USMLE Neuro Flashcards
Critical illness myopathy
Critical illness myopathy is characterized by an elevated serum creatine kinase (CK) level. Predisposing factors include the patient’s prolonged ICU stay, use of corticosteroids and neuromuscular junction–blocking agents, and hyperglycemia.
Meningitis
Age 2-50
Age > 50
Neurosurgery shunt
Immunocompromised
Penetrating trauma
- Age 2-50 Vanc + Ceftraisone
- Age > 50 Vanc + ceftriaxone
- Neurosurgery shunt : Vanc + cefepime
- Immunocompromised : Vanc + cefepime + ampicillin
- Penetrating trauma: Vanc + Cefepime
Cefepime alternative : ceftazidime or meropenem
ampicillin alternative: Bactrim for listeria
Asian patients Siezure meds
In an Asian patient with the HLA-B*1502 allele, the risk of Stevens-Johnson syndrome is increased with exposure to carbamazepine, lamotrigine, oxcarbazepine, and phenytoin but not with exposure to levetiracetam.
Bell’s palsy
Acute perpheral BP is due to HSV
Start patient on Steriods and Valacyclovir
Brain stem level of medulla oblongata
Brainstem at the level of midbrian
Posterior limb of internal capsule
numbness of ipsilateral face / cotralateral body, horners syndrom , gag and cough refles, nystagmus, ipsilateral ataxiawithout any motor symptoms
CNIII nerve palsey, horners, tongue intact, left sided hemiplegia left facial droop
Posterior limb of internal capsule / contralateral weakness numbness with or without facial weakness.
Capgras syndrome
delusional misidentification syndrome associated with lesions of the right hemisphere, have the delusion of imposters, believing that important and familiar persons in their lives have been replaced by fraudulent doubles.
Reduplicative paramnesia, in many ways the opposite of Capgras syndrome, is a delusion of familiarity in which a patient in a hospital bed insists that he or she is at home.
Clinical Uses of Amantadine
- Sever Tramatic brain injury
- Fatigue related to MS
- Parkinson Dz
Celebral Amyloid Angiopathy
- Second most common cause of Intercrainial bleed in > 75 yrs and older\
- in the cortical or subcortical areas usually
- patient get symptoms of stroke and siezures after that
Corticosteroid myopathy
presents with predominantly proximal weakness, preserved reflexes, a normal serum CK level, and normal or only mildly myopathic findings on electromyography (EMG).
Cryptogenic Stroke / TIA
Causes?
Up to 40 % of the ischemic strokes
- Foramen Ovale
- Paroxysmal A-Fib
- Aortic Arch Atheroma
- Vasculitis
- Lacunar infarct
- Complex migraine
Essential Tremor
Tremor with action or posture can happen to voice head, chin, legs
Tx
propranalol or primidone
features of glioblastoma multiforme seen on MRI
MRIs, glioblastoma multiforme typically has a ring-enhancing lesion with areas of central necrosis and hemorrhage.
Giant Cell arthritis
Fever / Fatigue / weight loss
Unilateral HA
JAw /arm claudication
Visual symptoms
Polymailgia rheumatica PMR
non productive cough
Aortic aneurism or dissection
Dont worry about Berney Start on Steriods then do the bx if negative then do a second Bx biatch ..
Hereditary hemorrhagic telangiectasia
or Osler Weber Rendu
- Freq epitaxis
- Multiple mucocutaneous telangiectasias
- Organ involvement (AVMs)
- First Degree relative with HHT
- Siezures
How can one reduce neurological injury in post cardiac arrest
therapeutic hypothermia induction with in 6 hrs post event and 12-24 hr maintanance
How to treat symptomatic treatments of multiple sclerosis–related fatigue.
related to muscle spasm/stiff ness
Overacitve bladder
Amantadine and modafinil are used as symptomatic treatments of multiple sclerosis–related fatigue.
Baclofen (oral or intrathecal pump), tizanidine, cyclobenzaprine, benzodiazepines, carisoprodol, botulinum toxin
Oxybutynin
HSV Encephalitis
- REpeate PCR for HSV fi first negative
- MRI most sensitive and specific
- IV acyclovir 10 mg/kg Q8H
Idiopathic intercrainial pressure (psuedotumor Cerebri)
- Sx
- Physical E
- Dx
- HA / Transient vision loss / pulsatile tinnitis
- Papilledema / prepheral vision defects / CN VI palsey
- Normal brain imaging / open pressure > 250 mmHg
Manage an unruptured cerebral aneurysm.
In the anterior cerebral circulation, the risk of rupture over 5 years is negligible until an aneurysm reaches 12 mm in diameter; in the posterior circulation, the risk of rupture increases as aneurysms become greater than 7 mm.
