Panda neuro 1 Flashcards
MCC SAH
Trauma
MCC Nontraumatic SAH (give locations!)
Ruptured Aneurysm (ACOMM > PCOMM > MCA > BA)
Risk Factors for SAH
HTN, Smoking, Cocaine, Vascular Disease (Marfans, ED), Fibromuscular Dysplasia, Aortic Coarctation
How do you work up a SAH?*
- CT without contrast —> if negative do LP for xanthochromia
- When either are positive, next step is cerebral angiogram for possible aneurysm
Complications of SAH (4)
Rebleed = Hemorrhage/Edema
Hydrocephalus
Vasospasm 4-14 days
Hyponatremia secondary to increase ANF/SIADH
How do you manage the 4 major complications of SAH?
Rebleed = Coil/Clipp
Hydrocephalus = EVD
Vasospasm 4-14 days = Nimodipine
Hyponatremia = monitor labs
How does a patient with SAH present?
Worst headache of their life with initially focal and rapidly spreading neurologic deficits. Don’t forget subhyaloid (preretinal hemorrhage) from acute increases in ICP.
“False Localizing Sign”
CN 6 dysfunction as a result of increased ICP
What is BP with elevated ICP?
Usually high (Cushing’s Reflex)
Basilar Bain Fracture
- 4 Signs
- Consequence
Signs:
- Raccoon
- Battle
- CSF Rhinorrhea
- CSF Otorrhea
Consequence - increased risk for Bacterial Meningitis
Alert vs. Lethargic vs. Stupor vs. Coma
- Alert= normal
- Lethargic= drowsy, sleeping but easily aroused
- Stuporous = hard to arouse, but doable
- Coma = unarousable
Which is better for acute bleed - CT or MRI? What about subacute bleed?
Acute = CT, Subacute = MRI
What does the following look like on CT? without contrast?
- Epidural Hematoma
- Recent Subdural Hematoma
- Chronic Subdural Hematoma
- Epidural Hematoma = acute bleed = hyperdense = bone
- Recent Subdural Hematoma: recent bleed = isodence = brain
- Chronic Subdural Hematoma: old bleed = hypodense = CSF
Patient on warfarin has epidural hematoma, going for NSx. What do you need to do before and after surgery?
- Before = FFP to reverse warfarin immediately
2. AFter = ASA until safe to use warfarin
Why are subdural hematomas more common in elderly?
Dura mater is fixed to the skull, more common for subdural > epidural.
Classic Script for Epidural Hematoma?
Closed head injury —> Lucid Period (1-2 hours) —> rapid deterioration in a cranio-caudal manner
4 Signs of increased ICP?
Cushing Reflex
CN 3 Problems/CN6 (False localizing signs) Problems
Change in Consciousness
Papilledema
DDx Primary Headache?
Tension, Cluster and Migraine
DDx Secondary Headache? (4)
- Intracranial HTN = Mass Effect, PTC, Dural vein thrombosis
- > 50 = Temporal Arteritis
- Meningeal Component = SAH / Meningitis
- Rx Overuse = Analgesic Withdrawal
MCC Daily Chronic HA?
Medication Overuse/Analgesic Withdrawal
Classic Components for Migraine Presentation?
Prodrome (no focal neuro) —> +/- Aura (focal Neuro) —> Migraine —> +/- Associated Symptoms (N/V/Photo-phonophobia).
Migraine = unilateral throbbing headache
Abortive Treatment for Migraine?
Prophylaxis?
Abortive = take at HA onset = Triptan, Ergot, Midrin Prophylactic = Propranolol, TCA, Topomax
Common signs of proximal muscle weakness?
Where does this localize the lesion?
Proximal Muscle Weakness = Arms heavy, can’t get out of chair, can’t reach for something in cabinet, trouble combing hair
HAIR CHAIR STAIR
Localize = Muscle + NMJ
Shortness of breath towards the end of the day that gets better with sitting up rather than laying down in a 24 yr old woman. Diagnosis?
MG
What should every patient with suspected MG be checked for at some point?
Thymic pathology
If a patient with MG by clinical eval has -antibodies and normal CXR, what is the next step?
