Week 2 Flashcards
1
Q
T/F - stroke is leading cause of long-term disability in the US
T/F - stroke is second leading cuase of death in US
A
TRUE
FALSE (5th)
2
Q
*stroke risk factors (CHAD / CHAD-VAS – NOT LO)
OTHERS??
T/F - smoking but not alcohol use is well known risk factor for stroke
A
-CHF/LVH (CVD)
-HTN
-AGE (75+)!! (x2)
-DM
((Vascular disease; Age (60+), SEX (FEMALE))
OTHERS = A fib, SMOKING, HTN, ETOH use (FALSE)
3
Q
**how do stroke mortality factors differ by race/location
T/F - stroke mortality is HIGHER IN SE
T/F - stroke mortality is higher for african americans compared to caucaisans at YOUNGER ages but NOT as much at older ages
A
TRUE !!
TRUE!!
*non-hispanic blacks have HIGHER MORTALITY RISK at YOUNGER AGE compared to whites (puts burden on INDIRECT COSTS - lost wages etc)
ex - blacks are at 4 fold increase risk of dying from stroke between 35 and 55 compared to whites (RR in 85+ age though is 0.8)
4
Q
- **ischemic vs hemorragic vs. subarachnoid strokes
- def
- whats most common
A
- hem = bleeding into brain (10%)
- isch = clot occluding artery (85%)
- subarach = bleeding around brain (5%)
5
Q
lacunar strokes
- def
- T/F - are NOT as severe
A
strokes in small branches of arteries that can still cause devestating disease (TRUE) … depends on WHERE it is not how BIG it is
6
Q
1 cause of cardioembolic stroke?
A
A fib
7
Q
2 types of hemorragic stroke
- def
- risk factors
**uncontrolled HTN is one of biggest risk factors for _______(subtype) of stroke
A
1 = INTRACEREBRAL HEMORRHAGE
- HTN!!!!
- amyloid angiopathy (amyloid deposition in BV)
2= SUBARACHNOID HEMORRHAGE
- aneurysm, trauma, abnroaml venous malformations, idiopathic
8
Q
**pathophys of hemorrhagic vs ischemic stroke **
_____has higher mortality while _____ has higher morbidity
A
ISCHEMIC - brain deprived of E (O2, glucose) because of inadequate blood flow
HEMORRAGIC (parenchymal)/ICH = MASS EFFECT = collection of blood pushing on surrounding structures
- higher mortaltiy = hemorrhagic
- higher morbidity = ischemic
9
Q
subarachnoid hemorrage is ______(more or less) common than intracerebral hemorrhage
-pathophys / cause?
A
-less common (makes up 30% of HS while IH makes up 70%)
- cause = aneurysm, AVM, idiopathic, trauma
- pathophys = raised ICP, hydrocephalus, vasospasm
10
Q
vasospasm and increased ICP is pathiophys of _______(ischemic, ICH, SAH) stroke
A
SAH - subarachnoid hemorragic stroke
11
Q
***coagulopathies like Protein C/S _____(deficiency/excess) leads to _____(ischemic, hemorragic, both) stroke
T/F - elevated homocystine levels can lead to stroke
T/F - elevated factor 8 levels can lead to stroke
A
- C/S deficiency (not breaking down clots)
- leads to ISCHEMIC stroke
True and True
12
Q
**name 4-5 things that cause ischemic stroke
A
- COAGULOPATHY = protein C/S deficiency, AT3 deficiency, DIC, MPD, factor V leiden mutation
- small/large vessel probs = atherosclerosis, embolism, vasculitis, arteritis (takayasu)
13
Q
headache symptom of _____ (subtype) while vomiting more symptom of _____
A
Headache: SAH>ICH>Ischemic stroke
●Vomiting: ICH>SAH>Ischemic stroke
●Bottom Line: Clinical presentation cannot reliably differentiate ICH from SAH or ischemic stroke. Need head CT. Not like MI, no ASA at onset of symptoms, call 911.
14
Q
aphasia
- def
- chx of ____ stroke
A
Aphasia: Loss of the ability to produce and/or comprehend language. (ex - fluency, repitition, naming, reading/writing …can have any combo of these)
-usually worse in the beginning and then gets better
-chx of left MCA stroke
15
Q
dx?
Left gaze deviation (loss of L FEF)
●Right homonymous hemianopsia (loss of L optic radiations)
●Right face/arm>leg weakness and numbness (loss of L motor and sensory cortex)
A
LEFT MCA
16
Q
superior vs. inferior division of MCA
- which clot leads to expressive vs. receptive aphasia
- why?
A
superior division»_space; motor speech (broca)
inferior divison»_space; wernicke area
- expressive aphasia = broca
- receptive = wernicke
17
Q
- frontal eye field is in ______ and is blocked by _____ strokes
- if lesion in R FEF then eyes will drift _____
A
internal carotid or middle cerebral artery
Frontal eye fields:
-R frontal eye field in »_space; L horizontal gase center (PPRF) in pons)»_space; L abducens nucleus»_space; R eye tells CNIII to go to left and L eye tells CNVI to goto left
**if LOF lesion»_space; the other dominates and eyes will drift TOWARDS side of lesion!
18
Q
what is PPFR? where is it?
A
- where horizontal eye fields communicate so that eye movements are COORDINATED
- in PONS
19
Q
*visual eye field deficits (ex- homonymous hemaniopsia) will be on ______(IL or CL) side in MCA stroke
A
-opposite side
20
Q
lateral geniculate body??
