Tutorial 2 Flashcards
Areas in brain that have pain receptors:
scalp, muscle, periosteum, blood vessels, meninges
Localization: Difficulty concentrating
Photophobia
Right face tingling
Right hemianopsia
Difficulty concentrating = bicerebral hemispheres
Right face tingling = left parietal lobe
Right hemianopsia = left cerebral hemisphere posterior to optic chiasm
Optic tracts and radiations path from eyes
optic chiasm -> through temporal and parietal lobes -> occipital lobes
Primary headaches
migraine, cluster, tension
Secondary headaches
Intracranial HTN, meningeal process, giant-cell arteritis, medication overuse
Giant Cell Arteritis
50+
Sx: fever, weight loss, monocular vision loss, jaw claudication, *polymyalgia rheumatic (aching pain/stiffness in neck, shoulders, hips), increase ESR & CRP
Mgmt: trend ESR and CRP, LT steroids, temporal artery Bx
Idiopathic Intracranial HTN
"pseudotumor cerebri" -obese, F, 15-45 yrs -Sx: bilateral papilledema, headache, diplopia Dx: MRI +/-, LP (open P) Tx: acetazolamide/shunt
Medication overuse
1 chronic daily headache
Why? excessive analgesic use
Tx: withdrawal, migraine prophylaxis, sedate
Migraine w/o Aura
Frq - 5+ episdoes
Duration - 4-72hr
Quality: 2+ unilateral, pulsating, mod/severe, inc headache with physical activity
Assoc feature: 1+ N/V, photophobia, phonophobia
-Auto-dom
-4 possible phases: prodrome, aura, headache, postdrome-Triggers: (hormonal, smell, EtOH)
-Etiology: SER in brainstem *not vascular
Migraine when no need to test / when you should
No: Hx, Fhx, known triggers, visual sx, sensory sx over min (vs seizure = seconds)
Yes: sounds bad, abn neuro exam
Headache w/u, migraine proph fails
MRI +/- (tumor)
LP (mening, SAH)
ESR, CRP (Giant C Art)
EEG (seizsure?)
Migraine mgmt proph - choose based on?
Proph: Anti-HTN, Anticonvulsants, TCAs, NSAID, Other
Choose based on SFx (are they desired?):
All antihypertensives (hypotension),
Beta-blockers (depression, sedation),
Tricyclic antidepressants (weight gain, sedation),
Valproic acid (weight gain, hair loss),
Topiramate (weight loss, abnormal cognition),
Naproxen (ulcers, renal disease),
Magnesium (loose stools)
Migraine abortive (frequent, disrupt ADLs)
nonspecific single agent (acet, NSAIDs, narcotics)
nonspecific combo (Excedrin)
Triptans: SSR agonists *not for pregnant, 60+, vascular dz risk, migraines with aphasia/hemiplesia/vertigo
last line abort: irgot, “IV” chlorpromazine (Thorazine)
Eye Sx: progressive vs nonprogressive
progressive - pain*, worse w/eye mvmt = inflammatory or inf
nonprogressive = ischemic events, *no pain
L’hermitte’s sign
posterior columns - cervical SC, all 4 limbs affected
+ urinary frq/urgency/hesitancy
+intermittent shock-like vibratory sensations (triggered by neck flexion)
Uthoff’s phenomenon
worsening or triggering sx by *heat = demyelinating conditions
worsening baseline sx or fatigue–occurs with inc body temp. may have new lesions
Vertigo locations
peripheral lesion: vestibular nerve
central lesion or brainstem vestibular nuclei
MS visual Sx Ddx: Optic disc = papilledema, papillitis (optic neuritis).
afferent pupillary defect.
