PANCE Prep- Neuro Flashcards
Management of Normal pressure Hydrocephalus
- Ventriculoperitoneal shunt
What is the term for impaired performance of rapidly alternating movements and what does it mean
dysdiadochokinesia
*cerebellar pathology
CN VII: ____ (S/M/B?)
Test by: ___
Abnormalities could mean: ___
CN 7: facial: B
Test: M: facial expression, S: taste anterior 2/3 of tongue
Abnormalities: Bells palsy, CN 7 palsy, Ramsay Hunt Syndrome
Tx of Tension Headache
- tx like migraines- 1st NSAIDS, ASA, acetaminophen
2. Anti-migraine meds
What are the following associated with:
1. Lewy bodies
- Lewy bodies= Parkinson disease
The ability to put three words together, feed oneself well with a spoon and build a tower of seven cubes are milestones for what age?
24 months
2 main Clinical manifestations of Myasthenia Gravis
- Ocular Weakness (usually 1st presenting sx and more severe)
- EOM involvement, Diplopia***, ptosis (more prominent w/ upward gaze)
- Pupils are SPARED - Generalized muscle weakness w/ repeated muscle use– relieved w/ rest
- Bulbar (oropharyngeal) weakness w/ prolonged chewing
- Respiratory muscle weakness may lead to resp. failure= myasthenic crisis
- MC in young women
- *MUSCLE WEAKNESS WORSENED W USE
Management of TIA
- FIRST LINE: Aspirin +/- dipyridamole or plavix
* *Thrombolytics contraindicated!!
* *avoid lowering BP unless >220/120 - Management of RF:
- carotid endartectomy if ICA stenosis > 70%
- oral anticoagulation for a-fib or LV thrombus
Symptoms of Restless Leg Syndrome (Willis-Ekbom Disease)
- uncomfortable itching, burning, paresthesias in the leg that creates an urge to move
- worse at night and prolonged period of rest/inactivity
- improved with movement
What is Myerson’s sign
tapping the bridge of nose repetitively causes a sustained blink
*often seen in Parkinson Disease
What is the most common and most aggressive of all the primary CNS tumors in adults
Glioblastoma (glioblastoma multiform) = Grade 4 astrocytoma
What is Lhermittes sign
Neck flexion causing lightening shock type pain radiating from the spine down the leg
*seen in MS
What makes up the diencephalon and where is it?
- Thalamus: deep in forebrain
2. Hypothalamus: below and ventral to thalamus
Management of Restless Leg Syndrome (Willis-Ekbom Disease)
- Dopamine agonist (TX OF CHOICE) ex. Pramipexole, Ropinirole
- Iron supplementation in those w/ serum ferritin lower than 75mcg/L
- Alpha-2-delta calcium channel ligands ex. Gabapentin
Valproic acid and Depakote 4 ADRs
pancreatitis, hepatotoxicity, TERATOGEN (neural tube defect), tremor
SE of Levodopa/Carbidopa
- NV
- Hypotension
- Somnolence
- Dyskinesia and wearing off bradykinesia associated with LT use
CN VI: ____ (S/M/B?)
Test by: ___
CN6: Abducens: M
Test: lateral rectus (lateral gaze), EOM
Seizures that develop during adolescence and adult life are predominantly due to:
tumor, trauma, drug use, or alcohol withdrawal.
This type of tremor is shortly relieved with alcohol ingestion
Essential Familial Tremor
benign intentional tremor
what is progressive, chronic intellectual deterioration: memory loss, loss of impulse control
Dementia
CN X: ____ (S/M/B?)
Test by: ___
CN10, vagus, B
Test: M: voice, soft palate, gag
Anterior CVA sxs
contralateral sensory and motor deficits greater in leg/foot
urinary incontinence
personality/cognitive deficits
What is Cushings reflex and what disease state is it typically seen in?
- irregular respirations
- hypertension
- bradycardia
**TBI and epidural hematoma
4 Indications for Carbamazepine (Tegretol)
- tonic-clonic and focal Seizure disorders
- bipolar
- Trigeminal neuralgia (Drug of choice)
- central diabetes insipidus
what is Central cord syndrome and presentation
MC type of incomplete spinal cord injury
CP: loss of motor function that is more severe in the UE than LE (more severe in hands); hyperesthesia over the shoulders and arms
s/s of Reye syndrome
- post-influenza or URI
- The patient develops lethargy, drowsiness, and vomiting. Babinski reflex is positive and hyperreflexia is noted. The liver is normal or enlarged.
On finger to nose testing, tremor increases as the target is approached
Intentional tremor (essential familial tremor)– benign
With Myasthenia Gravis, how can you tell if the weakness and respiratory failure is from myasthenic crisis or cholinergic crisis (too much acetylcholine)?
- If flaccid paralysis improves w/ Tensilon–> myasthenic crisis
- If flaccid paralysis worsens w/ Tensilon–> Cholinergic crisis
What type of intracranial hemorrhage?
CT: convex lens, shaped
*does not cross suture lines
Epidural
What causes Parkinson’s disease?
IDIOPATHIC loss of dopamine producing cells of the substantia nigra (in the basal ganglia)
*failure to inhibit acetylcholine in the basal ganglia (Ach is an excitatory CNS neurotransmitter and dopamine is inhibitory)
Cluster HA is diagnosed by:
Severe unilateral periorbital pain accompanied by one for more of the following:
ipsilateral. ..
1. nasal congestion
2. rhinorrhea
3. Lacrimation
4. redness of the eye
*Horners Syndrome: ptosis, miosis, anhydrosis
4 SE of Carbamazepine (Tegretol)
Hyponatremia (causes SIADH)
SJS,
blood dyscrasias
hepatotoxicity
Phenytoin is the drug of choice for ___
seizure prophylaxis *does not cause CNS depresssion
When are anticholinergics indicated and CI for Parkinson Disease
Indicated: less than 70y/o w/ tremor predominance (doesn’t improve bradykinesia)
CI: BPH, glaucoma
What is ALS? what functions are spared in these disease?
Amyotrophic Lateral Sclerosis “aka Lou Gehrig’s Disease”
-Necrosis of BOTH upper and lower motor neurons–> PROGRESSIVE MOTOR DEGENERATION
**sensation, voluntary eye movement, bowel/bladder, sexual function are SPARED
Management of Cluster HA
- 100% Oxygen (6-10L)
- Anti-migraine meds: SQ sumatriptan
Prophylaxis: Verapamil (1st line**)
CN II: ____ (S/M/B?)
Test by: ___
Abnormalities could mean: ___
CN2: optic: S
Test: visual acuity, visual fields, pupillary light reflex
Abnormalities: optic neuritis, marcus Gunn
What are the functions of the Parietal Lobe
- Perception/recognition of stimuli
- Orientation
- Movement
* body sensation and somatosensory
What type of intracranial hemorrhage?
