Step 2 CK stuff Flashcards
4 Deadly Ds of posterior circulation strokes
Diplopia
Dizziness
Dysphagia
Dysarthria
Stroke labs
CBC, PT/PTT, cardiac enzymes and troponin, BUN/Cr
Lateral corticospinal
movement (ipsilateral) limbs and body
Dorsal column/medial lemniscus
fine touch, vibration, proprioception (ipsilateral)
Spinothalamic
pain & temp (contralateral)
ALS treatment pharm?
For Lou Gehrig give NILOUZOLE
Bell’s Palsy is complication of?
ALexander Bell with STD
AIDS, Lyme, Sarcoidosis, Tumors, DM
Babinksi is sign of …?
UMN problem but normal in first year of life
Reflex nerve roots? (achilles, patella, triceps, biceps)
Achilles S(1),2 Patella L3,(4) Biceps C(5),6 Triceps C(7),8 (root in parenthesis)
Stroke thrombolytics (tPA)?
For ischemic (which is 80% of strokes)
If within 3-4 hours
And you can tell if it’s ischemic with CT without contrast (but may see nothing if
MCA stroke CHANGes?
Contralateral paresis and sensory loss (face and arm) Hemiparesis Aphasia (dominant) Neglect (nondominant) Gaze preference (toward side of lesion)
If more >3 hours since ischemic stroke?
Give ASA, or clopidogrel if already taking ASA
Contralateral paresis and sensory loss in le, with personality changes?
ACA stroke
Vertigo and homonymous hemianopsia?
PCA stroke
Stroke symptoms that are pure motor, pure sensory, dysarthria, ataxic hemiparesis?
Lacunar stroke
If neuro sx (can be any kind) last LESS than 24 hours (often
TIA
SAH LP findings (if CT without contrast is negative)?
RBCs, xanthochromia, incr protein, incr ICP
If SAH suspicion and CT plus LP are negative?
Do noninvasive angiography
“Blown pupil” suggests?
Ipsilateral brainstem compression
Vessels ruptured in subdural vs epidural hematoma?
Subdural: bridging veins (blood between dura and arachnoid)
Epidural: tear of middle meningeal artery (blood between skull and dura)
Seizure definition?
Sudden changes in neurologic activity due to abnormal electrical activity in the brain that can often be detected by EEG
Uncontrollable twitching while fully aware. Think what?
Simple partial seizure
Lip smacking with impaired LoC and followed by confusion. Think what?
Complex partial seizure
Simple vs complex partial seizure?
Simple has no impaired level of consciousness (and partial meas that it comes from abnormal activity in a discrete region so can have a variety of features dependent on where)
Majority of complex seizures originate in?
Temporal lobe (70-80%)
Generalized vs partial seizure?
General involves BOTH cerebral hemispheres (rather than a discrete area) and result in impaired LoC
Tonic-clonic (ie grand mal) generalized distinguished by?
Sudden loss of consciousness
Extension of back and contraction/relaxation of muscles
Incontinence & tongue biting
Postictal cyanosis, confusion, drowsiness
Postictal state in absence epilepsy (petit mal)?
None
First line anticonvulsant for kids?
Phenobarbital
Childhood absence EEG finding?
3-per-second spike and wave discharge
Tonic-clonic EEG finding?
10 Hz activity
Partial seizure EEG finding? Next step?
Discrete epileptogenic focus. If focal seizures are found, get a CT or MRI (with contrast) to check
Normal EEG during seizures. Think what?
Pseudoseizure
Absence seizures - first and second line?
First: ethosuximide
Second: valproic acid
When to start treatment/diagnostics for status epilepticus?
seizures >5 min
Order of status epilepticus diagnostics?
- H&P and labs
- Continuous EEG if nonconvulsive SE suspected or pt not waking up after observable seizures stop
- stat head CT if IC pathology suspected
- LP after safe CT, if fever or meningeal signs
Status epilepticus treatment?
1) ABCs
2) thiamine then glucose and naloxone (for rapid tx of potential etiologies)
3) IV benzo at 0-5 and 5-10 min
4) If still seizing at 20 min: FOSPHENYTOIN, other anticonvulsants, or continous IV midazolam
Vertigo red flags
Nystagmus for >1 min, gait disturbance, vomiting
Vertigo and vomiting 1 week after viral infection?
acute vestibular neuritis
Vestibular neuritis vs labyrinthitis (with similar presenters)
Labyrinthitis has auditory or aural sx - lateral PONTINE/CEREBELLAR strokes, similar pres
(VN does not - lateral Medulla/Cerebellar strokes similar pres)
Vertigo treatment
steroids
Recurrent vertigo with auditory sx, n/v, progressive low frequency hearing loss?