Cerebral vasoconstriction syndrome
Cerebrovascular imaging is used to document reversible cerebral vasoconstriction syndrome, which comprises a group of disorders characterized by recurrent thunderclap headache occurring over a few days or weeks and is associated with transient segmental cerebral vasoconstriction.
Migrain criteria
Without Aura
A. At least five attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache with at least two of the following four characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity that inhibits or prohibits daily activities
- Aggravation by walking on stairs or similar routine physical activity
D. During headache, occurrence of at least one of following symptoms:
- Nausea/vomiting
- Photophobia/phonophobia
E. Exclusion of secondary headaches
With Aura
A. At least two attacks fulfilling criteria B and C
B. Headache with at least three of the following four characteristics:
- One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brainstem dysfunction
- At least one aura symptom that develops gradually over more than 4 minutes, or two or more symptoms that occur in succession
- Duration
- Headache after aura with an intervening free interval
C. Exclusion of secondary headaches
- Migraine
- Tension
- Medication overuse
- paroxysmal hmicrania
- Cluster
Migraine
- Unilateral / Throbbing / N/V photophobia
Tension
- B/L and non throbbing / gradual onset / Mild to moderate without pericranial muscle tendernss
Medication overuse
- worsen with daily use of medication
Paroxysmal hemicarania
- Unilateral throbbing / ipsilateral autonomic symptoms / responds well to indomethacin
Cluster
- Unilateral in trigeminal region / orbital supraorbital or temporal pain / ipsilateral autonomic symptoms
Lithium intoxication
Malignant hyperthermia
Neuroleptic malignant syndrome
Serotonin syndrome
- Lithium intoxication: does not produce hyperthermia
- Malignant hyperthermia :inherited skeletal muscle disorder = a hypermetabolic state precipitated by exposure halothane, isoflurane, enflurane, desflurane, and sevoflurane
- Neuroleptic malignant syndrome :exposure to dopamine receptor antagonists and is characterized by muscle rigidity, hyperthermia, cognitive changes, autonomic instability
- Serotonin syndrome:high fever, muscle rigidity, and cognitive changes
Migranes and Kidney stone which drug to avoid
Amitriptyline
Propranolol
Topiramate
Valproic acid
topiramate and zonisamide are associated with an increased risk of calcium-containing kidney stones and thus should be avoided in patients with a history of such stones.
Meds to prevent of cluster headache
Verapamil and oral corticosteroids are effective therapies for the prevention of cluster headache but are not indicated for acute headache treatment.
Natalizumab is a disease-modifying therapy for multiple sclerosis that has been associated
Natalizumab is a disease-modifying therapy for multiple sclerosis that has been associated with an approximately 1:1000 risk of central nervous system infection with the JC virus, resulting in progressive multifocal leukoencephalopathy.
and liver toxicity
Neuro Drugs
- Dopamin percursors
- Dopamin agonist
- COMT inhibitors
- Anticholonergics
- **MAO inhib - **
- Levidopa/carbidopa-dizziness,HA, Aggitation
- pramipexole/Ropinirole/Bromocriptine - Orthostatic hypotension
- Tolcapone/Entacapone - Orthostatic hypotension
- Benzotropine - drymout, urinary retention
- Amantadine - Livedo reticularis , ankel edema
- Selegiline - N / HA
Foramen Ovale
What % in population?
How to treat cryptogenic strokes / TIA with this?
2025% at autopsy
Anti platlet therapy and Statin
normal pressure hydrocephalus: Triad
The diagnosis of normal pressure hydrocephalus, which is characterized by the triad of gait impairment, urinary incontinence, and cognitive change, can be suggested by findings on a brain MRI.
post tPA
ASA
nicardipine
cryoprecipitate
Nitropruside
- ASA hold for 24 hrs after tPA treatment
- Nicardipine use if bp >180/105
- cryoprecipitate and platelet infusion if there is evidence of bleeding
- ntiropruside is CI in stroke patients
POST TPA
CI
Avoid ASA for 24 hrs
Start heparin after CT of head r/o bleed after 24 hrs
Do not feed for 24 hrs
Keep BP < 180 SBP that is.
Pregnancy & Epilepsy - what to use
Carbamazepine is an appropriate antiepileptic drug for women of reproductive age, especially those who are actively pursuing pregnancy.
Resting temor
How to treat?
Trihexyphenidyl is used when carbidopa/levodopa is not helpful
Amantadine is indicated in treating Levodopa induced dyskenesias and rigidity in patients
Deep Brain Stimulation When therapy fails this is recommended for resting tremor
Apnea test
The apnea test is considered positive for brain death if the increase in arterial PCO2 is greater than 20 mm Hg (2.7 kPa) without observed respirations.
Role of IV heparin or subq LMWH in acute stroke
Both are inappropriate - clinical trials have shown no benefit of acute anticoagulation for acute stroke prevention, even in patients with presumed embolic stroke.
