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Neurology > Test #1 > Flashcards

Test #1 Flashcards

1
Q

Huntington’s Disease

A

Cerebral and caudate nucleus atrophy -> GABA and acetylcholine deficiency

Chronic, progressive chorea w/ impulsive and antisocial behavior from dopamine surplus

Dx: MRI (caudate atrophy), PET (caudate metabolic abnormalities), Genetic testing - gold standard

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2
Q

Huntington’s Disease Treatment

A

Goal: Downregulate dopamine, suppress chorea

Neuroleptic and Tetrabenazine to suppress and breakdown Dopamine

Anticonvulsants: Clonazepam, Valproic Acid

Antipsychotic: Risperidone, Olanzapine

Antidepressants: Fluoxetine, Sertraline, Nortriptyline (TCA)

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3
Q

Huntington’s Treatment Side Effects

A

Hyper-excitability, fatigue, restlessness

Antipsychotic SE mimic signs of Parkinson’s - dull facies, tardive dyskinesia

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4
Q

Essential Tremor

A

Most common tremor cause - inherited

Bilateral, occurs w/ action, constant frequency w/ variable amplitude

Have to r/o Parkinson’s - should be only abnormal thing on exam

Relieved by ETOH

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5
Q

Essential Tremor Treatment

A

Propanolol - 1st line (Atenolol w/ asthma/bronchospasm)

Mysoline/Gabapentin - anticonvulsants

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6
Q

Parkinson’s Disease

A

Progressive neurodegenerative disorder -> substantia nigra breakdown causes dopamine deficiency

TRAP, fixed facial expressions, Myerson’s sign (repeated tapping of the nose causes blinking), Lewy bodies

Onset usually after 50 years old

Tremor @ rest, disappears during sleep, cog-wheel/rachet-like motions

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7
Q

TRAP

A

Tremor - resting and postural = unilateral, @ rest

Rigidity = increased resistance to passive movement, unilateral -> bilateral

Akinesia (Bradykinesia) = difficulty/slow initiation movements, get “frozen or stuck” - huge fall risk

Postural instability = late stage, lean forward w/ shuffling gait, prone to falling backwards

  • All DTRs intact w/ no weakness
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8
Q

Parkinson’s Therapeutic Treatment

A

Depression: SSRI

Hallucination: Decrease Sinemet, Zyprexa

Orthostatic HOTN: TED hose, slow rising

Sexual dysfunction: Viagra, Dopamine agonist

Constipation: Cease causative medication; Reglan is CI - Dopamine antagonist

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9
Q

Deep Brain Stimulation

A

No more effective than highest med dose, no SE

Use in pts w/ drug-induced dyskinesias who lack any complicating med/psych conditions

Pulse generator at the STN and Thalamus - replace every 5 years

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10
Q

Restless Leg Syndrome/Wittmaack-Ekbon’s Syndrome

A

Uncontrollable urge to move limb to stop uncomfortable/painful/odd sensation - mot common in legs

Often have varicose veins, less common among Asian pop

Always get a CBC to r/o iron deficiency anemia

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11
Q

Causative agents of RLS

A

Meds: Anti-nausea, H2 Blocker, antihistamines, SSRI/anti-psych

Food: Diet soda/aspartame, ETOH

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12
Q

RLS Treatment

A

Tx underlying cause, OTC Ibuprofen, baths/massages, warm/cool packs

Pramipexole, Ropinirole, Sinemet, Lyrica (w/ Parkinson’s)

Gabapentin, Opioids

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13
Q

Parkinson’s Treatment

A

GOAL: Restore dopamine activity, manage SE of therapy

Selegiline (MAO-B) may slow progression w/ early therapy

All other meds replenish Dopamine or block Acetylcholine/GABA

Apomorphine (NMDA) is used only for emergent freezing instances

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14
Q

Levodopa/Carbidopa (Sinemet)

A

Gold standard, generally 1st line (>70 yo, dementia)

