spinal Disorders, brain abscess Flashcards
causes of brain abscess / organisms?
- spread from contguous infection in the sinuses, mastoid air cells or otitis media
- bacteremia (esp pneumonia and endocaditis)
organisms: staph, strep, gram (-) bacillim anaerobes (frequently mixed)
how to distinguish brain cancer from abscess
no way (not even on imaging study) --> only with biopsy (cancer can give fever) --> also to determine the precise organism and its sensitivity
brain abscess - best initial test / most accurate
- best initial: CT or MRI: ring or contrast enhancing lesions that will likely have surrounding edema and mass effect
- most accurate: brain biopsy
- LP: useless and contraindicated
brain abscess - treatment
- empiric therapy with penicillin + metronidazole + ceftriaxone (or cefepime) is acceptable while waiting for results
- if recent neurosurgery and risk risk of staph: vancomycin
- avoid prolonged empiric therapy
anterior spinal artery infraction - manifestation + treatment
- loss of al function except the posterior column (position + vibration intact)
- flaccid paralysis below infraction
- loss of DTR at the level of the infraction
- loss of pain and Q
- extensor plantar response
- evolves plastic paraplegia several wks later
- no specific treatment
sabacute combined degeneration of the Cord - causes and manifestation
- from b12 def or neurosyphilis
- position and vibratory sensation are lost
vitamin B12 deficiency - spinal cord lesions
sabacute combined degeneration –> demyelination of dorsal column, lateral corticospinal tracts, and spinocerebellar tracts
vitamin B12 deficiency - symptoms because of spinal cord lesions
- ataxic gaits
- paresthesia
- impaired progression and vibration sense
- weakness
tabes dorsasis - spinal cord lesion?
degeneration (DEMYELINATION) of dorsal columns and roots
spinal trauma - treatment
glucocorticoids
spinal trauma - manifestation
acute onset of limb weakness and/or ensory disturbance below the level of the injury with the severity in proportion to the degree of injury.
- Sphincter function impaired
- loss of DTRs at the level of injury and hyperreflecia below
Brown-Sequard syndrome - manifestation
- ispilateral UMN signs below the level of lesion
- ipsilateral loss of tactile, proprioception, vibration below the level of lesion
- contralateral pain and temperature loss below the level of lesion
- Ipsilateral loss of all sensation AT LEVEL OF LESION
- ispilateral UMN sign at the level of lesion
- Horner syndrome (if lesion above T1)
syringomyelia ?
fluid filled, dilated central canal in pinal cord –> widening bubble or cavitation first damages neural fibers passing near the center of the spine (bytumore or trauma or congenital) –> loss of pain and Q bilaterally across the upper back and both arms (capelike distribution –> ALSO LOSS OF REFLEXES + MUSCLE ATROPHY IN THE SAME BILATERAL DISTRIBUTION
Tourrete Disorder - diagnostic tests / treatment
- no specific diagnostic tests
- fluphenazine, clonazepam, pimozide or other neuroleptic. Methylphenidate and ADHD treatment are intrinsic to Tourrete management
Huntington disease - chromosome of trinucleotide / trinucleotide repeat / age
ch 4
CAG
30-50
Huntington disease - symptoms
- choreiform movements (dyskinesia)
- aggression
- depression
- dementia
Huntington disease - movement disorder
starts with fidgetiness or restlessness progressing to dystonic posturing, rigidity and akinesia
- movement disorder may be troubling, but it is far worse to progress to no movement (rigidity)
(also athetosis and chorea)
Huntington disease - diagnostic test
specific genetic test (99% sensitive) –> CAG trinucleotide repeat sequences are found on genetic analysis –> symptom triad (movement/memory/mood) is confirmed with the test
Huntington disease - treatment
no treatment reveres HD
- dyskenesia is treated with tetrabenazine, reseprine
- psychosis is treated with Haloperidol, quatiapine
Huntington disease - MRI
Atrophy of caudate and putamen nuclei with hydrocephalus ex vacuo
Huntington disease - a common cause of death / is sometimes mistaken for
- suicide
- substance abuse
Restless Leg syndrome - presentation
patient reports an uncomfortable sensation in the leg that is creepy and crawly at night –> discomfort is worsened by caffeine and relieved by moving the legs.
