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Wahba Notes > Wahba Part 4 - Movement Disorder, Infections, Encephalopathy > Flashcards

Wahba Part 4 - Movement Disorder, Infections, Encephalopathy Flashcards

1
Q

Etiology of drug induced Parkinsonism

A

Traditional antipsychotics - blockage of DA receptors in basal ganglia

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2
Q

Anti-DA S+S of drug induced Parkinsonism

A

Pseudoparkinsonism, prolactinemia, akathisia (tx: propanolol), dystonia (tx: stop antipsychotic; give amantadine+Bendryl+Benztropine)

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3
Q

Anti-HAM S+S of drug induced Parkinsonism

A

“WARP” - Weight gain, increased AST/ALT/jaundice, Rash, Photosensitivity

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4
Q

Other features of drug induced Parkinsonism

A

Tardive dyskinesia (neuroleptics>6 mo), neuroleptic malignant syndrome

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5
Q

Features of NMS

A

FALTER - Fever, ANS instability, Leukocytosis, Tremor, Elevated CPK, Rigidity; genetic mutation in chr 19 predisposes

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6
Q

Tx of NMS

A

Stop neuroleptics+support+sodium dantrolene (muscle relaxant)+Bromocriptine+Amantadine; plage NG tube, hydration+maintenance of urine flow, lower body temp

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7
Q

Etiology of serotonin syndrome

A

2 SSRIs or w/ MAOIs

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8
Q

S+S of serotonin syndrome

A

Muscle twitching+confusion+sweating+NO fever (???)

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9
Q

Tx of serotonin syndrome

A

Stop offending agents, give periactin (cyproheptadine, an anti-histamine, and anti-serotonin drug)

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10
Q

Etiology of acute dystonic reaction

A

Unwanrted, continuous contraction of group of muscles; could be drug induced dystonia from anti-psychotics or metaclopromide

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11
Q

S+S of acute dystonic reaction

A

Tongue hanging out+eye looking upward

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12
Q

Tx of acute dystonic reaction

A

Benadryl 50 mg IV once and can give small dose of atropine

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13
Q

Cervical dystonia

A

Cervical dystonia+tremor = genetic problem; pediatrics w/ cervical dystonia could be hemivertebral vs TB vs. self correction for diplopia

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14
Q

Essential diagnostic features of myasthenia gravis

A

Fluctuating, fatigable weakness of commonly used muscles (ocular, bulbar, respiratory), thymoma, thymic hyperplasia, Abs to nicotinic Ach receptor

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15
Q

Hallmark features of myasthenia gravis

A

Ptosis, diplopia+dysarthria+dysphagia, bulbar symptoms, respiratory+limb muscle weakness

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16
Q

Eye findings in MG

A

Ocular muscle weakness BL and asymmetric; pupil is spared; purely ocular likely seronegative MG

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17
Q

Abs in MG

A

Can have muscle specific kinase Abs, muscle protein titin,+ryanodine in pts with thymomas

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18
Q

Other features of MG

A

70% have lymphofollicular hyperplasia; flaccid muscles, skin pale/normal/cool, produce secretions

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19
Q

Myasthenic crisis

A

Diaphragmatic+intercostal weakness - respiratory complication+bulbar symptoms; requires mechanical ventilation

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20
Q

Tx of myasthenic crisis

A

Hospitalize+monitor; intubate, stop anticholinesterase and corticosteroids???, give plasmapheresis or IVIG

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21
Q

Diagnosis of MG

A

Edrophonium (xAchase) - don’t do on angina or pregnant pts; have atropine at bedside; serologic testing for ACHR Abs;
if Abs negative do ACHR modulating Ab, then MuSK Ab/titin/ryanodine

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22
Q

Electrodiagnostic studies in MG

A

Do not identify dysfunction at NMJ; slow repetitive conduction done; no change seen in CMAP over time; can be positive in LEMS vs myositis vs LMN dz; single-fiber EMG (95% sens)

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23
Q

Other screening in MG

A

Screened for thymoma w/ CT or MRI; look for autoimmune dz + thyroid dz; do rheumatologic profile

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24
Q

Ice pack test for MG

A

Symptoms get better - esp eyes when cooling down - slows consumption of Ach

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25
Q

When to intubate an MG pt

A

FCV

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26
Q

Tx of MG

A

Cholinesterase inhibitors (pyridostigmine); w/ dz progression may need immunosuppressive therapy (AZA), thymectomy, corticosteroids+NSAIDs