Levodopa = dopamine precursor, Carbidopa = prevent peripheral breakdown

Best for rigidity and slowness, less for tremor/balance/gait

Short acting, high doses cause dyskinesias

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15
Q

Sinemet side effects and contraindications

A

SE: Vivid dreams, hallucinations, HOTN, Dyskinesia

Wearing off effect - after 4-6 yrs, gets progressively worse

  • initial bradykinesia, tremor before next dose

CI: MAOI, psychotics, angle-closure glaucoma, history of melanoma

Use caution w/ cardiac dx, PUD

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16
Q

Monoamine Oxidase-B Inhibitors (MAO-B)

A

Selegiline/Rasagiline = stop dopamine breakdown, penetrate BBB

May slow progression if given @ early onset in young pt

1st line for mild dx, also to decrease Sinemet wearing off effect

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17
Q

MAO-B side effects and contraindications

A

SE: Insomnia, Jitteriness, Dyskinesias, Increases Sinemet SE

CI: TCA, SSRI, Demerol

Caution: Liver impairment, cardio/CV dx, seizure, hypothyroidism, DM, psych disorders

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18
Q

Dopamine Agonists

A

Older, Ergo derivatives: Bromocriptine

Newer, synthetic: Pramipexole, Ropinirole

Stimulate dopamine receptors in substantia nigra

  • Improve akinesia, postural instability

1st line in young pts w/ moderate symptoms

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19
Q

Dopamine agonist side effects and contraindications

A

SE: poorly tolerated - drowsiness/sleepiness, HA, constipation, nightmare/psychosis/dyskinesias

CI: psychotic illnesses, recent MI, PUD

Avoid ergo derivatives in pts w/ PVD

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20
Q

Apomorphine (Apokyn)

A

Emergent only, NMDA agent

Treats episodes of freezing/hypermobility

Give SQ, expensive

SE: N/V, yawning, dyskinesia, sedation, dizziness

  • give w/ antiemetic that is not Zofran/Kytril
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21
Q

Catechol-O-Methyltransferase Inhibitors (COMT-I)

A

Entacapone (Comtan, Tolcapone (Tasmar)

Inhibit enzyme that metabolizes levodopa in periphery

Only use w/ Sinemet - improves wearing off effect

SE: Happen immediately, poorly tolerated - dyskinesias, confusion/hallucinations, urine discoloration, cramps, N/D, HA, insomnia

