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Eugenie Notes > Notes 1b > Flashcards

Notes 1b Flashcards

1
Q

Chronic optic neuritis

A
  • Features: persistent visual loss, color desaturation, persistent APD
  • will eventually lead to optic atrophy with shrunken and pale disc
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2
Q

Benedikt’s Syndrome

A

midbrain stroke in ventral mesencephalic tegmentum

  • ipsilateral third nerve palsy with contralateral involuntary movements such as tremor and choreoathetosis
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3
Q

Claude’s Syndrome

A

midbrain stroke in midbrain tegmentum (more dorsal than Benedikt)

  • ipsilateral CN III palsy and contralateral ataxia and tremor
  • As compared to Benedikt;s, they have more ataxia bit no involuntary choreoathetotic movements
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4
Q

Weber Syndrome

A

midbrain stroke with

  • ipsilateral CN III pasy with contralateral hemiplegia
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5
Q

SPARCL trial

A

studied benefit of atorva 80 in reducing overall incidence of stroke and CV events

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6
Q

Regions involved in ASPECTs score

Score less than __ is bad?

A

4 deep structures (caudate, IC, lentiform nucleus, insular region)

and 6 cortical regions

Score less than 7 assoc with increased dependence and death

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7
Q

indications for revascularizing extracranial ICA

A

70-99% = should be revascularized

50-69% + symptomatic (stroke, TIA, visual sx all count) = revascularized

<50% = medical therapy alone

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8
Q

Moyamoya syndrome

A

Most commonly presents in children

presents with ICH, headaches, seizures, movement disorders, cognitive loss

on Angio: bilateral stenosis of carotids, MCA, ACA with extensive collateral circulation at the base of the brain appearing like a “puff of smoke” (on the R)

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9
Q

Dejerine Roussy Syndrome

A

thalamic pain syndrome

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10
Q

Anterior choroidal arteries arise from? Posterior?

A

ICA

PCA

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11
Q

Vertebral artery segments

A
  • The V1 segment extends from the subclavian artery to the transverse foramen of C5-C6.
  • The V2 segment runs within the transverse foramina of the cervical vertebra from C5-C6 to C2.
  • The V3 segment extends from the transverse foramen of C2 and turns posterolaterally around the arch of C1, between the atlas and the occiput. This segment is extracranial.
  • The V4 segment begins where the vertebral artery enters the dura at the foramen magnum and joins the contralateral vertebral artery to form the basilar artery —> gives off PICA and anterior spinal artery
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12
Q

In patients with stroke or TIA caused by ICAD, what is recommended

A

ASA 325 daily

If within 20 days, can use plavix 75mg for 90 days in addition to ASA

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13
Q

Know the venous drainage of the skull including the weird ones like ophthalmic, galen, trolard, labbe

A
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14
Q

Vein of Trolard/Labbe

A
  • The vein of Trolard is a large anastomotic vein that connects the Sylvian vein to the superior sagittal sinus
  • The vein of Labbe is a large vein traveling over the temporal lobe convexity connecting the Sylvian vein to the transverse sinus.
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15
Q

CADASIL: defect and characteristic finding

A

NOTCH3 on chromosome 19

characteristic finding: blood vessel with a thick wall containing basophilic granular material

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16
Q

Origins of the R/L common carotids and R/L verts

A
  • Right common carotid artery arises from the innominate artery that originates from the aortic arch.
  • right vertebral artery originates from the right subclavian artery, which arises from the innominate artery
  • left common carotid artery originates directly from the aortic arch (A small percentage of the population have what is called a “bovine aortic arch,” in which the left common carotid has the same origin with the innominate artery, and in some cases the left common carotid will originate from the innominate artery)
  • left vertebral artery arises from the left subclavian artery which originates from the aortic arch
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17
Q

Most frequent locations for intracranial aneurysms are

A

ACOM (30%), PCOM (25%)

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18
Q

carotid cavernous fistula

A

tear in the cavernous segment of the ICA allowing AV shunting to the cavernous sinus, therefore inc pressure in the sinus with drainage to the superior ophthalmic vein and impaired drainage in the eye

causes ophthalmoplegia, chemises, proptosis, inc IOP, retinal ischemia and vision loss.

