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1
Q

What are lab exclusion criteria for tPA?

A

• Bp > 185/110
• Platelets

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2
Q

Clinical presentation of lacunar infarct of posterior limb of internal capsule?

A

Unilateral motor impairment. No sensory or cortical deficits, no visual field abn

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3
Q

Where do lacunar strokes happen?

A

• Basal ganglia
• Posterior limb –> unilateral motor deficit, no sensory or cortical deficits (pure motor)
• Anterior limb –> weakness more prominent in LE, ipsilat arm and leg incoordination (ataxic-hemiparesis)
• Ventroposterolateral nucleus of thalamus –> unilateral numbness, paresthesia, hemisensory deficity (pure sensory)
• Subcortical white matter (internal capsule, corona radiata)
• Pons –> clumsy hand, hand weakness, mild motor aphasia, NO sensory abnormalities

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4
Q

What is common deficit of extrapyramidal system?

A

Basal ganglia, cerebellum. Fn of extrapyramidal system: modulation and regulation (indirect control) of anterior (ventral) horn cells.

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5
Q

Movement disorders show impairment in

A

Regulation of voluntary motor activity w/o directly affecting strength, sensation, cerebellar fn

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6
Q

Myoclonus

A

Jerky contraction of a group of muscles

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7
Q

Chorea

A

Rapid irregular muscle jerks that occur involuntarily, unpredictably

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8
Q

What is a movement disorder during pregnancy, and s/s?

A

Chorea gravidarum - rapid/fluid but not rhythmic limb/trunk movements during pregnancy or estrogen use

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9
Q

What is the transmission pattern of Huntington’s?

A

AD

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10
Q

What are dopaminergic drugs (3)?

A

L-dopa, bromocriptine, lisuride

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11
Q

What is a dopamine antagonist, and risks?

A

Haloperidol. Adverse effect: tardive dyskinesia

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12
Q

Pathology of HD?

A

Loss of several neuronal types in striatum (caudate and putamen). Increased response to dopamine because of increased sensitivity of dopamine receptors in remaining striatal neurons

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13
Q

Which area of the brain is affected by PD?

A

Brainstem nuclei

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14
Q

Pathology of PD shows

A

Lewy bodies = intracytoplasmic eosinophilic inclusion bodies

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15
Q

What is the name of an anticholinergic drug used to decrease signs of PD caused by antipsychotics?

A

Trihexyphenidyl

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16
Q

What is the language disturbance in PD?

A

Language not disturbed, but clarity/volume of speech is, due to dvlpmt of hypophonia. Also see smaller handwriting = micrographia

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17
Q

MOA of carbidopa?

A

Inhibit peripheral conversion of L-dopa to dopamine by inhibiting dopa decarboxylase

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18
Q

How to treat Tourettes?

A

• Haloperidol, pimozide, trifluoperazine, fluphenazine
• Antiepileptics are NOT helpful

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19
Q

What is the MOA of on-and-off phenomenon of PD meds?

A

Due to variability in responsiveness of CNS to the medication rather than in the medication levels

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20
Q

What is meige syndrome?

A

• A form of focal dystonia. Blepharospasm, foreceful jaw opening, lip retraction, neck contractions, tongue thrusting
• Rx: botulinum toxin

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21
Q

What is Olivopontocerebellar atrophy?

A

Neurodegenerative dz. Pts have cerebellar and brainstem s/s.

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22
Q

35 yo M develops progressive depression, memory impairment over 6 mo. Initial neuro eval shows metabolic acidosis. Firm liver, large spleen. Tremor and rigidity in arms, walks with little swing. Substantially reduced blink. Atrophy of putamen and globus pallidus. CSF nl. EEG nl.

A

Wilsons dz = Hepatolenticular degeneration. Pts have basal ganglia degeneration (Parkinson), asterixis, dementia, dyskinesia
Systemic problems include heart and lung dz, but most pts become symptomatic from brain and liver dz

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23
Q

62 yo M w/ excessive sleepiness, slow movements, mild depression, proximal muscle weakness/atrophy. Concerning for…

A

Hyperparathyroidism (even if Ca levels nl, check PTH!)

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24
Q

What is thought to cause cell death in pts with Huntington’s?

