Pance Pearls: Neuro Flashcards by Casey Emge

4 lobes of the brain=

Frontal, parietal, temporal, occipital

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Involuntary spasms or repetitive motions or abnormal voluntary movement

Dyskinesia

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Sustained contraction (muscle spasm) esp of antagonistic muscles (ex simultaneous biceps and triceps contraction); twisting of body, abnormal posturing (ex torticollis, writer’s cramp)

Dystonia

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Sudden brief sporadic single repetitive jerks/twitching of 1 muscle or muscle group (not suppressible)

Myoclonus

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Sudden repetitive nonrhythmic movements or vocals using specific muscles groups (suppressible unlike myoclonus): Ex. tourette’s syndrome

Chorea

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Muscle contractions; Tonic (prolonged sustained contraction/rigidity); Clonic (repetitive rapid movement)

Muscle spasms

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Rhythmic movement of a body part

Tremors

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Tremor at rest (ex. Parkinson’s)

Resting tremor

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Tremors occurring while holding position against gravity

Postural tremor

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Tremor occurring during moment or when nearing a target

Intentional tremor

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Disorder associated with tremor, bradykinesia, rigidity, and postural instability

Parkinsonism

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Loss of the dopamine producing cells of the substantia nigra (in basal ganglia)

Parkinsonism

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Medications that block dopamine (dopamine antagonists)- ex. typical and atypical antipsychotics can cause this=

Parkinsonism

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Disease with loss of anticholinergic neurons (similar to alzheimer’s) where the pt develops dementia and loss of dopaminergic neurons (sharing symptoms similar to Parkinson’s disease)

Lewy Body Dementia

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Autosomal dominant inherited disorder or unknown etiology; onset of age usually in 60s; may begin at any age, worsened with emotional stress & intentional movement;; Tremor shortly relieved with alcohol ingestion; On finger to nose test, tremor increases as target approached; MC in upper extremities (usually spares legs)

Essential familial tremor

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May be used to treat Essential familial tremor if severe:

Propranolol

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Idiopathic dopamine depletion-> failure to inhibit acetylcholine in basal ganglia (Ach is excitatory CNS neurotransmitter, dopamine is INHIBITORY); Cytoplasmic inclusions (Lewy Bodies) & loss of pigment cells seen in substantial nigra (which produces dopamine)

Parkinson’s Disease

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Classic: tremor, bradykinesia, rigidity with progressive postural instability (often occurs in ages 45-65)

Parkinson’s Disease

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In Parkinson’s disease, worse at rest, emotional stress (lesseTened with voluntary activity/intentional movement & sleep); often first symptom; usually confined to one limb or one side for years before it becomes generalized

Tremor

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MC sign in Parkinson’s disease

Resting tremor (“pill-rolling” tremor)

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In Parkinson’s disease; slowness of voluntary movement & decrease in automatic movements: lack of swinging of arms while walking/shuffle gait

Bradykinesia

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In Parkinson’s, increased resistance to passive movement (flexed posture); Festination (increased speed while walking); normal DTR; usually no muscle weakness

Rigidity

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Signs include relative immobile face (fixed facial expressions), widened palpebral fissures, seborrhea of skin is common; Decreased blinking

Parkinson’s disease

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In Parkinson’s, tapping the bridge of the nose repetitively causes a sustained blink

Myerson’s sign

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Most effective tx in Parkinson's disease

Levodopa/Carbidopa (Sinemet)

_____ is converted to dopamine

Levodopa

______ reduces the amount of levodopa needed reducing SE of the levodopa

Carbidopa

Bromocriptine, Pramiprexole, Ropinirole; directly stimulate dopamine receptors; Less SE than levodopa; sometimes used in young pts to delay use of levodopa

Dopamine agonists

Blocks excitatory cholinergic effects; indicated in pts

Anticholinergics

Increases presynaptic dopamine release & improves long term levodopa-induced dyskinesias

Amantadine

Autosomal dominant neurodegenerative disorder; the gene causes neurotoxicity, cerebral & caudate nucleus atrophy; Symptoms appear after 30yrs of age; usually fatal

Huntington Disease

Initial symptoms are behavioral changes (personality, cognitive intellectual, psych), chorea (atrophy of caudate nucleus in basal ganglia) & dementia; Chorea is rapid, involuntary or arrhythmic movement of the face, neck, trunk & limbs initially; may have facial grimacing, ataxia

Huntington disease

Diagnose by CT scan: shows cerebral and caudate nucleus atrophy

Huntington disease

Onset usually childhood (2-5y) & may be associated with obsession compulsions (50% have resolution of symptoms by 18yrs); Motor tics of face, head, and neck (blinking, shrugging, head thrusting, sniffling)

