impairment
And
C/L Hemiplegia
SxS of Benedikt syndrome
Ipsilateral CN impairment
And
C/L Ataxia
Damage to which artery of brain leads to Alexia without Agraphia
PCA occulsion
Also loss of both vertical and horizontal movements of eye
Damage to which artery of brain leads to reappearnce of Primitive reflexes
ACA occlusion
Impairment of which part of brains ends up with motor aprosodia
Non dominant frontal lobe lesion
Impairment of which part of brains ends up with Sensory aprosodia
Non dominant Temporal lobe lesion
Triad of Lesion in non-dominant parietal lobe
Hemineglect
Anosognosia
Contralateral apraxia
What syndrome arises due to Lacunar Stroke?
Pure Motor Hemiparesis
Pure Sensory stroke
Ataxic hemiparesis
Dysarthria clumsy hand.
What is lacunar stroke?
Type of stroke that occurs when blood flow to one of the small deep arteries within the brain becomes blocked
Important point of Carotid dissection
commonly causes partial ipsilateral Horner syndrome (ptosis and miosis without anhidrosis) due to damage of postganglionic sympathetic fibers supplying the head.
What will be seen on CT Scan of Epidural hematoma?
Biconvex (lens shaped) hyper-density that doesn’t cross suture lines
Risk factors of Subdural Hematoma
Elderly and alcoholic
Infants (Thin wall vessels)
Anticoagulant use
What will be seen on CT scan of subdural hematoma?
Crescent shaped hyper density (Acute) Or hypo-density (chronic) crossing suture lines
Triad of Uncal Herniation
Ipsilateral Hemiparesis
Ipsilateral Oculomotor nerve palsy
C/L Homonymous Hemianopsia
How Diffuse Axonal Injury occur?
Due to traumatic acceleration and deceleration injury of brain
Imaging findings of Diffuse Axonal Injury
CT scan characteristically shows numerous minute punctate hemorrhages with blurring of grey white interface.
Important information for stroke
Heparin doesn’t have any role in curing Stroke
How Intracerebral haemorrhage presents?
FNDs appear early followed by features of increased ICP
Name the medication to give in thrombotic stroke if patient present within 4 hours of symptoms onset and w/o contraindications
IV tPA
Which antiplatelet to give in stroke if patient has no Hx of antiplatelet?
Aspirin
What to give if patient develop stroke on aspirin therapy?
Aspirin with Dipyridamole Or Clopidogrel
What to give if patient develop stroke on aspirin therapy and have large intracranial artery atherosclerosis?
Aspirin with Clopidogrel .
What are the inclusion criteria for thrombolytics in Stroke?
I
schemic stroke with measurable neurodeficits
SxS onset less than 3-4.5hours before initiating t/m
How much blood pressure Should be to contraindicate thrombolytics?
More than 185/110
How much platelets and glucose level should be to contraindicate thrombolytics?
Platelets<100,000/mm3
And Glucose<50mg
How much brain area should be affected to contraindicate thrombolytics?
Hemorrhage Or Multilobar infarct involving >33% of cerebral hemispheres on CT
What are the contraindications of thrombolytics in stroke?
Stroke Or Head trauma in past 3 months
Hx of intracranial neoplasm, hemorrhage Or vascular malformations
Recent intracranial/spinal surgery
Active bleeding Or arterial puncture in past 7 days at non compressible sites
Important information
Blood pressure control is critical in patients undergoing fibrinolytic therapy, and should be kept below 185/110 during in the 24 hours after it is administered.
Important information
Aspirin should be held for 24 hours in patient who received fibrinolytic therapy
Important points for aspirin in t/m of stroke
Reduces the risk of early recurrence of ischemic stroke
Given to those who are not candidates for fibrinolytic therapy
What to give if CHADS2 score is 2-6?
Stroke risk is high so give anticoagulation
What to give if CHADS2 score is 1?
Stroke risk is intermediate so anticoagulations is preferred Or give aspirin
What to give if CHADS2 score is zero?