CT: concave, crescent shape
*can cross suture lines
Subdural
What are the functions of the Medulla oblongata
- Regulates vital body function (HR, breathing, autonomic fxn)
What is Marcus- Gunn pupil and what disease state is it common to see this in?
During swinging flashlight test from the unaffected eye into the affected eye, pupils appear to dilate (due to less than normal pupillary constriction). The response is due to the brain perceiving the delayed conduction of affected optic nerve as if light was reduced
**MS
Management of Migraine HA
- Symptomatic/Abortive: NSAIDS/ASA/TYL first line if mild, Triptans or Ergotamines (mod to severe with no response to first line): Serotonin 5HT-1 agonists
- Dopamine blockers (metoclopramide, prochlorperazine)+ Diphenhydramine (to prevent EPS, dystonic reactions)
- IV fluids
Prophylactic: anti-HTN meds (BB, Ca+ channel blockers) TCAs, Anticonvulsants
What spinal nerve root is most likely affect in a patient with triceps, elbow extension, wrist flexion weakness and paresthesias in the middle finger and diminished triceps reflex
C7
___ are suppressible while ___ are not suppressible
Tics- suppressible
Myoclonus- not suppressible
Berry Aneurysm MC occurs where?
DX by ___
Circle of Willis (asymptomatic until SAH)
DX: angiography gold standard
___ presents w/ ptosis of the eyelid, meiosis or constriction of the pupil, and anhidrosis or reduced sweat secretion
-pupillary response to light and accommodation is preserved
Horner Syndrome
What type of intracranial hemorrhage?
CT: star shaped
SAH
Epidural hemorrhage Location: MOI: SX: Dx: Tx:
Location: Arterial bleed, btwn skull and dura
MOI: temporal bone fx and middle meningeal artery disruption
SX: LOC followed by lucid interval, then neuro degeneration
Dx by noncontrast CT: Lens shape, does NOT cross suture lines, temporal bone fx
Tx: hematoma evacuation or craniotomy TOC in most
if small, close observation without surgery
**remember methods to reduce ICP
What is Alzheimer Disease and what is it usually due to?
MC type of dementia
hypotheses on causes: amyloid deposition (senile plaques) in brain, neurofibrillary tangles (caused by abnormal tau proteins), ACh deficiency
**see temporal atrophy
How do you manage an Essential Familial Tremor
- Tx not usually needed
1. Propranolol may help if severe or situational
2. Second line: Primidone (barbiturate)
3. Third line: Alprazolam (benzo)
What spinal nerve root is most likely affected in a patient with weak wrist extension, thumb and index finger paresthesias and diminished brachioradialis reflex?
C6
Indications for close contacts of a patient with bacterial meningitis to be treated
*unique to N. meningitidis
Rifampin (600 mg q 12 for 2 days) OR Ciprofloxacin (500 mg oral)
>8 hrs of exposure or direct exposure to respiratory secretions
MC type of astrocytoma in children/young adults vs adults
Kids/young adults: Grade I Pilocytic astrocytoma (most benign)
Adults: Grade 4 Glioblastoma multiforme
Suspect ____ in younger patients with Trigeminal Neuralgia
Multiple Sclerosis
How does Phenytoin (Dilantin) help w/ seizures and what are its SE
stabilizes neuronal membranes by blocking Na+ channels in CNS
SE: gingival hyperplasia, SJS, rash, hirsutism, hypotension, TERATOGEN
- osteomalacia or demineralization w. LT use
Describe the following pupil findings:
- Horner Syndrome
- Adie pupil
- Argyll Robertson pupil
- Marcus Gunn pupil
- Light-Near dissociation
- Horner Syndrome: unilateral small pupil w/ mild ptosis +/- ipsilateral anhydrosis w/ preserved pupillary response to light and accommodation
- Adie pupil: unilateral-dilated pupil that is sluggish to direct light stimuli
- Argyll Robertson pupil: usually affects both eyes, small bilateral pupils that accommodate but poorly react to light
- Marcus Gunn pupil: constricts slower to direct light stimulation than to the consensual stimulation
- Light-Near dissociation: bilateral and consists of preserved constriction to accommodation but impaired to response to light
what is a Lacunar infarct? biggest risk factor? MC presentation? how to dx? tx?
- small vessel disease of cerebral artery penetrating branches in pons and basal ganglia (usually NON cortical)
- RF: HTN (80%)
- MC presentation is PURE MOTOR DEFICIT (hemiparesis or hemiplegia)
- Dx made by CT: small punched out hypodense areas (usually centrally or noncortical areas- BG)
- Tx: ASA, control risk factors (good prognosis)
Most CNS lymphomas are ____ and a big risk factor is
large B cell lymphoma (secondary)
EBV 90% of time
What is a TIA? what is the classic CP sign?
TRANSIENT episode of neurological deficits WITHOUT acute infarction. often lasting <24hr
*MC cause embolus
CP sign: amaurosis fugax (transient monocular vision loss)
An 18 year-old male is involved in a motor vehicle accident with a question of cervical spine fracture. What is the imaging test of choice to initially evaluate this patient and clear his cervical c-spine?
Lateral radiograph
*MRI and CT of the spine may be performed in the setting of acute cervical spine injury when a major fracture or dislocation is identified.
When do the following reflexes disappear in infants:
- Moro:
- Grasp:
- Parachute:
- Tonic Neck:
- Moro: 3-6 months
- Grasp: 2 months
- Parachute: Remains throughout life
- Tonic Neck: 6-7 months
What is Tourette Syndrome? when is typical onset?
idiopathic movement disorder (maybe basal ganglia disorder) characterized by vocal and motor tics
**onset usually in childhood
What is the most common cause of subclavian steal syndrome and how do they present
atherosclerosis
- most are asymptomatic
- sx of arm arterial insufficiency- BP difference between arms >15mmhg in affected arm
What are the 4 upper motor neuron signs and 4 examples of conditions
- Spasticity (strong tone)
- Stiffness (posturing)
- HYPERreflexia (increased DTR)
- UPward babinski
*CVA, MS, cerebral palsy, spinal cord/brain damage
Acute relapses of MS are treated with
a short course of IV methylprednisolone followed by oral prednisone.
Most abundant excitatory NT in CNS:
Most abundant inhibitory NT in CNS:
Most abundant excitatory NT in CNS: Glutamate
Most abundant inhibitory NT in CNS: GABA
How can you tell the difference btwn Myasthenia Gravis and Myasthenic syndrome (Lambert-Eaton)
Weakness improves w/ repeated use in Lambert Eaton
**also usually hyporeflexia in LE syndrome whereas MG doesn’t affect reflexes
What are some dopamine antagonists?