Optic disc:
papilledema = inc ICP (swelling optic disc)
papillitis =
(anterior optic neuritis) optic nerve head inflam no swelling optic disc - with visual changes
optic neuritis: (other causes altitudinal defect or scotoma - progresses over hrs to days. involves entire visual field)
afferent pupillary defect = no PSNS activation to constrict pupils in response to light (RAPD-relative afferent pupillary defect)
Sensory level
loss proprioception
SC lesion at/near uppermost affected dermatome: Relative sensory level (decreased sensation),
Complete sensory level (complete loss of sensation)
loss proprioception: ataxia
Ddx Swollen Optic Disk (3):
Optic neuritis = young pt, triad: dec visual acuity, *painful, dyschromatopsia
Anterior ischemic optic neuropathy (AION):
old, dec visual acuity + painless
Papilledema: inc ICP, visual acuity is nrm**
Dz affect both optic nerve and SC: NMO, Lupus, Sarcoid, Syphilis, B12 def, Lyme, Lymphoma
Neuromyelitis Optica (NMO): demyelinating dz optic N + SC, no MRI MS lesions
Lupus: AI
Sarcoid: systemic granulomatous, neurosarcoidosis - meningeal involved: CN palsies: facial/optic N’s
Syphilis: chronic meningeal + vascular parenchymal, brain + SC. psychosis, uveitis, optic neuritis, CN palsies, tabes dorsalis
B12 def: paresthisias, sensory ataxia, cog changes, rare optic neuritis
Lyme: peripheral + cranial neuropathies, radiculopathies, meningitis, encephalitis, myelitis
Lymphoma - anywhere Nerv Sys: periph N, SC, brain parenchyma, meninges
MS Eval: MRI, LP
MRI C+T spine: T1 = active inflam
T2 = CSF bright, edema, ischemia, demyelinating lesions
T2 FLARE = CSF black, view lesions pariventricular lesions
LP - inf vs inflam CNS
view: myelin basic pr, oligoclonal bands, IgG synth rate
MS: prognosis, tx -proph/chronic
Relapse-remit: 70%
Primary Progressive (<5%)
Tx acute:*Before check/tx inf (UTI), No inf? = IV methylprednisolone (before PO)
Tx chronic: “ABCs” immunomodulators (dec exacerbations/relapse): INF-B, glatiramer. other-glatiramer, cytoxan
Tx other MS sx: spasticity, urinary, fatigue, depression, neuralgia
spasticity: baclofen (GABA), tizanidine (a2-adrenergic, inhib presyn motor) urinary = sx fatigue = amantadine, modafinil depression - SSRI neuralgia - AEDs
PD primitive glabellar (Myerson’s) reflex
- nonspecific, seen in neurodegen dz
- keep tapping forehead and pt can’t suppress blink (should be able to)
Basal Ganglia - what they do
- interconnect thalamus, cortex, brainstem
- initiate/regulate motor movement
PD - idiopathic
progressive degen N’s in substantia nigra and midbrain
PD Ddx
idiopathic, heredodegenerative dz, Parkinson-plus syndromes, secondary PD, non-basal ganglia imitators
Heredodegenerative Dzs
-hereditary degen Ds’s:
Wilson’s Dz, HD
PD-Plus
*respond poorly to PD Rx PSP - supranuclear verticle gaze paresis + early falls (postural instability) MSA-P -striatonigral degen MSA-A -severe ANS dysfunction LBD-dementia+early PD AD-late stage parkinsonism
PD-secondary
Dmg basal ganglia or substantia nigra
- acute
- symmetric
Non-Basal Ganglia PD imitators
NPH, hypothyroid, ankylosing spondylitis, Rheum Dz
Idiopathic PD vs “Parkinsonism”
Idiopathic PD:
*prominent resting tremor, *assym, *levo response, *late dementia, *falls late
“Parkinsonism”: *no resting tremor, *symmetric, *poor response levo, *early dementia/falls
PD MRI- when?
no 55+
yes atypical/rapid/young pt
T2 view BG/hydrocephalus (CSF bright)
PD - TRAP
Tremor
Rigidity
Akinesia (brady)
Postural instability
PD-late: gait
gait px worse
PD-Other Sx
Drooling - tx Anticholinergics (trihexyphenidyl, benztropine)ANS - constipation, sex, seborrheic dermatitis
Dementia - late
Depression - SSRIs
Psychosis + Dyskinesias (from DA agents, can use atypical antipsychotic quetiapine)
PD RX
1 - Carbidopa/Levodopa -vs brady/rigidity (wearing off effect)
2 - DA agonists: ropinrole, pramipexole, bromocriptine, rotigotine (SFx: sleep attacks, pathologic gambling)
3 - COMT inhibitors: entacapone, tolcapone (inhibits Levo->DA in periph)
4 - MAO-B inhibitors: selegiline (inhibits metab of meperidine=cause death), rasagiline (stop brain DA breakdown-neuroprotective)(SFx: cognitive)**be careful SER Syndrome with SSRIs
5 - Anticholinergics: trihexy, benz (vs tremor and drooling)
6 - Amantadine (inc DA release, SFx confusion/hallucinations/nightmares)
7 - Sxx DBS
*do not give Rx with metoclopramide, typical antipsychotics (with block DA)
Paraspinal tenderness?
