UW 1 Flashcards
central cord syndrome - etiology, definition
hyper-extension injuries in elderly with pre-existing degenerative changes in cervical spine
- damage in corticospinal tracts and decussating fibers of the lateral spinothalamic –> weakness in upper extremeties, maybe loss of pain and Q
hypertensive encephalopathy - acute hemorrhage on CT
no
MCC of intracerebral hemorrhage in children
cerebral AV malforamation
sub hemorrhage - complications
- rebleeding (1st 24h)
- vasospam (after 3 days)
- hydrocephalus/ increased ICP
- seizures
- hyponatremia (SIADH)
sub hemorrhage - treatment
angiographic procedure to stabilize anerysm by coilling +/or stenting (endovascular therapy)
2. nimodipine
clinical features of corenal abrasion - etiology
- trauma (eg. fingernails, paws, or foregin bod, wood, glass, paper) lodging under the lid
- contact lens
- spontaneous (no obvious foregin body or injury)
clinical features of corneal abrasion - clinical presentation
- severe eye pain due to trigeminal nerver sensory innervation (excpet in patients with V dysfunction due to tumor, trauma, prior VZV)
- possible sensation of foregin body on the eye
- photophobia with reluctance to open
clinical features of corenal abrashion - evaluation
- penlight test to document papillary function + inspect for foregin body
- visual acuity (referral if decreased)
- fluorescein examination after above test to show staining defect
trigeminal neuralgia bilaterally
MS
hemorrhagic stroke after ischemic stroke - when
within 48h –> emergency head CT
atrophy of lenticular nucleus - disease?
wilson
CN III - area of parasympathetic vs motor fibers
parasym: out
motor: central
craniopharyngioma - age
mc children but 50% in adults
sellar masses - types
- benign tumors: pituitary (MC), cranipharyngioma, meningioma, piticytoma (low grade glioma)
- malignant:
- 1ry (germ cell, chordoma, lymphoma,),
- metastatic (eg. lung, breast)
MS - LP (useful?)
only if diagnosis from clinical and MRI is not clear
MS exacerbation - plasma exchange?
only if does not response to steroids
non exertional stroke
affects individuals at the extremes of age incapable of obtaining adequate fluids and removing themselves from a hot environment
heat stroke - complications
rhabdomyolysis, renal failure, acute resp distress syndrome, DIC
idiopathic intracranial HTN - diagnosis
MRI +/- MRV
- LP (CSF presure mre than 250)
RF of stroke (most potent?)
- stroke (most potent)
- hypercholesterolemia
- DM
- smoking
- sedentary lifestyle
Argyl roberston
normal react in accommodation but not in light
neurosyhilis develops more rapidly if / treatmetn
HIV (+)
- 10-14 wks penicillin (IV)
dellirium - first step
focused history, physical evaluation, pulse oxymetry ,review of all medication, CBC, serum electrolytes, urinalysis
thearpy of ischemic stroke
- within 3-45h: alteplase
- non in antiplatelets: aspirin
- on aspirin: aspirin + dipyrodamole or clopidogrel
- with AF: long term anticoagulation
- with large ACA occlusion within 24 hours of symptom: mechanical thrombectomy (regardless if received alteplase) –> then aspirin
- with intracranial large artery atheroscleorisis: aspirin + clopidogrel for 90 d –> then aspirin
which antiplatelet can prevent early stroke after a stroke
only aspirin
serious bleeding (eg. intracerebral) due to excess anticoagulation with wafarin - management
stop the drug
- IV vit k
- prothrombin complex concentrate (fresh frozen plasm for 2nd line)
ototoxicity of aminoglycoside
damaging of the cochlear cells and some aminoglycosdes (esp gentamycin) can also damage motion sensitive hair cells in the inner ear to cause selective vsetibular injury (vestibulopathy) without significant ototoxicity
- oscillopsia: sensation of object moving around in the visual field when looking in any direction
cauda equina syndrome vs conus medullaris syndrome