Stroke risk is low so no anticoagulation Or give aspirin
What parts of brain affected most by intracranial Hx if patient is having hypertension?
Basal ganglia
Thalamus
Pons
Cerebellum
Clinical SxS of Intracranial Hx affecting thalamus
C/L hemiparesis with hemisensory loss
Eyes deviate towards hemiparesis with upgaze palsy
Non reactive miotic pupils
How patient presents with pontine haemorrhage?
Pinpoint reactive pupils
Deep coma
Total paralysis within minutes
What lobes affected due to lobar haemorrhage?
Occipital
And Parietal lobe
What are the main complications of Sub Arachnoid haemorrhage?
Rebleeding occur within first 24 hours
Vasopasm after 3 days
How to t/m Vasopasm occur due to subarachnoid haemorrhage?
Nimodipine and hyper dynamic therapy to reduce vasopasm
How cluster headache occur?
Due to alterations in the circadian pacemaker which due to hypothalamic dysfunction
How to t/m cluster headache prophylactically?
Verapamil
Lithium
Ergotamine
Prednisone
Methysergide
Cypoheptadine
Indomethacin
How to t/m cluster headache in acutely?
Inhalation of 100% O2 and subcutaneous Or nasal sumatriptans
How to t/m subarachnoid haemorrhage surgically?
Surgery (craniotomy with aneurysm clipping)
Endovascular methods (coiling and/or stenting of the aneurysm)
What are the methods to lower the ICP?
1) Increase Brain volume by decompressive Craniectomy
2) Decrease CSF volume via shunt
3) Decreases Brain parenchymal volume via mannitol or Hypertonic saline
4) decreases cerebral blood volume via sedation ,hyperventilation and head elevation
How venous sinus thrombosis occur?
Intracerebral hx along the courses of major cerebral draining veins due to backup pressure
Leads to headache for several days
What are the risk factors for Pseudotumor cerebri?
Overweight female
Use of Vit-A/ OCPs/ Growth hormone/ Steroids/ tetracycline
How patient present with Pseudotumor cerebri?
Holocranial headache increases with lying flat and decrease with standing
Pulsatile headache
Transient vision loss
And diplopia
What are the finding of LP in Pseudotumor cerebri?
Increases pressure with normal analysis
Important information of Pseudotumor cerebri
Empty sella but it is non dx
Short term use of steroids/serial LP uses patient awaiting definitive surgical t/m but cannot used as primary intervention
How to t/m Pseudotumor cerebri medically?
Acetazolamide
Also add loop diuretics if Sx continues
How to t/m Pseudotumor cerebri Surgically?
Surgical intervention with Optic nerve sheath decompression
Or Lumboperitoneal shunt
What is the imaging morality of choice for diagnosis of cavernous sinus thrombosis?
MRI with MRV
Important information
Be cautious when using over the counter medication (contains acetaminophen) with warfarin
Increases the toxicity of warfarin
How Neuroleptic malignant syndrome presents?
Malignant FEVER:
M= Myoglobinuria
F= Fever
E= Encephalopathy
V= Vitals unstable
E= increases Enzymes (eg, CK},
R= muscle Rigidity ("lead pipe")What are the medication used for neuroleptic malignant syndrome?
Dantrolene dopamine agonist (eg, bromocriptine)
What chemotherapy drugs cause peripheral neuropathy?
Vinca alkaloids (vincristine)
Platinum based med (cisplatin)
Taxanes (paclitaxel)
How Stiff person syndrome presents?
Rigidity with stiffness and muscle spasm
Autonomic instability
But no changes in mental status
What is the most specific test for MYASTHENIA GRAVIS?
Acetylcholine receptor antibody
And in case, test comes negative then check muscle-specific tyrosine kinase antibodies
Important information of myasthenia gravis
If Both antibodies come negative, then electrophysiologic studies (eg repetitive nerve stimulation, singlefiber electromyography) may be helpful
What are the factors precipitating myasthenia crisis?
