Wahba Notes Flashcards
1
Q
Foot drop weakness
A
Dorsiflexion and eversion of R foot
2
Q
MCC of Charcot Marie Tooth
A
AD and can be dx w/ DNA analysis
Hereditary and motor sensory neuropathy
3
Q
CMT type 1
A
Slowly progressive distal wasting and weakness of anterolateral muscle compartment, pes cavus
- Absent tendon reflexes, mild sensory loss, thick peripheral nerves*
- Demyelination*
4
Q
CMT type 2
A
Like type but but later onset and nerve conduction relatively preserved reflecting axonal, rather than demyelinating pathology
5
Q
Why are ankle inversion and plantar flexion normal in peroneal neuropathy
A
Tibial nerve innervates posterior calf muscles
6
Q
Where does the sciatic nerve divide
A
As high trochanter or above popliteal fossa
7
Q
Compression of common peroneal nerve at fibular head causes? What will you see
A
-Impaired dorsiflexion and eversion of ankle
-Sensory loss to anterolateral leg and dorm of foot
Will see: foot drop with tendency to invert foot + high stepping gait + sensory loss over the lateral aspect of the leg
8
Q
3 big predisposing factors in compression peroneal mononeuropathy at fibular head
A
- Recent anesthesia and surgery
- Prolonged hospitalization
- Total hip arthroplasty
9
Q
Where does the deep peroneal nerve get entrapped, what does it cause
A
Gets entrapped in the anterior tarsal tunnel of the ankle
Causes weakness of toe dorsiflexion, ** eversion spared, and sensory loss in first dorsal web space**
10
Q
What does the superficial peroneal nerve innervate
A
Peroneus longues and brevis
11
Q
Where does the superficial peroneal nerve get entrapped? What does it cause
A
Fascial exit on anterolateral leg
Causes weakness of eversion, DORSIFLEXION SPARED, sensory loss of anterolateral leg and and dorsum of foot
12
Q
L5 root sensory loss*
L5 radiculopathy occurs from?
A
Mostly BIG TOE, more medial
Occurs from L4-L5 disc herniation of spinal canal stenosis
13
Q
Lumbosacral chord arises from?
A
L4 and L5
14
Q
What does the straight leg raise test cause
A
Passive traction of lumbosacral roots
15
Q
S1 radiculopathy causes
A
Weak gastrocnemius and soleus
No ankle jerk
16
Q
What is preserved if L5 radiculopathy is not accompanied by S1 radiculopathy
A
Ankle jerk reflexes
17
Q
Shooting pain after pushing something heavy with foot drop; must suspect what
A
L5 radiculopathies
18
Q
Mom can’t move leg after giving birth think what? other examples?
A
Retroperitoneal hematoma of lumbosacral plexus
Also think from pelvic surgery on heparin or pelvic cancer
19
Q
Tight cast + foot drop; think what
A
Common peroneal nerve entrapment
20
Q
Think what if weakness of dorsiflexion, inversion, eversion and toe flexion
A
More of a sciatic picture –> hip rep. or osteophytes in sciatic foramen
21
Q
Muscular branches of sciatic nerve innervate what
A
Short head of biceps muscle
22
Q
Muscles innervated by L5 (not via common peroneal)
A
Flexor digitorum longus Tibialis posterior Paraspinals (lumber and high sacral) Gluteus medius Tensor fascia lata
23
Q
Best test to dx foot drop
A
EMG to ID L5 vs common peroneal nerve etiology
24
Q
How does SNAP predict peroneal nerve lesions
A
Slow - common peroneal head entrapment
Absent (sural nerve) likely sciatic
Normal: Root only because DRG is pseudo unipolar
Absent - plexus or peripheral nerve due to disconnection from cell body in DRG
25
CIDP features
Gradual progressive weakness over at least 2 mo, areflexia, increased CSF proteins without increased cell count
*Stocking glove pattern and loss of sense of vibration*
26
What weakness is highly suggestive of CIPD
Proximal hip flexor weakness
| *starts with mostly motor*
27
What is spared in CIDP
Breathing muscles**
28
What is F wave delay