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27
Q

Tx of intubated MG pts

A

Atropine to minimize secretions; beta 2 agonists to minimize bronchospasms

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28
Q

S+S of optic neuritis

A

Pain around one eye (esp on mvmt), blurred vision, loss of color vision - red desaturation; impaired visual acuity, pink/swollen optic disc, visual field defect, relative afferent pupil defect, pale optic nerve

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29
Q

Prognosis of optic neuritis

A

Resolve in weeks-months but some complications permanent

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30
Q

Other visual disturbances in optic neuritis

A

Diplopia, N/V, vertigo, cerebellar ataxia

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31
Q

DDx of optic neuritis

A

MS! neuromyelitis optica (Devic’s dz), Lyme, CT dz, B12, Sarcoid, Syphilis

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32
Q

Tx of MS related optic neuritis

A

DO NOT GIVE ORAL PREDNISONE; Give IV methylprednisolone (solumedrol), can taper off IV steroids orally

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33
Q

Features of 3rd nerve palsy from ruptured aneurysm

A

Dilated pupil, ptosis, exotropic (down-out) position

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34
Q

Other etiologies of 3rd nerve palsy

A

Compression, tentorial herniation, SAH of PCOM, cavernous sinus tumor/aneurysm/thrombosis (affects 3,4,5), superior orbital fissure/orbit tumor (Tolossa-Hunt), infarction in brainstem/nerve trunk, inflammation or infiltration of basal meninges (TB, sarcoid, syphilis, neoplasia), diurnal variation of MG+DM

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35
Q

Next step in management of 3rd nerve palsy

A

CT w/o contrast; if hemorrhage then load with normal saline to hemodilute and increase BP; Tx (HHH) - hypervolemia/hydration+hemodilution+HTN

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36
Q

Pathogenesis of giant cell arteritis

A

Granulomatous inflammatory changes w/ giant cells at brances of ECA; narrowing of lumen

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37
Q

S+S of giant cell arteritis

A

HA localized to the temples + scalp tenderness + pain w/ chewing + intermittent jaw claudication, transient vision loss in one eye, constitutional symptoms,

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38
Q

Dx of giant cell arteritis

A

ESR+normocytic normochromic anemia+LFTs+biopsy (can be false negative)

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39
Q

Tx of giant cell arteritis

A

IV hydrocortisone, 40-60 mg prednisolone req initially; taper down; Tx for 18 mo-2 yrs

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40
Q

Polymyalgia rheumatica

A

Girdle pain+morning stiffness w/ constitutional sx; seen with GCA

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41
Q

Hyperthyroid and stroke pathogenesis and management

A

Afib can cause embolic stroke w/ perfect vessels; paroxysmal Afib = big risk of stroke; hyperthyroid is as big a risk as someone w/ constant Afib; get Holter monitor to catch Afib

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42
Q

Associations with hyperthyroid

A

Myasthenia gravis, psuedotumor cerebri

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43
Q

Features of pseudotumor cerebri

A

Seen in young obese women, increased ICP w/ no mass lesions+normal ventricles

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44
Q

Tx and management of pseudotumor cerebri

A

LP to confirm ICP (>40); resolves w/ weight loss and LP; chronic - optic nerve affected - give acetazolamide+diuretics; surgical drainage

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45
Q

Pathophysiology of pseudotumor cerebri

A

Impaired CSF absorption

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46
Q

Presentation of pseudotumor cerebri

A

Morning HA, vomiting, diplopia, visual obscurations, sudden/transient BL visual loss w/ posture, BL papilledema, 6th nerve palsy (false localizing sign)

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47
Q

Venous strokes - paired vs unpaired?

A

Paired sinus - infection; single sinus - hypercoagulable state

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48
Q

Superior sagittal sinus thrombosis

A

Pt very sick + seizures + paraplegia + increased ICP + papilledema

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49
Q

Patients to suspect superior sagittal sinus thrombosis

A

Suspect in postpartum w/ severe HA - hypercoagulable state; also pts pregnant/labor/OCPs, dehydration, cachexia, cancer/anti-cancer meds, sickle cell, protein C/S coagulopathy

50
Q

Cavernous sinus thrombosis

A

Presents with red swollen eyelid+conjunctiva + III, IV, Va/Vb, VI palsies + papilledema; lateral+cavernous sinus may undergo thrombosis as a result of infection spreading; Tx is heparin+Abx

51
Q

Lateral sinus thrombosis

A

From infection in mastoid/inner ear + blood clot; increased ICP+seizures+drowsiness

52
Q

Cerebello-pontine angle tumors

A

Involves CN 5+7+8; sensorineural hearing loss - Weber lateralizes to healthy ear, AC>BC on both sides (normal Rinne); acoustic neuroma most common