-left LGB will see ______ (L or R) side of visual fields in both eyes
A
- body after optic chiasm where the stuff coming to one side of the eye ball now join together
- ex - RIGHT VISUAL FIELDS»_space; project onto LEFT SIDE OF RETINA»_space; join together after the optic chiasm to go to the LEFT LGB
21
Q
*visual field findings if lesion occurs before vs. after optic chiasma
**ex - patient has R homonymous hemaniopspia, defect must be _______(before or after) chiasm
A
- AFTER optic chiasma get HOMONYMOUS VISUAL FIELD DEFECT = similar defect in BOTH eyes
- BEFORE optic chiasm = vision loss in 1 eye
-
22
Q
- describe visual findings in person with R homonymous hemaniopsia
- dx = _____(L or R) MCA stroke
A
- R homonymous HP = R and L eye can’t see LEFT visual fields
- would be LEFT MCA STROKE (knocking out left optic tract = carries information from R visual fields (that project onto L side of retina)
23
Q
dx?
- left gaze prefereance, aphase
- right gaze preference, left hemiplegia
- right leg weakness, apathetic
- left leg weakness, apathetic
A
- left MCA
- right MCA
- left ACA
- right ACA
24
Q
T/F - aphasia can be chx of left MCA and left ACA strokes
- neglect is chx of _____ stroke
- apathetic is chx of _____ stroke
A
TRUE - but classically in left MCA, would have to be major ACA
neglect = right MCA apathetic = L/R ACA
25
dx? 70yo RH lady suddenly feels like the room is spinning around her. Spinning sensation persists for 1 hour associated with nausea and vomiting. When she reaches for the phone, she accidentally knocks it off the table with her left hand. She notices that her L face is numb and her R arm and leg are numb.
LEFT PICA >> affecting lateral BS !
>> KO of CL spinothalamic tract
>> LO of IL sensory trigem
26
dx? 70 year old comes in with double vision and becomes weak in her R arm and leg
double vision = thinking Midbrain (3 and 4 CN) and pons (6)
- weakness in arm and leg on R side = LEFT BRANCH OFF BASILAR (supplies CS motor tracts through the pons)
- may progress to "locked" in if basilar gets blocked
27
lacunar syndrome chx by _____(sensory deficiets, motor, both, neither)
- usually a little bit of both
- can be pure sensory or pure motor though
- all depends on locaiton
28
dx? 70 year old with paralysis of L side of face, weakness in R arm and R leg, no sensory visual or language abnormalities
- lacunar syndrome leading to pure motor hemiparesis
| - typically localized to deep penetrating arteries feeding internal capsule or pons
29
dx? 70 year old with numbness over face, arm and leg on R side, no motor visual or language changes
- pure sensory stroke lacunar syndromes
| - typically localized to posterior ventral nuclei of thalamus
30
*stroke that KO supply to posterior ventral nuclei of thalamus can lead to_____
Pure sensory stroke (lacunary syndrome)
| ●Isolated numbness over the face, arm and leg on one side without any motor, visual or language abnormalities.
31
dx? 70 year old with wekanss in her L aarm and leg and decreased sensory information on L side, no visual or alnguage chances
- sensorimotor stroke type of lacunar syndrome
| - typically localizes to thalmic-internal capsule (posterior limb) jxn
32
dx? 70 year old with weakness and incoordination on L side of the body without any sensory, visual or language abnormalities.
- lacunar stroke >> ataxic hemiparesis on R
| - typically localizes to internal capsule or pons
33
* where would localization of problem be in lacunar stroke patient with:
- weakness and coordination on one side only
- combo of motor and sensory deficits on one side only
- numbness over 1 side only
- paralysis over 1 side only
- weak/coordination = hemiparesis = internal capsule/pons
- motor/sensory = sensorimotor stroke = thalmic/internal capsule (posterior limb) jxn
- sensory only = pure sensory = posterior ventral nuclei of thalamus
- motor only = pure motor = deep penetrating arteries feeding internal capsule or pons
34
*early treatment of stroke patients with _____ results in decreased risk of disability
t-PA
35
dx? 70 year old R-handed F PMH of HTN, presents with facial droop, L arm/leg weakness, left hemineglect, left homonymous hemaniopsia
*what is NEGLECT / how do you test for it?!
- NEGLECT = don't recognize or have any awarenesss of One side! (ex - ask to clap and only move R hand, only describe R side of a picture, or show them their left hand but don't recognize it)
- dx = R MCA = neglect, left hemiplegia
36
–Left hemiparesis involving face, arm and leg equally, consistent with ______ lesion
–Left visual field deficit consistent with ______ lesion
–Left hemi-inattention (neglect) consistent with right _______ cortex lesion
–Left hemiparesis involving face, arm and leg equally, consistent with right SUBCORTICAL lesion
–Left visual field deficit consistent with right PARIETOTEMPRAOL/ OCCIPITAL lesion (optic radiations)
–Left hemi-inattention (neglect) consistent with right PARIETAL cortex lesion
= FULL RIGHT MCA
37
dx? 70 year old with severe left leg weakness, some left arm weakness, apathetic
right ACA
38
stroke ddx? (4-5)
●Partial SEIZURE with postictal hemiparesis (Todd’s paralysis)
●Hypoglycemia/hyperglycemia
●Toxic-metabolic insult with old cerebral lesion
●Subdural hematoma
●Tumor with edema, bleed, or seizure
--abscess from infection (leading to edema/seizure)
39
1st thing to do with suspected stroke is to get _______(imaging)
- on the way can start ordering ______ labs/tests
- what labs are we particularly interested in?
-start laboratories (CBC, CMB (esp GLUCOSE!!), PT/PTT, cardiac biomarkers) ON WAY TO GET NONCONTRAST CT SCAN
+ ECG esp if in ED and has chest pain?