Treated with endovascular embolization.

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19
Q

RCVS

more common in men/women

sx?

risk factors

imaging shows?

tx

A

women

  • headaches with or without other neurologic sx, with vasoconstriction of cerebral arteries that resolved spontaneously within 12 weeks
  • May develop focal neurologic sx and seizures (transient)
  • May be complicated by IPH, SAH, strokes (permanent)
  • Associated with PRES
  • Risk factors: vasoactive drugs including amphetamines, cocaine, cold medicines with decongestants, triptans, ergot alkaloid derivatives, and other adrenergic and serotonergic drugs. Patients also may report triggers such as strenuous activity, sexual activity, Valsalva, and/or stressful or emotional situations.
  • Vessel imaging will show “beading” pattern
  • tx: vasodilators such as calcium channel blockers and Mg sulfate
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20
Q

CREST Study

A

CEA vs stenting of the carotids

stenting: lower rates of MI, inc risk of periop stroke

stenting recommended in patients <70

CEA recommended in patients >70

also reasonable to stent patients that are more high risk surgical candidates

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21
Q

Know the CSF flow

A
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22
Q

Foramen of Monro connects

A

lateral and third vent

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23
Q

Cerebral aqueduct connects

A

3rd and 4th vent

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24
Q

roof of 4th vent is made by? floor?

A

cerebellum

pons and medulla

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25
Q

CSF leaves the ventricular system through the (2)

A

lateral foramen of Luschka

Midline foramen of Magendie

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26
Q

CSF is reabsorbed at the

A

arachnoid granulations

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27
Q

BUZZWORDS: ipsilateral 3rd nerve palsy and contralateral hemiplegia

A

Weber Syndrome (midbrain lesion)

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28
Q

BUZZWORDS: ipsilateral 3rd nerve palsy and contralateral involuntary movement

A

Benedikt Syndrome

lesion in ventral portion of the mesencephalic tegmentum

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29
Q

BUZZWORDS: ipsilateral 3rd nerve and contralateral ataxia and tremor

A

Claude’s Syndrome

lesion in the distal portion of the mesencephalic tegmentum

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30
Q

BUZZWORDS: ipsilateral 7th nerve palsy with contralateral hemiplegia

A

Millard Gubler Syndrome

lesion in the pons

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31
Q

BUZZWORDS: Limited upward gaze, convergence retraction nystagmus, light-near dissociation, lid retraction, skew deviation of the eyes

A

Parinaud Syndrome

lesion affecting the quadrigeminal plate

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32
Q

BUZZWORDS: Quadriplegia, inability to speak, limited horizontal gaze, preserved consciousness, vertical gaze and blinking

A

Locked in Syndrome

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33
Q

BUZZWORDS: Contralateral hemibody sensory loss with subsequent development of pain, allodynia, paresthesia. Results from a thalamic lesion

A

Dejerine-Roussy Syndrome

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34
Q

BUZZWORDS: finger agnosia, right-left disorientation, agraphia, acalculia

A

Gerstmann Syndrome

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35
Q

BUZZWORDS: Normal variant with vascular supply to both medial thalami

A

Artery of percheron

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36
Q

BUZZWORDS: Deep branch of ACA that supplies anterior limb of IC, inferior head of the caudate, anterior globus pallidus

A

Recurrent artery of Heubner

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37
Q

BUZZWORDS: caused by chronic HTN, associated with the pathogenesis of lacunar strokes

A

liphyalinosis

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38
Q

BUZZWORDS: Infarct in the posterior circulation causing behavioral abnormalities, altered LOC, abnormal ocular motion

A

Tip of the basilar syndrome

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39
Q

BUZZWORDS: Dilated thin-walled vessels, with no smooth muscle or elastic fibers, and no intervening brain parenchyma. Popcorn appearance on MRI

A

Cavernous malformation

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40
Q

BUZZWORDS: thin walled venous structure with normal intervening brain tissue

A

venous angioma

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41
Q

BUZZWORDS: abnormally dilated capillaries, normal intervening brain tissue.