53
Q

Acoustic neuroma

A

Benign tumor arising from Schwann cells of CN VIII; unilateral sensorineural hearing loss+tinnitus+CN VII palsy and facial drooping; get MRI of internal auditory canals w/+w/o contrast

54
Q

HSV encephalitis on imaging

A

EEG shows severe slowing on temporal lobes (triphasic waves), MRI of brain lit up on temporal lobes + positive PCR

55
Q

Location of HSV encephalitis

A

Temporal lobes + Broca’s area of frontal lobe

56
Q

Features of HSV encephalitis

A

Slow onset; seizures+AMS+speech output bad for the last 5 days+fever+obtunded

57
Q

Tx and management of HSV encephalitis

A

ABCs first, do CT w/o contrast; if CT does not look like stroke, assume meningitis and tx broad spectrum; do MRI - temporal lobe lighting up; ICP management, fluids, ACV therapy, DO NOT USE STEROIDS, seizure control; admit everyone w/ new onset seizure for 23 hr observation

58
Q

Who NOT to tap for HSV encephalitis

A

Don’t tap healthy w/ seizure etiologies - ex EtOH, barbiturates, family hx; leave previous stroke, EtOH, very old, or risky pts

59
Q

Guillain Barre Syndrome (AIDP)

A

Ascending weakness in all extremities; elderly at risk - monitor respiratory status

60
Q

Bugs that cause GBS

A

CMV, EBV, HIV, Mycoplasma pneumoniae, Campylobacter jejuni, swine flu vaccine

61
Q

S+S of GBS

A

Spinal pain and minor sensory symptoms, proceeds progressively, ascending, symmetric limb weakness - leg, arm, CN w/ diplopia, drooling, dysphagia, slurred speech, respiratory muscle weakness, dyspnea, fatigue, urinary hesitancy and retention

62
Q

Exam findings of GBS

A

Flaccid paralysis of limbs,+ early tendon areflexia + minor sensory deficits, CN palsies (esp bulbar)

63
Q

Miller Fisher Variant

A

Ataxia+Opthalmoplegia+Areflexia (AOA), little muscle weakness in limbs, antiganglioside Ab (GQ1b)

64
Q

Froin syndrome

A

Clotting of CSF from high protein

65
Q

Ddx for GBS

A

Periodic paralysis + hyper/hypo potassium/calcium

66
Q

LP findings with GBS

A

Increased CSF protein w/ normal white count - albuminocytological dissociation

67
Q

EMG findings w/ GBS

A

Nerve conduction shows demyelination; can be totally flaccid w/ normal conduction first few days; only patchy nerve fx early

68
Q

Other dx tests for GBS

A

Anti-gangliosides Abs, MRI head+C-spine to r/o basilar artery stroke, SC compression, TM, rupture of AVM

69
Q

Management of GBS

A

Measure vital capacity+ECG constantly; admit to ICU if decreased vital capacity or trouble swallowing; may need artificial ventilation + NG feeding

70
Q

Brain tumors

A

Medulloblastoma, Ependymoma, Posterior fossa tumors (young), corpus callosal tumors+oligodendroglioma+lipoma, GBM (the worst), 4th ventricle-ependymoma (can block CSF outflow), supracellar tumors

71
Q

Features of ependymoma

A

Pt w/ HA+blurred vision+projectile vomiting (morning)+papilledema

72
Q

Etiology of neurocysticercosis

A

Pork tapeworm (taenia solium); seizure + from Mexico is this until proven otherwise

73
Q

Presentation of neurocysticercosis

A

HA + seizure + focal signs; can obstruct ventricles, predispose to stroke

74
Q

Dx of neurocysticercosis

A

ELISA + CT w/ multiple calcifications+space occupying lesions+swiss cheese appearance on MRI

75
Q

Tx of neurocysticercosis

A

Steroids to decrease ICP, seizure meds, albendazole+praziquantil, shunt if CSF not flowing

76
Q

Prognosis of neurocysticercosis

A

Worsen before they get better; follow NIH guidelines, follow with ID and surgery; surgery won’t operate bc of rupture risk

77
Q

Classic presentation of neurocysticercosis

A

Severe occipital HA+decreased visual acuity; unable to distinguish color, seizures, from Guatamala, calcifications on CT, edema on T2 FLAIR