40
dx? person with left sided weakness and slurred sspeach ; CT shows white blob right by left ventricle on left side
T/F - give tPA IMMEDIATELY!
RIGHT ICH!
FALSE!! do NOTTT GIVE tPA ... will just make bleeding worse
41
if CT scans shows subacute ischemia _____(do or do not) give tPA?
do NOT
42
if CT scan shows white cortex with black blob at like 2'oclock on the right (touching cortex, right by lateral ventricles) might expect _____deficits
-would be more likely to have ____(expressive or receptive dysphagia or neither)
- lesion on right side of image = LEFT SIDE OF BRAIN
- would expect Right sided weakness (2'oclock = frontal lobe) if affecting motor cortex and EXPRESSIVE DYSPHAGIA (if affecting broca area)
43
children tumors are usually _____(supratentorial or infratentorial) while adult brain tumors are usually_______
```
kids = infra > supra
adults = suprae >infra
```
*below and above CEREBELLUM
44
* **2-3 signs of
- non-localized signs
- ITP
- localized signs
- nonlocal = dizzy, headache, listlissness, VOMITTING (>2wk)
- ITP = headaches, papilledema, irritiability
- local = gait problem (cerebellum), seizures, hemiparesis/sensory
45
headache chx in peds brain tumor patient
- onset/timing?
- other symptoms?
- onset usually at night or early morning (when inc CSF flows in)
* classic = wake up with headache and vomit
46
T/F - seizures are more common presenting symtpom in kids vs adults brain tumors (BT
FALSE ... because seixures are NOT generated in cerebellum/BS (infratentorial) where most BTs in kids are located
*may have seizures in kids though from hydrocephalus b/c of inc ICP though
47
what is NOT symptom of ICP:
- Headache (esp early morning) with vomiting
- Irritability, lethargy and vomiting
- Bulging fontanelle/separation of sutures
- Papilledema
- 6th nerve palsy
- Others (e.g. anisocoria, ataxia, head tilt)
ALL!
48
- would order _____(MRI, CT, PET) for kid with brain tumor
- T/F - always do a lumbar puncture\
-would order ______(MRI, CT, PET) for 80 year old patient with afib presenting with stroke symptoms onset 2 hours ago
- MRI/CT
- ALMOST NEVER - ITP can cause hemorrhage and will DIE
-DO CT!! - quicker than MRI and want to dx ischemic (vs hemoorage) ASAP to start on tPA (w/in 3 hours of onset).
49
T/F - Diffuse intrinsic pontine glioma can cause major balance problems
T/F - pilocytic (sp pilocytic) is one of most common brain tumors in kids and is high grade
TRUE
FALSE - low grade; has great survival
50
- -dx? 8 year old presents with headache and dizziness, see solid white/ BRIGHT mass ON CONTRAST in cerebellum
- -dx? same as above except vision loss and see white mass in optic nerve?
- both PILOCYTIC ASTROCYTOMA (MOST COMMON TUMOR!!)
| - can occur in 3 places = cerebellar, optic nerve, hypothalamis
51
* **pilocytic astrocytomas are characterized histologically by _________
- - they are tumors of ______cells and thus they are ______+ (histological marker)
- ROSENTHAL FIBERS = thick Pink blobs in see of pink .... PATHOLOGIC HALLMARK OF PILOCYTIC ASTROCYTOMA
- glial tumors - so usue glial tumor (GFAP+) to dx
52
***what is brain tumor?
- Rosenthal fibers, GFAP+ = _______
- Pseudorosettes, EMA+ = _______
- Small, round blue cells with Homer-Wright rosettes = _____
- vimentin, EMA+ in adults
*what is the most common malignant brain tumor in kids?
- pilocytic astrocytoma
- ependyoma (has a ton of calcium)
- medulloblastoma (not as much calcium) **
- meningioma
**medullo is most common malignant brain tumor
53
GFAP will be + or - in :
- medulloblastoma
- epindyoma
- astrocytoma
- medulloblastoma (neuronal cells)
+ epi (glial - ependymal - lining ventricles )
+ astro (glial - astrocytes -
*GFAP = marker of glial cells
54
which would be least catostrohic in terms of surgery to remove
- -cerebellar pilocytic astrocytoma
- -brainstem glioma
- -medulloblastoma
*cerebellar pilocytic astrocytomaa - neurosurgeons love this oen cause can take it out and cured
- BS very important obviously and has bad prognsis
- medulloblastoma has ppoor prognosis and spreads rapidly so less good for surgery
55
T/F - neurosurgery is obligatae for diagnosis
T/F - gross total resection is the ideal
T/F - radiation is common adjuvant therapy for pediatric brain tumors
- T
- T
- FALSE ... CHEMO is used in most cases
RADIATION just fucks everything up (get N/V, hair loss, moyamoya, hair loss, drop IQ) so radiation should be deferred as long as possible (later the better; never use in kids
56
T/F - chemotherapy used as adjuvant therapy in most cases and particularly good for germ cell and medulloblastoma
T/F - secondary malignancy is problem we have to worry about for CHEMO and RADIATION
TRUE
TRUE
57
msot common histology type of brain tumor in kids (5-15) is ________(astryocytoma, pituitary, menangioma) in adults is -____
kids = astryocytoma
teens =pityiatary
adults = menangioma
58
- histo chx of glioblastoma
- is it high or low grade
- GFAP ___(+/-)
pseudo-pallisades, necrosis, vascular porliferation, mitosis/anaplasia (HIGH GRADE)
-GFAP+
59
Ki-67+
- marker for what
- what adult brain tumor is +
- mitosis marker
| - glioblastoma
60
Oligodendroglioma is almost always ____(supra or infratentorial) and likes the ______lobe is characterized by ______ on H&E
- supra
- frontal
- fried eggs
61
brain tumor dx?