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22
Q

Amantidine

A

Antiviral, MOA unknown, Adjunct only

Use for early mild sx, short-lived

No effect on tremor

SE: sedation, vivid dreams, dry mouth, depression

Caution w/ renal dysfunction

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23
Q

Anticholinergic Acetylcholine-blocking drugs

A

Trihexyphenidyl, Benzotropine

Target Acetylcholine to prevent dopamine inhibition

Primarily for tremor, helps w/ rigidity - no effect on akinesias

SE: CNS and systemic, SE usually outweigh any benefit

  • CV, IOP, AMS

CI: BPH (causes retention), obstructive GI, angle-closure glaucoma

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24
Q

COMT uses

A

Try to improve on-off syndrome

Take off if not effect in a few weeks due to SE

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25
Q

Epidural hematoma

A

Most commonly skull fx - high force trauma

Arterial blood from venous sinus or dural artery

Dyperdense biconcave, respects suture lines

Acute presentation

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26
Q

Subdural Hematoma

A

Venous blood - from venous plexus

Cresent shaped, doesn’t respect suture lines

Low force trauma

Insidious presentation - worsening HA over days

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27
Q

Subarachnoid Hemorrhage

A

Below arachnoid/Within the brain

Arterial blood from circle of Willis - aneurysm rupture or high-force trauma

Acute presentation - thunderclap HA

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28
Q

Glasgow Coma Scale components

A

Eye Opening - 4 points

Best Verbal Response - 5 points

Best Motor Response - 6 points

GCS 13-15 = Mild TBI

GCS 9-12 = Moderate TBI

GCS <8 = Severe TBI

GCS 3 = Totally unresponsive, lowest possible score

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29
Q

GCS Eye opening

A

Spontaneous = 4

Response to verbal command = 3

Response to pain = 2

No eye opening = 1

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30
Q

GCS best verbal response

A

Oriented = 5

Confused = 4

Inappropriate words = 3

Incomprehensible sounds = 2

No verbal response = 1

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31
Q

GCS best motor response

A

Obeys commands = 6

Localizing response to pain = 5

Withdrawal response to pain = 4

Flexion to pain = 3

Extension to pain = 2

No motor response = 1

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32
Q

Seizure and Types

A

Sudden, excessive disorderly discharge of neuronal activity in brain

  1. Sudden, transient
  2. Motor/sensory/autonomic/psychic manifestations
  3. Temporary alteration of systemic arousal
  4. Often manifests as convulsions; different kinds of seizures
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33
Q

Seizure disorder/Epilepsy

A

Recurrent seizures without any immediate treatable cause such as hypoglycemia or ETOH withdrawl

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34
Q

Convulsion

A

Rapid contraction and release of muscle causing an uncontrollable shake

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35
Q

Epilepsy

A

Occurrence and reoccurrence of seizures without know or correctable cause

Can get strange sensations/emotions/behavior -> convulsions, spasms, LOC

Idiopathic or primary generalized epilepsy usually present by puberty

Seizures after 20 yo -> usually focal process/metabolic derangement

Cancer, stroke, degenerative brain disorders cause seizures later in life

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36
Q

Epilepsy Pathophysiology

A

A. Complex gene mutations or environmental factors = abnormal connections

B. Hypersensitive neurons have sudden, violent depolarizations

-Temperature, electrolyte imbalances set off

C. Epilectogenic neurons fire more often and intensly w/ greater amplitude than normal

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37
Q

Provoked vs Unprovoked Seizures

A

Provoked = triggered by provoking factors in healthy brain

  • metabolic, ETOH, drugs, high fever

Unprovoked = occur with persistent brain pathology

-repeat seizures may be similar or different, get a complete H&P after initial seizure to r/o other conditions

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38
Q

Sudden unexpected death (SUDEP)

A

Sudden, nontraumatic, nondrowning death of a person w/ epilepsy

Happens in refractory epilepsy or poorly controlled seizure disorder

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39
Q

Seizure phases

A

Prodrome (1st phase) = hours/days before seizure

-deja vu, smell/sounds/taste, fear, dizzy, HA, nausea

Aura = 1st seizure sx, beginning of seizure

Middle “ictal phase” = from Aura to end of seizure

  • awareness lost, confused/daydreaming, can’t talk/swallow

Ending “postictal” = recovery can be immediate or takes minutes/hours

-sleepy, slow to respond, confused, HA, nausea

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40
Q

Loss of consciousness

A

Complete/partial unawareness or lack of response to sensory stimuli

Induced by hypoxia, metabolic or chemical depressants, brain pathology, trauma

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41
Q

Focal Seizures

A

Occur on one side of the brain

Occur w/ and w/out consciousness impairment

w/out: Jacksonian March (motor), Todd’s Paralysis, sensory, autonomic, psychic

w/: pt unresponsive, may evolve from w/out

  • most common, arise from temporal lobe - pt appears to be “daydreaming”
  • 30 seconds to 1 minutes w/ confusion and tired 15 min postictal
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42
Q

Jacksonian March

A

Motor focal seizure w/out consciousness impairment

Starts at fingers and works its way up limb

Abnormal activity in primary motor cortex

Also get sudden head & eye movement, tingling, numbness, lip smacking, and muscle spasms

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43
Q

Todd’s Paralysis

A

Focal seizure w/out impaired consciousness - Postictal state

Temporary (30 min to 36 hours), unilateral paralysis of limb

Have to r/o stroke

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44
Q

Generalized Onset Seizures

A

Disturbed consciousness, bilateral cerebral cortex malfunction

Absence, Atypical, Myoclonic, Atonic, Febrile, Tonic-Clonic, and Secondary seizure types