(blocks dopamine)
- Typical antipsychotics: Haloperidol
- Atypical antispychotics: Clozapine, risperidone
- Antiemetics: Promethazine
Management of ischemic CVA
1) . Thrombolytics w/in 3 hrs of onset
* * rTPA (alteplase) if no contraindications: recent bleed, bleeding disorder, recent trauma, BP over 185/110
2) . Mechanical thrombectomy within 24 hrs (can be done in combo with TPA)
3) . GRADUAL BP control: only lower if greater than 185/110 if TPA used or >220/120 if no TPA
If onset of sxs > 3 hrs: Long-term management
1) . Antiplatelet: ASA or Plavix therapy (no ASA within 24 hrs of TPA)
2) . Statin therapy
3) . NPO, HOB 30 degrees, no hypotonic fluids, DVT proph
Sx of middle cerebral artery stroke
contralateral sensory and motor deficits of FACE and ARM (only lower half of face) dominant (usually left) hemisphere: aphasia, math comprehension probs non dominant (usually right): spatial deficits, flat affect, impaired judgement, impulsivity
Management of Multiple Sclerosis
Acute exacerbation: IV corticosteroids*** and plasmapheresis if not responsive
Relapse-remitting disease: B interferon** or Glatiramer acetate
-Amantadine is helpful for the fatigue in MS
What is the diagnostic test of choice for MS
MRI with gadolinium: hyperintense white matter plaques
**use in combo with clinical
Describe the CSF findings for:
- MS:
- Guillain Barre Syndrome:
- Bacterial Meningitis:
- Viral Meningitis:
- Fungal or TV Mengitis
- Pseudotumor Cerebri
- SAH
- MS: High IgG/Oligoclonal bands
- Guillain Barre Syndrome: high protein w/ normal WBC/cell count
- Bacterial Meningitis: high protein, high WBC (PMNs), decreased glucose
- Viral Meningitis: high WBCs (lymphocytes), normal glucose, usually normal protein
- Fungal or TV Meningitis: Decreased glucose, high WBCs (lymphoctyes), increased protein
- Pseudotumor Cerebri: increased CSF pressure otherwise nl
- SAH: xanthocromia, blood in CSF
What are the Clinical manifestations of an Essential Familial Tremor
BILATERAL and SYMMETRIC
- Intentional Tremor: postural, bilateral ACTION tremor of the hands, forearms, head, neck or voice–> MC in UE and head (titubation) (usually spares legs)
- Tremor worsens w/ emotional stress and intentional movement
- No other sign. neuro findings
Describe what CN control what eye movements
CN 3 (Oculomotor): superior rectus, inferior rectus, and medial rectus CN 4 (Trochlear): Superior oblique CN 6 (Abducens): Lateral rectus
SO4, LR6 and the remainder 3
(Superior oblique: CN 4– Lateral rectus: CN 6)
Clinical Manifestations of ALS and PE findings
MC sxs: ASYMMETRIC Limb weakness
- loss of ability to initiate and control motor movements due to muscle weakness
- Bulbar sxs: dysphagia, dysarthria, resp problems
- cognitive impairment
PE signs: Mixed upper and lower motor neuron signs**
difference in sxs between Viral meningitis and Encephalitis
Both present with meningeal sxs and signs on exam
BUT encephalitis will have profound lethargy/AMS, changes in personality, speech, and movement PLUS FOCAL neuro deficits
CN V: ____ (S/M/B?)
Test by: ___
Abnormalities could mean: ___
CN 5: Trigeminal:B
Test: M: muscles of mastication, S: light touch of face
Abnormalities: trigeminal neuralgia
How do you diagnose Guillain Barre Syndrome
strong clinical suspicion
- CSF shows high protein w normal WBC
- Electrophysiologic studies most specific: decreased motor nerve conduction velocities and amplitude
What are the functions of the Frontal Lobe
- Reasoning
- Problem solving
- Parts of speech
- Movement
- Emotion
What makes up the Cortex and what is its fxn
Frontal, parietal, tempora, occipital lobes
- fxns in higher brain processes such as thought and action.
- Controls all voluntary activity (w/ help of cerebellum)
What type of spinal cord injury causes loss of proprioception and vibratory sense only
Posterior cord syndrome (rare)
What are 5 lower motor neuron signs and 4 conditions
- Bilateral FASCICULATIONS
- Muscle ATROPHY and WEAKNESS
- HYPOreflexia (Decreased DTR)
- Flaccidity/HYPOtonia (loss of muscle tone)
- DOWNward Babinski
**GBS, botulism, cauda equina, bell palsy
Twisting of the body, abnormal posturing (ex. torticollis, writers cramp)
Dystonia
What s/s occur in order of prevalence for an impending cerebral aneurysm rupture
- HA (MC 48%)
- Dizziness (10%)
- Orbital pain (7%)
- Sensory and motor disturbance (6%)
- diplopia (4%)
What is the most appropriate initial disease-modifying treatment for a patient diagnosed with MS
- Beta-interferon
Flexion teardrop fracture may cause ____.
Extension teardrop fracture may cause ___.
anterior cervical cord syndrome
central cord syndrome
What is the difference between meningitis and encephalitis
Meningitis: inflammation of MENINGES that can be infectious (bacterial)
Encephalitis: infection of BRAIN PARENCHYMA
You have just stuck yourself with a sharp needle. In order for you to be able to interpret this sensation, which of the following areas must be intact?
Lateral spinothalamic tract, thalamus, and sensory cortex
*Sensory impulses reach the sensory cortex from the spinothalamic tract or the posterior columns. Fibers transmit this to the thalamus which sends impulses to the sensory cortex of the brain
What are the functions of the Midbrain
- Relays audio/visual info
2. Eye movement
What term is given to an ocular examination finding where small, irregular pupils are seen that react with near vision but not to light?
Argyll-Robertson
What is a flexion teardrop fracture and its MOI
anterior displacement of a wedge shaped fracture gragment of the anterio-inferior portion of the superior vertebra
MOI: severe flexion and compression
How to manage Huntington’s Disease?
- *No cure– usually fatal w/in 15-20 yrs after presentation
- *No medication stops the progression
Chorea management: tetrabenazine
mood: antipsychotics
what disease causes localized brain degeneration of the frontotemporal lobes? common CP? what is seen on histology?
Frontotemporal Dementia (Picks Disease)
CP: marked personality, social behavior, and language changes (preserved visuospatial), this progresses to dementia
**socially inappropriate behavior, HYPERORALITY
Histology: PICK bodies (aggregates of Tau proteins)
What is Bell’s Palsy? common sxs/signs
idiopathic, unilateral CN7 palsy (FACIAL WEAKNESS ONLY)
- Strong association w/ HSV reactiviation**
- sxs/signs: ipsilateral hyperacusis followed by unilateral facial weakness WITH forehead involvement, taste probs, dec lacrimation, inability to fully close eyelid)
What seizure medication is associated with gingival hyperplasia?
Phenytoin
*Also associated w/ anemia and hirsutism
Sudden, repetitive NONRHYTHMIC movements or vocals using specific muscle groups
Tics
CN III: ____ (S/M/B?)