- cauda: bilateral, severe radicular pain, saddle hypo/anesthesia, assymetric motro weakness, hyporeflexia, areflexia, late-onset bowel + bladderdysfunction
- conus: sudden onset severe back pain, perianal hypo/anesthesia/ symmetric motor weakness, hyperreflexia, early bowel + bladder dysfunction
tick-borne paralysis
rapidly progressive ascending paralysis (may be assymetrical), absence of fever sensory abnormalities, normal CSF examination –> ticks must feed 4-7 days and then are typically found on patients after menticulous searching –> removal –> spontaneous improvement
levidopa - involuntarily movements
as a SE after 10 years
TIA vs new MS episode
MS lasts for days to weeks
TIA –> less than 24h
initial treatment of TIA
modifying risk factors: aspirin ,statin,control BP
carvenous sinus thrombosis
facial/ophthalmic venous system is valveless –> uncontrolled infection of the skin can results in cavernous sinus thrombosis –> severe headache, bilateral periorbital edema, CN 3,4,5,6 defects
amaurosis fumax - description
curtain descending
Trihexyphenidyl - mechanism of action / clinical use
anticholinergic
- treatment of Parkinosn, generaly in tyounger patients where tremor is the 1ry symptom
aspirin after alteplase
wait 24 hours
lacunar stroke - mechanism
due to microatheroma formation feand lipohyalinosis in the small penetrating arteries of the brain –> they only affect the internal capsule and result in pure motor hemiparesis
lacunar stroke - RFs
hypertension, hyperlipidema, DM, smoking
Myasthenia Gravis - women vs men
women: 20-30 years old
men: 60-80
Myasthenia gravis - causes of exacerbation
- infection
2, surgery esp thymectomy) - pregannta/childbirth
medications:
medications that can cause exacerbation of Myasthenia gravis
- antibiotics: quinolones, aminoglycosides
- anesthetics
- cardiac meication (beta blokcets, procainaminde)
- otehr: MgSO4, penicillamine
- tapering of immunosuppressive medication
Myasthenia gravis - diagnosis
- beside: edrophonium (Tensilon test), ice pack test
- Acetylocholine receptor antibodies (higly specific
- Ct scan : thymoma
Myasthenia gravis - treatment
- ACEi
- immunotherapu
- thymectomy
brain metastasis - management
- surgical resection is recommended for solitary brain metastasis in patients with a good performance status + stable intracranial disease
- if multiple bran metastases –> whole brain radiation
spastic gait is seen in
UMN lesions (ALS)
Parkinson - gait
hypokinetic gait: general slowing of all motor activity –> stooped posture and walk in series of short, accelerating steps (shuffling gait)
spinal epidural abscess - epidemiology
- S. aureus (65%)
- inoculating sources (distal infection, spinal procedure, IV drugs)
spinal epidural abscess - manifestation
classic triad
- fever (50%)
- focalsevere back pain
- Neurologic findings
essential tremor - 2 other characteristics
- bilateral on hands, usually no legs
- isolated head tremor without dystonia
physiologic tremor
low amplitude (10-12 Hz) not visible under normal conditions
- acute onset with increased sympathetic activity (eg. drugs, hyperthyroidism, anxiety, caffeine)
- usually worse with movement + can involve the face + extremities
- postural tremor (eg. outstretched hands)
aortic valve endocarditis - surgery?
- significant valvular dysfunction –> HF
- persitent or difficult to treat meidically
- reccurent septic embolization
when there is no point for endarterectomy
- 100% occlusion
2. less than 5 years of life expectancy
DDX of myopathy and CK/ESR
- Glucocortcoid: both normal
- Polymyalgia rheumatica: increased ESR
- infl: boh iincreased
- statin: increased CK
- Hypothyroid: increaesd CK
type of alzheimer memory loss
ealry insidious short term memory loss, language decificts, spatial disoreientation, later personality changes
torticollis?