A

Capillary telangiectasia

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42
Q

BUZZWORDS: nidus, with arteries and veins communicating without an intervening normal capillary bed in between

A

AVM

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43
Q

BUZZWORDS: assoc with Charcot Bouchard Aneurysms

A

Hypertensive ICH

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44
Q

BUZZWORDS: Congo Red positive, apple-green birefringence with polarized light

A

Cerebral Amyloid Angiopathy

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45
Q

Types of edema (3)

A

Interstitial, vasogenic, cytotoxic

46
Q

Interstitial edema: mechanism and seen in?

A

Seen in acute hydrocephalus, CSF is forced by hydrostatic pressure to move from the ventricles to the interstitium of the brain parenchyma

47
Q

Vasogenic edema: mechanism and seen in

A

extracellular accumulation of fluid 2/2 BBB disruption → extravasation of fluid from intravascular space.

Tumors, PRES

48
Q

Cytotoxic edema: mechanism and seen in?

A

intracellular accumulation of fluid (hypoxia-ischemia) that leads to a lack of energy to the cells, leading to depletion of ATP and failure of Na/K ATPase, causing alteration in the selective permeability of the cellular membrane

Strokes, anoxic injury

49
Q

Evidence for hypothermic therapy?

A

32-34C for V-fib

Evidence is limited in non-VF rhythms, including PEA or asystole

50
Q

Complications of hypothermic therapy?

A
  • coagulopathy
  • arrhythmias
  • electrolytes abnormalities
  • risk of infections.
51
Q

Uncal herniation:

What is it

CN most commonly affected?

Features?

A

mass effect on ipsilateral midbrain

CN3

  • Mass effect causes compression of parasympathetic fibers = mydriasis
  • Contralateral hemiparesis
  • unconscious (disturbance in ascending arousal system)
52
Q

Weird way that uncal herniations can cause ipsilateral hemiparesis?

A

pressure can lead to displacement of the midbrain against the contralateral Kernohan’s notch, resulting in compression of the contralateral corticospinal tract = ipsilateral hemiparesis.

53
Q

Risk of hemorrhage and infection for intraventricular catheters?

A

6

22

54
Q

Hyperventilation to lower ICP therapy typically lasts for? risk?

A

10-20 hours

Can cause rebound increase in ICP

55
Q

Normal ICP?

A

5-15

56
Q

Interventions to reduce ICP?

A
  • Hyperventilation (lasts for 10-20 hrs)
  • Osmotic agents (mannitol: given in boluses of 0.5 to 1.5g/kg)
  • Hypertonic solutions
  • Steroids
  • CSF drainage
  • Decompression
  • Barbiturate coma (in refractory cases, reduced cerebral metabolic activity)
  • Pharmacological paralysis
  • Hypothermia
57
Q

Complication of mannitol (2)?

A
  • hypotension/ hypovolemia (causes diuresis, serum osmolarity should be checked at regular intervals, should be not higher than 320)
  • depletion of K, MG and phosphorus
58
Q

Side effects of propofol

A
  • hypotension
  • respiratory depression
  • hypertriglyceridemia
  • infections
  • propofol infusion syndrome
59
Q

Propofol infusion syndrome

A
  • lethal complication, seen in high doses for long period of time and manifests with
    • hypotension
    • bradycardia
    • lactic acidosis
    • hyperlipidemia
    • rhabdomyolysis.
60
Q

Side effects of barbituate coma

A
  • hypotension
  • myocardial depression
  • hyperlipidemia
  • hypothermia
61
Q

Vasospasm from SAH can occur between what days? when is the peak?

A

3-15 days

6-8 days

62
Q

Diffuse axonal injury: mechanism

seen in?

macroscopic findings?

microscopic findings?