A

Glutamate –> overexcitation –> cell death

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25
When do EtOH withdrawal seizures occur? What about delirium tremens?
1-2 days. 2-4 days.
26
Next step for a hx of simple partial seizure?
MRI to r/o focal brain lesion
27
Which of the following visual field cuts is most often seen with B12 deficiency?
Centrocecal scotoma
28
In liver dz pts, which neuro cells show change?
Astrocytes
29
What does the CSF of pts w/ hypertn encephalopathy?
Proteins increased, but
30
What are sx of hypertn encephalopathy?
• Seizures • AMS • Vision changes
31
What helps allieviate sx in restless leg?
• Clonazepam • Gabapentin - ALTERNATE (alpha2 Ca ch ligand) • L-dopa, dopamine agonist - FIRST LINE • Opiates • Supportive: give Fe
32
Tx of peripheral neuropathy 2/2 CKD?
Kidney transplant
33
Minoxidil?
Vasodilates arterioles
34
Why do pts on INH need pyridoxine supplementation?
INH doesn't interfere w/ pyridoxine absorption, but does interfere w/ its participation in metabolic pathways. Absence --> peripheral neuropathy
35
What is the precursor to niacin?
Tryptophan.
36
What is most common childhood syndrome of vit E?
Spinocerebellar degen, polyneuropathy, pigmentary retinopathy. Most obvious sx will be ataxia
37
Which lobe is usu involved in herpes encephalitis?
Temporal
38
Triphasic waves typically seen in
Hepatic encephalopathy, uremia, and other metabolic
39
Teratogen result of Valproate?
Neural tube defects because it's a folate antagonist (think of high jumper's "tube")
40
What is a neuro pathology associated with fragile X?
Epilepsy, but it is easily controlled
41
What is true of women carrying chromosomes for fragile X?
Half are MR.
42
What are the sx of hartnup dz?
Poor absorption of neutral amino acids esp tryptophan --> niacin deficiency --> pellagra (dementia, dermatitis, diarrhea)
43
What in the mom can cause hydrocephalus in fetus?
Viral infx - specifically mumps, rubella
44
50 yo M presenting with dizziness found to have cyst occupying 50% posterior fossa, incomplete fusion of cerebellar elements inferiorly. Concerning for
Dandy Walker. Patient will remain asymptomatic throughout life if obstructive hydrocephalus doesn't develop soon after birth
45
What are 2 motor neuron dzs in kids?
Presumed to be anterior horn dz --> LMN sx. Werdinig-Hoffman (weakness, hypotonia, muscle atrophy, floppy baby). Or Kugelberg-Welander (less lethal)
46
What is Lennox-Gastaut?
20% of tuberous sclerosis pts develop this. Pesistent seizures (mixed seizure d/o), significant mental retardation (think Lennox --> jughead)
47
What is major pathologic effect of EtOh on CNS of dvlping fetus
Not entirely clear, but primarily impair neuronal migration
48
How do the findings of papillitis differ from papilledema?
Papillitis causes vision loss, whereas papilledema has inconsequential vision loss. Papillitis is often early sign of MS (optic neuritis of the nerve head)
49
What are 4 drugs/toxins that can cause visual field cuts?
Methyl alcohol, INH, ethambutol, streptomycin
50
What is most common form of retinal degeneration?
Retinitis pigmentosa, a hereditary degen dz involving retinal reeptors and adjacent pigment cells.
51
What are the sx of retinitis pigmentosa?
Night blindness (nyctalopia)
52
Injuries to the macula or fovea centralis affect vision by producing what defect?
Severe loss of visual acuity
53
What are causes of night blindness (3)?
Retinal degeneration, vit A deficiency, and color blindness.
54
What causes nicking in the hypertensive eye?
Thickened arteriolar wall compresses venule at point of intersection
55
6 yo girl with facial pain, blurry vision, abducens nerve deficit. Concerning for…
Gradenigo syndrome. A complication of OM and mastoiditis that --> osteo in the apex of temporal bone. Therefore abducens and trigeminal nerves effected
56
Which occular muscle is vulnerable from trauma?
IV
57
Which ocular muscle is vulnerable from aneurysm pressure?
III
58
Which ocular muscle is vulnerable from VZV infx?
IV (shares nerve sheath w/ ophthalmic division of V)
59
Central and peripheral CN III contains…
Central (Middle) - motor output. Peripheral - Parasympathetic