Test by: ___
Abnormalities could mean: ___
CN3: oculomotor: M
Test: inferior rectus, ciliary body, EOM
Abnormalities: Oculomotor, dilated pupil
How do you diagnose Multiple Sclerosis
- mainly clinical- at least 2 discrete episodes of exacerbations
- MRI w/ gadolinium (test of choice to confirm MS)– white matter plaques (hyperdensities)
- LP w./ increased IgG (Oligoclonal bands) in CSF
Spinous process avulsion fx MC at the lower cervical C6 or C7
Clay-Shoverlers fracture
What is Unthoffs Phenomenon
MS sx worse in heat
How to dx and manage ALS? most common cause of death?
Dx: electromyography (loss of neural innervation and reinnervation in muscle groups)
Riluzole: reduces glutamate (excitatory) buildup in neurons, decreases progression for up to 6 months
*usually fatal w/in 3-5 yrs after onset
MC cause of death: respiratory failure
Dx and Management of Bell Palsy
Dx: clinical
TX: no tx is required and typically resolves in 1 month
**supportive with artificial tears
-severe cases: Acyclovir w or wo steroids
s/s of thoracic outlet syndrome
- pain that radiate from the point of compression to the base of the neck, axilla, arm, forearm, and hand
- paresthesias to the volar aspect of the 4th and 5th digits
- sensory sx may be aggravated at night or by prolong use
- weakness and muscle atrophy
- vascular/arterial ischemia
what is Charcots neurologic triad
- Nyastagmus
- Staccato speech
- Intentional tremor
*seen in MS
A mother brings in her 4 year-old son with complaints that he falls frequently and he “stands funny”. The mother also notes that he has lost the ability to easily stand from a seated position. She reports that he met developmental milestones as an infant. Which of the following is the most likely cause?
Muscular dystrophy age of onset is by age 5 and begins in the pelvic girdle.
A patient presents w/ left hand weakness and slurred speech. What test is most likely to determine the source of an arterial thrombus
Carotid US
*s/x consistent w/ pathology arising from anterior cerebral circulation including carotid arteries- a CT should be also ordered to r/o acute hemorrhage
Describe the anatomy of UMN and LMN
UMN: connects cortex to LMN in SC (NT: glutamate to active LMN)
LMN: in SC, links UMN to muslces (NT: Acetylcholine stimulates muscle contraction)
Describe Central Cord Syndrome
“Because MalefiCENT developed frostbite when she EXTENDED her hand to touch the cold window pane, she couldn’t put on her SHAWL with her WEAK HANDS”
- Extension injuries
- Loss of pain and temp sensation
- UE>LE (especially hands)
- Shawl distribution
Sxs and PE findings of Huntington’s Disease
SXS: 3 M's Mood (behavioral changes), Memory (dementia), Movement (chorea) PE signs: 1. Restlessness 2. Fragility 3. Quick, involuntary hand movements 4. Brisk deep tendon reflexes
___ is vision loss due to a central lesion, anisocoria has unequal sized pupils, unilateral loss of vision due to multiple sclerosis
amaurosis fugax
Management of Alzheimer Disease
- Ach-esterase inhibitors (CNS): Donepezil, Tacrine, Rivastigmine, Galantamine
* *help memory function and sxs (doesn’t slow dz) - NMDA antagonists: Memantine (adjunct or monotherapy in mod-severe dz)
What is Guillain Barre Syndrome? causes of it?
-acquired autoimmune demyelinating polyradiculopathy of the peripheral nerves (immune mediated)
PP: autoantibody attacks myelin sheath of peripheral nerves
-MC w/ Campylobacter jejuni or other antecedent respiratory or GI infections, INFLUENZA vaccine
What is Multiple Sclerosis
Autoimmune, inflammatory demyelinating disease of CNS. Associated w/ axon degeneration of WHITE MATTER
-Relapsing-remitting disease is MC w/ episodic exacerbations
Describe the nerve roots that are tested with each reflex testing: ankle/achilles, knee, biceps, triceps
Achilles/ankle: S1-2
Knee: L3-4
Biceps: C5-6
Triceps: C7-8
Problems in the basal ganglia can lead to what type of disorders?
- Movement disorders (dyskinesia, dystonias, Parkinsonism, Huntingtons)
- Behavior control (Tourettes, Obsessive compulsive)
*Basal ganglia is involved in coordinated movement, emotion and cognition
What is Myasthenia Gravis? what is it strongly associated with?
Autoimmune peripheral nerve disorder
-autoimmune antibodies against acetylcholine postsynaptic receptor–> decrease ACh receptors–> progressive weakness w/ repeated muscle use and recover after periods of rest
- 75% have thymic abnormality (hyperplasia or thymoma)
- May occur postpartum
Sx of vertebral artery posterior stroke
specific findings of vertebrobasilar and basilar
3 V’s
- vertigo (nystagmus)
- vomiting (and nausea)
- visual changes (diplopia)
* *vertebrobasilar artery: IPSIlateral CN deficits (FACE) with CONTRAlateral motor/sensory deficits
* *basilar infarct: asymmetric but bilateral deficits
What makes up the brainstem and what is its fxn
Controls vital life functions (breathing, HR and BP)
- midbrain
- pons
- medulla oblongata
How do benzos help with seizures
increases GABA- GABA is an inhibitory NT in the CNS
Where is the likely TIA?
SX: gait and propriocetion, dizziness, vertigo
-brainstem/cerebellar sx
Vertebrobasilar
With a ____ hemorrhage, do not perform an LP BEFORE CT scan/PE bc it may cause brain herniation
intracerebral hemorrhage (ICH)
What are the functions of the Temporal Lobe
- Hearing (perception/recognition of auditory stimuli and speech)
- Memory
CT scan: ring enhancement
*infectious cause
Toxoplasma
What is Kernig’s sign and Brudzinski’s sign
Kernigs: inability to straighten knee w/ hip flexion
Brudzinskis: neck flexion produces knee/hip flexion
**seen w/ meningitis
3 Clinical Manifestations of CP, PE findings
- Spasticity (**Hallmark)
- varying degrees of motor deficits
- +/- seizures
PE: hyperreflexia, limb-length discrepancies
**Often associated w/ intellectual and developmental abnormalities
A 75 year-old male presents to the ER with the following stroke findings: right-sided hemiparesis (face and hand more affected than leg), homonymous hemianopsia of the right half of both visual fields, and aphasia. Where is the location of his stroke?