- "chicken wite" capillaries on frontal lobe biopsy
- small, round blue cells ,GFAP-
- GFAP+, pseudopalisading with endothelial cell proliferation
- oligodendroma
- medulloblastoma
- glioblastoma
62
*glioblastoma chx arises in the ______(part of brain) and looks like ____ on imaging
-cerebral hemispheres - chx crosses the corpus callosum - BUTTERFLY LESION
63
*most common neoplasm found in CNS is _____
-metastasis! usually from lungs, breast, skin, kidney and GI ... via hematogenous spread
64
T/F - metastatic brain tumors usually occur via hematogenous spread and have MULTIPLE LESIONS
T/F - methylated MGMT in glioblastoma therapy have worse prognsis than unmethylated
T/F - most mets to brain are hemorrhagic
- TRUE
- FALSE ... methylated responds BETTER
- false (3-14%)
65
dx? 65 year old male presents with seizure and inability to concentrate, agitated and confused, see mass in frontal lobe on MRI, biopsy shows nests of small cells with hyperchromatic nuclei
met pulmonary small cell
66
dx? 49 year old women presents with recurrent headaches and pounding in ears, MRI shows mass in frontal lobe, biopsy shows WHORLS
MENINGIOMA
- female pre-dominance
- symptoms depend on location
- can also see PSAMMOMA bodies
67
*psomma bodies can be seen with ______ brain tumor which _____(does or does NOT) invade the cortex
MENINGIOMA ...does not invade the cortex
68
#1 benign brain tumor in adults is _____ which is a tumor of _____ cells
MENINGIOMA
- arachnoid cells
- F>M
- tumor compresses but DOES NOT INVADE THE CORTEX
69
T/F - give t-PA in stroke patient especially if see blood on CT indicating hemorrhage (ie, from intracerebral or subarachnoid hemorrhage)
FALSE
70
penumbra??
- def
- importance for stroke
- Penumbra is salvageable within ______ hours after ischemic stroke onset
Penumbra is zone of reversible ischemia around core of irreversible infarction ... since in the center it has no collaterals and it dies first!!
Penumbra is salvageable within first few hours after ischemic stroke onset
```
Penumbra is damaged by:
Hypoperfusion
Hyperglycemia
Fever
Seizure
```
71
* **criteria for IV t-PA in stroke patient
- ______ type of stroke
- Onset within _____ hours
- Need CT?
- Give to person with ____(major or mild or both) symptoms
- BP?
- ACUTE ISCHEMIC
- w/in 3 hours
- YES - to make sure its acute ischemic
- BP
72
which of the following is NOT contraindication for administering tPA:
- seizure at onset of symptoms
- back or chest pain
- 95 year old
- abnormal PT
- major symptoms (neglect, gaze preference etc)
- no upper age limit so 85 is OK !
| * the rest ARE contraindications (seizure, pain, major symptoms
73
should you give tPA?
- 85 year old w/ stroke onset 1 hour ago with BP of 200/100
- 46 year old w/ symptoms onset 2 hours ago BP of 170/100
- 65 year old symptoms onset 5 hours ago with BP of 145/80
- NO (BP too high > 185/110)
| - YES! (onset
74
which is/are NOT true:
-tPA benefits all acute ischemic patients regardless of etiology
-there is NO upper size limit (ie, still give even if large infarcts)
- TRUE!
| - TRUE!
75
***if clot is too large that it doesn't respond to tPA, what do we do next??
EX - if patient presents w/ qualified for tPA but clot is 8mm what do we do?
EX - if take to angio and core is 10 ml and hypoferfusion area is 60 (so mismatch 6:1) ... should we do thrombectomy??
EX - if mismatch ratio is 1:1??
- take to ANGIO for THROMBECTOM! ... angio so can see access to BVs and can measure core / penumbra area (use to decide what to do)
- if meets criteria then still give tPA but probably won't work so get ready for angio/thrombectomy
- YES! mismatch 6:1 = 6x amt of tissue to salvage as there is damaged tissue ... so recovery probability pretty good because can restore blood to large area around the core (SALVAGE the 60ml of PENUMBRA! )
- NO! if core is just as large as tissue at risk then DON't becuase reperfusion injury is too high
76
*if stroke patient has factor C deficiency, should give _____ to treat
T/F - daily aspirin can help prevent future stroke
- warfarin (antiplatelet like tPA probably not good enough)
| - true
77
**post-stroke evaluation**??
- when to do TTE vs TEE (which is invasive)
- should we do a carotid duplex or MCOT first
1 - non-invasive evaluation to find source (MRI, carotid duplex, TTE)
2- if no source consider invasive (TEE, angiogram, MCOT)
3-if
78
carotid duplex ?
T/F - non-invasive way to find source of stroke?
- done after stroke ... watch flow through chambers of art ... assess plaques/ flow
- TRUE
79
- -TTE findings in post-stroke pt that signal increased risk of recurrence?
- -is high or low Ejection fraction more worrisome?