78
Q

Types of brain herniation

A

Cingulate, uncal, cerebral hemisphere mass, central tentorial, tonsillar

79
Q

Cingulate herniation

A

Ventricle compression

80
Q

Uncal herniation

A

Stretching of CN III - IPSI dilated pupil + ptosis; compression of IPSI PCA - CL homonymous hemianopia; compression of CL crus cerebri - IPSI paresis; caudal displacement of brain stem - Duret hemorrhages (paramedian aa. rupture)

81
Q

Cerebral hemisphere mass herniation

A

Shift of medline structures, temporal lobe herniation through tentorial hiatus, compression of reticular formation leads to decreased consciousness, CN3 palsy - compression of nerve+nucleus - IPSI fixed dilated pupil, long tract signs - upgoing plantar responses

82
Q

Central tentorial hernation

A

Diffuse cerebral swelling, unchecked lateral herniation, vertical displacement of structures through tentorial hiatus, decreased consciousness, pupils initially small and ultimately fixed and moderately dilated, CDI d/t downward traction on pituitary stalk + hypothalamus

83
Q

Tonsillar herniation

A

2/2 subtentorial mass or unchecked tentorial herniation, cerebellar tonsils herniated through the foramen magnum, posterior fossa mass may cause upward herniation through tentorial hiatus, causes neck rigidity+head tilt, decreased consciousness w/ respiratory arrest, HTN+bradycardia

84
Q

Dysphasia vs aphasia vs dysarthria

A 
Dysphagia = trouble swallowing
Aphasia = impairment of language function as a result of brain damage
Dysarthria = muscle problem w/o language problem
85
Q

Broca’s (Area 44) location

A

Inferior frontal gyrus, anterior division of MCA on dominant side

86
Q

Broca’s aphasia

A

Mute then can say short sentences, can read if they avoid hemianopic part of vision, nonfluent, intact comprehension, naming/repetition/writing all poor, reading variable, disordered grammar, hemiparesis common

87
Q

Wernicke’s (Area 22) location

A

Posterior superior temporal lobe = Post division of MCA

88
Q

Wernicke’s aphasia

A

Fluent, paraphasic; comprehension, naming, repetition, writing poor; reading is variable, hemiparesis infrequent, repetitions of substitutions

89
Q

Arcuate fasiculus of supramarginal gyrus aphasia

A

Fluent paraphasic, poor repetition but fluent speech + intact comprehension, repetitions of substitutions, repetition/writing poor, naming+reading variable, hemiparesis infrequent

90
Q

Literal vs semantic substitutions

A

Literal - substitute one letter for another (wife vs wafe)

Semantic - substitute one word for same type of another (wife vs mom)

91
Q

Essentials to Dx of botulism

A

Hx of ingestion of home-canned foods or honey (infants), rapid onset of ocular symptoms (diplopia, ptosis, blurry vision), bulbar symptoms (dysarthria, dysphagia), descending pattern of weakness from oculobulbar to limb involvement, dilated pupils

92
Q

Pathophysiology of botulism

A

Ingestion of toxin and absorption into blood stream; irreversible binding of toxin to presynaptic nerve endings of PNS + CNS; gets internalized and blocks Ach release thru cleavage of polypeptides essential for docking of vesicles

93
Q

S+S of botulism

A

N/V/D w/in 2-26 hr of ingestion, constipation, oculobulbar (dry mouth, blurred vision, diplopia, dysarthria, dysphagia, dysphonia), respiratory weakness (may need intubation), unreactive pupils+areflexia

94
Q

S+S of infantile botulism

A

Infection + early constipation + weak cry + poor feeding; days - progressive weakness + poor suck + head control + hypotonia + decreased movement; autonomic - hypotension, tachycardia, dry mouth

95
Q

Dx of botulism

A

Toxin detected in blood or stool; C. botulinum can be detected in stool; electrodiagnostic - small CMAP in response to supramaximal stimulus

96
Q

Management of botulism

A

Intensive supportive care; admit and manage airways; trivalent botulinum antitoxin - give early while toxin still in blood (side effect of anaphylaxis), guanidine hydrochloride,, anticholinesterase drugs controversial

97
Q

Cholinergic crisis causes

A

Anticholinesterases to treat MG

98
Q

S+S of cholinergic crisis

A

Increased salivation+lacrimation, vomiting, abdominal pain+diarrhea, sweating, papillary constriction, fasiculation, worsening weakness in extreme cases

99
Q

Wernicke syndrome

A

Acute global confusion state + abnormal eye movements + ataxic gait (mostly truncal)

100
Q

Progression of Wernicke’s

A

Evolves over days to weeks w/ inattentiveness, indifference, decreased spontaneous speech, impaired memory, lethargy; can prgoress to coma, loss of pupillary reactivity rare; autonomic signs - tachycardia, orthostatic hypotension