common form of focal dystonia involving the SCM muscle
-iodiopathic or very often medication related (typical antipsychotics, metoclopramide, prochlorperazine)
heart acceleration after atropine administration in dead pearson
no (no vagus)
restless leg syndrome - diagnostic criteria
urge to move the legs and:
- unpleasant sensation in the legs or tother bodyparts (eg. arms) that begin/worsen during inactivity (lying down, sitting)
- unpleasant sensation in the legs that are releived by movement and worsen or occur only at evening/night
- not explained by other disorder
restless legs syndrome - 2ry causes
- iron def anemia
- uremia
- DM
- MS, Parkinson
- Pregnancy
- Drugs
restless leg syndrome - treatment
mild intermittent symptoms: iron, supportive measures (massage etc), avoid aggravating factors (sleeg. sleep deprivation
- persistent/moderate to sever: 1st line is dopamine agonists (pramiperxole), alternate is alpha - 2 delta Ca2+ channel ligants
how to confirm diagnosis of parkinson
physical examination
2/3: resting tremor, rigidity, bradykinesia
intracerebrral vs sub hemorrhage regarding manifestation
- intracerebral focal symptoms appear early followed by features of increased ICP (vomiting etc), history of un
- sub: severe headache meningeal irritation, focal deficits uncommon
alzheimer - where is the atrophy
temporal and parietal lobe atrophy, most prominent in the medial temporal lobes and hippocampus
alcoholic cerebellar degeneratio - epidimiology
after 10 years of heavy alcohol
- degeneration of Purkinje cells (cerebellar vermis)
alcoholic cerebellar degeneration - manifestations
- develops over weeks to months
- wide based gait
- in-coordination in legs
- cognition usually intact
alcoholic cerebella degeneration - diagnosis
clinical: impaired tandem walking heel-knee-shin BUT PRESERVED FINGER NOSE
- CT/MRI: cerebellar atrophy
alcoholic cerebellar degeneration - treatment
- alcohol cessation
- nutritional supplements
- ambulatory assistance devices (eg. walker)
gait disorders - types
- cerebellar
- gait apraxia (frontal gait
- Parkinsonian
- Steppage
- Vestibular
cerebellar gait - description / associated signs / causes
description: ataxic, staggering, wide based
- dysdiadochokinesia, dysmetria, nystagmus, Romberg sign
- Cerebellar degeneration, stroke, drug/alcohol intoxication, Vit B12 def
gait apraxia (frontal gaint) - description, associated signs, causes
magnetic (freezing): start + turtn hesitation
- demential incontinence, frontal lobe signs
causes: frontal lobe degeneration, normal pressure hydrocephalus
parkisonian - description, associated, causes
- short steps, shuffling
- bradykinesia, resting tremor, postural instability, decreased arm swing
- Parkison
steppage - description, associated, causes
- Footdrop, excessive hip + knee flexion while walking, slapping quality, falls
- distal sensory + weakness
- motor nephropathy
vestibular - description, associated, causes
- unsteady, falling to one side
- normal sensation, reflexes + motor strength, nausea, vertigo
- acute labyrinthitis, Meniere
intracerebelar hemor - characteristics
history of uncontrolled hypertensionm coagulopathy, ilicit drugs
- symptomes progress over mins to hours
- focal neurologic symptoms appear ealy, followed by featrues of increased intracranial pressure (eg. vomiting, headache …)
spontaneous sub hemorrhage - characteristics
bleeding from arterial saccular (berry) or AV malformation
- severe headache at onset
- menningeal irritation
- focal deficits are uncommon
Cancer pain management
- mild –> nonopioids (acetaminophen, NSAID)
- moderate –> weak opioid +/- nonopioids (codeine, hydrocodone, tramadol
- severe –> short acting opioids (morphine, hydromorphine) –> calculate total daily dose and convert it to long acting formulation (fentanyl patch, oxycodone) plus short acting opiods for breakthrough pain
other than campylobacter organisms that are associated with Guillain barre
HSV, Mycoplasma, Hemophilus infl
Wernicke encephalopathy - associated conditions