Infection Or Surgery
Pregnancy Or childbirth
Tapering immunosuppressive drugs
Medication (aminoglycosides/ BB / azithyromycin)
How to t/m Myasthenia crisis?
Intubation for deteriorating respiration
IVIG or plasmapheresis
Steroids (used once patient stabilise)
Used of ACHe inhibitors contraindicated in case of mysthenia crisis to avoid airway secretion and aspirations
How to t/m Lambert Eaton syndrome?
Symptomatic therapy includes guanidine or 3,4-diaminopyridine to increase presynaptic acetylcholine levels.
Refractory symptoms may respond to immunologic therapy with IVIG or oral immunosuppressants (steroids / azathioprine
What will be seen in MRI of MS?
Hypo/hyperintense lesions are seen on MRI—periventricular, juxtacortical and infratentorial regions.
Spinal cord may also be involved
What will be seen in CSF report of MS?
Normal pressure
total cell count and total protein conc. Predominant cell type: T lymphocytes
How to t/m Acute relapse of MS?
Steroids
Steroids
Plasma exchange Or Corticotropin injection gel, a purified from of adrenocorticotrophic hormone as a alternate therapy
What are the long term medications for MS?
Long-term disease modifying therapy:
Glatiramer
interferon
mitoxantrone
cyclophosphamide
methotrexate and cladribine
How infant botulism presents?
B/L bulbar palsies viz ptosis,sluggish pupillary response to light,poor suck and gag reflexes)
followed by symmetric descending flaccid paralysis (hypotonia
At what place infant botulism common?
Highest incidence seen in California, Pennsylvania and Utah due to greatest conc. Of soil botulism spores
How to t/m infant botulism?
Human derived botulism immune globulin
What are the source of food borne botulism?
Improperly canned food such as fruits and vegetables
Aged seafood (cured fish)
How to dx food borne botulism?
Serum analysis for toxins
How to t/m food borne botulism?
Equine derived botulism antitoxin
How to assess the respiratory functions in GBS?
FVC is gold standard
Peaked flow meter also used but less accurate than FVC
When is ETT required in GBS?
When FVC shows less than 20ml/kg then it indicates respiratory arrest and needs intubation
In which diseases GBS is more common?
Sarcoidosis
Lymphoma
SLE
What organisms associated with GBS?
Campylobacter jejuni most frequently associated.
Other organisms: Herpes virus, Mycoplasma and H.influenza also associated.
Recent HIV infection and recent immunization
Name the medication given in PARKINSON’S TREMORS
Anticholinergics (eg benztropine, trihexphenidyl)—treatment of choice.
Trihexphenidyl typically used in
younger pts where tremor is predominant symptom
Important point for tremors
To have physiological tremors there must be underlying trigger which increases sympathetic activity such as drugs, hyperthyroidism, anxiety and caffeine.
Important point of Parkinson disease
Anticholinergics do not improve bradykinesia but improves tremors and rigidity
What are the secondary causes of Restless leg syndrome?
Uremia is due to ESRD/ CKD)
DM
MS / Parkinson disease
Pregnancy
Drugs viz antidepressants / Metoclopramide
How to t/m Persistent/mod-Severe Restless leg syndrome?
First line such as Dopamine agnostic (pramipexole)
Alternate such as alpha 2 delta Calcium channel ligand (Gabapentin / enacarbil)
What is the t/m of mild/intermittent symptoms?
Supplement iron when serum ferritin less than 75ug/L
Use supportive measures (leg massage/heating pad/exercise)
Avoid aggravating factors (sleep deprivation/medications)
How much MMSE should have to consider dementia?
Less than 24
Important information
Normal aging will have expressive aphasia
Whereas dementia will have both expressive and receptive aphasia
What clinical features suggest CJ disease?
Rapidly Progressive Dementia
Myoclonus
Ataxia with mutism
Cerebellar Or visual disturbance
What will be seen in CSF and EEG of patient who have CJ diseases?
CSF:: 14-3-3 assay
EEG:: Periodic sharp waves complexes
What is the gold standard test to Dx CJ diseases?