A

disruption of intracerebal axons and is caused by effect of angular forces and shear injury, but not from direct contusion or penetrating trauma

seen in severe head injuries such as MVCs where brain is subject to rotational or stretching forces.

Macro: small hemorrhages in the corpus callosum, superior cerebellar peduncle, deep nuclei, hemispheric white matter

Micro: evidence of swollen “bulb-like” and disconnected axons throughout the brain.

63
Q

In basal skull fractures, what should be avoided? What should be started

A

NG tubes

Also should start ppx antibiotics since there is potential external access to the CSF

64
Q

Apneustic breathing

A

respiratory pause at full inspiration and occurs from bilateral pontine strokes (Pontine respiratory group in the pons is responsible for cessation of inspiration)

65
Q

Cheyne Stokes breathing?

A

periodic breathing in which hyperventilation alternates with apnea and depth of breathing increases and decreases gradually → forebrain impairment in the setting of an intact brainstem

66
Q

Ataxic breathing?

A

irregular pattern (gasping respiration) seen with lesions damaging the respiratory rhythm generator in the upper medulla.

67
Q

Antidote for dabigatran (pradaxa)?

A

ibarucizimab (Praxbind)

68
Q

Antidote for apixaban and rivaroxaban?

A

Andexanet alfa (Andexxa)

69
Q

Critical illness myopathy?

A

common cause of failure for patients to wean off the vent

primary myopathy with loss of thick myosin filaments and varying degrees of necrosis.

70
Q

Somatosensory evoked potentials with median nerve stimulation showing bilaterally absent N20 responses at days 1 and 3 accurately predict poor outcome post cardiac arrest

A

just know

71
Q

Apnea test is performed how?

A
  • patient should be pre-oxygenated for 10min with an FiO2 of 100%.
  • A baseline ABG should be obtained with a pCO2 between 35-45
  • Patient is then disconnected from the ventilator but should receive ventilation at a rate of 6L/min
  • Patient is then observed for 10min for any chest or abdominal rise suggesting an inspiratory attempt
  • After 10min, ABG is obtained, if pCO2 > 60 then the test is positive and patient can be turned brain dead
  • To perform apnea test, patient should not be hypotensive or hyper/hypo thermic
72
Q

Other ways besides apnea testing to confirm brain death?

A

EEG showing no activity >30 mins

Transcranial dopplers showing no flow signal

Angiogram showing no flow in circle of willis

73
Q

Decorticate rigidity cause and mechanism?

A

hemispheric dysfunction or a lesion above the red nuclei

disinhibition of the red nuclei with facilitation of the rubrospinal tracts (involved in flexor tone in UE)

74
Q

Decerebrate rigidity cause and mechanism?

A
  • lesion in the brainstem or below the superior colliculi and the red nuclei but above the vestibular nuclei

vestibular nuclei are intact → enhancing the extensor tone without the influence from the red nuclei

75
Q

Lesion below the vestibular nucleus?

A

Will knock out red-flexor and vestibular-extensor connection, usually assoc with flaccid limbs

76
Q

Formula for CPP

A

CPP = MAP-ICP

77
Q

Malignant hyperthermia

Mechanism

Cause

presents with?

tx?

A
  • Autosomal dominant disorder
  • There is an excessive release of calcium from the sarcoplasmic reticulum in skeletal muscles in response to halogenated inhaled anesthetic and depolarizing muscle relaxants (succinylcholine)
  • Associated with mutation in ryanodine receptor gene and patient with central core disease (myopathy resulting from mutation in the ryanodine receptor gene)
  • Initially presents with rise in the end tidal partial pressure of CO2 during anesthesia, muscle rigidity, hyperthermia, altered consciousness and autonomic instability
  • Rhabdomyolysis occurs, leading to renal failure
  • Dantrolene should be administered early on
78
Q

NMS vs Serotonin Syndrome

A

NMS: febrile, muscle rigidity, AMS, autonomic instability

SS: AMS, hyperthermia, muscle rigidity, autonomic hyperactivity, hyperkineses, clonus

79
Q

Terson’s Syndrome

A

intraocular hemorrhage secondary to SAH/SDH. Caused by rapid increase in ICP leading to ocular bleed.