60
65 yo has tingling in feet. He has pupillary constriction with attempted adduction of globe. This suggests…
Aberrant CN III regeneration. Oculomotor fibers that have been damaged reversibly may regeneration and connect to wrong target. May be 2/2 aneurysms, cholesteatomas, and neoplasms
61
Mesencephalon =
Midbrain
62
Which drugs most frequently cause nystagmus?
EtOH, barbiturates
63
Child w/ rapid downward deviation of both eyes followed by slow upward conjugate eye movements suggests
Ocular bobbing, develops with pontine damage
64
Nystagmus that's less obvious with a rotating drum suggests lesion in
Parietal lobe
65
Optic neuritis and cavernous sinus thrombosis always cause this defect
Vision loss (cav sinus thrombosis due to impaired venous drainage imparing eye acuity)
66
What is amaurosis fugax?
Fleeting loss of vision
67
Cyclosporine and tacrolimus may produce what sort of syndrome?
Resembling hypertensive encephalopathy. Called by some reversible posterior leukoencephalopathy (though involves more than white matter and may cocur in anterior frontal areas). Pts develop h/a, visual dysnfn (occipital), confusion, seizure
68
What is the most common cause of monocular blindness?
• Ischemic optic neuropathy = anterior ischemic optic neuropathy. Sudden, painless, permanent vision loss. Usu occlusion of posterior ciliary artery. Not associated w/ carotid dz. • Optic nerve may appear swollen --> pale disc signifying previous injury
69
Large meningeoma on left side of optic chiasm produces what sort of visual field cut?
Contralateral eye - right upper field cut. Ipsilateral eye - possible macular loss
70
What is common cause of syringomyelia?
Chiari I
71
What causes vertigo w/ cerebellar infarct (2 causes)?
1. Medial branch of PICA supplies brainstem 2. Cerebellar flocculonodular lobule injury may induce vertigo
72
Likely vascular cause of positional vertigo?
Vertebrobasilar ischemia
73
Which frequencies affected in Meniere's?
Low (Sx: dizziness, tinnitus, hearing loss)
74
What can cause a toxic labyrinthitis?
Acetylsalicylic acid
75
What can be used to reduce sx of vertigo?
Promethazine, dimenhydrinate, meclizine
76
45 yo M has decreased sense of smell, unilat anosomia, ipsilat optic atrophy, and contralat papilledema.
Olfactory groove meningeoma --> etends posteriorly to ipsilateral optic nerve. Interferes w/ ICP transmission of that eye
77
Asa vs. aminoglycoside toxicity?
Asa - tinnitus. Aminoglycoside - vestibular dysfn
78
Vertebral artery occlusion can cause sx of what?
Lateral medullary syndrome - progressive vertigo, ataxia, sensory loss, dysphagia, hiccups
79
When does hyperreflexia and spasticity appear with spinal cord injury?
3 days to 3 weeks
80
Where does the arteria radicularis magna (artery of Adamkiewicz = great anterior medullary artery) enter?
T10 to L1
81
What does it supply?
Lower 2/3 of spinal cord. At risk of occlusion w/ AAA repair (upper segments are supplied by vertebral arteries)
82
A cervical syrinx after a MVA is likely to evolve if the pt has
Intraspinal contusion
83
Which tract contribute to graphesthesia, 2 pt discrimination?
Spinothalamic
84
What's spondylolisthesis?
Slippage of vertebral elements
85
What's spondylolysis?
Idiopathic dissolution of vertebral elements
86
Sensory fibers for patellar reflex coem from which spinal segmt
L2, L3
87
What's most common cause of mononeuropathy multiplex?
DM. Also, various rheumatoid dz and sarcoidosis.
88
Thoracic outlet syndrome causes defects in which nerves?
Lower trunk
89
Where is the damage in Friederich's ataxia?
Spinocerebellar tract
90
What does the CSF show with GBS?
Elevated protein
91
What causes the peripheral nerve damage in Friederich's?
Loss of cells in dorsal root ganglia
92
What's used to treat GBS?
1. Plex 2. IVIG
93
What's used to treat Lambert-Eaton?
3,4-Diaminopyridine
94
What are sx of cauda equina compresion?
Loss of bladder and bowel control, paraparesis or paraplegia
95
What is the tx for osteo of the vertebral body?
Decompressive laminectomy
96
What is the tx to terminate cluster headaches?
4L 100% O2. Methysergide is effective but side effects :(
97
What are the side effects of methysergide?
