UW-Med/Neuro Flashcards
What sort of lesion does pronator drift represent and why?
UMN lesion -> Cause weakness in supination, pronator muscles become dominant
What major functions is the parietal lobe responsible for?
Sensation, perception, integration of sensory inputs
What cranial nerve is primarily affected in diabetic peripheral neuropathy and how? What results?
Ischemic injury of CN III –> Somatic fibers affected (parasympathetic left intact) –> Ptosis and down/out gaze
What results from compression of CN III?
Ptosis, down and out gaze, a fixed dilated pupil, and no accommodation reflex
What are the clinical features consist with stroke + intracerebral hemorrhage?
History of uncontrolled HTN, caogulopathy, illicit drug use (meth, cocaine)
Symptoms progress over minutes to hours
Early focal neuro sx –> followed by sx of increased ICP (vomit, bradycardia, headache)
What are the characteristics of an ischemic thalamic stroke (Dejerine-Roussy Syndrome)?
Contralateral hemianesthesia, transient hemiparesis, athetosis or ballistic movements, and Dysesthesia (thalamic pain phenomenon)
What is progressive ascending paralysis over hours to days indicative of? What are some characteristics of this type of paralysis?
Tick-borne paralysis (check body thoroughly for tick and remove)
Localized or more pronounced in 1 leg/arm
What are characteristic features of the paralysis in GBS and how do you treat this?
- Ascending symmetrical paralysis over DAYS/WEEKS
- Autonomic dysfxn (tachycardia, urinary retention, arrhythmia)
- High protein and few cells in CSF
Tx: IVIG or plasmapheresis
What are the characteristic features of Central Cord syndrome and which populations are primarily affected?
Occurs with hyperextension injuries in elderly patients with pre-existing degenerative changes (OA, spondylosis etc.)
Pronounced weakness and sensation loss in UE (selective loss of pain/temp possible)
What are the features of anterior cord syndrome, and who is at risk of this?
bilateral spastic motor paresis distal to lesion and pain/temp loss
Occlusion of anterior spinal arteries (aortic repair surgery, Ao aneurysm etc.)
A patient with extensive history of opioid abuse presents to ED with severe injuries after being hit by a car. He has excruciating pain, how should you treat?
IV morphine (greater chance of relapse if pain not treated adequately)
What are the features of Lewy body dementia? How can you treat?
Alterations in consciousness, disorganized speech, visual hallucinations, extra-pyramidal symptoms, early compromise of executive functions
Tx: Acetylcholinesterase inhibitors (Rivastigmine)
What are the clinical features of multiple lacunar strokes?
Vascular dementia - Dementia with patchy focal neurological findings (depending on infarct location). Numerous old infarcts on MRI
What over the counter Rx can potentiate the effects of Warfarin and what could result from this?
Acetaminophen –> Warfarin associated intracerebral hemorrhage
What is the MoA and use of Riluzole?
Glutamate inhibitor used in Tx of ALS
What is a major cause of nonexertional heatstroke? Exertional?
NE: Patients with chronic medical conditions (from medication/underlying illness)
Ex: Inadequate/failure of thermoregulation (in otherwise healthy ppl undergoing condition in extreme heat/humidity)
What is a typical presentation for cerebellar tumor?
Ipsilateral ataxia (difficulty maintaining balance), patient falls toward side of lesion, Nystagmus, intention tremor, difficulty coordinating movement, headache, nausea, progressive/chronic onset
What is a characteristic movement of someone with hemiparesis?
Usually in patients following stroke -> affected arm is adducted and leg extended, leg is swung in outward semicircles as patient walks
What are dystonias? Akathisia? Athetosis?
Dystonia = Sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures
Akathisia = sensation of restlessness causing patient to move frequently
Athetosis = slow writhing movements, typically affecting hands/feet
A patient presents with migraine headaches associated with nausea/vomit and photophobia. What is the best initial step in management?
IV antiemetic (Prochlorperazine, chlorpromazine, or metoclopramide) as monotx or with NSAIDs/Triptans
What are the symptoms of hypothyroidism?
