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