T/F - if see "spontaneous echo" should start on anti-coag like warfarin becuase of high risk of recurrence
TTE - if ejetion fration low (ex > blood pools >> inc CLOTS >> get "sponateneous echo" = HIGHER RISK >> start on anti-coagulat or other agent like warfarin (not just antiplatelet like asprin)
TRUE
80
* should you start on antiplatelet or anticoag
- large artery atheroscclerosis
- cardioembolism
- hypercoagulable state
- small vessel state
- antiplt
- anticoag
- anticoag
- antiplatelet
81
* *are each antiplatelet or anticoagulation therapy:
- clopdrogel (plavix)
- warfarin (coumadin)
- dabigatran
- apixaban
ANTIPLT = aspirin, clopidrogel
ANTICOAG = warfarin (coumadin), newer agents (dabigatran, endoxaban)
82
_______ is #1 cause of ischemic stroke
-name 4-5 etiologies
THROMBOEMBOLISM
- cardio (afib, low EF)
- large-artery atherosclerosis
- hypergoagulable state (pregnancy, DIC)
- small-vessel disease
- hypotension (blood loss etc)
83
*how do you counsel patient on warfarin?
-- INR must be followed closely (so F/U FREQUENTLY!)
●Bleeding risk (DON"T FALL!!)
●Vitamin K inhibits warfarin
●maintain consistent diet
●Avoid medications that interact with warfarin
84
***give 4-5 recommendations you would give to stroke patient to prevent recurrence?
- control BP (exercise/diet)
- control hyperlipids (statin, fish oil)
- control DM (Aic
85
* REVIEW END OF 4th STROKE LECTURE* (IMAGING)
| * how do you tell difference between acute ischemic vs subacute ischemic vs acute hemorrhagic (COLOR)?
OK
- SUBACUTE = DARK(GRAY)/DELINEATED AREA (gray = less dense; delineated = edema developing)
- ACUTE HEMORRHAGE = WHITE (acute blood is hyperdense)
- ACUTE ISCHEMIC = BLURRING of gray/white jxn (no obvious mass)
86
T/F - deep brain stimulation can be used for parkinsons?
TRUE -parkinsons and dystonia and others?
FOR PARKINSONS:
-stimulation of Gpi or STN
-mech of action unkown
-improves dyskinesia by allowing dose reduction of levodopa
87
dx? tremor at rest, difficulty arising from chair (akinesia) and slowing of activities of daily living (bradykinesia), rigidity
PARKINSONS
88
sporadic cases make up ______(majority or minority) or parkinsons' diseaes while genetics make up ______
- sporadic = majority >80%
| - genetic = minority
89
* **parkinsons dx?
| - requires __________
**Definite diagnosis requires BRADYKINESIA + at least one of …
–Muscular rigidity
–4–6 Hz rest tremor (very typical for Parkinson’s disease!)
–Postural instability
•Onset typically asymmetric, progression typically slow and smooth
•“Red flags”
–Presence of cerebellar signs
90
_____ is most effective drug for parkinsons
- mech
- always used w/ _____
LEVODOPA = Most effective drug for parkinsonism
•Large AA needing active transport across gut/brain blood barrier
•Converted into DOPAMINE! in dopaminergic neurons and other cells
•Always given in conjunction with blockers of peripheral conversion (CARBIDOPA)
91
dx? 62 year old man presents with tremoring or hands that has gotten worse over past two years, mostly in arms only, and is WORSE in the right hand vs the left hand, have noticed that they are also
-probably a problem in ______(basal ganglia or cerebellum)
TREMOR - prob cerebellum not basal ganglia
92
dx? 65 year old F presents with difficulty sleeping, change in appetite and lack of attention. Also has notice tremoring in her R hands that hs gotten progressively worse. PE+ for hyposmia, oriented x2, +romberg sign
lewy body dementia (presents with parkinson symptoms early)
93
Rx for essential tremor
- beta blockers
- primidone
- benxos
- botulism
surgery - thalactomy or thalamus stimulation
94
slow/sustained involuntary muscular contractions and abnormal posture is chx of ______(parkinsons, dystonia, essential tremor, dyskinesia)
DYSTONIA
-NOTE - NOT a dx, a symptom that can be associated with various disorders
95
dx? 50 year old presents with "twitching" in her R neck that; worse when she moves her head or is tired, describes twitching as slow but continuous. Alleviated by touching her face or holding her chin
-what would you used to treat?
- FOCAL (CERVICAL) DYSTONIA ... alleviated by "sensory trick"
- BOTOX, ANTICHOLINERGICS (trihemiphenidyl, benxotropine) BENZOs, BACLOFEN (GABA agonist)
- most common type of dystonia in adults
- usually action-dependent (ex - in hand after writing or playing instrument)
- pathophys unclear
96
GAG deletion at DYT1 locus can lead to ______
GENERALIZED DYSTONIA = muscles all just contracting randomyly >> twisting/squeezing (video of child w/ limbs and neck and everything just haywire)
*other mutations can lead to limb dystonia (fast and slow "squeezing")
97
T/F - Pallidal deep brain stimulation is current neurosurgical treatment for generalized dystonia
TRUE
98
BACLOFEN
- mech
- use
- GABA receptor agonist
| - used to treat muscle spasms (DYSTONIA, MS) ... not recommended for parkinsons!
99
BLEPHAROSPASM
- def
- rx?