Middle Cerebral Artery
Management of Trigeminal Neuralgia
- Carbamazepine (Tegretol) 1st line
2. Gabapentin
What are Lewy bodies
loss of pigment cells seen in the substantia nigra
*seen in Parkinsons disease (localized lewy bodies) and diffuse lewy body dementia
Types of muscle spasms
- Tonic: prolonged sustained contraction/rigidity
2. Clonic: repetitive rapid movement
MC cause of:
- Viral Meningitis
- Encephalitis
- Viral Meningitis: Enterovirus (echovirus, coxsackie), Arboviruses
- Encephalitis: HSV1 (other viruses- west nile, VZV)
Describe the three types of tremors
- Resting tremor: at rest (Parkinsons disease)
- Postural tremor: while holding position against gravity
- Intentional tremor: during movement or when approaching nearer to target
What brain bleed is commonly associated with a temporal bone fracture
epidural hematoma
Subdural hemorrhage Location: MOI: SX: Dx: Tx:
Location: venous bleed btwn dura nadn arachnoid due to tearing of cortical bridging veins
MOI: blunt trauma, elderly/alcoholics, anticoagulant use
SX: gradual increase in generalized neuro sxs (HA, N/V, dizziness)
Dx with non contrast CT: crescent shaped, crosses suture lines
**midline shift can occur due to increased ICP
Tx: nonop management if small and clinically stable pt or midline shift < 5mm
SURGERY if midline shift > 5mm
How do you assess narcolepsy
multiple sleep latency test
Clinical manifestations and PE findings (3) of Parkinson Disease
TRIAD: resting tremor, bradykinesia, rigidity
- Resting tremor- “pill rolling” (MC)
- Bradykinesia: slowness of voluntary movement (lack of swinging arms while walking and shuffling gait)
- Rigidity: COGWHEEL, flexed posture
PE: Fixed facial expressions, myerson’s sign, Postural instability– “pull test”, pt falls when pull shoulders from behind
What type of ligament injury is common with hyperextension and compression of neck?
transverse ligamental injury and axis fracture
Management of Tourette Syndrome
FIRST LINE: Habit reversal therapy: 50% have sx resolution by age 18
Meds:
- Dopamine blocking agents: TETRABENAZINE, haloperidol, risperidone
- Alpha-adrenergics: clonidine, guanfacine
What are the functions of the Pons
- Relay station between medulla and cerebrum (motor/sensory info)
- Regulates breathing
Demyelination of peripheral nerves is seen w/
multiple sclerosis
what is Vascular dementia? most important risk factor? CP? how to dx and tx?
brain disease due to CHRONIC ischemia and multiple infarction (lacunar infarcts)
-HTN biggest RF
-CP: SUDDEN decline in function with stepwise progression of sxs (random infarct leads to decline, stable until another infarct that causes decline); can have cortical vs subcortical manifestations depending on area of brain affected
-dx: clinical with similar workup to alzheimer’s
(MRI can show cortical or subcortical infarcts)
-Tx: NONE
prevention: treat high BP
Describe the GCS
Eye opening: 4- spontaneous 3- to verbal 2- to pain 1- no opening
Verbal response: 5- oriented 4- confused 3- inappropriate words 1- no words
Motor response: 6- obey commands 5- localizing response to pain 4- withdrawal from pain 3- flexion to pain 2- extension to pain 1- no motor response
Score: 3-15
mild 13 or above
mod 9-12
severe 8 or under
Clinical Manifestations of Multiple Sclerosis
Sensory deficits (TRIGEMINAL neuralgia), followed by visual disturbances (optic neuritis, diplopia) and weakness (gait, balance problems)
Unthoff’s Phenomenon: worsening sx with heat
Lhermittes sign: neck flexion causes lightening shock type pain radiating from the spine down the legs
charcot’s neuro triad
spasticity, + Babinski, hypereflexia
bladder, bowel, sexual dysfunction
What is the function of the basal ganglia
- Voluntary movement
- coordination
- Cognition
- Emotion
Clinical presentation and diagnosis of Normal pressure Hydrocephalus
Classic Triad- 2 W’s
- Dementia (WACKY)
- Gait disturbance (WOBBLY)- wide-based, shuffling gait
- Urinary incontinence (WET)
Dx: MRI is SUPERIOR to CT scan
**enlarged ventricles
Clinical manifestations and diagnosis of Tourette Syndrome
Diagnosis: multiple motor and at least 1 vocal tic (not necessarily occurring together) for greater than ONE YEAR + onset prior to 18 yo
Motor Tics (MC initial sxs): face, head and neck
Verbal or phonetic tics
Self-mutilating tics: hair pulling, nail biting, etc.
meningiomas are associated with ___ and most commonly arise from
neurofibromatosis
dura or sites of dural reflection
*usually benign
How do you dx TIA
Neuroimaging: CT scan initially (rule out hemorrhagic stroke)
**MRI more sensitive
Neurovascular imaging: Carotid doppler, CTA or MRA
Angiography is GS
Examples and SE of Dopamine Agonists
Bromocriptine, Pramipexole, Ropinirole
SE similar to levodopa
- Orthostatic hypotension/ dizziness
- Nausea
- HA
- Anorexia
Sx of Neuroleptic Malignant Syndrome
- decrease dopamine activity
1. AMS: delirium
2. Autonomic instability: hyper salivation, incontinence*
3. Hypertermia: fever
4. Muscle rigidity, bradykinesia, “lead pipe rigidity*”, hypotonia
Management of Myasthenia Gravis
Long term tx:
-Acetylcholinesterase inhibitors: Pyridostigmine or Neostigmine (1st line) ((increases acetylcholine)
Severe sxs or Myasthenic crisis: plasmapheresis or IVIG
Thymectomy can remove source of autoantibodies
***AVOID FLUOROQUINOLONES AND AMINOGLYCOSIDES (may exacerbate myasthenia)
Cognitive loss in Alzheimer’s dementia may be delayed with which of the following medications?
Donepezil (Aricept) is a reversible cholinesterase inhibitor that leads to increased acetylcholine, which is necessary for learning and memory
Management of Parkinson Disease
- Levodopa/Carbidopa (**Most effective treatment- levodopa is converted to dopamine)
- Dopamine agonists: Bromocriptine, Pramipexole, Ropinirole (More useful in young patients to delay the use of Levodopa)
- Anticholinergics (trihexyphenidyl, benztropine): tremor predominant
- Amantadine
- MAO-B Inhibitors
- COMT (Catechol-O-Methyltransferase) inhibitors
Management of Guillain Barre Syndrome
FIRST LINE: plasmapheresis or IVIG
- Plasmapheresis best if done early (removes harmful circulating autoantibodies that cause demyelination)
- IVIG
**PREDNISONE IS CONTRAINDICATED
-Prognosis: 60% recover fully in 1 yr. (10-20% left w/ permanent disability)
Regulates breathing, serves as a relay station btwn the cerebral hemisphere and the medulla
Pons
Where is the Amygdala located, and what is its function
in temporal lobe
-involved in memory, emotion and fear
Clinical Manifestations of Huntington’s Disease
- Sx appear 30-50y/o
- Progressive sx Behavioral–> chorea–> dementia
- Behavorial: personality, cognitive, intellectual, and psychiatric including irritability
- Chorea: worse w/ voluntary movements and stress and usually disappears w/ sleep
- Dementia
- Gait abnormalities/ataxia
Huntington chorea is due to ____
caudate nucelus atrophy int he basal ganglia
What is a Jefferson Fracture and its MOI
aka atlas C1 Burst fracture
-bilateral fractures of the anterior and posterior arches of C1
MOI: vertical compression force through the occipital condyles
The source of pain experienced during a migraine headache is a result of activation of which nerve?