Can develop from focal seizures

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45
Q

Absence seizure

A

“petit mal seizure”

Looks like daydreaming, disturbed consciousness w/o convulsions

Typically in childhood

Abrupt onset and termination w/ brief impairment ~10 seconds

May have mild tonic-clonic, or atonic components; no postictal

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46
Q

Atypical Absence Seizures

A

Lapse in awareness w/ gradual onset and resolve

Autonomic features and muscle tone lost

Often occurs in mentally impaired kids

Doesn’t respond well to AED therapy

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47
Q

Myoclonic Seizures

A

Rapid, recurrent muscle spasms

Bilateral or unilateral, synchronous or not

Often terminate into generalized tonic-clonic (grand mal)

Often cluster after waking or while falling asleep

48
Q

Atonic Seizures

A

“drop attacks”

Abrupt muscle tone loss, pt just collapses

Often seen in kids w/ diffuse encephalopathies

49
Q

Febrile Seizures

A

Most common convulsion cause in kids 6 mo to 5 years

Temp > 38C (100.4 F), simple or complex

Have to r/o brain infection, metabolic issue, hx previous seizure w/o fever

No association/cause from mental impairment, behavioral problems, or poor school performance

Sx: Body stiffens, arm/leg twitch, vomit, foam @ mouth, incontinence

50
Q

Tonic-clonic Seizures

A

“Grand mal”

Sudden LOC and involves all extremities

Primary deep brain structure or secondary focal generation

Tonic: <1min, sudden LOC and collapse, respiration arrested

Clonic: 2-3 min, muscle jerking and AMS

May recover, sleep, or go into status epilepticus

Postictal = HA, disorientation, drowsiness, N, muscle soreness

51
Q

Secondary Generalized Seizure

A

Focal seizure that becomes generalized - 30% focal episodes

1-3 minutes, longer recovery time

Sx: muscle stiffening, LOC, bite tongue/cheek, tonic/clonic phases

Dx: EEG, MRI

Tx: Carbamazepine

52
Q

Post-traumatic Epilepsy

A

Degree of injury matters

Many develop seizures by 1-2 yrs, mostly focal or secondary generalized

Penetrating, cerebral contusions, intracerebral hematoma, unconsciousness, or amnesia >24 hours

53
Q

Seizure Diagnosis - 3 Objectives

A
  1. Determine if pt has epilepsy
  2. Classify seizure and type
  3. Identify (if possible) specific underlying cause

PE should be normal between seizures

-Look for lateralized sx, Todd’s, bruits, heart murmur

54
Q

4 Conditions that mimic seizures

A

REM behavior disorder = sudden arousal from REM, aggressive behavior

-Dx w/ overnight sleep test

Transient Ischemic Attack = lateralizing weakness/vision loss

Transient Global Amnesia = vascular, >50yo, recurrent short-term amnesia w/o other impairments

Migraine = aura w/ AMS, mimics complex partial seizure, tonic-clonic postictal

55
Q

Seizure Workup

A

EEG: Most important, get during active seizure and during sleep

MRI: study of choice, used to identify brain pathology

-get in all kids and in pts >20 w/ suspected neoplasm and seizures

Labs: baseline and to r/o systemic causes

56
Q

Status Epilepticus

A

Seizure >30 min, or prolonged series of seizures w/o consciousness recovery between

Life-threatening, caused by drug noncompliance/withdrawal, fever

Tx: Give Thiamine, glucose, Ativan (lorazepam if fever), Fosphenytoin

No response in 20 min = Phenobarbital and Pepacon

Still nothing = General anesthesia w/ vent and neuromuscular junction block

57
Q

Seizure Treatment Guidelines

A

Unprovoked - typically don’t treat until 2nd or 3rd seizure

Referral to Neurology for further surgery/treatment/workup

60% controlled w/in 1st year, 15% controlled later

25% have seizures despite treatment

58
Q

Seizure Medications - 3 MOA

A
  1. Affect voltage-dependent Na or Ca Channels
    - Na: Effective for tonic-clonic and partial seizures
    - T-type Ca: absence seizures
  2. Increase inhibitory neurotransmission (GABA)
  3. Decrease excitatory neurotransmission (glutamate, aspartate)
59
Q