- chronic alcoholism (MC)
- malnutrition (anorexia nervosa)
- hyperemesis gravidarum
wernicke encephalopathy - clinical features
- encephalopathy
- oculomotor dysfunction (eg. horizontal, nystagmus, bilateral abducens palsy)
- postural + gait ataxia
wernicke encephalopathy - treatment
IV thiamine followed by glucose infusion
positive antibodies againste aChe receptor - next step
chest CT
exertional heat stroke - RF
- strenuous activity durin hot + humid weather
- dehydration
- poor acclimatization
- lack of physical fitnesss
- obesity
- medications: anticholinergics, antihistamines, phenothiazines, tricyiclics
exertional heat stroke - clinical manifestation
core Q more than 40 immediately after collapse AND
- CNS dysfunction
- additional organ or tissue damage
exertional heat stroke - management
- rapid cooling: ice immersion preferred, can consider high flow cool water dousing, ice/wet rotation, evaporateive cooling
- fluid resuscitation
- electrolyte corrction
- management of end organ complications
- no role of antipyretic therapy
foodborne botulism - pathogenesis
C. botiulinum toxin inhibirs presenaptic Ace release at NMJ
foodborne botulism - sources
improperly canned foods (fruits, vegetables
- aged seafood (cured fish
foodborne botulism - manifestation
acute onset within 36h of ingestion
- bilateral cranial neuropathies: Blurred visision, diplopia, facial weakness, dysarthria, dysphagia
- symmetric descending muscle weakness
- diaphragmatic weaknes with resp failure
foodborne botulism - treament
equine serum heptavalent botulinum antitoxin
foodborne botulism - diagnosis
serum analyssis for toxin
CSF - WBC count in normal, bacterial meningitis, TB, viral, guillain barre
normal: 0-5
bacterial: more than 1000
TB: 100-500
viral: 10-5000
guillain barre: 0-5
CSF - GLUCOSE count in normal, bacterial meningitis, TB, viral, guillain barre
normal: 40-70
bacterial: less 40
TB: less 45
viral: 40-70
guillain barre: 40-70
CSF - PROTEIN count in normal, bacterial meningitis, TB, viral, guillain barre
normal: under 40
bacterial: more than 250
TB: 100-500
viral: less than 150
guillain barre: 45-1000
myasthenic crisis - precipitating factors
- infection or surgery
- pregnancy or childbirth
- tapering immunosuppresive drigs
- medication
myasthenic crisis - signs/symptoms
elevated generalized + oropharyngeal weakness
- resp insufficiency/dyspnea
myasthenic crisis treatment
intubation for deteriorating resp status
- plasmapheresis or IVIG, + corticosteroids
- maybe hold temporarily ACEi to reduce airway secretions and the risk of aspiration
….. are useful for treating acute agitation in elderly patients with dementia
typical and atypical antipsychotics
stiff person syndrome
rare autoimmune disorder
- rigidity, stiffness, muscle spasms involving the axial muscles
- autonomic instability can also occur
- normal mental status
Type A vs type B adverse effect reaction
Type A: dose-dependent
Type B: unexpected, dose-independent
broca vs wewernicke vs conduction regarding associated features
broca –> right hemiparesis (face + upper limb)
wernicke –> right superior visual field defect
conduction: none
suspicion of dementia - next step
neurocognitive testing –> next –> lab tests
brain abscess - micriobiology
- S. aureus
- Viridans strep
- anaerobes
which patient are at increased ris for heart embolic strokes
AF PLUS existing structural heart disease
Common causes of vertigo
- Meniere
- Benign paroxysmal positional vertigo
- Vestibular neuritis
- Migraine
- Brainstem / cerebellar stroke
vestibular neuritis - characteristics
acute single episode that can lasts days
- often follows viral syndrome
- abnormal head thrust test
benighn paroxysmal positionalvertigo - diagnostic vs treatment maneuvers
diagnosis: Dix-Hallpike
treatment: Epley
Uhthoff phenomenon
symptoms of MS may worsen during exposure to high Q
nystagmus - lesion in lateral or medial cerebellum
medial
broad gait - lesion in lateral or medial cerebellum
medial
postoconcussive syndrome?