Trigeminal nerve
What is a odontoid fracture and its MOI
fracture of the dens (odontoid process) of the axis C2
MOI: head placed in forced flexion or extension in an anterior-posterior orientation (fall onto forehead)
**Type 2 is most common
Describe the presentation of anterior cord syndrome
- paraplegia or quadriplegia
2. loss of lateral spinothalamic fxn w/ preservation of posterior column fxn
Etiologies of UMN lesions
- CVA
- MS
- CP
- Brain/SC damage
Most common presenting signs of multiple sclerosis
- optic neuritis
2. transverse myelitis
Management of Pseudotumor Cerebri (Idiopathic intracranial HTN)
- Acetazolamide +/- Furosemide +/- short course steroids
What is the most common etiology for a subarachnoid hemorrhage
Ruptured aneurysm (80%)- usually berry at ACA
What is Huntington’s disease?
Autosomal Dominant- trinucelotide repeats (CAG) on chromosome 4
- neurotoxicity from mutation as well as cerebral, putamen, and caudate nucleus atrophy
What are the functions of the Cerebellum
- Balance and coordination
2. Seat of motor control
What is a Hangman’s Fracture and its MOI
aka C2/axis pedicle fracture
- Traumatic bilateral fractures (sponylolysis) of the pedicles or pars interarticularis of the axis vertebra C2
- may lead to spondylolisthesis btwn C2-C3
MOI: extreme hyperextension of skull, atlas and axis
**Dx w/ CT
What dermatome is at the umbilicus
T10
Rapid involunatry jerky, uncontrolled, purposeless movements
Chorea
CN XI: ____ (S/M/B?)
Test by: ___
CN11, Accessory, M
Test: shoulder shrug, turn head from side to side
What are the functions of the Occipital Lobe
- visual processing
With SAH lower BP gradually with ___
Nicardipine**, Nimodipine, labetalol
MC type of anterior circulation ischemic stroke
Middle Cerebral artery
*anterior cerebral artery less common 2%
Injury to what nerve gives you a foot drop
Peroneal nerve injury
3 Clinical manifestations of Guillain Barre Syndrome, most concerning complication
- SYMMETRIC Ascending weakness and sensory changes (paresthesisa)
- Decreased deep tendon reflexes
- Autonomic dysfunction: tachycardia, hypotension, HTN,
* *complication: respiratory muscle weakness
SE of Lamictal (lamotrigine)
Rash, SJS,
What is an Essential Familial Tremor? how to diagnose?
*Benign
- Autosomal Dominant inherited disorder of unknown etiology
Dx of exclusion: use history, family history
Describe the CSF in bacterial vs viral meningitis
bacterial meningitis: cloudy appearance, elevated protein, elevated WBCs (predominantely polymorphonuclear (PMN) leukocytes, LOW glucose
Viral: WBC ~1000/mL (predominately lymphocytes or monocytes), normal glucose and protein
What is the first-line treatment for acute inflammatory demyelinating polyneuropathy variant of Guillain- Barre?
IV immunoglobulin
CN VIII: ____ (S/M/B?)
Test by: ___
Abnormalities could mean: ___
CN8, acoustic, S
Test: hearing, weber and Rinne, Vestibular fxn w balance and proprioception
Abnormalities: Acoustic neuroma
What is the most common finding in a person with a brain abscess?
Headache (69%)
The following presentations are associated with what type of seizures?
- Cessation of breathing and incontinence:
- Loss of muscle tone and collapse to the ground:
- Loss of consciousness with focal motor or autonomic sx or subjective sensory or psychic sx that may precede, accompany or follow the period of altered responsiveness
- Focal motor, sensory, psychic and/or autonomiic sx but the patient does not lose consciousness
- Tonic-Clonic
- Atonic
- Complex partial seizures (focal seizure with LOC)
- Simple partial seizures (focal seizure w/o LOC)
What does the limbic system include
- Thalamus
- Hypothalamus
- Amygdala
- Hippocampus
What is the function of the hippocampus
- learning/memory
2. converts short-term memory into longterm memory
CN IV: ____ (S/M/B?)
Test by: ___
CN4: Trochlear: M
Test: Superior oblique rectus, EOM
Cardinal s/s of Complex regional pain syndrome (AKA reflex sympathetic dystrophy)
- pain localized to an arm or leg
- swelling of the involved extremity
- disturbances of color and temp in the affected limb
- dystrophic changes in the overlying skin and nails
- limited ROM
- radiograph: generalized osteopenia or demineralization
*often preceded by direct trauma, often of relatively minor nature, to the soft tissues, bone or nerve
CN XII: ____ (S/M/B?)
Test by: ___
CN12, hypoglossal, M
Test: tongue- look for fasciculations and asymmetry
How do you diagnose Pseudotumor Cerebri (Idiopathic intracranial HTN)
- Papilledema
- CT to r/o mass
- LP w/ increased CSF pressure but otherwise normal
What are signs of Wernicke-Korsakoff
- vitamin B1 deficiency (thiamine)–> Commonly seen in chronic alcoholics
1. Horizontal nystagmus
2. opthalmoplegia
3. ataxia
3. Confusion
What is the Corpus callosum
bundle of axons that connects the 2 hemispheres.
Subarachnoid hemorrhage Location: MOI: SX: Dx:
Location: arterial bleed btwn arachnoid and pia
MOI: berry aneurysm rupture, AVM
SX: thunderclap HA (SUDDEN, MAXIMAL, DIFFERENT), meningeal signs, may have LOC/Syncope
CT w/o contrast FIRST: star shaped–>
if negative CT and no signs of papilledema, GET LP: xanthrochromia (yellow pink fluid due to RBC breakdown)
angiography GS
CN IX: ____ (S/M/B?)
Test by: ___
CN9, glossopharyngeal, B
Test: M: swallow, gag S: taste, posterior 1/3 of tongue
How do you diagnose Myasthenia Gravis
Initial test: + Acetylcholine receptor antibodies (get MuSK antibody test if ACH -)
EP studies: MOST accurate
CXR, CT or MRI: shows thymoma or thymus gland abnormality
Emergent setting:
1) . Edrophonium (Tensilon) Test: brief improvement in sxs
2) . Ice pack test: on eyelids for 10 min. —> improvement of ptosis in ocular MG
Empiric ABX tx of bacterial meningitis
- <1 month yo
- 1 mon- 50y/o
- 50+/Immunocompromised/Chronic ETOH
- Ampicillin + Cefotaxime (Amp covers Listeria)
- Ceftriazone + Vancomycin
- Ampicillin + Ceftriaxone + Vancomycin
Describe Anterior Cord Syndrome
“Because ANT COULDN’T WALK to the bathroom in the TeePee, he peed his pants when his bladder busted into FLECKS”
- LE motor deficits
- Loss of temp and Pain sensation (“TeePee”)
- bladder dysfunction, LE involvement
- Flexion compression injuries common mechanism
What is the difference btwn partial (focal) and generalized seizures?