Assoc with worse prognosis

80
Q

Foster-Kennedy Syndrome

A

Tumor in optic nerve or frontal lobe causes contralateral papilledema (due to inc ICP and atrophy of unilateral optic nerve), can also cause anosmia

81
Q

rhinorrrhea lacrimation, sinus pressure, nasal congestion, and conjunctival injection frequently coexist with migraine because of?

A

CN 5 cross activation of the parasympathetics by stimulation of the superior salivatory nucleus of the facial nerve.

82
Q

migraine criteria?

A

5 HAs, each lasting 4-72 hours

with 2/4 of: Unilateral, pulsatile, severe intensity, aggravated by routine activity

and also: nausea OR vomiting/photo + phonophobia

83
Q

Migraine with brainstem aura criteria

A

Migraine criteria + at least 2 attacks with a fully reversible aura consisting of sensory, visual, speech, language sx and at least 2 of the following:

  • Dec LOC
  • Diplopia
  • Dysarthria
  • Tinnitus
  • Hyperacusis
  • Vertigo
  • Ataxia
84
Q

Chronic migraine criteria?

A

Migraine criteria for >15/mo for more than 3 months.

85
Q

Types of TACs?

A
  • cluster headache
  • paroxysmal hemicrania
  • hemicrania continua
  • short-lasting unilateral neuralgiform headache attacks
    • SUNCT: short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing
    • SUNA: short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms
86
Q

Difference between retinal migraine and migraine w aura

A

retinal migraine presents with monocular vision disturbance

87
Q

Tension HA criteria

A

10 HAs, each lasting between 30 mins and 7 days.

2/4 of the following: bilateral location, pressing/tighthening (nonpulsating) quality, mild or moderate pain intensity, it should not be aggravated by routine physical activity.

  • Neither nausea or vomiting is present
  • Only one of either photophobia or photophobia can be present
88
Q

Pathophysiology of headaches

A
  • Activation of central generator (cortex vs brainstem vs both)—> cortical spreading depression —> meningeal blood vessel dilation —> release of vasoactive neuropeptides (calcitonin gene-related peptide (CGRP), substance P …) —> neurogenic inflammation —>worsening dilation and inflammatory response causing more pain —> pain signals reaching the trigeminal nucleus caudal (TNC) (in brainstem)—> continuous TNC firing leads to central sensitization (allodynia) if activated pathways are not stopped (triptan has minimal to no effect at this stage)
89
Q

MOA of triptans?

A

agonists of serotonin receptors 5HT-1B and 5HT-1D

90
Q

New daily persistent HA

A
  • begins abruptly and patient charactistically recall the exact date it started, must be present for more than 3 months
91
Q

Criteria for hemicrania continua

A
  • continuous one-sided headache for at least 3 months with moderate to severe exacerbations
  • At least one autonomic sign on the side of the headache: conjunctival injection, lacrimation, facial sweating or flushing, rhinorrha, congestion, sense of ear fullness, partial Horner’s (ptoisis and/or miosis) or eyelid edema
  • Very responsive to indomethacin (patient must respond completely to indomethacin)
92
Q

Criteria for hemicrania continua

A
  • continuous one-sided headache for at least 3 months with moderate to severe exacerbations
  • women>men
  • At least one autonomic sign on the side of the headache: conjunctival injection, lacrimation, facial sweating or flushing, rhinorrha, congestion, sense of ear fullness, partial Horner’s (ptoisis and/or miosis) or eyelid edema
  • Very responsive to indomethacin (patient must respond completely to indomethacin)
93
Q

Cluster HA criteria

A
  • Duration 15- 180 min
  • More common in men (in contrast to HC and PH)
  • At least 5 attacks of severe unilateral temporal, orbital, and/or supraorbital pain
  • Presence of either agitation or restlessness and/or at least one autonomic sign (check HC part)
  • Can occur up to 8 times per day
94
Q

Paroxysmal hemicrania criteria

A
  • At least 20 attacks of severe unilateral temporal, orbital, and/or supraorbital pain lasting 2-30min
  • At least one autonomic sign
  • Very responsive to indomethacin (patient must respond completely to indomethacin)
95
Q

Trigeminal neuralgia criteria

tx?