Brain biopsy
Which gene mutated in CJ disease?
PRNP
What test help in distinguishing dementia and pseudo-dementia?
Dexamethasone suppression test is abnormal in 50% of pseudo-dementia
Triad of Lewy body dementia
Dementia with SxS of Parkinson
Fluctuating cognition and visual hallucination
Rapid eye movement sleep behaviour disorder
(Dream enactment behaviour during loss of normal REM sleep atonia)
How to distinguish Lewy body dementia and Alzheimer diseases?
Visual spatial decline before memory deficit in Lewy body dementia
How to distinguish Lewy body dementia and Parkinson disease?
Early appearance of dementia in Lewy body dementia
Motor symptoms in Parkinson disease
What will be seen in autopsy of Lewy body dementia?
Lew bodies (eosinophilic Intracytoplasmic inclusions
It represents accumulation of alpha synuclein protein seen in neurone of the substantia migration / Locus ceruleus / dorsal raphe / substantia innominata
What will be unchanged in Pick disease?
Visuo spatial functions usually remain intact
What lobes of brain most affected in Alzheimer’s diseases?
Parietal and temporal lobes esp hippocampus
How to t/m moderate to severe Alzheimer’s dementia?
Memantine (NDMA Receptor blocker)
How to t/m mild to moderate Alzheimer’s dementia?
ACEI viz Donepezil / Galantamine /Rivastigmine / Galantamine ER
Triad of Multiple System Atrophy / Shy Drager Syndrome
Symptoms of Parkinsonism
Autonomic dysfunction
Wide spread neurological signs (cerebellar / pyramidal Or lower motor neuron)
How to t/m Multiple system Atrophy?
Increase IV volume with steroids / salt supplementation / alpha adrenergic agonist and application of constrictive garments to lower body
Features of familial Dysautonomia (Or Riley day syndrome)
Gross dysfunction of the autonomic nervous system
With
Severe orthostatic hypotension
How to t/m delirium?
Regardless the cause, t/m of agitation in elderly is low dose haloperidol
Important point
Avoid to use typical antipsychotic in Lewy body dementia who may exhibit neuroleptic hypersensitivity
Triad of Exertional heat stroke
Core temperature of >40’c (104f) immediately after collapse
CNS dysfunction
Organ damage/DIC
Name the medication which can cause exertional heat stroke
Anticholinergics
Antihistamines
Phenothiazines
Tricyclics
How to t/m exertional heat stroke?
No role for antipyretic therapy
Ice immersion preferred with fluid resuscitation
Electrolyte correction
How to t/m non exertional heat stroke (Or Classic heat stroke)
Evaporative cooling (ie spraying the naked patient with lukewarm water and running fans to circulate air) is preferred for nonexertional or classic heat stroke
Avoid to use ice water immersion
What’s the work up for first time seizure?
Baseline tests—>ECG—>Neuroimaging—>lumber puncture—>Routine EEG
What’s the hallmark on Neuroimaging of prolong seizures (STATUS EPILEPTICUS)?
Cortical laminar necrosis leads to persistent neurologic deficits and recurrence seizures
How to t/m trigeminal neuralgia?
Carbamazepine
If medication fails then surgical Ganaliolysis Or sub occipital craniectomy for decompression Of trigeminal nerve
Important point
Multiple sclerosis should be suspected when trigeminal neuralgia presents B/L
what is the carotidynia?
Neurological condition caused by inflammation of the carotids and the vagus
- Sharp pain which is localised to the carotid artery distribution in the neck
Triad of Burning Mouth syndrome
Facial pain aggravate by dryness
Caused by virus
Reddened mucosa
What lobe of brain would be involved if otitis media and mastoiditis occur?
Temporal lobe
And cerebellum
What lobe of brain would be involved if frontal and ethmoid sinusitis occur?
Frontal lobe
What lobe of brain would be involved if Dental infection occur?
Frontal lobe
Triad of Brain abscess
Fever
Headache
And Focal neurological deficits
What is the most common cause of Spinal Epidural abscess?