Meniere’s dz
Meniere’s tx?
Acute: meclizine or benzos, and antiemetics
Chronic: limit salt intake
Cardiac vs noncardiac syncope? Then to be sure?
- Noncardiac has prodromal sx (eg, warmth, nausea, sweating), cardiac does not
- Unless it is clearly vasovagal in young pt do EKG with troponins and eznymes, plus Holter monitor or telemetry
Myasthenia Gravis vs Lambert Eaton Myasthenic syndrome
- Gravis is Ab to post synaptic ACh-R, worst at end of day, treated with ACh-esterases, then immune treatment
- Syndrome is Ab to presynaptic Ca channels, gets better through day, and treated with 3,4-diaminopyridiane and guanidine plus immune tx
Lambert Eaton Myasthenic syndrome assoc with?
Small cell lung cancer
MS Charcot’s triad?
scanning speech, intranculear opthalmoplegia, nystagmus
MS type with best prognosis?
relapsing and remitting
Administration of corticosteroids for optic neuritis?
IV not oral
MS MRI and LP findings?
MRI: (best) multiple, asymmetric, periventricular white matter lesions, esp. corpus callosum, ehnace with gadolinium
LP: incr IgG in CSF and at least 2 oligocolonal bands (not found in serum)
MS treatment?
Acute: high dose IV steroids, then PLEX if poor response
Chronic: immunomodulators
ABC of MS immodulator tx?
A - Avonex/Rebif (INF B1a)
B - Betaseron (INF B1b)
C - Copaxone (Copolymer-1)
MS symptomatic tx?
Anticholinergics for urinary incontinence
Baclofen for spasticity
Cholinergics for urinary retention
anti-Depressants
plus Carbamazepine and amitripyline for painful paresthesias
Four “A”s of Guillain Barre?
Acute inflammatory demyleinating polyradiculopathy
Ascending paralysis
Autonomic neuropathy
Albuminocytologic dissociations (i.e. incr albumin in CSF)
Guillain Barre diagnx?
decr nerve conduction velocity and CSF protein >55 mg /dL
Guillain Barre tx?
PLEX and IVIG, NOT steroids
with AGGRESSIVE PT rehab
55 yr old man: slow progressive and ASSYMETRIC UE weakness assoc with fasciculations and atrophy but NO bladder disturbance, normal cervical MRI?
ALS
What is bulbar onset ALS?
Suggests pathology where?
Presents with difficulty swallowing, speaking and loss of tongue movement
Suggests pathology above the foramen magnum
UMN signs?
Weakness in arm extensors and leg flexors
Spastic (incr.) tone
HYPERreflexia
Plus: Babinski reflex and pronator drfit
LMN signs?
Weakness is variable
Flaccid (decr.) tone
HYPOreflexia
PLus: Atrophy and fasciculations
D.E.M.E.N.T.I.A.S. Ddx?
neuro-Degenerative Endocrine Metbolic Exogenous Neoplasm Trauma Infection Affective disorder Stroke/Structural
Dyspraxia
difficulty with learned motor tasks
Drugs that slow decline in Alzheimer’s (mild-moderate vs moderate-severe)?
mild-mod: donepezil (cholinesterase inhib)
mod-severe: memantine (NMD-R antagonist)
Abrupt changes in dementia sx over time rather than gradual?
Vascular dementia
Three “W”s of NPH?
Wet (incontinence)
Wobbly (gait apraxia) - “feet glued to floor”
Wacky (dementia)
Two dementia with ventricular enlargement?
Alzheimer
NPH
Possible treatment for NPH?
LP or continuous lumbar CSF drainage (for several days)
If that works then surgical ventriculo-peritoneal shunting
MMSE score threshold when it’s probably no longer normal aging if below?
24
Rapidly progressing dementia with myoclonus?
CJD
Elevated CSF proteins in CJD?
And that indicates?
14-3-3 and tau
Indicates rapid destruction of neurons
Dementia with cognitive, movement, and psychiatric sx?
Lewy body
Huntington’s sx tx?
Reserpine and tetrabenazine for movement
Atypical antipsychotics for psychosis
SSRIs for depression
Essential tremors vs Parkinsonian tremors
- essential are suppressed at rest, unlike parkinson
- essential more likley to be bilateral then early parkinson
- essential can be the only sx
Essential tremor tx?