Retroperitoneal, pulm, and endocard fibroses
98
What can trigger Wernicke's?
Glucose influx --> thiamine depletion
99
What's anisocoria?
Unequal pupils
100
What is needed to change the color of the iris after birth/infancy?
Sympathetic innervation of iris
101
57 yo F w/ hx of DM and hyperthyroid presenting w/ vertical and horizontal diplopia, moderate orbital pain. Likely 2/2…
DM --> CN III palsy
102
MOA of botulinum?
Blocks release of Ach
103
Rapid bulbar paresis ddx
GBS, botulism, tick paralysis
104
66 yo F w/ fever and generalized convulsion. MRI shows high T2 signal in medial temporal lobes (R>L). CSF shows 100 lymphocytes / uL, 15 RBCs, xanthochromia, mildly elevated pressure.
Viral encephalitis
105
Likelihood of developing MS in a pt w/ optic neuritis?
75%
106
What meds can be used for bladder dysfn in MS (2)?
Pts have spastic bladders. 1. Oxybutinin 2. Imipramine or other TCAs
107
In status, what should be used in conjunction to benzo?
Phenytoin - to prevent relapse. Must be administered parenterally to reach rapid therapeutic levels. Can't give rapid infusions b/c risk for cardiac depression
108
What meds are used to decr frequency of exacerbations in MS?
1. Beta interferon 2. Glatiramer acetate
109
Dementia pattern of vascular dementia?
Stepwise decline
110
Sx of NPH?
Dementia, ataxia, incontinence, dilated ventricles on MRI
111
Suspect primary CNS lymphoma in HIV pt w/…
• AMS • EBV DNA in CSF • Solitary ring-enhancing on MRI
112
Neurocardiogenic syncope episodes are preceded by
Nausea, diaphoresis, bradycardia, pallor.
113
Where do you see blood on CT with amyloid angiopathy?
Lobar (intracerebral)
114
Pts w/ negative CT for SAH need
LP
115
44 yo M w/ anorexia, fatigue, memory impairment. Hx of IV drug use, decreased sex drive, MMS of 24/30. Concern for…
HIV (also hep C)
116
What are first line tx for pseudotumor cerebri?
Acetazolamide +/- furosemide. Corticosteroids and serial LPs can be used as bridging therapies while awaiting surgery
117
What are first line tx for NPH?
Large volume LPs and, if successful, ventriculoperitoneal shunt
118
What are first and second studies in a pt w/ first time seizure?
CT noncon, then EEG
119
What are drugs that can cause torticollis?
• Typical antipsychotics • Metoclopramide • Prochlorperazine
120
What meds can cause stocking-glove loss of pain, temp, ankle reflexes?
• Platinum-based (cistplatin) • Taxanes (paclitaxel) • Vinca alkaloids (vincristine)
121
Hemineglect caused by which lobe?
Nondominant parietal
122
Characteristic CSF for herpes encephalitis?
1. Lymphocytes 2. RBCs 3. Elevated protein
123
What are tx for myclonus?
Sodium valproic acid, clonazepam
124
What is tx for Huntington's chorea?
Haloperidol
125
Early use of what in atherosclerotic stroke?
Asa (NO heparin as it increases risk of symptomatic ICH)
126
Do you need any additional therapy from abx for septic emboli?
No - no anti-platelets, heparin, or warfarin
127
What is a complication concerning for status?
Cortical laminar necrosis
128
What are examples of extrapyramidal sx?
• Tardive dyskinesia • Dystonic rxns • Parkinsonism
129
Side effects on ears 2/2 aminoglycoside toxicity?
1. Ototoxicity = hearing loss. 2. Vestibulopathy w/ or w/o oto
130
What are the origins of mets to brain?
Lung (multiple) > Br (solitary) > Unknown > Melanoma (multiple) > Colon (solitary). RCC (solitary)
131
Epidural hematoma results from rupture of
Middle meningeal artery
132
What is used for ALS, and MOA?
Riluzole - glutamate inhibitor. Doesn't treat, but may prolong survival and time to trach
133
What are side effects of above?
Dizziness, nausea, weight loss, elevated liver enzymes, skeletal weakness
134
Tx for drug-induced acute dystonia?
Benztropine or diphenhydramine (Benedryl)
135
What is Akathisia?
Subjective restlessness, inability to sit still
136
Tx for drug-induced akathisia?
Benzo (lorazepam)
137
Tx for GBS?
IVIG and Plex
138
What causes neuro sx in Wilson's?
Copper deposition in basal ganglia
139
What does the liver show in pts w/ alpha 1 antitrypsin?
Hepatocytes containing granules that are PAS positive and diastase-resistant

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