S.aureus
Triad of Spinal Epidural abscess
Fever
Lower back pain
Neurological deficits
What would be cause of Spinal epidural abscess ?
Staph aureus
Triad of herpes Encephalitis
Fever
FNDs
Behavioural changes can be seen and behavioural syndromes like hypomania, Kluver-Bucy syndrome (hyperphagia, hypersexuality) and amnesia have been reported
What is the gold standard diagnosis of Herpes encephalitis?
PCR analysis of HSV DNA in CSF
What will be seen EEG report of herles encephalitis?
Prominent intermittent high amplitude slow waves in 70-80% cases
What is the drug of choice for heroes encephalitis?
IV acyclovir
Triad of Tick Borne Paralysis
Ascending Paralysis with Or without fever and prodromal SxS
Normal autonomic system (Unlike GBS)
Normal CSF findings
Important information of Tick borne paralysis
Ascending paralysis due to tick will take time to develop at least 7 to 8 days
Triad of PRIMARY CNS LYMPHOMA IN HIV PATIENT
Altered mental status
EBV DNA in CSF
and solitary weakly ring-
enhancing periventricular mass on MRI
How to dx acoustic Neuroma?
Audiometry is the best initial screening laboratory test for acoustic neuroma
Best diagnosed by MRI with gadolinium staining—preferred over CT.
Different types of mutation which cause NF 2
Autosomal dominant caused by a mutation in tumor suppressor gene on chromosome 22
Severe variant: Wishart caused by frameshift or nonsense mutation
Milder variant: Gardner result from splice site or missense mutation
What will be seen in Neuroimaging of GLIOBLASTOMA MULTIFORME?
Butterfly lesion with central necrosis is classic and heterogeneous,
serpiginous contrast enhancement is typical of high grade astrocytoma
How to t/m meningioma?
complete surgical resection in symptomatic cases cures in most cases.
Focused tumor radiation (stereotactic radiosurgery) can be considered
in partially resected or unresectable tumors
Cancer which cause Primarily Solitary Brains Mets
Breast
Colon Cancer
Renal cell carcinoma
Cancer which cause Multiple Brains Mets
Lung cancer
Malignant melanoma
How to t/m Single Brain mets?
Single brain metastasis in surgically accessible location and good performance status->surgical resection is best therapeutic option.
This is typically followed by stereotactic radiosurgery (SRS) or whole brain radiation therapy (WBRT) to tumor bed
How to t/m Multiple Brain mets?
WBRT or supportive care is typically recommended
How nasal hemianopia occurs?
Due to lesion in ipsilateral peri chiasmal
Causes are calcification or aneurysm of Internal Carotid artery impinging on “”Uncrossed”” lateral retinal fibers
How mono-ocular Scotoma occurs?
Partial lesion in the retina, optic disc, optic nerve
Causes are macular degeneration / Optic neuritis
How optic nerve lesion occur?
Due to central retinal vein occlusion Or Retinal artery
What Optic function doesn’t affect in INTERNUCLEAR OPHTHALMOPLEGIA?
Convergence and the pupillary light reflex are preserved.
How unilateral MLF occurs?
lacunar stroke in the pontine artery distribution
What are the clinical findings of EDINGER WESTPHAL NUCLEUS INJURY?
Ipsilateral fixed and dilated pupil
that is nonreactive to light or accommodation
Impairment of which cranial nerve leads to vertical Diplopia
Cranial nerve 4
What are the causes of compression oculomotor neuropathy occur?
transtentorial (uncal) herniation or
aneurysm of posterior communicating artery
How ischemic oculomotor neuropathy occurs?
Diabetes
Name the test used to assess vestibular dysfunction due to gentamicin.
head thrust test
What are MRI findings of CJ disease?
Wide spread atrophy of cerebrum and cerebellum
Cortical enhancement (cortical ribboning)
Hockey stick signs (enhancement of putamen & caudate test)
What is the CSF findings of CJ disease?