Anterior Mediastinal tumors
4 most common ones
Thymoma
Teratoma
thryoid goiter
Terrible Lymphoma
Thymomas are associated with Myasthenia Gravis
Schwannomas manifestations
Schwannomas are benign tumors of the nerve sheath that make up 8% of primary CNS tumors. They are extraparenchymal lesions that typically affect cranial nerve VIII and manifest as hearing loss or tinnitus.
Seizure treatment:
Antiepileptic drugs on ly if patient has had >=2 seizures seprated by 24 hrs and are unprovoked
Valporic acid is not prefered in yyoung women.
Could give lamotrigine / Levetiracetam
Short acting Carbidopa / Levodopa
Cause Extrapryramidal symptoms
change to long acting
- Site of hemorrhage
- Basal ganglia
- Cerebellum
- Thalamus
- Cerebral lobe
- Pons
Site of hemorrhage
Basal ganglia
- Hemiplegia / hemisensory loss
- Homonymous hemianopsia, Gaze palsy
- Stupor and coma
Cerebellum
- Neck stiffness
- Facial weakness
- Usually no hemiparesis
- Stupor or coma from brain stem herniation / look for postural extension/flexion
Thalamus
- Heiparesis, hemisensory
- upgased palsy
- eyes deviated towards hemiparesis
Cerebral lobe
- Siezures
- Contralateral homonymous hemianopsia (occipital)
- Contralater plegia/paresis(frontal lobe)
- Contralateral heiparesis (partial lob)
- Eyes diviated from the hemiparesis
Pons
- Pinpoint reactive pupils
- Deep coma total paralysis with in minutes oafter hemorrhage
- interferon SE
- Glatiramer SE
- Flulike symptoms and depression
- Skin lipoatrophy
temporal lobe epilepsy
uvenile myoclonic epilepsy
convulsive seizure with or without an aura can be the initial presentation of temporal lobe epilepsy
Patients with juvenile myoclonic epilepsy have infrequent convulsive seizures often provoked by alcohol or sleep deprivation and can also experience absence seizures and myoclonic seizures that are worse in the morning.
The eligibility criteria rtPA
Minor or rapidly improving symptoms
Seizure at stroke onset
Other stroke or trauma within 3 months
Major surgery within the last 14 days
History of intracerebral hemorrhage
Sustained blood pressure ≥185/110 mm Hg
Aggressive drug therapy needed to control blood pressure
Suspicion of subarachnoid hemorrhage
Arterial puncture at a noncompressible site within 7 days
Heparin received within the last 48 hours and PTT elevated
INR >1.7
Platelet count
Plasma glucose level 400 mg/dL (22.2 mmol/L)
- Acute angel closure glaucoma
- Central retinal artery occlusion
- nonarteritic anterior ischemic optic neuropathy
- Optic neuritis
- Retinal detachment
Acute angel closure glaucoma
- Vision loss with sever eyepaind N/V, seeing Halos
Central retinal artery occlusion
- acute painless, sever vision loss in one eye no pain with movement
Nonarteritic anterior ischemic optic neuropathy
- painless vision loss, > 50, optic nerve swelling and papiledema
Optic neuritis
Retinal detachment
The most appropriate treatment of Bell palsy is —————, preferably administered within the first 72 hours
prednisone Oral / (Acyclovir no good evidence for it)
IV methyprednisone is good for MS not bell palsy
transient ischemic attacks whose ABCD2 scores
3 or mor admit with in 72 hrs
one point for an Age of 60 years or greater
one point for a Blood pressure of 140/90 mm Hg or greater
two points for the Clinical symptom of hemiparesis
two points for Duration of 60 minutes or greater
one point for the presence of Diabetes mellitus
Transverse myelitis
- best available evidence supports the use of plasmapheresis and/or cyclophosphamide as rescue treatment for corticosteroid-refractory transverse myelitis.
- T2-weighted MRI eveals hyperintensity in the spine, which enhances with administration of gadolinium.
Treat chronic paroxysmal hemicrania.
Chronic paroxysmal hemicrania responds dramatically and specifically to indomethacin.
Chronic paroxysmal hemicrania is a syndrome related to cluster headache that differs in frequency and duration
Treatment of MS
In a patient with acute optic neuritis and MRI lesions suggestive of demyelination, treatment with intravenous methylprednisolone and disease-modifying agents, such as glatiramer acetate or interferon-beta agents, decreases the short-term risk of multiple sclerosis.
What is next for a young patient with convulsive syncope.
In a young patient with convulsive syncope, further testing with electroencephalography or MRI is typically unnecessary.
Which one is better in elderly
- Carbamazepine
- Lamotrigine
- Oxcarbazepine
- Phenytoin
Lamotrigine