101
Q

Korsakoff syndrome

A

Chronic amnestic d/o - anterograde + retrograde; preservation of alertness, and behavior; does NOT respond to tx like mental symptoms of Wernicke

102
Q

Pathophysiology of Wernicke-Korsakoff

A

Lesions in medial thalamus, hypothamus, PAG of midbrain and mammillary bodies caused by thiamine deficiency

103
Q

Other causes of Wernicke-Korsakoff

A

Chronic hemodialysis+drug therapy for obesity + hyperthyroid

104
Q

Tx of Wernicke-Korsakoff

A

Thiamine 50-100 mg daily + multivitamin + bed rest bc autonomic symptoms

105
Q

Brain death criteria

A

Clinical/neuroimaging evidence of acute CNS problem compatible w/ brain death; exclusion of complicating medical condition that may confound clinical assessment; no drug intoxication or poisoning; core temp of 32 degrees???

106
Q

Cardinal findings of brain death

A

Coma - no cerebral motor response to pain, absent brainstem reflexes - pupils+EOM+facial sensation+motor response+pharyngeal/tracheal reflexes, apnea testing - must have core temp of 36.5, systolic BP of 90, euvolemia, normal arterial PO2

107
Q

Conditions where confirmatory test recommended for brain death

A

Severe facial trauma, preexisting pupillary abnormality, toxic levels of any sedative, sleep apnea, severe pulmonary dz

108
Q

NOT to be confused with brainstem functions

A

Tendon, superficial abdominal or triple flexion reflexes, babinski, respiratory-like movements w/o significant tidal volume, sponatenous movements of limbs other than pathologic flexion or extension, sweating, blushing, tachycardia, normal BP w/o pharmacological support or change in BP, absence of DI

109
Q

Repeat exams for brain death

A

Children

110
Q

Confirmatory lab tests for brain death

A

Children

111
Q

Essentials of Dx of B12 deficiency

A

Gradual onset, distal symmetric sensory loss + weakness (late)

112
Q

Lab findings in B12 deficiency

A

Elevated homocysteine + methylmalonic acid

113
Q

Neurologic features of B12 deficiency

A

Myeloneuropaty (subacute combined degeneration), cognitive impairment, optic neuropathy (atrophy less common), isolated cerebellar ataxia, demantia less common, gait instability+muscle atrophy if left untreated

114
Q

Exam findings of B12 deficiency

A

Decreased propioception and vibration sense + distal weakness + Babinski + increased DTR?

115
Q

Etiologies of B12 deficiency

A

Strict vegetarians (vegans?), gastric disorders (pernicious anemia, gastrectomy, achlorhydria, ileal d/o w/ bacteria, Diiphyllobothrium latum), surgery, IBS, nitrous ox abuse

116
Q

Myelopathy in B12 deficiency

A

Subacute combined degeneration of corticospinal and dorsal columns - myelopathy + PN = combination of areflexia + sensory ataxia + paraparesis + extensor plantar response

117
Q

Dx o B12 deficiency

A

Elevated homocysteine + MMA, low B12, normal folate, MRI spine normal, somatosensory evoked potentials+motor evoked potentials usually abnormal, nerve conduction reveal peripheral neuropathy, anti-intrinsic factor Abs+anti-parietal cell Abs in pernicious anemia, macrocytic anemia

118
Q

Tx of B12 deficiency

A

1 mg of IM cyanocobalamin QD x 7d; IM Qweek x 3 mo, then maintenance IM qmonth or q3mo

119
Q

Presentation of Horner’s syndrome

A

Miosis + enophthalmos + anhidrosis

120
Q

Etiology of Horner’s syndrome

A

Brainstem = glioma + infarction + syringobulbia
Cervical cord = glioma + syringomyelia
T1 root = neurofibroma + brachial plexus lesion
ICA = occlusion + dissection
Other = cluster hA + syringobulbia + Pancoast tumor

121
Q

Location of Horner’s lesion

A

Lesion to superior sympathetic nervous system that supplies muscles for elevating eyelid; SNS to eye originates in hypothalamus, exits sympathetic chain w/ T1 and enters cervical sympathetic chain and attaches to ICA; tumor catches medial cord first;
Tingling or numbness above wrist = root or cord;
Hand spliting ring finger = ulnar nerve

122
Q

Bacterial meningitis prophylaxis

A

Meningococcal + Hflu w/ rifampin or cipro

Wahba Notes (4 decks)

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