1st line for Generalized Tonic-Clonic

A

Carbamazepine (Tegretol)

Phenytoin (Dilantin)

Valproic Acid (Depakote)

60
Q

2nd line for Generalized Tonic-Clonic

A

Levetiracetam (Keppra)

Gabapentin (Neurontin)

Phenobarbital

Felbamate (Felbatol)

61
Q

1st line for Focal seizures

A

Carbamazepine (Tegretol)

Phenytoin (Dilantin)

Valproic Acid (Depakote)

Lamotrigine (Lamictal)

Topiramate (Topramax)

Oxcarbazepine (Trileptal)

62
Q

2nd line for Focal seizures

A

Gabapentin (Neurontin)

Phenobarbital

Zonisamide (Zonegram) - Adjunctive tx only for focal w/o consciousness impairment

Felbamate (Felbatol)

Tiagabine (Gabitril)

63
Q

1st line for Absence Seizures

A

Lamotrigine (Lamictal)

Ethosuximide (Zarontin)

64
Q

Seizure drugs Pregnancy category D

A

Carbamazepine (Tegretol)

Phenytoin (Dilantin)

Valproic Acid (Depakote)

Phenobarbital

So all 1st line for Generalized tonic-clonic

65
Q

Lumbar Puncture Contraindications

A

Site skin infection

Increased intracerebral pressure - except w/ pseudotumor

Spinal cord mass/intracranial mass lesion

Bleeding/coagulation defect

Spinal column deformities

Spinal epidural abscess

Noncompliant pt

66
Q

Rule out ICP

A

Get a CT on pts w/:

Altered mental status

Focal neurologic signs

Papilledema

Seizure w/in 1 week

Impaired cellular immunity

67
Q

CSF normals:

Pressure

Appearance

Total protein

Glucose

Cell count

A

Pressure: 70-180

Appearance: clear, colorless

Total protein: 15-45

Glucose: 45-85

Cell count and diff: 0-5 wbc/uL, 0 rbc

68
Q
A
69
Q

Elevated ICP DDx

A

Meningitis

Intracerebral Hemorrhage (ICH)

Neoplasm

70
Q

Xanthochromia DDx

Yellow

Orange

Pink

Green

Brown

A

Occurs w/in 2 hours, lasts 2 weeks

Yellow: Blood lysis, hyperbilirubinemia, protein > 150, rbc >100,000 (hemorrhage)

Orange: rbc lysis, high carotenoid ingestion

Pink: rbc lysis products

Green: Hyperbilirubinemia, purulent CSF

Brown: Meningeal melanomatosis (CNS melanoma)

71
Q

Protein DDx

A

One of the most sensitive CNS pathology indicators

150 in newborns, normalizes around 6-12 months

Low: repeat LPs, CSF leak, acute water intoxication

High: Infection, ICH, Guillain-Barre, Neoplasm, endocrine, inflammatory

Can be falsely elevated w/ traumatic tape -> -1 protein/1000 rbc

72
Q

Glucose DDx

A

Normal w/ viral

Low w/ bacterial/fungal/neoplasms

High if peripheral glucose is also elevated

73
Q

Cell count and Differential

A

Wbc: Meningitis - <1000 = viral, > 1000 = bacterial

-increased post-seizure, ICH, malignancy, inflammation

Rbc: Traumatic tap = #rbc decreases in consecutive tubes

-ICH = no consecutive decrease in #rbc

Cell differential: Normally 70% lymphocytes, 30% monocytes

-Meningitis: neutrophils = bacteria, lymphocytes = viral/fungal/TB, eosinophils = parasites