Weight gain, fatigue, constipation, hoarseness, and memory changes
What are the clinical features and risk factors for multi-infarct dementia?
Stepwise deterioration with psych disturbances like depression/agitation
Risks = vascular disease, history of cerebrovascular disease, evidence of strokes on imaging
What region is most commonly involved in ulnar nerve syndrome? How may this arise?
Ulnar nerve entrapment in elbow at medial epicondylar groove; like from prolonged inadvertent compression of nerve by leaning elbows on desk for long time
What are the clinical features and infarct location in Wallenberg syndrome?
- Vestibulocerebellar - vertigo, falling to side of lesion, diplopia/nystagmus
- Sensory sx - Loss of pain/temp on ipsilateral face and contra trunks/limbs
- Ipsilateral bulbar muscle weakness - Dysphagia/aspiration, dysarthria, dysphonia, HOARSENESS
- Autonomic dysfunction - Ipsilateral Horner’s, lack of automatic respiration, hiccups
Loc = Lateral Medullary from infarction of intracranial vertebral artery
How can you differentiate lateral/mid pontine lesions from those in the medulla?
Pattern of cranial nerve involvement:
Lateral pons = motor/principal sensory nuclei of CNV (weak chewing, impaired facial sense),
Lateral medullary = dysphagia, hoarseness and diminished gag (CN IX, X)
What are the signs of a medial medullary syndrome (from stroke), which vessels are affected?
Branch occlusion of vertebral/anterior spinal arteries –> Alternating hypoglossal hemiplegia; contralateral paralysis of arm/leg, tongue deviation to side of lesion, contra loss of tactile/position sense (with dorsal extending infarcts)
What are the signs of medial mid-pontine lesions?
Contralateral ataxia, hemiparesis of face, trunks, limbs (i.e. ataxic hemiparesis) and variable loss of contra tactile/position sense
What are the clinical signs of severe hypokalemia? What can predispose patients to this?
Motor: Weakness/cramps, flaccid paralysis, hyporeflexia, tetany, rhabdomyolysis
CV: Arrhythmia, broad flat T waves, U waves, ST depression, premature ventricular beats (a-fib, v-fib, torsades possible)
Look out for Potassium wasting diuretics, hydrochlorothiazide!!!
What are the clinical signs of ALS?
UMN/LMN affected with sparing of sensation/cognition –> Weakness, difficulty chewing, swallowing, coughing, breathing
Hyperreflexia, spasticity, fasciculations
What are the clinical features of lumbar spinal stenosis?
Back pain radiating to butt/thighs that interfere with walking/lumbar extension
Lumbar flex improves symptoms
What should you consider if a patient has weakness with no UMN/LMN signs?
Neuromuscular junction disorder (MG, Eaton-lambert) or muscle fiber itself (polymyositis)
What are the cardinal signs of Myasthenia gravis?
Extraocular muscle weakness (diplopia,ptosis), symmetrical proximal weakness of extremities (upper > lower), neck muscle weakness, bulbar muscle weakness ( dysarthria/dysphagia)
What are the symptoms of fibromyalgia?
Multiple well defined, localized tender muscle points. May have proximal pain-limited weakness (but not ptosis, diplopia, dysphagia as in MG)
What triad is associated with Wernicke’s syndrome?
Encephalopathy, oculomotor dysfunction, gait ataxia
What are the key features of Multiple System Atrophy (Shy-Drager Syndrome)?
- Parkinsonism
- Autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel/bladder, abnormal salivation, lacrimation, impotence, gastroparesis etc.)
- Widespread neuro signs (cerebellar, pyramidal, or LMN)
What is the most common cause of non-trauma SAH? Top 2 causes of intracerebral hemorrhage?
SAH - saccular “berry” aneurysm
ICH - 1. HTN 2. Amyloid angiopathy
What is the most appropriate management step for a patient who has severe myasthenia crisis, with weak respiratory effort?
Intubation (do not increase pyridostigmine dose as this will increase risk of aspiration from excess secretions)
What are the first, second and third line treatments for Myasthenia gravis?