Restless Leg syndrome - treatment
dopamine agonists such as pramipexole
Movement disorders - types
- athetosis 2. chorea 3, Dystonia 4. Essential tremor
- Hmiballismus 6. intention tremor 7. Myoclonus
- Resting tremor
Athetosis - presentation / characteristic lesion
slow, writhing (snake-like) movements, especially seen in fingers
Huntington (basal ganglia)
Chorea - presentation / characteristic lesion
sudden, jerky purposeless movements
Huntington (basal ganglia)
dystonia - presentation and example
sustained involuntary muscle contraction
ex: Writer’s cramp
blepharospam (sustained eyelid twitch)
hemiballismus - presentation / lesion
sudden, wild flailing of 1 arm +/- ispilateral leg
- contralateral subthalamic nucleus (eg. lacunar stroke)
intention tremor - presentation / lesion
slow, zigzag motion when pointing extending toward a target
- cerebellar dysfunction
Myoclonus - presentation / causes
sudden brief uncontrolled muscle contraction
- hiccups are common
- metabolic abnormalities such as liver or renal failure
Resting tremor - presentation / seen in
uncontrolled movement of distal appendages (most noticeable in hands) (pill rolling tremor)
tremor alleviated by intentional movement
- seen in parkinson
Essential tremor occurs
- at both rest and with intention
- greatest in the hands but can affect the head as well
- it may affect manual skills such as handwritting or the use of a computer keyboard
essential trempr
the best therapy is propranolol
- improved with alcohol
Parkinsonism - definition
loss of cells in the substatia nigra resulting in a decrease in dopamine –> significant movement disorder presenting with tremor, gait disturbance and rigidity
MCC of parkinsonism / other causes of parkinsonism
MCC of parkinsonism: idiopathic
other:
1. encephalitis
2. drugs: a. metroclopramide b. reserpine c. antipsychotics
Parkinson disease - histology
- Lewy bodies (composed of a-synuclein - intracellilar eosnophilic inclusions)
- loss of dopaminergic neurons of substantia nigra pars compacta (de-pigmentation)
Parkinson disease - symptoms
MNEMONIC: TRAP
- Tremor (pill-rolling tremor at rest)
- Rigidity (cogwheel) –> slowing on passive flexion or extension
- Akinesia (or bradykinesia)
- Postural instability (orthostatic hypotenstion
- Shuffling gait
- FACIAL expression is limited (hypomimia and writing is small (micrographia)
Parkinson disease - age
50-60
all Parkinson drugs and mechanism of action (shortly)
- Bromocriptine (dopamine agonist)
- Pramipexole (dopamine agonist)
- ropinirole (dopamine agonist)
- amantadine (incr dopamine release and inh reuptake)
- Levodopa (increases dopamine levels in CNS)
- carbidopa (DOPA decarboxylase inhibitor)
- entacapone(peripheral COMT inhibitor)
- tolcapone (central and peripheral COMT inhibitor)
- selegiline (MAO-B inhibitor) (and rasagilini)
- benzotropine and trihexyphenidyl (antimuscarinic)
Parkinson disease - anticholinergic medications
benzotropine and trihexyphenidyl –> releive tremor and rigfitidy
SE: dry mouth, worsening prostate hypertrophy, constipation
Parkinson disease - medication for patients above 60 with anticholinergic medications intolerance
amantadine
which medications are for mild parkinson disease
anticholinergic and amantadine (all the other are for severe - inability to care for themselves)
best initial therapy for severe parkinson
dopamine agonists: pramipexole, ropirinole
most effective medication for parkinson
Levodopa/carbidopa (ON/OFF episodes)
COMPT inhibitors - drugs / role
- tolcapone, entacapone
- extend the duration of levodopa/carbidopa by bloccking the metabolism of dopamine
- use when there are on/of, or when the response is inadequate
Parkinson treatment - electrical stimulation
highly effective for tremors and rigidity in some patients
MAO inhibitors - role / drugs / be careful
- resagiline, selegiline
- adjunct to levodopa/carbidopa
- block metabolism of dopamine
avoid tyramine containing food –> hypertension
medications of Parkinson that slow progression of the disease
ONLY MAOi
antiprakinsonism medication complicated withpsychosis and confusion - next step
start antipsychotic with the fewest extrapyramidal effects (eg. clozapine)
you cannot stop medications because lock in with severe bradykinesia
Shy-Drager syndrome
parkisnosnims predominantly with orthostasis
spasticity - definition, associated with
- painful, contracted muscles from damage of CNS
- associated with MS
spasticity - treatment
- no single treatment is universally effective
- baclofen, dantrolene and central acting α-agonists tizanadine