74
Q

LP Microscopic DDx

A

India Ink + = cryptococcus

Wright/Gimesa + = toxoplasmosis

75
Q

Other LP findings

Latex agglutination and PCR

A

Latex agglutination = rapid detection of bacterial antigens in meningitis

PCR for viral: HSV, EBV, enterovirus, CMV, TB, acute neurosyphilis

76
Q

Nerve Fibers

A-alpha

A-delta

C fibers

A

A-alpha = large, myelinated; touch, vibration, position

A-delta = small, myelinated; cold, pain

C fibers = unmyelinated; warm, pain

77
Q

Nerve Conduction Velocity

A

Only studies A-alpha fibers

Can miss polyneropathies in small fibers

Measures quality and speed of the signal sent to peripheral fibers

Used to study demyelinating polyneropathy (Guillain-Barre) or focal demyelination (carpal tunnel)

78
Q

Nerve Conduction Studies

A

Test peripheral nerves to diagnose focal or generalized disorder

Can differentiate muscle from nerve disorders depending on whether nerve signal or muscle response is altered or appropriate

Indicated w/ paresthesias/weakness of limbs, or nerve conduction disorders

79
Q

Electromyography (EMG)

A

Measures muscle electrical activity @ rest and contraction

Indicated for disease that damage muscle, nerve, or nerve-muscle junction

  • herniated disc, amyotrophic lateral sclerosis (ALS), MS
80
Q

Electroencephalogram (EEG)

A

Distinguish epileptic seizures from:

-psychogenic spells, syncope, movement disease, migraine variants

Differentiate between organic or psychiatric encephalopathy or delirium

Test for brain death, or for discontinuation of antiepileptic drugs (AED)

81
Q

EEG waves and amplitude

A

Delta: 0-4 Hz

Theta: 4-8 Hz

Alpha: 8-12 Hz

Beta: >12 Hz

Increased slow waves (Delta and theta) in awake patients = focal brain lesion/abnormality

A normal EEG does not r/o epilepsy

82
Q

Head CT: Contrast or no

A

Contrast: Neoplasm, infection, vascular or inflammatory disease

-contrast lights up the blood vessels

No Contrast: trauma, stroke/hemorrhage r/o, hydrocephalus, dementia, epilepsy, congenital malformations

83
Q

CT Scan interpretation

A

Look for

  1. Fluid
  2. Mass
  3. Shift
  4. Compare both sides for symmetry

Water is dark, skull is white

More dense the tissue, the brighter it is

84
Q

CT Angiography indications

A

Atherosclerosis

Thromboembolism

Vascular dissection

Aneurysm

Vascular malformations

Penetrating trauma

Carotid evaluation

85
Q

MRI T1 and T2 indications

A

T1: Look at normal brain function

  • fat is bright, water is dark

T2: Look for abnormal processes or brain pathology

  • water and blood are bright, white matter is dark

Indications: subacute/chronic hemorrhages, stroke f/u, metastasis, intracranial abscesses, MS/demyelination, vasculitis, new onset/refractory seizure

86
Q

Basilar skull fracture indications

A

Raccoon eyes

Battle’s Sign

CSF Leak

Hemotympanum

  • get an MRI to evaluate
87
Q

TBI Hospitalization

A

GCS <15 or deteriorating

Abnormal CT or bleeding parameters

Seizure

88
Q

Decorticate vs Decerebrate

A

Decorticate = elbows and fingers flexed w/ UE adduction

-Cerebral cortex or thalamic dysfunction, better prognosis

Decerebrate = UE adduction w/ extension

-Caudal diencephalon, pons, or midbrain injury

LE Extension w/ plantar flexion and inversion occur w/ both

89
Q

Coma Respiratory Patterns

Cheyne-Strokes

Hyperventilation

Apneustic breathing

Ataxic breathing

A

Cheyne-Strokes: cyclic hyperpnea and apnea from bilateral hemisphere or diencephalic insult