Tourettes syndrome

May include verbal/phonetic tics ex. grunts, throat clearing, obscene words (coprolalia), repetitive phrases, repeating phrases of others (echolalia), self-mutilating

Tourette syndrome

Can be managed with Dopamine blocking agents or Alpha-adrenergics

Tourette syndrome

Acute/subacute inflammatory demyelinating polyradiculopathy with symmetric LOWER--> UPPER extremity weakness (ASCENDING WEAKNESS)

Guillian Barre Syndrome

Increased incidence with Campylobacter (MC) or other antecedent respiratory or GI infections, CMV, EBV, immunizations, surgery

Guillian Barre Syndrome

Immune-mediated demyelination & axonal degeneration slows impulses --> symmetric weakness & paresthesias; thought to be secondary to post-infection immune responses which cross-reacts with peripheral nerve components (molecular mimicry)

Guillian Barre Syndrome

Symptoms include weakness and paresthesias (usually symmetric); Decreased DTR; tachycardia, hypotension/hypertension, breathing difficulties

Guillian Barre Syndrome

Dx by CSF with high protein & normal WBC count (albuminocytological dissociation)--> may be d/t altered nerve capillary-CSF barrier defect

Guillian Barre Syndrome

Procedure done early in Guillian Barre Syndrome; removes harmful circulating Autoantibodies that causes the demyelination

Plasmapheresis

Tx of Guillian Barre; suppresses harmful inflammation/autoantibody & induces remyelination

IV immune globulin (IVIG)

Autoimmune disorder of the peripheral nerves; 75% have thymic abnormality (hyperplasia or thymoma) or other autoimmune disorders; MC in young women (HLA-DR3)

Myasthenia Gravis

Inefficient skeletal muscle neuromuscular transmission d/t autoimmune Ab against Ach (nicotinic) post synaptic receptor @ NMJ (decrease Ach receptors)--> progressive weakness with repeated muscle use and recovery after periods of rest

Myasthenia Gravis

Clinical manifestations include extra ocular muscle weakness--> diplopia; ptosis (eyelid weakness more prominent with upward gaze); pupils spared

Myasthenia gravis

Generalized muscle weakness; least in the morning worsened with repeated muscle use throughout day (relieved w/ rest), fluctuation; bulbar (orapharyngeal) muscle weakness (weakness w/ prolonged chewing, dysphagia) ; Respiratory muscle weakness (leading to respiratory failure)

Myasthenia Gravis

Test for Guillian Barre; rapid response to short acting IV edrophonium

Edrophonium (Tension test)

Dx with + Ach-receptor Antibodies; + muscle specific tyrosine kinase Ab

Myasthenia Gravis

Increases acetylcholine by decreasing acetylcholine breakdown

Acetylcholinesterase inhibitors

Associated with small cell lung CA, develop Ab preventing Ach release; weakness is improved with continued use

Myasthenia

Autoimmune inflammatory demyelinating disease of the CNS idiopathic origin with axon degeneration of white matter of the brain, optic nerve & spinal cord; MC in young adults (women) 20-40; associated with CNS IgG production abnormal T lymphocyte reaction

Multiple Sclerosis

MC type of Multiple sclerosis=

Relapsing-remitting disease (RRMS)

Clinical manifestation includes optic neuritis* (retrobulbar)-unilateral eye pain worse w/ eye movements, diplopia, scotoma/vision loss (esp color), blurry vision

Multiple sclerosis

In Multiple Sclerosis; both pupils constrict when you shine light into the normal eye but pupil's "DILATE" when you quickly shone the light into the affected eye (response d/t brain perceiving the delayed conduction of affected optic nerve as if light was reduced)

Marcus Gunn pupil

Clinical manifestations include sensory deficits; weakness, parasthesisas, fatigue (75%); muscle cramping (spasticity); Uhthoffs's phenomenon (worsening of sx w/ heat; pain, numbness, paresthesias in a limb, muscle cramping) & Lhermitte's sign (neck flexion causes lighting-shock pain radiating from the spine down the leg)

Multiple sclerosis

Includes spinal cord sxs: bladder, bowel, or sexual dysfunction; Charcot's neurological triad**(nystagmus, staccato speech & intentional tremor)**; Spasticity & positive (upwards) babinski*

Multiple Sclerosis

Test of choice to confirm dx of Multiple Sclerosis

MRI* w/ gadolinium

MRI will show white matter plaques* (hyperdensistites)

Multiple Sclerosis

CSF will show increase IgG (oligoclonal bands)-sm, discrete bands in the gamma globulin seen on electrophoresis, which reflecting inflammatory cells penetrate the blood brain barrier)

Multiple Sclerosis

CSF revealing 'High IgG (oligoclonal) bands'

Multiple Sclerosis

CSF revealing 'High protein with NORMAL WBC cell count'