Positive 14-3-3 protein Titers
Positive RT-QuIc test
Rest indices are normal
What is the EEG finding of CJ disease?
Sharp , triphasic, synchronous discharge
Name the medicine for General Tonic clonic seizures?
First IV benzo like lorazepam, diazepam Or IM dormi to terminate
IV non benzo like fosphenytoin, Phenytoin, valprolate, Lerrace
How to t/m Acute LBP that is less than 4 wks?
1) Maintain Moderate activity
2) NASIDs or acetaminophen
3) otherwise muscle relaxants / spinal manipulation
How to t/m Subacute (4-12wks) Or Chronic (>12 wk) LBP?
1) I/M use of NASIDs or acetaminophen
2) Exercise therapy (strengthening/ stretching, Aerobic)
3) TCA / SSRI if considered
How Idiopathic transverse myelitis occurs?
Infiltration of inflammatory cells into segment of spinal cord leading to death of neuron, oligodendrocytes and demyelination
Triad of Idiopathic transverse myelitis
B/L loss of sensory function with autonomic instability
Distinct sensory level
B/L motor weakness with early flaccid then spastic
Name the test to DX Idiopathic transverse myelitis
MRI shows no compression lesion with T2 hyper intensity
LP shows increase WBC and increase IgG index
How to treat Idiopathic transverse myelitis?
High dose steroid
Plasmapheresis
What are Red flag associated with U/L facial paralysis?
If these are absent consider it Bell palsy
FNDs or sparing of upper face
Or
Rash or arthritis like Lyme disease
Or
Hearing loss vertigo
Or
Lower limb weakness / Deceased DTR like in GBS
How to t/m bell palsy?
Steroid
Eye lubricant
±Anti virals
If weakenss worsen over 3 wks or no improvement in 4months consider imaging
How to Manage Migraine In pregnancy?
NI—-> no improvement
Non pharma like rest —->NI—-> Acetaminophen
Still NI—->Antiemetics/codeine/caffeine
Still NI —-> NASID like naproxen only in 2nd trimester
Still NI —-> Opioid
Important point of Treatment of migraine in pregnancy
Metacolon used only acutely
Ergotamine is not used due to hypertonic uterine contractions and Vasoconstriction
Triptans Also not used due to above reason and LBW / Preterm birth.
Name the types of Herniation
Subfalcine herniation
Uncal
Tonsillar
Difference b/w Subfalcine and Uncal
In Subfalcine, only C/L leg weakness seen without pupillary changes
In uncal I/L motor weakness with pupillary involvement
Tonsillar herniation shows fixed and mid position pupil due to disruption of both para and sympathetic innervation
Name the bacteria causing meningitis in age 2-50 yrs and Abx for it
Strep pnemonia and N.meningitis
Abx vancomycin and 3rd Generation cephalosporin
Name the bacteria causing meningitis in age over 50 yrs and Abx for it
Strep pnemonia and N.meningitis
Listeria
Abx vancomycin and 3rd Generation cephalosporin/ ampicillin
Name the bacteria causing meningitis in immunocompromised
Strep pnemonia and N.meningitis
Listeria and Gram negative rod
Abx vancomycin and ampicillin
Cefepime
Name the bacteria causing meningitis in neuro surgery procedure/ penetrating trauma and Abx
MRSA , Coagulase negative staphylococci and Gram negative rod
Abx vancomycin and cefepime
Alternative medicine for meningitis
For listeria—-> ampicillin or TMX-SD
Cefepime—->meropenem Or Ceftazidime
Name the cancer in terms of frequency which spread in brain
Lung>breast>unknown>melanoma>colon
Name the cancer which shows single or Multiple brain mets
Single brain mets—-> breast, colon, RCC
Multiple brain mets—-> lung cancer, malignant melanoma
Categories the tremor when they occur?