Hyperventilation: pontine or midbrain tegmentum injury

Apneustic: prolonged pause @ inspiration end from mid and caudal pons lesion

Ataxic: irregular rate and tidal volume from medulla damage

90
Q

Mini-Mental Status Exam Rankings

A

24/30 = suggestive of dementia

20-26 = functional dependence

10-20 = moderate, immediate dependence

<10 = severe, total dependence

91
Q

Neuropathologic Hallmarks of Alzheimer’s Disease

A

Begin years before symptom onset

Amyloid-rich senile plaques

Neurofibrillary tangles

Neuronal degeneration

92
Q

Alzheimer’s Disease Diagnosis

A

Definite: Histopathological evidence (autopsy), course and exam have AD characteristics

Probable: 2 or more cognition deficits, 40-90 yo onset w/ progressive course and no other explanation

Possible: Deficit in 1 cognition area, atypical course, other dementia causes present

Unlikely: Sudden onset, focal signs, early seizures or gait disturbances

93
Q

Alzheimer’s Disease Clinical Course

Stages 1-4

A

1: Normal, symptom free but pathology underway
2: Normal forgetfulness with age, concentration difficulty
3: Mild cognitive impairment, subtle deficits noted by close contacts
- repeated questions, cannot master new tasks, performance decline
4: Mild AD - can Dx w/ accuracy, pt less able to manage complex ADLs (finances, cooking)
- Lasts ~2 years

94
Q

Alzheimer’s Disease Clinical Course

Stages 5-7

A

5: Moderate AD - independent survival limited, struggle w/ basic ADLs
- cannot recall major events, current life events, lasts ~1.5 yrs
6: Moderately severe AD - cannot do basic ADLs (dress themselves, live alone) - lasts ~2.5 years
7: Severe AD - speech and facial expression lost, cannot ambulate/sit independently, primitive/infantile reflexes restored
- Can last several years

95
Q

Medications to avoid w/ Alzheimer’s Disease

A

Benzodiazepines

Antihistamines

Anticholinergics

These all worse symptoms, provide no benefit

96
Q

Vascular Dementia

A

Cognitive deficit onset w/ CVA and stepwise deterioration

May be present or a predisposition for AD

97
Q

Frontotemporal Dementia (FTD)

A

Focal atrophy of frontal and temporal lobes w/o AD pathology

-Pick’s Disease = subtypes w/ Pick bodies in neocortex and hippocampus

35-75 yo

Insidious onset w/ gradual progression resulting in early decline of emotions, conduct, and insight

98
Q

Normal-Pressure Hydrocephalus

A

Pathologically enlarged ventricles w/ normal LP opening pressures

Triad: dementia, gait disturbances, urinary incontinence

-Wacky, wobbly, wet

Reversible w/ ventriculoperitoneal shunt

Dx w/ MRI and Miller Fischer gait test

99
Q

Dementia with Lewy Bodies (DLB)

A

Associated w/ Parkinsonisms

Most common dementia syndrome, 2nd most common neurodegenerative dementia after AD

  • pronounced variable attention/alertness, recurrent visual hallucinations, spontaneous motor features (Parkinsonisms)

Distinguish from Parkinsons? Dementia is presenting feature of DLB, occurs in the last 1/2 of Parkinson’s clinical course

100
Q

Progressive Supranuclear Palsy (PSP)

A

Rare, mimics PD early on

Restricted up and down eye movement - head is either straight or tilted back

Postural instability w/ frequent falls backwards

Distinguish from PD = PD pts lean forward, PSP pts head tilts back

101
Q

Delirium

A

Treatable, attention impaired at onset

Consciousness and effect on memory varies

Have attention deficit and psychomotor disturbances

Risk: Post-op, Elderly, AIDS, burns, withdrawal

High indicator for death w/in 6 months, death if hospitalized

Lasts 10-12 days or up to 2 months

102
Q

Delirium Causes

A

I WATCH DEATH

Infection

Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia

Deficiency, Endocrinopathies, Acute vascular, Toxins/drugs, Heavy metals

44% have 2 or more pathologies

103
Q

Agitation Pharmacological management

A

Haloperidol (neuroleptic), Risperidone (anti psych), Inapsine (sedative)