- Pyridostigmine
- Add immunotherapy (glucocorticoids, azathioprine, mycophenolate mofetil & cyclosporin)
- Crisis => Plasmapharesis/IVIG + Glucocorticoids
What is a good way to differentiate pseudodementia from Alzheimer’s?
With Pseudo, patients are overly concerned of their memory loss and will seek help
What type of drug is Trihexyphenidyl and what will result from toxic levels?
Antimuscarinic drug used in the treatment of Parkinson’s in Younger patients with pronounced tremor
Toxicity = Anticholinergic excess (Red as a beet, dry as a bone, hot as hare, blind as a bat, mad as a hatter, and full as a flask) and it can precipitate acute glaucoma causing retro-orbital pain
What are the key features of serotonin syndrome?
Agitation, confusion, tachycardia, muscle rigidity, sometimes seizures
What type of drug is bromocriptine and what are it’s toxic effects?
Dop agonist
Toxic = Hypotension, nausea, constipation, headache and dizziness
What spine lesion is common among diabetic patients?
Epidural Abcess
What are the clinical features and findings in a patient with idopathic intracranial HTN (pseudotumor cerebri)?
Young obese women, transient vision loss, pulsatile tinnitus, diplopia
Papilledema, peripheral vision defect, CN VI palsy (empty Sella in ~70%)
How do you treat idipathic intracranial HTN?
medical cause -> stop offending medication (e.g. glucocorticoids, vitamin A, OCP)
Idiopathic -> weight loss and acetazolamide if that doesn’t work
What is the most serious complication in idiopathic intracranial HTN and how can it be avoided?
Visual defects can progress to blindness
VP Shunting or optic nerve fenestration can prevent
What are the treatment options for essential tremor?
Propranalol (beta blocker) and Primidone (anticonvulsant that converts into phenobarbital)
What is a risk factor associated with using Primidone?
May precipitate acute intermittent porphyria -> abdominal pain, confusion, headaches, hallucination, dizziness (neuropsych abnormalities)
What type of drug is Clozapine and when is it used?
Atypical antipsychotic used for schizophrenia and rarely for essential tremor (if refractory to propranalol and Primidone)
What are the clinical features associated with CJD?
Rapidly progressive dementia, myoclonus, and sharp triphasic synchronous discharges on EEG
What abnormality results in Huntington’s disease?
Autosomal dominant mutation on chrom 4 in huntingtin gene (increased CAG repeats)
What is the best therapy and management in a patient with a solitary brain metastases from NSSLC?
Surgical rsxn of mass followed by Stereotactic radiosurgery or whole brain radiation therapy (Start with SRS for nonsurgical candidates)
What is Brachytherapy?
Implant of radioactive source directly into intracerebral mass or surgical cavity –> delivers higher radiation dose to the brain region without affecting other organs
What are key signs of cerebellar dysfxn as in alcoholic cerebellar degeneration?
Progressive gait dysfunction, Truncal ataxia, Nystagmus, Intention tremor/dysmetria, Impaired rapid alternating movements, muscle hypotonia which leads to pendular knee reflex
Is Babinski sign present with cerebellar disease?
Not likely if pathology is confined to cerebellum
What are the key features of Normal pressure hydrocephalus?
Ataxia early in disease, Urinary incontinence, Dilated ventricles on neuroimaging
What is steppage gait and how does it arise?
Footdrop with excessive hip/knee flexion while walking, slapping quality, frequent falls
Motor neuropathy (#1 of L5 radiculopathy and #2 of common peroneal nerve)
What may result from sensory neuropathy in the leg/foot?
Loss of proprioception leads to postural/gait instability and wide based gait, and a “SLAP” gait as patient stomps foot down to identify their location
How do you differentiate cauda equina syndrome and conus medullaris?
Cona Medullaris -> Hyperreflexia, Symmetric weakness, early onset bowel/bladder sx
Cauda Equina -> Hyporeflexia, asymmetric, late onset bowel/bladder sx
What is the most common cause of brain abscesses?