epidural abscess, hematoma, mass lesion
Bilateral medial cerebral hemispheres or brainstem - what finding makes less likely
normal mental status, normal CN exam
Sensation: relative vs absolute, “hung”
relative - diminished
absolute - gone
“hung” below lesion lvl
Ddx Polyneuropathy: cord compression, myelitis, SC AVM, SC tumor
Cord compression: by bone, tumor, inf, hemorrhage pain
Myelitis (transverse myelitis-TM): inflam myelopathy, *hrs to days, etio-post inf TM (bacteria/virus/lupus/sarcoid)
SC AVM: bleed, compress, shunt blood
SC Tumor: intramedullary (in SC), extramedullary (meningioma/NF), extradural (bony met), intradural (low-grade: astrocytoma, ependymoma, hemangioblastoma)
Cervical synringomyelia
-w/cong brainstem anomalies, SC trauma, SC tumors.
-vs ant horn cells, ant white commissure, lateral columns: 1-hand weakness, atrophy
2-cape-distribution pinprick+temp loss
3-spastic paraparesis
Neurosyphilis
-tabes dorsalis
-posterior columns:
1 - loss vibration/proprioception
B12
- myelopathy, wk-mo
- Sx like HIV vacuolar myelopathy
- posterior columns, lateral corticospinal tract: dec vibration/proprio, spastic parapareis
Anterior SC infarction
- (ant bc posterior has 2 vessels)
- 2/3 cord
- lateral columns, spinothalamic tracts: spastic paraparesis, loss pain/temp
- Etio: trauma, dissecting aortic aneurysm, hypotensive crisis
HTLV-1
T-cell leukemia/T-lymphoma retrovirus
- inf of SC
- chronic progressive demyelinating inflam myelopathy
- cortico-spinal tracts of thoracic cord: bilateral LE weakness and spasticity
Brown-Sequard Syndrome
- SC hemisection
- posterior columns, lateral corticospinal, spino-thalamic: weakness and sensory lvl to vibration & proprio ipsilateral below lesion, pain/temp contralateral below lesion
SC eval: (4)
1 - xray (bone)
2 - MRI cervical/upper thoracic (SC, CSF, bony strxs)
3 - labs
4 - LP
SC with meningioma - Mgmt
- irreversible dmg after 24hrs
- IV Cytoxan
- Emergent neuroSxx consult = resect mass, decompression of SC
- Cx: autonomic hyperreflexia C/T cord lesions (stim excessive SNS activation- inc BP, inc HR, sweat, flush), Neurogenic bladder, Neuropathic pain
HTN Due to sleep apnea - where localize?
hypothalamus
OSA triad
daytime sleepiness, obese, HTN
HF in OSA?
right HF, repetitive anoxic insult to myocardium during sleep
Ddx Daytime Sleepiness
- Insufficient sleep
- Toxic-metabolic abn (Rx, electrolyte, inf, hypothyroid)
- sleep apnea: central and obstruct
- Narcolepsy-cataplexy/other
- RLS (85% pt have periodic limb mvmt)
- Periodic limb mvmt Ds
- Cardiac rhythm Ds
- Depression
Eval Daytime Sleepiness: (3)
labs - CBC, chemistries, TFTs (polycythemia?)