Haloperidol and Inapsine associated w/ Torsades and prolonged QT - monitor via telemetry

Benzodiazepines TOC for ETOH/benzo withdrawal

  • may worsen delirium, cause respiratory depression
  • CI w/ hepatic failure
104
Q

Sleep-promoting and arousal promoting neurotransmitters

A

Sleep: GABA from VLPO

Arousal: Norepinephrine from LC, Serotonin from Raphe, and Histamine from TMN

105
Q

Sleep Stages and breathing

A

1: light sleep, between conscious and asleep
2: Intermediate; HR slows, brain only does simple tasks

Breathing in 1&2 - cyclic waning and waxing of TV and R w/ brief apneic periods (periodic breathing)

3&4: Slow wave sleep; 3- body repairs, 4- temp and BP decrease

Breathing is 3&4 is regular, slower

REM: Eye movements; HR, BP, breathing and temp increase

Breathing is irregular +/- apneic periods, not periodic

106
Q

Blood gases in sleep

A

PCO2 increases 2-8

PO2 decreases 5-10

pH decreases 0.03 - 0.05

107
Q

Insomnia medications - Trouble falling asleep

A

Zolpidem (Ambien) - 1st line

Zaleplon (Sonata)

MOA: Interact w/ GABA-benzodiazepine receptor complexes

108
Q

Insomnia medications - Trouble maintaining sleep

A

Eszopiclone (Lunesta) - 1st line

Benzodiazepines (Triazolam, Lorezepam, Estazolam)

Melatonin Agonists (Ramelteon)

Orexin receptor Antagonists (Suvorexant, Belsomra)

109
Q

Hypersomnolence Disorder

A

Recurrent excessive daytime sleepiness or prolonged nighttime sleep - common in adolescents and young adults

Dx: excessive sleepiness for 1 month (acute) or 3 months (persistent) w/ prolonged sleep or daytime sleepiness at least 3x/week

Tx: Modafinil (Provigil) 1st line, Dextroamphetamine 2nd line

-Dextro has BBW for high abuse potential

110
Q

Narcolepsy Tetrad and Meds

A
  1. Extreme drowsiness w/ sleep attacks - 15 mins, wake up refreshed
  2. Sleep paralysis = muscle flaccidity between asleep and awake
  3. Cataplexy - 30 seconds to a few minutes
  4. Hypnagogic Hallucinations - preceding sleep or during a sleep attack

Tx: Modafinil (Provigil) 1st line, Dextroamphetamine

111
Q

Non-24 hour sleep-wake phase and treatment

A

Common in blind

Internal day is longer than 24 hours

Tx: Hetlioz for blind pts

MOA: Binds melatonin to MTI and MT2 receptors

Pregnancy C, SE: HA, abnormal dreams

112
Q

Non-REM sleep arousal disorders

A

Sleepwalking

Night terrors

Enuresis (Parasomnias)

113
Q

REM Sleep Behavior Disorder

A

Dream enactment during REM w/ sleep atonia loss

Antidepressants, Narcolepsy, Alpha-synuclein neurodegeneration (elderly)

Tx: Melatonin 1st line -prepares body for sleep

Clonazepam 2nd line

114
Q

RLS treatment

A

Dopamine agonist (Ropinirole) OR

Alpha-2-delta Ca channel ligand (Gabapentin)

115
Q

Bruxism

A

Teeth grinding

Jaw soreness, teeth flattening, radiating AM HA

Tx: Clonazepam, Botox, oral appliances

116
Q

Periodic Limb Movement Disorder (PLMD)

A

Unilateral or bilateral involuntary limb movement in sleep

Pt is unaware, may be related to PD or narcolepsy

Tx: Dopamine agonist 1st line

Anticonvulsants, Benzodiazepines

Neurology (5 decks)

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