Serology for anti-musk antibodies
Other than Antibodies and thymus evaluation, how else can you evaluate for MG?
Tensilon (Edrophonium) test
What determines Myasthenia crisis?
Respiratory distress
After stabilizing patient in Myasthenic Crisis, what do you monitor bedside?
FVC
3 CNS Lesions in HIV Patients
- Toxoplasmosis: multiple ring enhancing lesions
- Primary CNS Lymphoma: SINGLE ring enhancing lesions with EBV DNA in the CSF
- PML: non-ring enhancing lesion
DDx for Stroke in young patient (3)
Carotid Dissection (Horner's) Vascular Malformation (AVM) Cryptogenic (PFO)
Describe Vascular Malformations and the most severe form
Vascular malformations (AV) are high flow high pressure AV connections with lots of A-V shunting. Severe form = moyamoya.
Management of carotid artery stenosis:
- Asx
- Sx
Asx: CAE if 60-99% occlusion
Sx: CAE if 70-99%
if Long Term ASA
What PD Rx are used mainly for the tremor?
Anti-AcH = Triphenhexidyl and Benztropine
Diffuse Atrophy —-
Atrophy of Caudate —
Atrophy of Lentiform —
Diffuse = AD Caudate = Huntington's Lentiform = Wilson's
Progressive HA + decreased consciousness suggests…
Elevated ICP
- HA = localizes to meninges, periosteum, vessels, etc.
- Decreased Consciousness = bicerebrum vs. RAS
- Combine the two = elevated ICP
Double vision that corrects with one eye covered up is _________ and is usually secondary to ______.
Binocular Diplopia
CN 3/6 weakness (if problems with seeing nearby = CN3, far = CN6)
TVO
Transient visual obscurations = b/l vision loss lasting seconds that are associated with increased ICP (transmitted along the optic nerve).
DecerEbrate vs. Decorticate position
Decerebrate = Extension predominates Decorticate = Flexion predominates
4 Types of Herniations
- Subfalacine (Cingulate): when medial anterior lobe is pushed under Falx Cerebri
- Central (Transtentorial): when structures above the midbrain compress down upon the midbraine, usually pushing down upon the brainstem
- Uncal: medial temporal lobe compressing midbrain ipsilaterally
- Cerebellum: supra-cerebelllar structures push tonsils through foramen magnum
Consequences of Uncal Herniation
Ips CN 3 Compression = Ips CN 3 Palsy
Ips PCA Compression = C/L Homohemianopasia
Contralateral Crus Compression = Ips Hemiapresis
Consequences of Cerebellar Herniation
When it hits medulla - cardiopulmonary arrest
Most common benign brain tumor?
Meningioma
Patient with elevated ICP needs to be managed. What is the eventual step and what 4 things to do before that?
Eventually: Decompressive Craniectomy
- Elevate Bed 30
- Intubate + Hyperventilate (hypoxic vasoconstriction decreases blood volume component of iCP)
- Mannitol
- Dexamethasone + Anticonvulsant
Adult onset seizures is secondary to _______»_space;> ______ until proven otherwise.
Tumor»_space;» Stroke
What is the management for any new adult seizure?
B-E-M: Blood, EEG, MRI
Do you start anticonvulsant medications after 1st seizure?
No, unless there is abnormality on B-E-M above or neuro exam that predisposes to more seizures (anti-convulsants)
Know This:
- Common Rx for Partial (3)
- Common Rx for Generalized (5)
Partial: Gabapentin, Phenytoin, Carbamazapine
Generalized: Valproate, Leviteracetam (keppra), Lamotrigine, Zonisamide, Topomax
Describe Complex Partial Seizure
- Focal Neurologic Signs
- Impaired Consciousness
- Before: aura
- During: automatism
- After: Post-ictal
How can you test for absence seizure bedside?
Hyperventilate
Patient loses consciousness and then has some myoclonic activity — Dx?
Patient starts having myoclonus of right hand and then loses consciousness —- Dx?