- polysomnography
- TTE
RDI/Apnea-Hypopnea Index 9AHI)
RDI > 5 is abn
sum of both apneas/hr
Apnea (2 types)
central - cessation of respiratory effort
obstructive - respiratory effort continues but airflow is obstructed
(loss oxygen > 10 sec)
OSA can cause transient central sleep apnea if dec oxygen and inc CO2 –> transient BS dysfcn
OSA -NS
impaired oropharyngeal dilatation during sleep
- inc SNS activity = acute inc BP, tachycardia
- cyclic PSNS = bradyarrhythmias
- over time: chronic nocturnal hypoxemia nd hypercapnia –> cHTN and arrhythmias
OSA - Apnea Cycle
Onset of sleep
Airway obstruction
Apnea (cessation of breathing):
Hypoxia & apnea - results in bradycardia early in the cycle
Hypercapnia & hypoxia - trigger sympathetic activation, HTN, tachycardia, & other arrhythmias late in the cycle
Hypercapnia - triggers ventilatory effort. These efforts, although ineffective, cause changes in intrathoracic pressure that affect BP and cardiac output
Following the apnea cycle - marked in sympathetic activity results in bradycardia
Arousal
Breathing resumes but sleep architecture is disturbed
Narcolepsy - findings
- nrm polysomnography, abn multiple sleep latency testing (MSLT)
- 1st degree relatives/HLA
- dec hypocretins/orexins: hypothal NTs
- inc incident sleep apnea, periodic limb movements
Narcolepsy - tetrad and tx
1 - Narco appears
2 - Cataplexy 70%
3 - Sleep paralysis
4 - Hypnagogic Hallucinations (visual, auditory, tactile)
Tx:
Narco - naps, stimulants
Cataplexy - TCAs, SSRIs
subhyaloid hemorrhages
preretinal (subhyaloid) hemorrhages - assoc w/sx: N/V, acute headache, lethargy…suggest inc ICP
Ddx Sudden Onset, Severe Headache
SAH, Intracerebral hemorrhage (inc ICP, esp when extends into ventricular system), subdural hematoma, meningitis, migraine
Acute severe headache - w/u path
1 - get CT-, is it + for SAH?
2 - yes: get cerebral angiogram (look for other aneurysms)
3 - no: get LP (RBCs in 2hr, breakdown 4-6 and see for 2 wks. yellow=bili. xanthrochromia)
SAH CT- review (4) areas
fissures, sulci, ventricles, cisterns
(interhemispheric fissure, suprasellar cistern, sylvian fissures, lateral ventricles)
*CSF is dark, blood will show up bright
Brain MRA and CT Angio common aneurysm locations
1 - ACA (40%)
2 - PCA (30%)
3 - MCA (20%)
4 - Basilar A (10%)
Risk Factors for SAH
ADPKD Fibromuscular dysplasia AVM CT Ds Aortic Coarc Cigarettes Fhx
sentinel headache/bleed
minor blood leakage from an aneurysm –SAH occurs hrs to mo’s later
CN 3 and SAH
- exits midbrain anteriorly -> cavernous sinus -> orbit
* PCA aneurysm = compresses CN3 and assoc PSNS fibers –> CN3 palsy + dilated, nonreactive pupil
SAH Cx Mgmt:
1 - Rebleed: Clip/Coil
2 - Vasospasm: nimodipine
3 - Seizures: fosphenytoin prophylaxis
4 - Hyponatremia(SIADH): avoid fluid restriction
5 - Hydrocephalus: shunt
6 - Cardiac arrhythmia/MI (because catecholamines): ECG, NO anticoag
SAH - Mgmt Vasospasm and Delayed Cerebral Ischemia (DCI)
-Oral nimodipine
-Have a constant transcranial doppler running-checks arteries for vasospasm
-Triple-H Therapy (in order):
1 - Hypervolume: IV NS
2 - Hemodilution: albumin
3 - HTN: DA
-Triple-H fails: Go to Intra-arterial therapy:
Angioplasty, papaverine, nicardipine
Asymptomatic aneurysms: when intervention?