50% - Head/neck infection (sinusitis) from Viridans strep and other anaerobes
25% - Staph Aureus (lung/heart infection hematogenous spread)
What can cause acute angle closure glaucoma?
Pupillary dilation from meds (anticholinergic, sympathomimetics) or dim light
What is the best choice of treatment for elderly patients with delirium (from infection/metabolic derangements)? Younger patients?
Low-dose Haloperidol - elderly
Lorazepam/benzos - young
What is the most characteristic sign of dementia in elderly?
Impaired daily functioning
What are the characteristic features of Creutzfeld Jakob disease?
Rapidly progressing dementia and myoclonus, insomnia, apathy, behavioral changes, and impaired vision (eventually lose ability to move/speak -> comatose)
What are the signs of intracranial HTN?
- Headache (worse at night), N/V, AMS
- Focal neuro signs: Vision changes, unsteady gait, seizure
- Sx worsen w/ leaning forward, Valsalva, cough
- Papilledema and focal neuro defects
What are the clinical features of acute angle closure glaucoma?
age >60, conjuctival erythema, mild dilated pupil poorly reactive to light, frontal HA/eye pain, blurry vision
What are the 4 most common lacunar syndromes? Location? Presentation?
- Pure motor hemiparesis of ipsi face/arm/leg; Post limb of internal capsule
- Pure sensory stroke; VPL of thalamus; unilateral paresthesias & hemisensory deficit
- Ataxic-hemiparesis; Anterior limb of internal capsule; Prominent LE weak & ipsilateral leg/arm incoordination
- Dysarthria/clumsy hand syndrome; basis pontis; Hand weak, mild motor aphasia, NO sensory problems
A patient w/ severe N/V is given Metoclopramide, and 2 hrs later develops neck pain and stiffness. How do you treat?
Discontinue anti-emetic, administer benztropine or diphenhydramine
What are key signs of lumbar spinal stenosis, and what are the main causes of this? How can you confirm the diagnosis?
Low back pain, exacerbated by spine extension (walking downhill or standing), improved by spine flexion (walk uphill or sitting), weak, sensory loss, numb/tingle
Causes = Degenerative joint disease (disc herniation, facet osteophytes)
Spine MRI to confirm
How does ankylosing spondylitis usually present?
Young males (15-30) low back pain, limited spinal mobility, sx better w/ exercise, HLA B27
What are major causes of idiopathic intracranial HTN (pseudotumor cerebri)?
Overweight female of childbearing age, Links to certain medication (growth hormone, tetracyclines -mino/doxycycline), Hypervitaminosis A
What is the first thing that should be done when considering a Dx of Myasthenia Gravis?
CT scan of chest to rule out Thymoma (present in 15% of patients)
What are the clinical features of infectious cavernous sinus thrombosis?
HA –> Intolerable HA, Low grade fever, periorbital edema, binocular palsies, vomit and papilledema from increased ICP, and sx can quickly spread bilaterally.
What is the source of most emboli causing strokes/TIA (e.g. isolated vision loss), and what study should be done to confirm?
Carotid bifurcation –> conduct duplex ultrasound of neck to confirm
What are the features of benign paroxysmal positional vertigo (BPPV)? How does this dz arise?
Recurrent brief episodes of vertigo brought on by predictable head movement/position change, No neuro/auditory symptoms, Dix-Hallpike maneuver causes nystagmus
Cause= Semicircular canal dysfxn, from dislodged crystalline deposits (canaliths)
What cardiovascular dysfxn can lead to dizziness and what are common symptoms?
Causes = Aortic Stenosis, Arrhythmia, hypovolemia
Global cerebral hypoperfusion -> lightheaded/presyncope (not vertigo)
What are the main early SEs of levodopa/carbidopa and other Dop agonists? Amantadine?
- Somnolence, confusion, hallucinations (dyskinesia later on for levo/carbi)
- Ankle edema, livedo reticularis
What are the clinical signs of cluster headaches?
- Intense, unilateral, retro-orbital pain, starts suddenly (common at night), peaks rapidly and lasts for 2 hrs
- Greater in men,
- Redness in ipsilateral eye, tearing, stuffed/runny nose, and ipsilateral Horner’s can accompany
What is the best treatment for an acute attack of cluster HAs? Ppx?