Syncope
Seizure
Cardiogenic Syncope is decreased CBF secondary to (2)
- Decreased CO
2. Arrythmia
DDx CO and Arrhythmia
Decreased CO: Aortic Stenosis + Valsalva/Micturation
Arrythmia: Sick Sinus, WPW, age, electrolyte imbalance
Vasovagal Syncope Paph
Emotional experience —> abnormal increased in vagal tone —> decreased HR/BP —> syncope
DDx Orthostatic Hypotension:
Old: dehydration + increased venous pooling
Young: prolonged standing
Other: ANS dysfunction (diabetes, amyloid) = withdrawal of PaNS tone with abnormal increases in SNS tone = low catecholamines = syncope
Pseudoseizure Definition
Psychiatric mechanism (conscious or not) to cope with emotional/physical stress = Conversion Disorder
How do you recognize pseudoseizure?
other than odd seizure, the degree of neurologic signs will not correlate to the degree of consciousness
How do you manage/diagnose pseudoseizure?
Admit to inpatient service and get EEG + Video Camera
Symptomatic Seizure Definition (vs. idiopathic)
Secondary to underlying pathology (stroke, temporal lobe); therefore the seizure is a symptom of the underlying pathology
Idiopathic = hereditary disorer
Describe the following pediatric seizure disorders: 1. JME 2. West Syndrome 3. Lennox Gestaut (Benign Rolandic discussed separately)
- JME: related to sleep, consciousness unimpaired, multiple types of seizures
- West: infantile spasms, hypsarrhythmia, developmental regression
- Lennox: Slow 1.5-2 Hz, multiple seizures, developmental delay
(T/F) All pediatric idiopathic disorders resolve spontaneously.
False, all do except JME
Do you perform an LP on a 17 month old with febrile seizure?
Yes, all patients 18 months, only perform LP if +meningeal signs.
What is the MC idiopathic seizure disorder?
Benign Rolandic
BRE Of Childhood:
- Paph
- Classic Presentation
- Management
Paph: complex partial seizure around central sulcus
Presentation: nocturnal seizure of face/saliva with loss of conscoiusness in a patient with +FHMx
Management: resolves, Rx only if 3+
GSE Definition
Tonic CLonic Seizure >30 min
2+ TC seizures without return to baseline in between
Management for GSE?
Ativan —> Phosphenytoin —> Intubate —> phenobarb/propofol —> burst suppression
Once Stable: BEM
Blood/urine: any imbalances, drugs
EEG
MRI: recall in adult new onset seizure is tumor until proven otherwise
3 Etiologies of Dizziness?
- Vertigo: disease of vestibular system (inner ear, vestibular nerve, nuclei)
- Ataxia: instability; disorder of cerebellum (if constant) or dorsal columns (if worse in the dark)
- Lightheadedness: syncope; disorder of low blood flow
Menier’s Disease
- Pathophysiology
- Presentation
- Treatment
- Paph: Idiopathic Endolymph Hydrops = too much endolymph
- Presentation: gradual vertigo, hearing loss (sensorineural) and aural fullness. The hearing loss is specific for loss of low frequency sounds (finger rub, but not watch tic-toc)
- Treatment: Acetazolamide, salt wasting diet, shunt
Vestibular Neuronitis vs. Labyrinthitis
Neuronitis: vertigo without hearing loss
Labyrinthitis: vertigo with hearing loss
(T/F) Central vertigo is more severe than peripheral vertigo.
False, central vertigo is more constant and low level, peripheral is more intermittent and severe.
5 Characteristics of Vertigo and Nystagmus seen in BPPPV
Episodic/Transient Position Dependent Latency - takes a second to start Habituation Fatigued
You do the Dix Hallpike to diagnose BPPV, how do you manage the patietn?
Epley Maneuver
Teach Brandt Daroff Exercises for them to do at home
Best imaging for stroke?
Best imaging for tumor?
MRI without contrast = stroke
MRI with contrast = tumor (so it will enhance)
Two diseases that present with infranuclear facial weakness, sensorineural hearing loss and vertigo?
CPA Tumor
Ramsy Hunt
How to distinguish between CPA Tumor
and Ramsy Hunt on exam?