- focal dystonia of eye lids
| - anticholinergics or botulism toxin (block release of ACh)
100
tardive dyskinesia
- etiology
- def
- rx
- IATROGENIC (cuased by drugs)
- involuntary movements (other than tremor) resulting from rx neuroleptic drug for at least 3 months (>1 month if >60 yo)
- stop drug,
101
T/F - dystonia can be caused by neuroleptic drugs llike haloperidol (butyrophenone)
FALSE - drugs like haloperidol causes tardive dyskinesia not dystonia
HALO = antipsychotic with strong dopamine antagonism properties
102
T/F - tardive dyskinesia may appear during or late after use of neuroleptics
T/F - if presents when on drug, stopping drop will reverse the dyskinesia
T/F - atypical antipsychotics (cloxapine) or dopamine depleting agents (tetrabenazine) can be used to improve symptoms in person with dyskinesia
TRUE
FALSE - not always, can be irreversible
TRUE
103
trihexyphenidyl and benztopine
- mech
- use
- anticholinergics (non-specific muscarinic antagonist)
| - used for tremor and rigidity (parkinsons, essential tremor, and dystonia) but NOT for dyskinesia
104
- parkinsons is a ______(hypo or hyperkinetic) disorder
- essential tremor is a ______ disorder
T/F - tremors seen in majority of parkinsons
- parkinsons = hypokinetic (akinesia or bradykinesia is key chx)
- ET is hyperkinetic
FALSE!! only 20% have tremors... loss of movement (akinesia or brady) is relaly defining chx
105
T/F- neurosurgery like DBS can be used for most movement disorders including parkinsons, dystonia and dyskinesia
T/F- most movement disorders are ASSYMETRIC
TRUE
TRUE
106
T/F - there is a strong genetic component in essential trmeor (with ~50% of pts have affected 1st degree relative)
T/F - there are no known non-genetic risk factors for ET
TRUE
| TRUE
107
dopamine _______(accumulation or loss) is associated with parkinsons
T/F - degree of dopamine (gain/loss) is associated with SEVERITY
DOPAMINE LOSS = PARKINSONS
| 90% = advanced disease
108
difference between tremors in parkinsons vs. essential tremor?
- -PARKINSONS = REST TREMOR (when muscle relaxed)
| - -ET = postural and/or kinetic (while moving/holding)
109
chorea is a ______(Hypo or hyper) kinetic movement that is _____(non-repetative or repetative) and seen in _____(Parkinsons, Hungtingtons, both)
- hyperkinetic ; jerky / spastic (like in DYSTONIA oR HUNGTINGTONS)
- non-repetative movements
- seen more in HUNTINGTONS but not as much in parkinsons
110
sterotypy vs tics
- def
- associated disorders
STEROTYPY = repetative movements/behaviors like bounching leg or messingwith fingers or rocking back and forth ...associated with schizophrenia, ASD etc)
TIC= repetative behavior usually motor (blinking, twitching , jerking) but can be vocal ...assoc with tourettes and drugs
111
CLONUS/MYOCLONUS
- def?
- how to test?
- _____(UMN or LMN) problem
- -involuntary, rhythmic JERKS/TWITCHES ("large" motion contractions (hand flapping, patellar jerk)
- -ask to hyper-flex hand, or quickly hyperflex foot back and hold (initiate clonus by reflex)
--UMN!!
112
kayser-fleischer ring is chx of ______ disorder
WILSONS (copper metabolsim problem) ... looks like sand around border of iris
113
dx? 75 year old presents with double visionand coomplaining that she cant' read the newspaper anymore, no balane probs, NEURO EXAM - eyes can't fixate (twitch back and forth when asked to focus on finger) and eye tracking movements are jerky (ex - "stair-case" saccades)
PARKINSONS
114
T/F - focal dystonia can be treated effectively by c. botulism
TRUE!
115
- DBS into globus pallidus can be used for ______
| - DBS for lesions of cerbellar thalamus can be used to treat ______
- parkinsons
| - ET
116
"alien" limb (constantly holding left hand with right hand) and can't raise the right hand associated with _______
- contralateral stroke
| - corticobulbar syndrome
117
are each input or output in BG: putamen, pallidum, substantia nigra, subthalamic nucleus
```
INPUT = putamen and subthalamic nucleus (STN) - ... project via internal circuits to >>
OUTPUT = pallidum (GPi) and substantia nigra >> THALAMUS
```
118
T/F - BG circuit of primary motor is similar to oculomotor circuit just different parts
T/F -limbic system has loop through the BG that is involved in depression and OCD
TRUE
-oculomotor /prefrontal/limbic run parallel to the the motor loop ...there 1st stop is in the caudate (cognitive) vs the putamen (motor) part of striatum
TRUE
119
indirect vs. direct pathway of striatum
D1 receptor = ____ pathway
D2 receptor = ____ pathawy
*parkinsons has too much of _____(indirect or direct) pathway
INDIRECT (D2) = INhibits cortical movement) ... too much indirect signals in PARKINSONS
DIRECT (D1, "D1Rect") = stimulates movement
120
striatum ?
lentiform?
*what is pathway from motor cortex out of BG?
STRIATUM = putamen (motor) and caudate (cognitive)
LENTIFORM = putamen + globus pallidus
motor cortex >> putamen (striatum) >> globus pallidus externus >> globus pallidus interna >> STN / thalamus
(STN can also stimulate Gpi
121
4 cardinal chx of "parkinsonism" (B.R.A.T)
- bradykinesia (slowing down)
- rigidity
- akinesia (freezing, can't move, can't get up)
- tremor at rest
122
excitatory/inhibitory BG pathways:
- which is direct vs. indirect
- which involves GPi vs GPe
- which involves STN?
DIRECT = "stimulates thalamus/movt by blocking Gpi"
[[cortical input >> STRIATUM >> GABA blocks GPi >> thalamus no longer blocked >> INC MOVEMENT]]
INDIRECT = "inhibits thalamus by stimulating GPi via blocking Gpe"
[[cortical input >> STRIATUM >> release GABA >> blocks GABA from GPe >> STN no longer blocked >> STN STIMULATES Gpi>> BLOCKS THALAMUS >> blocks movement]]
123
**Stimulation of thalamus will ____(inc or dec) movement via BG pathway
- thalamus is ____(inhibited or stimulated) by Gpi
- Gpi is _____(inc or dec) in parkinsons
- THALAMUS = INC MOTION
- thalamus inhibited by GPi (so blocking Gpi will inc motion by disinhibting thalmus)
- INC GPi (because less direct pathway >> more Gpi >> more thalamus inhib >> less motion)
124
- early symptoms of parkinsons
| - "red flags" / bad prognostic signs in parkinsons disease?