Propranolol
Primidone
Topiramate
Gait changes in NPH vs Parkinson?
NPH preserves arm swing
The Parkinson T.R.A.P.?
Plus the 3 “M”s?
Tremor (pill roll) Rigidity (cogwheel) Akinesia/bradykinesia Postural instability - masked facies, memory loss, micrographia
Parkinson tx: ankle edema and livedo reticularis? What drug?
Amantadine
Levodopa/carbidopa
hallucination, dizziness, HA, agitation, then involuntary movement
DZ with dopamine defic and ACh excess?
Parkinson
DZ with ACh and NE defic?
Alzheimer
DZ with blocked ACh activity?
Myasthenia gravis
Proportion of intracranial neoplasms that are primary vs metastatic?
30% primary
70% mets
Common primary cancers that met to brain?
Location of brain mets?
lung, breast, kidney, GI, melanoma
Mets at gray-white junction
Most common primary CNS tumors in adults?
glioblastoma multiforme
meningioma
Most common primary CNS tumors in kids?
astrocytoma
medulloblastoma
3 types of astrocytoma and which is benign?
diffus (benign)
anaplastic (malignant)
gliobalstoma (malignant)
ICP management (5)
Elevate head Hyperventilate (decr CO2 -- cerebral vasoconstriction) Corticosteroids Mannitol Removal of CSF
Symptoms of incr ICP (4)
Nausea
Vomiting
Diplopia
HA (worse in morning and with bending over or lying down)
Ages that NF1 and NF2 are evident?
And both are inherited AR or AD?
15 and 20
AD
NF1 diagnx (2 or more of this 7)? aka von Recklinghausen
- 6 cafe au lait
- 2 neurofibromas
- freckling in axillary/inguinal areas
- optic glioma
- 2 Lisch nodules
- Bone abnormality
- first degree relative with NF1
NF2 diagnx?
Bilateral acoustic schwannomas
OR First degree reltive with NF2 and either:
- unilateral acoustic schwannoma
- or 2 neurofibromas, meningiomas, gliomas, schwannoma
Plus possible seizures, skin nodules, cafe au lait spots
Tuberous sclerosis (inheritance, presentation)
AD, infantile spasms/seizures
ASH LEAF hypopigmented lesions
Mental disability
Small benign tumors on skin, CNS, heart , retina, kidneys
Motor aphasia, expressive aphasia, nonfluent aphasia?
Localization?
Aware?
Broca’s (posterior inferior frontal lesion on dominant side)
AWARE of PROBS
Sensory aphasia, receptive aphasia, fluent aphasia?
Localization?
Aware?
Wernicke’s aphasia
(posterior superior (perisylvian) temporal lesion on dominant side)
UNAWARE of PROBS
Impaired on intact repetition in aphasia?
Impaired in true Broca and Wernicke
If intact then lesion is around the Broca area (transcortical motor apahasia - TMA) or Wernicke (TSA)
Broca’s aphasia often 2/2 what stroke?
Left SUPERIOR MCA
Wernicke’s aphasia often 2/2 what stroke?
Left INFERIOR/POSTERIOR MCA
Coma is caused by dysfunction of?
Due to?
Dysfxn of both cerebral hemispheres brainstem (pons or higher)
Due to structural or toxic-metabolic insults
Coma Initial treatment
1) Stabilize (ABCs)
2) Reverse (with D.O.N.T.
- dextrose, oxygen, naloxone, thiamine)
3) Identify (and treat underlying cause)
4) Prevent (further damage)
Order of imaging for coma
1) CT without contrast (checking for hemorrhage and structural changes), before LP
2) MRI
Paralyzed but wakeful and alert, able to move eyes and eyelids?
Locked in syndrome
Wakefulness WITHOUT alertness?
pVS
No sleep-wake cycles WITH resp drive?
And WITHOUT?
Coma
Brain death
Wernicke encephalopathy and Korsakoff dementia - are they reversible?
Wernicke - yes! With thiamine
Korsakoff - no.
Closed angle vs open angle glaucoma bilateral or unilateral?
More common?
Closed unilateral Open bilateral (more common)
Headaches triggered by dark/bright light?
Dark: closed-angle glaucoma (due to pupillary dilation)
Bright: migraines
Cataracts assoc with?
DM, HTN, Age, radiation exposure