Average of several responses taken as a very variable subpopulation to anterior horn cells and moves back down without synapsing
29
What do you test for after diagnosing CIDP
Underlying disease (esp Heme issues)
30
What causes Lambert-Eaton
Pre-synaptic - antibodies against P/Q type voltage gated Ca channels
31
Cancer associated with LE syndrome
Small cell carcinoma (60%)
32
Test to dx LE
Compound muscle action potential
| *At rest is best marker for severity*
33
LE drug for patients who don't have malignancy
Guanidine Hydrochloride - inhibits mitocondrial Ca uptake and causes increased Ach release
*Bone Marrow Suppression*
34
Cauda equina syndrome effects what nerve routes
Below T10
35
1st test for an old man that can't climb stairs
MRI to rule out nerve compression
36
Red flags for myelopathy vs back pain
Loss of weight, night sweats, endemic areas, tender areas on spine
37
CSF of acute myelopathy
Mild to moderate lymphocytic pleocytosis, elevated protein, and normal or mildly decreased glucose
38
Acute vs Chronic phase of myelopathy
Acute: tone and reflexes of affected limbs are decreased
| Chronic phase: spasticity w/ pathologic reflexes int he affected limbs
39
Markedly increased protein in CSF from viral myelitis suggests
Froin syndrome from chord compression
40
MRI of poliomyelits
Affected areas appear swollen, enhance with gadolinium on T1 and display high signal on T2
41
TPA inclusion criteria
```
0-3 h IV TPA 0.9 Mg/Kg
3-4.5 hours could also
4.5-6 IA TPA
3-8 hours- mechanical embolectomy
*Give aspirin if doesn't meet criteria*
```
42
What do you look for in a patient with stroke like features and bacterial endocarditis
Pericardial tamponade
43
Anticoagulation TPA contras
Heparin in last 48 hours
| Coumadin with INR >1.7
44
How big stroke too big for TPA
> 1/3 MCA
45
NIH stroke scale TPA inclusion criteria
If above 4, but less that 28
| If less that 4 but pt has aphasia or hemianopia
46
Sudden eye deviation with what kind of stroke
Basilar artery
47
Status epilepticus
Diazepam for premonitory
Early: IV lorazepam
Established: Phenobaritone bolus and/or phenytoin
48
Refractory status epileptics (>30 min) tx
Thiopentone (don't forget artificial ventilation)
49
Why no flumenazil if benzo overdose isn't confirmed
Can induce seizures
50
Epidural hematoma in posterior fossa usually means
Venus sinus is torn
51
MCC of subdural hemorrhage? Why can false localization signs be seen
Tearing of bridging veins
| Can see false localization signs due to uncal herniation compressing the brain stem
52
Akathisia tx
Beta blockers
53
Acute dystonia tx
Diphenhydramine (can also give atropine)
54
MG cause
Autoantibodies with nicotinic acetylcholine receptor
55
What is spared in MG
Pupil
56
70% of of MG patients have what? Ages?
Lymphofollicular hyperplasia
| women in their 30s, men in their 60s
57
Myasthenic crisis features and tx
Respiratory complications + bulbar symptoms
| Give plasmapheresis or IVIG
58
MG diagnostic test? Tx?
Edrophonium test
| Tx is cholinesterase inhibitors (pyridostigmine)
59
Optic neuritis exam
Impaired visual acuity, pink/swollen optic disk, visual field defect, RAPD (affected eye will respond slower to direct light)
60
Acute MS related optic neuritis
IV methylprednisone
| *Do not give oral prednisone --> makes worse*
61
Most common artery with congenital aneurysms
Posterior communicating artery
62
Tx for aneurysm rupture
Hemodilution, hydration, hypertension --> Load with normal saline (for hemodilution)
63
PMR features
Girdle pains and morning stiffness with some constitutional symptoms
64
Stroke in young patient with perfect vessels think
Embolic stroke from a-fib
65
suspect what in postpartum woman with very severe headache? Why?