traumatic brain injury of any severity can lead to (few hours to days later) it
- headache, confusion, amnesia, low concentration, vertigo, mood alternation, low quality of sleep, anxiety
- resolve in weeks to months
- maybe persistent for more than 65 months
initial diagnostic workup of a 1st time seizure in an adult should include
basic blood tests (electrolytes, glucose, Ca2+, Mg2+, CBC) RENAL + LIVER), AND A TOXICOLOGY SCREEN –> IF UNPROVOKED –> FURTHER EVALUATION WITH NEUROIMAGING AND eeg
CT after a seizure - contrast or not
not
pronator drift
relative sensitive and specific sign for UMN or pyramidal tract disease affecting the upper extremities
- performed by the patient having outstretched the arms with the palms up and eyes closed –> the affected arm drifts downward and the palms pronates
types of infarct in the posterior limb of internal capsule
lacunar infract
clinical presentation with infract in the posterior limb of internal capsule
UNILATERAL motor impairment
- no sensory or cortical deficits
- no visual anomalies
urinary incontinence - infract
anterior cereb artery
another finding in idiopathic intracranial HTN
empty sella (in 70%)
acute angle glaucoma - complications
if untreated can develop permanent vision loss within 2-5h of symptom onset
eldery patients with frequent fall - think of
chronic subdural
lacunar infarct - manifestation
- absence of cortical signs (aphasia, agnosia, neglect, apraxia, hemianopia, seizure, or mental status change
- common syndromes: pure motor hemiparesis (most frequent), pure sensory, ataxic, dysarthria-clumsy hand
chemi-induced periphearal neuropathy
- symmetric distal sensory neuropathy that spreads in stocking-glove pattern
- early loss of ankle jerk reflexes, loss of pain and Q
- occasionally motor
multiple system atrophy
- Parkinsonism
- orthostatic hypotension, impotence, incontincence or other autonomic symptoms
- widespread neurological signs
antiparkinsonism drugs are ineffective
- treat with fluids, fludrocortisone, salts, a1 agonists,
Riley day syndrome or familiar dysautonomia
gross dysfunction of the autonomic nervous system with severe orthostatic hypotension. Also
symptoms of sever hypokalemia
flaccid paralysis, hyporeflexia, tetanym rhabdomyolysis, arrhythmia
cauda equina vs conus medullaris - bowel + bladder dysfunction
late in cauda
- early in conus
cauda equina vs conus medullaris - symmetric?
cauda: asymmetric
conus: symmetric
cauda equina vs conus medullaris - hypo/anesthesia?
cauda: saddle
conus: perianal
acute neuritis epidemiology
- 1ry in young women
- MS
- immune mediated demyelination
optic neuritis - manifestations
- acute, peaks at 2 wks
- monocular vision loss
- eye pain with movement
- washed out color vision
- afferent pupillary dfect
optic neuritis - diagnosis
MRI of the orbits + brain
optic neuritis - treatment
IV steroids
- 35% of cases recur
NSAID resistant pain in a previeous heroin addict
give IV morphine and close observation
neurologic findings of haemorrhage on basal ganglia
- contralateral hemiparesis + hemisensory lsss
- homonymus hemianopsia
- gaze palsy
neurologic findings of haemorrhage on cerebellum
- NO hemiparesis
- facial weakness
- ataxia + nystagus
- occipital headache + neck stiffness
neurologic findings of haemorrhage on cerebral lobe
contralateral hemiparesis + hemisensrory loss
- nonreactive miotic pupils
- upgaze palsy
- EYE deviate Torward hemiparesisis
neurologic findings of haemorrhage on pons
deep coma + total paralysis wihin minuts, pinpoint reactive pupils
neurologic findings of haemorrhage on thalamus
- contralateral hemiparesis + hemisensrory loss
- nonreacive miotic pupils
- upgaze palsy
- eye deviated TORWARD hemiparesis
Alzheimer vs frontotemporal
In Alzheimer, the personality changes are a late finding
Parkinson drugs that cause hallucinations
- Levodopa
- Entacapome
- Tolcapone
Seizures - danger of permanent damage after …. minutes
5
Retnal venous thrombosis can progress to
Ischemic form (painful)
Presbicusis also has
Tinnitus
Anterior cord syndrome
Motor, Q, pain
Brain abscess in neuro imaging
Uniform contrast enhancement
Bublar symptoms is a sign of
UMN
First step to avoid cluster headaches
Avoid precipitant factors (alcohol, physical exam)