Guillian Barr Syndrome

CSF revealing 'High protein with INCREASED WBC (polymorphonuclear neutrophils), DECREASED glucose*'

Bacterial Meningitis

CSF revealing 'Normal glucose, Increased WBC lymphocytes'

Aseptic Viral Meningitis

CSF revealing 'Increased WBCs (lymphocytes) and decreased glucose'

Fungal Meningitis

An acute, abrupt confused state (transient global disorder of attention) usually as a result of systemic problems with rapid onset and fluctuating mental status changes; Marked deficit in short term memory; usually 1 week with full recovery in most cases

Delirium

Progressive, chronic deterioration of selective functions; MEMORY LOSS and loss of impulse control, motor & cognitive functions NOT d/t delirium, medications, or psychiatric illness

Dementia

MC type of dementia; Loss of brain cells, amyloid deposition (senile plaques) in the brain, neurofibrillary tangles (tau protein); cholinergic deficiency--> memory, language, visuospatial changes; CEREBRAL CORTEX ATROPHY on CT scan*

Alzheimer's disease

Used to manage Alzheimer's disease; reverses cholinergic deficiency, may not always slow down progression of dz but helps with sx

Acetylcholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine)

Used to manage Alzheimer's disease; blocks NMDA receptor, slowing calcium influx and nerve damage; Glutamate is excitatory receptor--this reduces Glutamate's excitotoxicity

NMDA antagonists

2nd MC type of Dementia; brain dz d/t chronic ischemia and multiple infarctions (ex. lacunar infarcts**); assoc w/ HTN

Vascular Dementia

Type of dementia; Rare; Localized brain degeneration of the frontotemporal area may progress globally; marked personality changes*; aka Pick's disease

Frontotemporal Dementia

Abnormal protein deposits (Lewy bodies) in nerve cells; Visual hallucinations, delusions, Parkinsonism

Diffuse Lewy Body disease

Rapid dementia d/t prions

Creutzfeldt-Jakob dz

Predominantly middle-aged males with severe UNILATERAL periorbital/temporal pain (sharp, lacinating)* bouts lasting

Cluster headaches

Physical exam reveals IPSILATERAL Horner's syndrome (ptosis, miosis, anhydrosis)*, nasal congestion/rhinorrhea, conjunctivitis & lacrimation

Cluster Headaches

First line tx in cluster headaches=

100% O2

Prophylaxis tx for cluster headaces=

Verapamil

MC in females; 2 types (w/ and w/o auras); Family hx 80%; Thought to be caused by vasodilation of the blood vessels innervated by the trigeminal nerve; Neuro findings d/t internal carotid constriction

Migraine headaches

Lateralized, pulsatile/throbbing headaches associated with N/V, photophobia & photophobia for 4-72 Hr duration; worse w/ physical activity, stress, lack/excessive sleep, ETOH, certain foods, OCPs/menstruation

Migraine headaches

Bilateral* tight band-like, constant daily HA worsened w/ stress, fatigue, noise, or glare (NOT ACTIVITY); usually not pulsatile; NO N/V or focal neurologic sx

Tension headaches

Compression of trigeminal nerve root (by superior cerebellar artery or vein); Brief episodic, stabbing/lancinating pain in the 2nd/3rd division of the Trigeminal nerve (CN V) worse with touch, eating, drafts of wind, and movements (often unilateral): pain starts near mouth & shoots to eye, ear, nostril on ipsilateral side

Trigeminal Neuralgia

First line tx for trigeminal neuralgia

Carbamazepine

If this is present in younger pts, suspect Multiple sclerosis

Trigeminal Neuralgia

MC type of stroke=

Ischemic

Transient episode of neurological deficits caused by focal brain, spinal cord or retinal ischemia (WITHOUT acute infarction); MC due to embolus

Transient ischemic attack (TIA)

Internal carotid artery: Amaurosis fugax (monocular vision loss-temporary "lamp shade down on one eye"), weakness in contralateral hand; sudden HA, speech changes, confusion

TIA

Mild traumatic brain injury; alteration in mental status with or loss of consciousness; confusion, amnesia, HA, dizziness, visual disturbances, delayed responses and emotional changes; signs of increased intracranial pressure (persistent vomiting, worsening HA, increasing disorientation, changing levels of consciousness)

Concussion syndrome

MC type of stroke; Most d/t thrombus (49%) others d/t embolus

Ischemic

Type of ischemia stroke; small vessel disease (penetrating branches of cerebral arteries in pons, basal ganglia); MC is hemiparesis, hemiplegia; Ataxic hemiparesis weakness/clumsiness in LEG>arm; ;dysarthria (clumsy hand syndrome); hx of HTN (80%)

Lacunar infarcts

On CT scan, small punched out hypotedense* area

Lacunar infarcts