- 100% O2 and subQ sumatriptan
2. Verapamil, Lithium, Ergotamine
What should be the first diagnostic step in a patient who presents with unprovoked first seizure?
MRI or non-con CT of head (especially if associated with trauma/fall)
What type of tremor is associated with action/intention?
Essential tremor
What are deep intracranial hemorrhages and lobar hemorrhages most associated with?
Deep = HTN vasculopathy Lobar = Amyloid angiopathy (esp in elderly)
What are the features associated with basal ganglia hemorrhage?
Contralateral hemiparesis & hemisensory loss, homonymous hemianopsia, gaze palsy
What features are associated with thalamic hemorrhage?
Contra hemiparesis/hemisensory loss, nonreactive miotic pupils, upgaze palsy, eyes deviate towards hemiparesis
What should you consider in a patient with broad-based gait and Sx of Parkinsonism? Other causes of wide based gait?
Multiple system atrophy, spinocerebellar atrophy, multi-infarct disorders
Sensory ataxia, cerebellar disorders, muscular dystrophy
What is carotidynia?
Inflammation of carotids and vagus causing a sharp localized pain over the carotid artery distribution of neck
What are the clinical features on presentation of undiagnosed/advanced HIV infection?
Anorexia, weight loss, fatigue, mild/borderline cognitive impairment. Associated with dementia.
Check history for IV drug abuse, other social factors
What radiographic finding may be associated with schizophrenia?
Enlargement of cerebral ventricles
What is a good initial treatment for the management of psychosis?
Second generation anti-psychotic -> Quetiapine, Risperidone, Olanzapine, Ziprasidone, Aripiprazole
What are the two most common associations with syringomyelia?
Arnold chiari malformations and prior spinal cord injuries
What is a physical sign consistent with complete rotator cuff tear?
Arm drops rapidly from the 90 degree position
What clinical features are consistent with epidural hematoma?
Unconsciousness followed by a lucid interval, leading to gradual deterioration of consciousness and sx of elevated ICP (N/V, HA, seizure), dilation of pupil on side of lesion (CN III compress), contralateral hemiparesis, biconvex hematoma on CT
What are 5 main interventions for lowering ICP?
- Head elevation -> increased venous outflow
- Sedation -> decreased metabolic demand & control HTN
- IV mannitol -> extraction of free water from brain tissue (osmotic diuresis)
- Hyperventilation -> CO2 washout -> cerebral vasoconstriction
- Removal of CSF
What lab screening should be done to rule out other (non-alzheimers) causes of dementia?
Thyroid, LFTs, B12/folate, infections (HIV, syphilis)
What is the CSF profile in a patient with MS?
Pleocytosis rarely w/ PMNs - WBC 20, PMN 5%
Normal glucose, and mildly elevated proteins (glucose 75, prot 80)
IgG and oligoclonal band elevation
What condition other than MS can cause mononuclear visual loss, urinary urgency, and tingling? What factor is involved in this disease?
Neuromyelitis optica - more prominent inflammatory response (more aggressive therapy needed)
Antibodies to aquaporin-4-channel
What is the best AED for a female patient of child bearing age with generalized seizures and why?
Lamotrigine - b/c least risk of birth defects and low freq of cognitive side effects (Valproic acid and phenytoin have high birth defects, topiramate causes cognitive abnormalities)
What are the features of temporal epilepsy? How do you best treat this?
Episodes of Deja vu, unpleasant olfactory aura, staring, confusion, unresponsiveness; followed by staring confusion and unresponsiveness
Tx = Lamotrigine
A young teen male presents with previous generalized tonic-clonic seizure (after a night of having a few beers with friends). He denies recent falls, trauma, or fever/illness. What is the most important test to have before leaving ER?
Urine drug screen (MRI and EEG should be done but not emergently)
What disc level is involved in a patient has pain in the lateral border of the right arm that radiates down to thumb and index finger. Pt also has weak right bicep and absent bicep jerk?