-examples of each?
Partial: confined to small area of brain- one hemisphere
ex. Simple and complex
Generalized: diffuse brain involvement- both hemispheres
Ex. Tonic-Clonic (grand mal), Absence (petit mal), myoclonus, atonic
MC cause of bacterial meningitis in:
- <1 month
- 1month -10y/o
- 10-19 yo
- 19-50y/o
- 50+ or IC
- <1 month: GBS*, Listeria, E. Coli
- 1month - 10 yo: S. pneumo
3) . 10-19 yo: N. meningitis* (associated w/ petechial rash)
4) . 19-50 yo: S. pneumo* - 50+, immunocompromised: Listeria monocytogenes
How do you diagnose Huntington’s Disease?
clinical + family history + genetic confirmation
** CT scan: cerebral and caudate nucleus/putamen atrophy
PET scan: decreased glucose metabolism in those brain areas
Sx of Serotonin syndrome
- AMS- agitation
- Autonomic instability: tachy, BP fluctuations
- Hyperthermia: fever
- Neurologic changes: tremor, HYPERreflexia, Myoclonus
Sudden brief, sporadic involuntary jerking/twitching of 1 muscle or muscle group (not suppressible)
Myoclonus
Involuntary spasms, repetitive motions or abnormal voluntary movements
Dyskinesia
acute, abrupt TRANSIENT confused state due to an identifiable cause (ex. meds, infections)
Delirium
Reye syndrome is typically develops ____.
post-influenza or URI
what is Normal pressure Hydrocephalus and PP of it?
dilation of cerebral ventricles with NORMAL opening pressures on LP
-PP is unknown but thought to be due to impaired CSF absorption after CNS injury
Spontaneous ICH is MC caused by ___ in ___
DX by ___
HTN especially in basal ganglia
*LOC
DX: noncontrast CT– do not perform LP if LCH is suspected!
A pain syndrome disproportioned to injury with continuing pain that is disproportionate to any inciting event
Presentation:
- Following trauma, injury
- Extremity pain and at least 1 other sensory, motor, vasomotor, edema, sudomotor symptom
Complex Regional Pain Syndrome
Tx of Complex regional pain syndrome
**NSAIDS, PT/OT
Stage 1: Neurontin, Elavil and bisphosphonates
Stage 2: Add steroids
Stage 3: Include pain management specialist
Tx of peripheral neuropathies
- Gabapentin, amitriptyline, Topiramate, tramadol, NSAIDs.
2. Glycemic control
Hereditary neuropathy: Motor and sensory loss, loss of reflexes, hammer toes. “stork leg deformity”
Charcot-Marie-tooth
treatment of SAH
Supportive: Pain control, antiseizure meds, antispasmotics (Nimodipine), antihypertensives (Nicardipine, Labetolol), ventricular shunt placement if hydrocephalus
Neurosurgery consult: endovascular coiling or surgical clipping of aneursym
which type of stroke is most common? what is the biggest risk factor for both types of strokes?
ISCHEMIC- most common (2/3 thrombotic)
**HTN is biggest risk factor
overall most common cause of ICH?
MC cause in elderly vs children?
overall: HTN
children: AV malformation
elderly: cerebral amyloid angiopathy (amyloid proteins build up in cerebral arteries)
sxs of ICH
HA- blood build up
N/V, syncope, focal neuro findings, AMS
management of ICH/hemorrhagic stroke
SUPPORTIVE:
1) . gradual BP reduction w IV Labetalol, Nicardipine (more important than ischemic)
2) . reduction of increased ICP: IV mannitol (shrinks brain) or hyperventilation (constricts BVs) VS surgical tx (ventricular shunt or craniotomy)
3) . prevention of increased ICP: HOB 30 degrees, NPO, fluid restriction, BP management, pain meds/sedation
What is the ABCD2 score assessment used for? scoring system
risk of stroke 3-90 days after a TIA A- age > 60 B- BP > 140/90 C- clinical sxs (1 point slurred speech vs 2 for unilateral weakness) D- duration (1 point > 10 mins vs 2 > 60 mins) D- diabetes 0-3 = 3.1% 90 day risk 4-5 = 9.8% risk 6-7 = 17.8% risk
clinical sxs/signs of meningitis
sxs: HA, neck stiffness, fever, photo sensitivity, N/V
* * may get AMS/seizures
signs: nuchal rigidity, Kernig sign, Brudzinski sign
* *sxs/signs are milder in viral
what medication has been shown to reduce mortality and sequelae of S pneumo and N meningitidis?
dexamethasone
tx for viral meningitis
supportive: antipyretics, fluids, and pain meds (can discharge home if stable)
approach to diagnosis for encephalitis
usually CT done first to first out space occupying lesion
-LP performed after CT
MRI is preferred imaging (HSV shows temporal involvement)
PCR of CSF fluid is most accurate for HSV**
tx for encephalitis
HSV- IV acyclovir plus supportive care
what is Lambert-Eaton myasthenic syndrome ? and it is most often associated with?
antibodies against presynaptic VG Ca channels which prevents ACh release (leads to muscle weakness)
-associated with small cell lung cancer
CP of LE syndrome
proximal muscle weakness that IMPROVES with repeated muscle use
dry mouth
hyporeflexia
Dx and Tx of LE syndrome
Dx: VG Ca channel antobody assay, EP studies confirm, CT scan to assess underlying malignancy
Tx: tx underlying malignancy, 1st line med is pyridostigmine (2nd line: plasmaphoresis, IVIG)
5 peripheral nerve disorders
1) . bell’s palsy
2) . Guillian barre syndrome
3) . myasthenia gravis
4) . LE syndrome
5) . peripheral neuropathy
how to diagnose parkinson’s disease?
CLINICALLY
no imaging is needed
*can confirm with post mortem histology: “Lewy bodies” seen in substantia nigra
restless leg syndrome is due to what?
usually idiopathic but can occur secondary to CNS iron deficiency
what is AV malformation? what is it associated with? dx and tx
abnormal vascular circuit where arteries flow directly into veins without passing through capillary system -20-25% associated with aneurysm, seen in ICH in children
dx: MRI best test, angiography is GS
tx: neurosurgery referral
acute management of TBI (5)
- *neurosurgical ICU with frequent assessments
1) . Prevention of hypoxia (PaO2 < 60) or hypotension = often leads to putting pt on mechanical ventilation
2) . reduction of ICP: IV mannitol, HOB 30 degrees, hyperventilation (not within first 24-48 hrs tho) - *below 22 mmgHg
3) . neurosurgical consult for surgery
4) . antiseizure meds (keppra)
5) . prevent fever or hyperglycemia
what is a concussion? 4 groups of clinical manifestations? how to dx and tx?
mild brain injury usually due to blunt force trauma that leads to AMS with OR without LOC
- CP: somatic sxs (HA, N/V, dizzy, vision changes), cognitive impairment (fog, delayed reaction time, confusion), amnesia of event or posttraumatic amnesia, emotional instability
- Dx: clinical, normal CT scan (rule out bleed)
- Tx: cognitive and physical rest, observe for at least first 24 hrs
- *can resume activity after sxs resolution and recovery of memory/cognitive fxn
what is post-concussive syndrome? CP? Dx? Tx?
sequelae of concussion where 3 or more sxs are still present 3 months after a concussion
- CP: same as concussion (somatic sxs, cog impairment, emotional changes, amnesia)
- Dx: clinical, normal imaging
- Tx: rest and reassurance, maybe therapy
what is delirium and what are common causes?