If on action only—> essential and cerebellar
If on rest only —-> Parkinson
If both on action and rest —> physiologic
Difference b/w lithium induced physiological tremor and Lithium toxicity tremor
Lithium induced physiological tremor::
Symmetric and limited to hand and upper limbs
Rx:: just observe
Lithium toxicity tremor::
Irregular, coarse tremor
Involved multiple part of body with GIT and neurological SxS
Rx:: dialysis
Name the brain tumor which shows Butter fly lesion with central necrosis
Serpiginous contrast enhancement is typical of high grade Astrocytoma
Glioblastoma Multiforme
What are the neuropsychological consequence of Wilson disease?
Autosomal dominant due to mutation in ATP7B
Sxs like parkinson
Gait disturbance
Dystharia and “hype reflexia”
Depression with psychosis or personality changes
How to Prevent and abort Migraine?
Abortive (TANE)
Preventive ABA
Abortive::
(Triptans, Antiemetic, Acetaminophen, NSAIDs, Ergotamine)
Prevent::
Anticonvulsant like topiramate Or Valproate
B BB (given in pregnancy unlike others )
A antidepressants ( TCA or Venlafaxine)
How RILEY DAY SYNDROME OR FAMILIAL DYSAUTONOMIA present?
Autosomal recessive seen predominantly in children of Ashkenazi Jewish ancestry
Gross dysfunction of the autonomic nervous system with severe orthostatic hypotension
How B12 deficiency present?
Ataxia due to spinocerebellar
Loss of vibration and position sensation due to dorsal column
Upper motor neuron SxS due to lateral corticospinal tract
How Chronic inflammatory demyelinating Polyneuropathy Occur?
Subacute to chronic condition (>8wk)
Occur due to immune mediated demyelination of peripheral nerves and nerves roots independent of length
How Chronic inflammatory demyelinating Polyneuropathy present?
Both sensory and motor SxS occur With LMN signs
Proximal and distal symmetrical muscles weakness
How to dx and manage Chronic inflammatory demyelinating Polyneuropathy?
Dx—-> (1) increase protein with Normal WBCs in CSF
(2) segmental demyelination on nerve bx
(3) NCS shows decreases conduction velocity
Name the d/f subtypes of Hepatic Neualgia and How to Rx it?
NASID AND Analgesic for first two types
Last type—-> TCA , Gabapentin and pregabalin
1) Acute —>persist less than 30 days from rash onset
2) Subacute—>persist more than 30 days but resolves within 4 months of rash onset
3) Postherpatic ->persist more than 4 months from rash onset
How Autoimmune encephalitis(Anti NMDR receptor encephalitis) present?
Condition seen in Tumor esp ovarian teratoma
Psychiatric SxS with autonomic instability and SxS like UMN after flu like syndrome
How to dx and tx Autoimmune encephalitis ?
Dx (1) CSF—> Ab against GIuN1 subunit of NMDR
(2) Neuroimaging
Rx is Immunosuppressants
How Cervical spondylosis leads to myelopathy?
Degenerative condition associated with spinal canal narrowing
due to the formation of osteophytes in the lateral vertebral bodies and ossification of posterior longitudinal ligament / ligmentum flavum
How cervical myelopathy present?
SxS just like ALS
Sensory SxS
Neck pain and current like sensation on neck flexion
How Miller fisher GBS present?
Positive GQ1B antibody
Ataxia like cerebellar
Ophthalmopalegia
Loss of reflex without loss of motor
strength
How ALS present?
UMN
•SxS of UMN with presence of pathological reflexes like jaw jerk and up going planters
- LMNs
- bulbar symptoms like dysphagia and dysarthria
What are the causes of Cervical Radiculopathy and How does it present?
(Sxs depend on nerve involvement)
Causes are disk herniation Or spondylosis
Sxs are loss of upper limb reflexes with pain and paresthesia
Name the test which is Dx and therapeutic for cervical Radiculopathy
Shoulder abduction relief test
Abduction relief the tension on impinged nerve root and improve radicular pain when hand is placed on the top of hand
Triad of Marchiafava bignami disease
Dementia
dysarthria
Motor dysfunction
How Marchiafava bignami disease occur?
Due to alcoholic or severe malnutrition result severe damage to corpus callosum and surrounding white matter