- watch if <7mm with serial MRI/MRA
- >7mm = intervention
Ddx Vesicles Under Breast
HSZ, Candida albicans, Monoradiculopathy (dmg to nerve root): DM (nerve-root ischemia), cMeningitis (nerve root inflammation), Osteophyte/Tumor (nerve root compression)
HZV + Herpetic Neuralgia Mgmt
1 - most pts: oral antiviral +/- prednisone (Acyclovir, Valcyclovir, Famcyclovir)
2- ImC pts: IV antivirals (Acyclovir, Foscarnet)
Neuropathic Pain defined and Mgmt
Def: dmg to central or peripheral nerve fibers. Responds poorly to pain Tx. Leads to disability. “burning, stabbing, electric shock”
PO Rx: Antidepressents (TCAs, other), Antiepileptic drugs,
gabapentin/carbamazepine, topical capsaicin, lidocaine analgesic patch
Sxx: Dorsal root entry zone lesioning, epidural steroid injections, nerve blocks
HZV vaccine
Zostavx, 60+, ImmunoCOMPETENT
Other neuropathic pain syndromes: Trigeminal neuralgia, Chronic polyneuropathy (DM), Thalamic pain syndrome
Trigeminal neuralgia - unilateral face pain: triggered by move/touch, relieved by carbamazepine, idiopathic
Thalamic pain syndrome: 2-4 wks after thalamic stroke* –develops same area as impacted by stroke
Basilar Skull Fx Signs:
Racoon sign - periorbital hematoma
Battle sign - postauricular hematoma
CSF rhinorrhea - CSF leak from nose
CSF otorrhea - CSF leak from ear
Levels of consciousness
Alert - awake/attentive
Lethargic
Stuporous
Comatose - not arousable
Lesions localization:
R homonymous hemianopsia
R facial weakness
R homonymous hemianopsia - L temporoparietal or occipital cortex
R facial weakness - L cerebral hemisphere (CS tract) or *R pons (R facial nerve nucleus)
Ddx SDH Sx
SDH, Epidural hematoma, Cerebral contusion, Intracerebral hemorrhage, Ischemic stroke, Mass lesion
SDH/EDH - CT and MRI evaluation
CT:
acute = bright/hyperdense
subacute = isodense (same as brain tissue)
chronic = dark/hypodense
MRI:
T1 - acute = bright
T2 FLAIR - subacute = bright
SDH - MGMT
1 - make coagulable state: stop warfarin (ASA till cleared by neurosxx), FFP, give vit K
2 - Sxx: neurosxx evacuation
DDx Previously healthy man, found confused
cerebral stroke with aphasia, brain tumor, seizure and postictal state, toxic-metabolic encephalopathy, meningitis
Acute bicerebral dysfunction w/ dec consciousness and attention = ? (2)
delirium or acute confusional state
Delirium vs Dementia vs Aphasia
Delirium - acute, change in consciousness, agitation/autonomic hyperactivity (tachy-cardia/pnea). Pt does and says strange things
Dementia - chronic, no change in consciousness
Aphasia - not confused, does not do strange things, says strange things, dominant hemisphere findings
global aphasia
broca + Wernicke
expressive vs receptive
expressive = motor = anterior receptive = sensory = posterior
all aphasias
dysnomia - difficulty naming objects (*first test if pt “confused” or abn speech)
Delirium Ddx
Toxic-metabolic (Rx, chemistries, systemic inf/fever), meningeal Dzs (meningitis, SAH), focal brain lesions w/bicerebral dysfunction (bi-thalamus ischemic strokes, cerebral vein thrombosis, PML, herpes encephalitis, SDH, complex-partial seizures)
Delirium Eval
1 - CT
2 - Labs: chemistries (calcium), CBC, tox
3 - LP
Tx delirium secondary to hypercalcemia (lung CA)
1 - IV NS (dilution)
2 - Loop diuretics
3 - Bisphosphonates (pamidronate) - inhibit osteoclast activity
Binocular diplopia
-double vision resolves when one eye is closed
-due to weakness of extraocular muscle
1 - horizontal diplopia: medial or lateral rectus weakness (medial rectus weakness CN3 compression by aneurysm or uncal herniation. Lateral rectus weakness from CN6 compression against bony strxs due to inc ICP
-“false localizing sign”
Transient visual obscurations (TVO)
-bilateral visual loss (seconds) –> inc ICP transmitted along the optic nerve sheath
Cushing’s Response to inc intracranial P:
HTN, bradycardia, irregular respirations
Cheyne-Stokes respirations
variable respiratory rate associated with apnea
-etiology: maybe bilateral deep brain lesions
CN3 Palsies +/- dilated, unresponsive pupil
CN 3 palsy (-) dilated, unresponsive pupil = infarction of the CN 3 nerve, spares overlying PSNS
CN 3 palsy (+) dilated, unresponsive pupil = right ptosis w/dil unresp pupil w/ inability to adduct the right eye on Doll’s eye maneuver ===compressive lesion
Hyperreflexia signs: clonus, Hoffmann, Babinski
- Clonus
- Hoffman sign: flicking terminal phalanx of one finger and observing forward flexion of the thumb
- Babinski sign
Glasgow Coma Scale – when bad prognosis?