CPA Tumor has +CN5 findings +cerebellar finding
Alcoholic Cerebellar Degeneration
- Localize Lesion
- Findings
Superior Cerebellar Vermis Lesion
Truncal Instability (Titubation)
Diffuse Cerebellar Signs + Dysphagia over several years in 50 year old woman.
PNP cerebellar degeneration from breast, lung, ovarian, lymphoma cancer
Disk herniation can result in compression of what two structures? And how can we tell the difference between the two clinically?
- Spinal Cord = myelopathy
- Nerve Root = radiculopathy
When pain is involvement, the nerve root is more likely to be involved.
What is a simple test you can do to tell whether or not the disc is herniating onto the cord or root, if the patient is not presenting in pain?
Bear down (valsalva) to increase intraabdominal pressure —> increase pressure on nerve root —> increase pain. If no increased pain, then disc is on the vertebral column
What are the following segments:
- Patellar
- Medial lower leg
- Lateral lower leg
- Medial foot
- Lateral Foot
- Patellar: L3
- Medial lower leg: L4
- Lateral lower leg: L5
- Medial foot: L5
- Lateral Foot: S1
MCC Radiculopathy and MC Locations
Herniated Disks:
- L4-5
- L5-S1
Give the actions of the following roots: L3 L4 L5 S1
L3: knee = extension of lower leg
L4: dorsiflexion of ankle
L5: eversion
S1: inversion
Sciatic N Compression vs. L5-S1 disc hernation?
No back pain with sciatic nerve compression
Cauda Equina Syndrome
- Paph
- Presentation (4)
Paph: damage to CE (LMN = ROOTS, not spinal cord) before exiting the spinal canal
Classic Presentation:
- Back pain
- Saddle Anesthesia
- LMN Signs = low rectal tone
- Bowel/Bladder Dysfunction
Difference between lateral and posterior herniation of nucleus pulposus?
Lateral Herniation = compress nerve roots (LMN + PAIN = radiculopathy)
Posterior Herniation = compress cord/CES
Neurogenic vs. Vascular Claudication?
Neurogenic: occurs secondary to spinal canal stenosis associated with STANDING STILL b/c venous pooling in epidural venous plexus
Vascular: occurs secondary to muscle ischemia associated with INCREASED ACTIVITY
Causes of Hypothyroidism (5)
- Repetitive Movements
- Hypothyroidism
- Diabetes
- Pregnancy
- Idiopathic
Diagnostic Test for CTS vs. Cervical Radiculopathy
CTS = EMG?NCS
Cervical Rad = Imaging for Spien
5 Steps in Working Up Someone with ED Signs of Meningitis?
- ABC
- Blood Studies (CBC, INR, BCx, CMP)
- IV Amp, Cef, Vanc, Acyclovir, Dexamethasone
- Image
- LP
Chronic Meningitis Causes
Think about bugs that kill slowly / other chronic disease:
Fungal, TB, Lyme, Sarcoidosis, Carcinomatous (h/o canceR)
Aseptic Meningitis Definition/Causes
Meningitis not caused by pyogenic organism (viral, NSAID, etc)
NL CSF Findings
- Opening Pressure
- Protein
- WBC/RBC
- Glucose
- Opening Pressure
3 Non-ID consequences of meningitis?
- Hyponatremia = SIADH from inflammation of hypothalamus
- Seizure = bicerebral inflammation
- Elevated ICP
Stroke: if a patient has head turned to the right, what could cause this?
L sided Neglect
R sided gaze preference
In cortical/spinal cord, where are arms/face vs. legs?
Arms and face are lateral, legs are medial
(T/F) Hypoglycemia can produce focal neurologic symptoms/
True
How does toxic metabolic insult cause stroke like symptoms?
Usually cause decompensation of previous stroke/injury
MCC TIA?
Embolic from atherosclerotic plaques in the carotid/vertebrobasilar systems
Patient in eval had a TIA and is now completely resolved, what is the next best step?
Admit ASAP for evaluation of etiology
MC Locations for Hemorrhagic Stroke
Basal Ganglia (PUTAMEN)»_space;» Thalamus, Cerebellum and Pons