ABRUPT transient confused state due to an identifiable cause with fluctuating mental status and deficits in short-term memory
I-WATCH-DEATH: infectious, withdrawal, metabolic, trauma, CNS disease, hypoxia, deficiencies, endocrine, vascular, toxins, heavy metals
**usually fully recover within a few weeks and tx of cause
what is cerebral palsy? how do you dx and tx this condition?
NON-PROGRESSIVE CNS disorder associated with 1). muscle tone 2). movement and 3). postural abnormalities
**due to brain injury during pre or perinatal period
spastic, dyskinetic, and ataxic types
hyporeflexive early stages of life and then turns to hyper
Dx: clinical but requires MRI in all patients
Tx: team approach, pain management
spasticity: baclofen, diazepam
anti-seizure meds
what is the typical sxs progression for alzheimers?
ST memory loss (usually first symptom), progresses to LT memory loss and cognitive deficits (disorientation, behavior and personality changes, language difficulties)
how do you diagnose alzheimers?
CLINICAL- extensive work-up to rule out other diseases/causes
MRI is preferred neuroimaging: temporal lobe atrophy, reduced hippocampal volume
histology findings: amyloid plaques, neurofibrillary tangles
what is diffuse lewy body disease? common CP? what is seen on histology and tx?
progressive dementia characterized by DIFFUSE lewy body infiltration in brain (vs localized in parkinson’s)
- CP: visual hallucinations, episodic delirium, Parkinsonism, autonomic dysfunction, dementia is late finding
- histology: cortical lewy bodies
- Tx: balance between tx parkinson’s sxs and neuropsych sxs (one might make the other worse)
what is the definition of a partial seizure? what are the two categories of this? what CP might you find with one of these types?
abnormal neuronal discharge from one section of one hemisphere
A). simple: consciousness MAINTAINED
B). complex: consciousness IMPAIRED
**CP depends on area of brain affected but automatisms often found with complex (repetitive behaviors like lip smacking, facial grimace, chewing, coordinated movements)
what is the definition of epilepsy?
2 unprovoked seizures 24 hours apart
*imbalance between excitatory and inhibitory NTs
what are the two medications used to treat partial seizures?
carbamazepine or lamotrigine
what is an absence seizure? how long do episodes last? what age is this typically diagnosed?
gneralized seizure with a pause/stare that marks sudden impairment of consciousness WITHOUT loss of body tone lasting 5-10 mins, can have oral automatisms
**usually diagnosed in childhood
1st line treatment of absence seizures
ethosuximide
6 types of generalized seizures and what characterizes them
1) . Tonic-Clonic (Grand mal): sudden LOC with TONIC activity followed by 1-2 mins of CLONIC activity followed by post-ictal state (can have incontinence)
2) . Tonic: LOC followed by rigidity
3) . Clonic: repetitive rhythmic jerking
4) . Myoclonic: sudden brief involuntary twitching (arrhythmic)
5) . atonic: sudden partial or complete loss of muscle and postural tone (rare, i.e. CP)
6) . absence
what two labs can be elevated after a seziure?
prolactin and lactic acid
**could be used to rule out pseudoseizure
medications used to treat generalized seizures
valproate (esp moyoclonic), lamitrigine, toprimate, carbamazepine (tonic-clonic), benzos (tonic clonic), phenobarbital
what is status epilepticus?
single seizure lasting > 5 mins OR more than 1 seizure within a 5 min period with NO recovery between seizures
**can be any seizure type
order of therapy for status epilepticus?
1) . BENZOs
2) . Phenytoin or Fosphenytoin if no response to benzos
3) . Phenobarbital if no response to 2nd line
what nerve roots correspond to knee and ankle jerk reflex?
knee: L3-L4
ankle: S1-S2
CP of trigeminal neuralgia
HA: brief, stabbing or shock like pain lasting seconds to mins in 2nd or 3rd division of trigeminal nerve
*worse with touch, chewing, brushing teeth, wind, movements
USUALLY ONE SIDED
1st line tx for pseudotumor cerebri
acetazolamide- decreased CSF production
what are astrocytomas and 4 types? common CP
tumor of astrocyte cells (glial cells of CNS that support endothelial cells of BBB, provide nutrition, repair brain post injury)
1). Pilocystic: most benign and localized, CHILDREN and young adults (cysts, rosenthal fibers seen on biopsy)
2). Diffuse
3). Anaplastic (tentacle projections on biopsy)
4). Glioblastoma multiforme: MOST COMMON PRIMARY BRAIN TUMOR, adults
**MC in frontal and temporal brain regions
CP: HA (worse in AM, wake pt up at night), focal deficits, seizures, signs of increased ICP (AMS, HA, papilledema)
general tx of astrocytomas
SURGICAL EXCISION
+/- chemo/radiation
what is a meningioma? common CP sxs? how to dx? how to tx?
benign, slow growing tumor which arises from meningeal arachnoid cells, sometimes dural reflections
CP: often AS but can get sxs due to compression/displacement of brain tissue (usually doesn’t invade brain parenchyma)
Dx: contrast MRI “enhancing, well defined lesion attached to dura
Psammoma bodies on histology
Tx: AS- observe if small, Sxs: surgical excision if possible
2 types of glioblastoma
Primary (MC): adults over 50, arises new, most aggressive
secondary: adults under 45 yo, due to malignant progression from low grade astrocytoma (2 or 3)
how to diagnose glioblastoma
MRI with contrast (initial test): ONE LESION of variable enhancement with central necrosis, irregular margins. may cross CC
oligodendroglioma vs ependymoma
oligo: cell that makes up glial tissue of brain (support), found within cerebral hemispheres
epend: cells that line the ventricles and spinal column, MC in children, pseudorosettes on biopsy
what three clinical findings make you suspicious for korsakoff syndrome?
1) . retrograde and anterograde amnesia with preserved remote, long term memory
2) . confabulation (filling in memory gaps with false information, unintentionally)
3) . lack of insight in context of chronic alcohol disorder
three clinical features of wernicke syndrome?
1) . encephalopathy
2) . oculomotor dysfunction
3) . postural and gait ataxia
what are some signs of fetal alcohol syndrome?
thin upper lip, short palpebral fissures (small eye openings), flattened philtrum (space between nose and mouth), sunken nasal bridge