Superior sinus thrombosis - hyper coagulable
| HA w/ papilledema an other ICP features, bilateral
66
What do you need to have lateral sinus thrombosis
Infection in mastoid/inner ear in addition to blood clot
67
Think what with red swollen eyelid, and CN II, IV, V, VI palsies
Cavernous sinus thrombosis
68
What CN are in cavernous sinus
III, IV, V1, V2 and VI
69
Paired vs unpaired venous sinus thrombosis
Paired- likely infection
| Unpaired- likely hypercoag state
70
CPA tumors affect what
CN V, VII, VIII
Sensoneural hearing loss
MC tumor is acoustic neuroma
71
Acoustic neuroma comes from
Schwann cells of CN VIII
72
EEG of HSV encephalitis
Several slowing on temporal lobes (triphasic waves), MRI of brain lites up on temporal lobe
73
Do what with new onset seizures
Admit everyone for 1 day obs
74
GB exam
Flaccid paralysis of limbs, early tendon arrflexia, usually only minor sensory symptoms
75
What is the miller fisher version of GB
Little muscle weakness in the limbs
76
What do you do constantly in GB
Measure vital capacity and EKG constantly
77
First part of the MCA supples
Internal capsule and basal ganglia
78
Superior division of MCA supplies
Lateral frontal lobe, anterior lateral parietal lobe
79
Superior division of MCA stroke
Contralateral hemiparesis and sensory loss that affects FACE AND ARM MORE THAN LEG
*spares internal capsule
Contralateral gaze paralysis WITHOUT homonymous hemianopia
80
Inferior MCA stroke
Contralateral homonymous hemianopia
Little or NO weakness
Wenicke aphasia (on dom side), personality change on non-dom
81
ACA supplies
Medial portion of the frontal lobe
82
Unilateral ACA infarction causes
contralateral leg weakness and sensory loss (distal greater than proximal) --> trouble initiating spontaneous speech and urinary incontinence
*Can cause sever behavioral stuff*
83
Memory problems from what stroke
Bilateral PCA
84
Why macular sparing in PCA stroke
B/c of collateral MCA to occipital pole
85
What is weber syndrome
proximal PCA stroke that causes midbrain infarction with contralateral hemiparesis and ipsilateral ocular motor palsy
86
SCA infarct causes
Prominent dysarthria, ipsilateral limb ataxia, truncal ataxia, nystagmus (fast phase towards lesion)
87
AICA infarct causes
Lateral pons in addition to anterolateral region of cerebellum
88
MC cerebellar infarct
PICA --> can cause life threatening edema from compression of 4th ventricle
89
Pure sensory infarct from
Thalamoperforate branches of the PCA supplying the thalamus
90
What branches of MCA supply internal capsule
Lenticulostriate branches
91
What is Dejerine-Roussy syndrome
Complication of thalamic infarct characterized by severe intractable pain and allodynia
92
What supplies the pons
Paramedian penetrating branches of the basilar artery supplying the pons
93
Ataxia and hemiparesis --> stroke likely where
Pons, internal capsule, or corn radiata
94
Dysarthria + Upper limb ataxia --> stroke where
Internal capsule or pons
95
Seizure and from Mexico is what until proven otherwise
Neurocysticercosis (tiaenia sodium)
| *Leading cause of epilepsy worldwide*
96
Neurocysticercosis MRI appearance
"Swiss cheese' from space occupying lesions
97
Compression of ipsilateral PCA causes?
Contralateral homonymous hemianopia
98
Pupils in central tectorial herniationg
Pupils initially small, ultimately fixed and moderately dilated
Impaired up-gaze due to pressure on superior midbrain
99
What do cerebellar tonsils herniate through
Foramen magnum
100
Dysphagia vs Aphasia vs Dysarthria
Dysphagia: difficulty swallowing
Aphasia: Impairment of language function as a result of brain damage
Dysarthria: Muscle problem without language problem
101
Wha supplies Broca's area
Anterior division of MCA on dominant side (Left)
| *In the inferior frontal gyrus*
102
When can Broca's patients read
If they avoid the hemianopia part of their vision
103
What supplies Wernicke's area
Posterior division of MCA
| *Posterior superior temporal lobe*
104
Broca's vs Wernicke's aphasia
Brocas: Nonfluent, intact comprehension, naming/repeition/writing poor
Wernickes: Fluent (paraphrasic), but comprehension, naming, repetition poor
105
Arcuate fasiculus of supra marginal gyrus lesion
POOR REPETITION but fluent speech and intact comprehension
106
Literal vs Semantic poor repetition
Literal: substitute one letter for another
Semantic: substitute one word of same type for another (wife vs mom)`
107
Botulism pattern of weakness
Descending
| *dilated pupils*
108
Botulism pathophys
Irreversible binding of toxin to pre-synaptic nerve endings, inhibits release of Ach through cleavage of polypeptides
109
Early neuro symptoms of botulin
Oculobulbar (dry mouth, blurred vision, diplopia, dysarthria, dysphagia, dysphonia)
110
2 big things on late botulism exam
Pupils are unreactive and reflexes are absent
111
Infantile botulism timeline
Early constipation, weak cry and poor feeding followed by progressive weakness and decreased head control
112
Electro studies in botulism? Tx?