- Eye opening (4-1)
- Best Motor (6-1)
- Best Verbal (5-1)
*GCS <9 poor prognosis
Abnormal Posturing - CNS damage
-any combination possible
1 - decerebrate (upper midbrain lesion by lesion or compressions of BS): arm rigidly extended/internally rotated, wrist flexed, leg extended
2 - decoritate (dmg corticospinal tract between midbrain and cortex): leg extended, arm flexed/adducted over chest
*better than decerebrate
Localize ICP, Bilateral upper midbrain
Increased intracranial pressure
Chronic progressive headache, worse upon awakening
Transient CN 6 palsies and TVOs
Bilateral upper midbrain, right > left
Decreased consciousness brainstem vs. bicerebral process
Right CN 3 palsy with dilated pupil * upper right midbrain
Left decerebrate posturing upper right midbrain
Cheyne-Stokes respirations upper midbrain
Bilateral hyperreflexia, Hoffmann, Babinski bilateral UMN
Subfalcine (cingulate) herniation
medial frontal lobe is pushed under the falx cerebri, an extension of the dura mater that separates the cerebral hemispheres.
Central (transtentorial) herniation
structures that lie above the tentorium cerebelli are squeezed downward, compressing the brainstem. The tentorium cerebelli is an extension of the dura that separates the cerebellum from the occipital lobes. The anterior border of the tentorium cerebelli forms a large oval opening, the incisura tentorii, which surrounds the midbrain as the brainstem descends through this opening.
Uncal (transtentorial) herniation
most medial part of the temporal lobe, the uncus, is squeezed through the incisura tentorii, resulting in unilateral midbrain compression. Cranial nerve 3 and its associated parasympathetic fibers exit the midbrain anteriorly on their way to the orbit and are often compressed, resulting in a 3rd nerve palsy with a dilated, unresponsive pupil.
Herniation of the cerebellar tonsils
brainstem is pushed downward through the foramen magnum. Compression of the medulla results in respiratory and cardiac arrest and is usually fatal.
Monro-Kellie Hypothesis/Doctrine
- rigid container = cranium, vertebral canal, dura
- 3 intracranial components: brain, blood, CSF
- inc vol of components inc ICP… inc one component = dec other 2 components
Ddx for inc ICP and bilateral upper midbrain R>L
- Tumor (primary, met) Px: hemorrhage or seizure
- AVM (mature capillary bed fails to form. direct flow A to V) Px: hemorrhage, seizure, headache, neuro deficit
- Abscess. Px: fever, headache, lethargy, seizure, neuro def
- Hemorrhage
- Infarction (cerebral infarction, cause brain herniation, cerebral edema peaks 48-72 hrs)
CT with mets and herniation concern
- see ring-enhancing masses
- diffuse bilateral hypodense regions = vasogenic edema -> uncal herniation, obliteration of ventricles and perimesenscephalic cisterns
Mgmt: CA mets, vasogenic edema, uncal herniation (4 steps)
vs traumatic brain injury (do Hypothermia)
1 - Elevate head 30 deg (optimize venous drainage, maintain cerebral perfusion -> patency jugular veins)
2 - Intubate and hyperventilate (pCO2 28-32 = vasoconstriction intracerebral vessels -> dec cerebral BF, lower ICP (fast pCO2 reduction =ischemic injury to brain))
3 - Mannitol IV push 100 g (+bladder cath) (osmostic diuretic moves brain water to capillaries and reduce ICP *give IVFH)
4 - Dexamethasone (dec vasogenic edema by stop BBB breach inflame)