EARLY = sleep problems, don't swing arm w/ gait
RED:
- cerebellar signs (balance, finger tracking intention)
- gaze palsy (indicates supranuclear?)
125
Lewy bodies
- def?
- where is it found?
- found in ____ disease
- deposits of proteins (esp alpha-synuclein) in brain cells/within axons
- ascend from brainstem >> to substantia nigra >> cortex
* may explain why get sleep probs (BS) before motor dysfunction (SN)
- in PARKINSONS
126
- alpha-synuclein role in parkinsons?
| - leads to _____(loss or gain) or pigment in substantia nigra ??
alpha-synuclein >> forms fibriles that make "LEWY BODIES" (intracellular eosinophilic (PINK) inclusions) >> loss of dopaminergic neurons (DEPIGMENTIATION) of substantia nigra
-note - lewy bodies may have "prion" qualities (secreted from one cell to the other)
127
T/F - loss of even 10% of dopamine can lead to parkinson symptoms
T/F - severity of dopamine loss does NOT strongly correlate with balance probs/dimentia etc
FALSE --- need >70% loss for symptoms, >90% for advanced parkinsons
TRUE !
128
get loss of dopamine primarily in ____ part of striatum in parkinsons
- lose more in the PUTAMEN (motor), less in the caudate (cognitive)
- less dopamine >> less D1 receptor binding >> less "DI"rect pathway in basal ganglia >> less movement
129
**substantia nigra pars compacts (SNc) _____(inhibits or stimulates) the putamen
BOTH ... can stimulate (via D1 receptor w/ dopamine) or inhibit (via D2 receptors)
130
Amantadine
- mech
- use?
- -Antiviral agent; antiparkinsonian benefit found empirically
- -Effective against tremor, bradykinesia, rigidity and dyskinesias
- -Mechanism of action unknown
131
LEVODOPA
- mech
- use?
- -Converted into dopamine in dopaminergic neurons and other cells
- -PARKINSONS
132
T/F - dopamine receptor agonists are LESS effective than levodopa in all stages of parkinsons disease
TRUE
133
pramipexole/ropinirole
- mech
- uses
- non-ergot dopamine agonist (bromocriptine = ergot , not preferred)
- PARKINSONS
134
T/F - a lesion or surgical ablation of the STN would be expected to ameliorate parkinsons
T/F - DBS of STN can be used to treat parkinsons
--TRUE ... part of the indirect pathway (inhibiting movement) which is stimulated in parkinsons (INDIRECT = input thru putamen >> GPe>> STN >> GPi>> down-reg thalamus)
--TRUE! .... someonewhat paradoxical - that stimulationg and inhibting can both help
135
*pallidotomy procedure destroys the _____(Gpi or Gpe) and is therefore helpful to treat parkinsons
* remove Gpi = inhibtior of the thalamus
* basically mimic the direct / excitatory pathway again which downregs Gpi thus increasing thalamus stimulation of motion
136
***ablation of the STN would be expeccte dto lead to ____
STN = stimulates Gpi which blocks thalamus / blocking movement
So can help parkinsons (akinesia/bradykinesia) and rigidity and tremor
137
DBS of the thalamus can be used to treat ______(parkinsons, tremor , dyskinesia , dystonia none)
used for HYPERKINETICS -- tremor / dyskinesia / dystonia but NOT PARKINSONS
stim Vim/VLp for tremor ; stim VLa for dyskinesia, chorea, dystonia
138
Which meets DSM for TOURETTES:
--16 year old presenting w/ progressive motor tics, including blinking and nose twitching, and sustained eye closure. No drugs. No phonic tic
--20 year old with phonic tic, onset 4 years ago. Daily to every other day. No drugs. Rubs his eyes and blows nose continuously until nose bleeds.
- NO
- YES
- -Multiple motor and at least one phonic tic with onset before age 18.
- -Tics may be intermittent, but must be present many times during the day, daily or almost daily for at least 1 year with tic free intervals no longer than 3 months.
- -The tics cannot be explained by other medical conditions or drugs.
139
T/F - most tourettes onset before 10 years of age
| T/F - over half of TS patients have OCD and/or ADHD
- T
| - T (60-90% have OCD, 50-90% have ADHD)
140
T/F- OCD and ADHD has a much higher prevalence in TS than in general population
TRUE
141
T/F - in patients with TS/tic disorders the presence/severity of ADHD are the MAIN predictor of associated behavior and social probs
TRUE
142
T/F - msot TICS don't require treatment
T/F - should treat ADHD and OCD symptoms before TICS in severe cases
TRUE
FALSE: TICs >>> OCD >>> ADHD
*treating for ADHD Can make tics worse
143
dx? 25 year old F with no PMH presents with nystagmus, intention tremor and telegraphic speech
CHARCOT TRIAD = MS
-but not unique to MS
144
* *MS**
- age of onset
- F or M dominated
- _____(F/M) more likely to be dx later and be more progressive
- 15-50
| - F >> M (3:2) ... men more likely to develop later in life and be more progressive
145
* etiology theory of MS
- more likely in _______countries
- environmental risk factors related to this geography??