Small CMAP in response to supramaximal stimulus
| Give Trivalent Botulinum antitoxin
113
What adults need AEDs for life
Brain tumor patients with resection and radiation
| HIV patients with low CD4 who already seized
114
What ER patient doesn't need LP or seizure meds
Someone who just stopped taking baclofen
115
Wernicke vs Korsakoff
Wernicke: acute global confusion, ataxia (truncal)
Korsakoff: chronic amnestic disorder (anterograde and retrograde)
116
Causes of WK besides thiamin def
Chronic hemodialysis, drug therapy for obesity, hyperTH
117
Core temp for brain death
32 C (90 F)
118
When to repeat brain death exam in different ages
2mo-1 year: Repeat after 24 hours
1y-18y: repeat 12 hours
Adults: 6 hours unless pt has anoxic ischemic injury then 23 hours
*2 tests in children under 2mo*
119
Myelopathy + Perps think
B12 def: areflexia, sensory ataxia, paraparesis, and extensor plantar response
120
Antibodies that pernicious anemia patients have
70% have anti-intrinsic factor
| 90% have anti-parietal cell
121
SNS to eye path
Originates in hypothalamus
Exits spinal chord with T1
Enters cervical sympathetic chain, attaches to internal carotid artery
122
Causes of T1 root lesion
Neurofibroma, Brachial plexus lesion
123
Any tingling or numbness in wrist is what part of brachial plexus
Root or chord
124
Tumor in chest will hit what part of brachia plexus
Medial chords first
125
Where is the cubital tunnel? compression features?
between medial epicondyle and olecranon
| Pins and needs in ring and small finger, often when elbow is bent a long time, like when holding a phone or sleeping
126
Radial nerve compression above spiral groove
Weakness in elbow extension, wrist, and thumb
| Sensory loss over posterior arm, forearm, and hand
127
Radial nerve compression at spiral groove
Elbow extension is spared, weakness at wrist and thumb
128
Posterior interosseous nerve compression
Finger drop, wrist spared (will extend with radial deviation)
129
Pan coast tumor gets what part of brachial plexus
Lower trunk or medial chord
130
CIPD featuers
Weakness, falls, perps over years (like chronic guillan barre)
131
CIPD vs GB tx
CIPD: steroids, IVIG and plasmapheresis (Steroids BAD for GB)
132
Cauda equina affects what? MCC?
At or below T10 that affects any roots from T12 to S5
| MCC is disc prolapse followed by tumors
133
Egg shaped tumor with tail? Ass w/ what?
Meningioma --> genetic tendency to have breast cancer
134
Medulloblastoma vs Ependymoma
Medulloblastoma in KIDS
Ependymom in Adults
Both w/ massive signs of increased ICP (Epy blocks 4th ventricle, medullo- vermis of cerebellum)
135
What kind of stroke can you do TPA in later
Basilar artery occlusion
136
Pure motor lacunar stroke where
Posterior limb of internal capsule
137
Pure sensory stroke where
Ventroposterolateral nucleus of thalamus
138
Stroke at corona radiata causes
Ataxic hemiparesis -- mild weakness and poor cerebellar functions
139
Clumsy hand syndrome from stroke where
Lacunar at base of the pons
140
Lacunar stroke at base of the pons causes
Dysarthria-clumsy hand syndrome
141
DM CN III palsy spares
Pupillary reflex
142
What is primary progressive aphasia
Alzheimer's but aphasia happens early
| Will see strong family history
143
Two Tauopathies
Alzheimers
| Pick's (personality dz)
144
Two synucleopathies
Parksinsons
| Dementia with lewy bodies (hallucinations)
145
Picks (FTD) vs Lewy body
Picks- personality
| LBD- hallucinations
146
EEG of CJD? features?
1 hz triphasic waves
| Myoclonus, hallucinations, seizures
147
Presenting symptoms in 45% of wilsons? tx?
Parkinonian features
| Tx: Penicillamine
148
Wilsons MRI
Panda face
149
Multi system atrophy MRI
Hot cross pun in pons
150
Progressive supra nuclear palsy MRI
"Hummingbird" in brainstem
151
PD features plus can't look up
Progressive supranuclar palsy
152
Epidural hematoma causes what herniation
Trans-Tensorial
153
Hyperventilation does what to cerebral vessels
Contrils
154
RLS tx
Pramipexole or ropinirole
155
Rapid phase in peripheral nystagmus
Away from lesion
156
How does ice water in ear work
Slows down ipsilateral vestibular nerve if patients brainstem is working --> fast phase to other side