A
  • Not associated with autonomic features
  • At least 3 attacks of unilateral facial pain in trigeminal nerve distribution, with no radiation outside the boundaries of this territory
  • Pain characterization (should have 3/4): lasts 1 sec - 2min, severe intensity, shooting/electric shock-like/stabbing or sharp, precipitated by stimuli to affected area
  • Most commonly V2 and V3
  • 1st line tx: carbamazepine
96
Q

What disorders should come to mine when there is bilateral trigeminal neuralgia?

A

MS, Lyme, Sarcoidosis, stuff like that

97
Q

SUNCT and SUNA criteria?

Difference between the 2

A
  • More common in males
  • At least 20 attacks of mod to sev unilateral head pain in the temporal, orbital, supraorbital and/or other trigeminal distribution
  • Duration 1-600 sec
  • At least 1 autonomic sign
  • Difference between SUNA and SUNCT: SUNCT requires both conjunctival and lacrimation, whereas SUNA requires only one or neither of conjunctival injection and lacrimation
98
Q

Hypnic headache

A
  • “alarm clock headache”
  • More common in women
  • Recurrent headaches developing only during sleep and causing the patient to wake up
  • Must occur 10 or more days/months for at least 3 months
  • Lasts between 15min and 4 hrs after waking
  • Begins after the age of 50
99
Q

Characteristics of HA in patients with Chiari Malformations

A

occipital area

precipitated paroxysmally by cough, bending forward, valsalva

100
Q

Low pressure headache features

A

positional HA in nature

Common after LPs, neurosurgery procedures, dural tear

101
Q

Most common location of spontaneous CSF leaks?

A

T spine

102
Q

MRI findings in dural leaks/low pressure HAs?

A
  • pachymeningeal enhancement
  • downward displacement of the brain and crowding of the posterior fossa due to the sagging and traction of intracranial structures and dura, which may mimic Chiari I malformation
  • subdural hematomas or hygromas
  • engorgement of cerebral venous sinuses
  • pituitary enlargement
  • flattening of the optic chiasm
  • increased anteroposterior diameter of the brainstem
  • decrease in the size of cisterns and ventricles
103
Q

How to diagnose a dural leak?

A

MRI myelography with fat suppression

104
Q

Treatment for dural leak

A

bedrest, hydration and caffeine

If doesnt work → blood patch

105
Q

Which triptan has a long half life and is not ideal for abortive tx?

A

Frovatriptan

106
Q

How long do you anticoagulate for CVST?

A

3 months, unless hypercoag panel is positive than lifelong.

107
Q

Familial hemiplegic migraine type 1

A

chromosome 19p13 (CACNA1A gene), resulting in a defect in P/Q calcium-channel subunit

108
Q

Familial hemiplegic migraine type 2

A

Chromosome 1q23 (ATP1A2 gene) resulting in a defect of A1A2 sodium potassium ATPase.

109
Q

Familial hemiplegic migraine type 3

A

Linked to chromosome 2q24 (SCN1A gene), resulting in defects of pre and post synaptic voltage gated sodium channels

110
Q

Findings in idiopathic cranial pachymeningitis on imaging? CSF? biopsy?

A

prominent leptomeningeal enhancement

CSF with lymphocytic pleocytosis

leptomeningeal biopsy may show perivascular inflammation

111
Q

Association with women who have migraine with aura and inc risk of stroke

A

higher in women <45yo

even higher with smoking and estrogen containing OCPs

Eugenie Notes (10 decks)

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