C5 - C6 disc herniation
What is a possible presentation for a migraine without aura?
35F w/ 3-4 bad HAs per month, each lasting 2 days, pain behind eyes bifrontally, nasal congestion, increased tears and snot, throbbing quality with nausea, HA triggered by weather changes
What are the 3 major causes of paroxysmal focal symptoms? How do you differentiate?
- TIAs - Abrupt onset & loss of fxn with no residual deficits
- Seizures - 2-3 minutes
- Migraine auras - 15-30 minutes most commonly involving visual disturbance or tingling which spread slowly
What is the most important first diagnostic step in a patient with signs consist with idiopathic intracranial HTN?
MRI of the brain
-Follow up with LP if no mass lesion etc. (not safe to do LP in setting of papilledema)
What are the first line treatments for migraine prevention therapy? What would preclude the use of each of these drugs?
- Topiramate - can cause renal stones and cog defects
- Propranolol - exacerbate asthma, bradycardia
- Valproic Acid - hepatotox, birth defects
- Amitriptyline - Convulsions, coma, cardiotox
Verapamil is 2nd line
What are the classifications necessary to Dx migraine without aura?
At least 5 episodes of HAs lasting 4-72 hrs and associated with:
- Two of following sx: moderate to severe, worse w/ moving, throbbing
- one of following: light and noise sensitivity, or N/V
What are signs of depression in someone with MS and predisposing factors?
Complaints of worsening physical impairment despite stable findings, uncharacteristic irritability, sleep disturbances
Chronic illness, beta interferon Tx, and recent losses put pt at risk
What brain region is responsible for differentiating objects and their features? Which patients are at risk for loss of this function (semantic problem)?
Dominant lateral temporal lobe
Alzheimer disease
Which brain region is responsible for recognition of faces?
Inferior occipitotemporal cortex (Fusiform gyrus)
Which spinal tract is responsible for descending cerebellar projections?
Rubrospinal
What features are characteristic of pineal gland tumors?
Parinaud syndrome - vertical gaze, loss of pupillary light reflex, lid retraction, convergence-refraction nystagmus from upward gaze
What are the cardinal features of Parkinson disease?
Resting tremor, radykinesia, rigidity and postural instability (2/4 required to diagnose)
What drug is best for a patient with Parkinson who has nausea?
Ondansetron
What are the features of Wernicke encephalopathy?
Mental status change, opthalmoplegia, ataxia, nystagmus (THIAMINE DEFiCIENCY)
What signs are consistent with dysfunction of the muscles?
Proximal symmetrical weakness with normal tendon reflexes
What is the best initial step in managing carpal tunnel syndrome?
Wrist splinting
What is the genetic cause of Duchenne and Becker muscular dystrophy? What is the difference?
X-linked
BMD progresses at a much slower slower rate. Corticosteroids can help with DMD
What are the symptoms and features associated with hyper/hypokalemic periodic paralysis?
Profound generalized weakness following waking up in the morning or precipitated by rest following exercise
Hypo - defect in calcium channel, high carb meal can cause attack
Hyper - sodium channel defect
both autosomal dominant defect
What distinct physical feature is associated with B12 deficiency?
Beefy red tongue
What positional arrangement can lead to common peroneal nerve injury?
Crossing legs at the knee -> compression at fibular head
How do you differentiate median nerve damage at carpal tunnel vs. forearm?
In CTS weakness is in thumb adduction not flexion, and thenar sensation intact
Forearm - sensory loss at thenar eminence and weakness in thumb flexion (flexor pollicus longus innervated before nerve enters carpal tunnel)
What are possible signs that could indicate a high grade primary brain tumor in the posterior frontal and parietal lobes?
Right pronator drift, aphasia, seizures with right sided posturing
What is the presentation for spinal dural AV fistulas?
Present with gradual onset over months, most commonly localizing to cervical or upper thoracic spinal cord
What malignancy is most likely to present with epidural spinal metastasis?
Lung cancer
What is the best treatment for isolated back pain unrelated to radiculopathy, malignancy, infection or trauma?
NSAIDs