- more likely in Northern/Southern countries (away from equator)
- risk factors = less VITAMIN D (sun exposure) .. vit D levels inversely assoc with MS risk
146
T/F - increased vit D is associated with higher risk of MS
T/F - higher vitamin D is associated with better progression in MS after diagnosis (for ex - REDUCES RELAPSE RATE)
- FALSE - opposite
| - TRUE
147
which is NOT associated with MS risk:
- gut microbiome
- race
- EBV
- HLA-B27
- smoking
-HLA-DRB1 ... increases risk 3 fold
148
-HLA_____ and ____ virus are assoc with MS
- HLA-DRB1
| - EBV
149
* **symptoms of MS
- GI/GU
- Neuro
- MSK
- eyes
- bladder problems
- cognitive difficulties
- depression
- fatigue
- muscle rigiditystiffness
- numbness/tinglinging
- NYSTGMUS (MS common cause)
- optic neuritis
**NOTE - NO PATHOPNEUMONIC SYMPTOMS **
150
dx? 54 year old with numbness and tingling in legs and face gotten progressively worse over last year, weak L leg, urinary incontinence, nystgmus has intention tremor in L hand, see "black" hole on MRI in frontal cortex and whitem atter changes/plaques
MS
- MRI >> look for plaques/abnormal intensity (white) in cerbrum
- CSF >> inc Ig, seperation into OLIGOCLONAL BANDS, abnormal WBC
151
* Pathophys of MS
- due to ________
- _____(cold or heat) makes pathophys worse
- break down of BBB >> Lymphocytic infiltrate (CD4 T cells + macros / microglial) >> demyelinate axons + inflammation
- conduction not stable/prone to fail
- Factors leading to block = local inflammation, large number of impulses, HEAT (ex - if optic neuritis, hot shower can make vision worse)
152
***what tests do you do to dx MS?
- MRI (plaques, white matter changes in cerebrum -- "finger projections" coming of corpus collasum)
- CSF (inc Ig in the CNS, seperation into OLIGOCLONAL BANDS)
- evoked potentials (abnormal visual evoked potentials
153
Gd-enhanced lesions on MRI indicates _______
- means break down in BBB >> inflammatory cells allowed to get in
- assoc with MS
154
MRI findings in MS (2-3)
- multiple white matter changes in dif parts of cereberum (classic = "finger projections" around corpus callosum/lat ventricles)
- periventricular "plaques" = areas of oligodendryocyte loss/reactive gliosis
- Gd-enhanced lesions
- T2 hyperintense (white) lesions= shows prior inflammatory response
- T1 black hole = irreversible axon damages
155
-autoimmune destruction of myelin sheaths is chx of _______ disease
MULTIPLE SCLEROSIS
156
T/F - in MS, myelin sheath is attached by an immune response, Specifically, CD4 T cells, macrophages and microglial cells initiate an attack on the sheath after passing through the blood-brain barrier
T/F - myelin can regenerate and symptoms can spontaneously improve in MS
TRUE
TRUE
157
T/F - response of T-lymphocytes from patients with MS for reactivity with Myelin Basic Protein (MBP).
T/F- No specific oligoclonality has been found to help differentiate patients outcome/rx with MS.
True?
| True
158
***treatment of acute episode of MS
T/F - Acute treatment is intended to ONLY decrease length of relapse but Does not affect degree of recovery
***treatment for prevention of future MS attacks / disease progression
-IV methylpredinsolone (3-5 days) ... or oral predinsone/dexameth
TRUE
-immunemodulating/supressant (IFN-beta , glatiramer Acetate, daclizumab)
159
dx? 25 year old F with no PMH presents with nystagmus, intention tremor and telegraphic speech
CHARCOT TRIAD = MS
-but not unique to MS
160
* *MS**
- age of onset
- F or M dominated
- _____(F/M) more likely to be dx later and be more progressive
- how to make diagnosis?
- 15-50
- F >> M (3:2) ... men more likely to develop later in life and be more progressive
- DX = CSF (inc IgG/oligoclonal bands) and MRI (periventricular plaques, multiple white matter lesions)
161
* etiology theory of MS
- more likely in _______countries
- environmental risk factors related to this geography??
- more likely in Northern/Southern countries (away from equator)
- risk factors = less VITAMIN D (sun exposure) ... vit D levels inversely assoc with MS risk
162
T/F - increased vit D is associated with higher risk of MS
T/F - higher vitamin D is associated with better progression in MS after diagnosis (for ex - REDUCES RELAPSE RATE)
- FALSE - opposite
| - TRUE
163
MS drugs:
- _______ is naturally occuring cytokine that supresses CD4 response
- _______ is synthetic protein that simulates myelin and may block myelin-damage. Safest drug for MS
- ______ activates GABA receptorsin spinal cord and helps muscle spasms
- IFN-beta
- Glatiramer acetate
- baclofen
164
Daclizumab
-mech
T/F - 1st line therapy for MS
- monoclonal Ab binding to CD25 (blocking IL-2 recpetor of T cells)
- False - 2nd or 3rd line, Lots of SEs
165
Natalizumab
- mech
- use
- SE
- monoclonal ab against alpha4 integrin on leukcoytes (prevents migration across BBB)
- MS
- inc risk of PML
166
**list types of drugs (oral vs. injectable vs infusion) that will prevent future attacks / reduce relapse rate in MS
- ex of each
- which is MOST EFFECTIVE?
- injectables = IFN-beta, glatiramer acetate, daclizumab
- oral = terifulunamide, fingolimod, dimethyl fumarate
-infusion immunosupressant = NATALIZUMAB (MOST EFFECTIVE)
167
______ drug used to treat _____ is monoclonal ab against alpha4 integrin on leukcoytes (prevents migration across BBB)
treats MS = NATALIZUMAB
