Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
179 Cards in this Set
- Front
- Back
|
CN III, IV, and VI
|
Oculomotor, trochlear, abducens
All 3 tested together Eye movement EOMs, conjugate gaze, pupillary response to light (direct and consensual) & accommodation (CN 3) CN4= 4oclock nasally |
|
|
CN 7
|
Facial. Motor and sensory. Hook, closes eye.
Symmetry and facial expression. Taste anterior 2/3 of tongue. |
|
|
CN 3
|
Oculomotor. Opens eye
|
|
|
CN 5
|
Trigeminal. Sensory & motor. Sensation of face-> ophthalmic, maxillary, mandibular. Test with sharp, dull, light in 3 areas.
Motor: Temporal & masseter muscle strength, lateral movement of jaw. |
|
|
CN 9 and 10
|
Glossopharyngeal and Vagus.
Motor and sensory, tested together. Position of uvula, soft palate, gag reflex. CN 9 posterior 1/3 of tongue. |
|
|
CN 11
|
Spinal Accessory. Motor. SCM/TZ muscles. Elevate shoulders & move head against resistance.
|
|
|
CN 12
|
Hypoglossal. Motor; innervation of the tongue. Inspect tongue position protruded, and side to side, push against cheek.
|
|
|
CN 2
|
Optic. Sensory/vision. VA, VF, fundoscopic.
|
|
|
CN 8
|
Acoustic. Sensory. Cochlear branch: hearing (whisper, fingers, weber/rinne). Vestibular branch: Balance
|
|
|
TIA etiologies
|
Embolism: Cardiac from RA, endocarditis, atrial myxoma, atrial septal defects, atherosclerosis.
Inflammatory: (SLE, polyarteritis, GCA) Hematologic: sickle cell, anemia |
|
|
Anterior circulation (70%)
|
Anterior cerebral artery
Middle cerebral artery Posterior cerebral artery Carotid |
|
|
Posterior circulation (30%)
|
Vertebra
Basilar Cerebellar |
|
|
Internal Carotid sxs
|
Slowly occludes. Mimics MCA or ACA. Contralateral body weakness, numbness or paresthesia, dysphonia, visual loss non-ocular (ipsilateral to lesion)
*Ipsilateral blindness! |
|
|
Anterior Circulation sx
|
ACA(rare): Contralateral paralysis of leg, UMN wkness,
MCA (common): Contralateral paralysis of arm and face PCA: Homonymous hemianopsia, difficulty reading and calculations, memory impairment |
|
|
Posterior circulation sxs
Vertebrobasilar |
-Cranial nerve palsies
-Diplopia, VF loss, vertigo, N/V, dysphagia -Limb and gait ataxia, bilateral weakness *Crossed Sensory & Motor deficit: ipsilateral facial sensory/motor loss with contralateral hemiparesis. -Coma or impaired consciousness |
|
|
TIA imaging?
|
CT (shows blood or no blood)
then MRI ->can show stroke immediately then U/S |
|
|
TIA s/s
|
<24 hours, 80% resolve in 60 min or less.
10% will have stroke in 90 days Risk highest in 70s and 80s |
|
|
TIA diff dx?
|
Seizure, migraine
|
|
|
TIA tx, when surgery?
|
-Surgery for focal carotid stenosis >30%, <98%-> carotid endoerectomy
|
|
|
TIA tx medical therapy?
|
Anti-platelet: ASA, Plavix, Aggrenox
Anti-thrombotic: Warfarin, then coumadin (for pts with afib or cardioembolic stroke) |
|
|
Types of stroke
|
Ischemic 80% (Thrombotic: 2/3 Embolic: 1/3 -> afib, heart, etc.)
Hemorrhagic: 20% |
|
|
Ischemic Stroke Thrombotic
|
50--60%; occlusion at site of atherosclerosis
-occurs in sleep, present upon arising |
|
|
Ischemic Stroke Embolic
|
10-20%; Cardiac or atherothrombotic
-Can occur anytime, rapid progression -RFs: Afib, dilated myopathy, MI previous 4-6 weeks |
|
|
Stroke w/u
|
CT (dry) to r/o hem stroke/acute bleed vs hem
MRI/MRA ->poor with hems CBC, coags, renal function ECG- (afib rule in or out) |
|
|
Diff dx of stroke?
|
Intracerebral bleed vs ischemic stroke
migraine, trauma, brain tumor, bell's palsy, systemic infection. |
|
|
Lacunar Stroke
|
-20%; Caused by occlusion of small arterioles
-Longstanding HTN |
|
|
Ischemic Stroke Tx
|
Recombinant tPA: Alteplase:
Diagnosed ischemic, measurable neurologic deficit, onset within 3 hours, BP <180/110 (if >, give labetalol before) Contraindications: Surg or trauma within 2 wks, GI bleed. ICU monitor for 24 hours |
|
|
If thrombolytic therapy is contraindicated?
|
Maintain o2, control hyperglycemia, tx BP if >185/110, prevent hyperthermia,SQ heparin, Carotid endarterectomy for stenosis of >70%
|
|
|
Hemorrhagic Stroke types
|
15% total
Intracerebral (ICH) 10% Subarachnoid (SAH) 5% |
|
|
ICH RFs, S/S
|
RFs: HTN, smoking, 55 or younger, ETOH
S/S: Sudden severe h/a, pass out, marked elevation of bp, focal neuro deficit -CT!!-> blood shows up immediately |
|
|
SAH, causes, RFs
|
-Can be spontaneous(20%) or traumatic (80%)
-Due to aneurysms (40-70 yo) -Arteriovenous malformation (AVM) (20-40 yo) -RFs: smoking, binge drinking, phenylpropanolamine or other sympathomimetics |
|
|
SAH S/S
|
-Young adults
-97% sudden, severe ha, "worst headache of life", stiff neck, elev bp, coma, syncope -may just present with n/v, meningeal irritation, may lose consciousness, may dev focal deficits |
|
|
SAH (ICH) w/u
|
1) CT, if negative:
2) LP (rbcs and xanthochromia, yellowish color) 3) If either is positive, Cerebral angiogram is done. |
|
|
SAH (ICH) tx
|
Prevent rebleeding, hydrocephalus, cerebral vasospasm
-Surgery: Hem clipped or coiled -After aneurysm is protected, triple H therapy: hypertensive, hypervolaemic, haemodilution. |
|
|
Complex regional pain syndrome S/S
|
-Usually an extremity
-Limited ROM, vasomotor instability, skin changes and patchy bone demineralization |
|
|
Complex regional pain syndrome usually follows what?
|
Injury, surgery, vascular events
|
|
|
Complex regional pain syndrome DDX
|
DDX: nerve root impingement, vasculitis, RA, peripheral neuropathy, venous thrombosis, angioedema.
|
|
|
Complex regional pain syndrome DX
|
Response to therapy: regional sympathetic nerve block ->abrupt relief of pain often suggests CRPS.
Also, resting sweat output, resting skin temp, |
|
|
Complex regional pain syndrome TX
|
Preventative: early mobilization, PT & OT, smoking cessation.
Meds: anticonvulsants, biphosphonates, oral glucocoeticoids, nasal calcitonin |
|
|
Bell's Palsy
|
Unilateral facial paralysis (CNVII), without other symptoms.
-may be link to herpes simplex virus, DM, exposure to cold |
|
|
Bell's Palsy S/S
|
-Sudden onset or onset over days
-Paralysis of forehead and lower face -Trouble closing eye on affected side -Ipsi tear production -Ipsi loss of taste -Ipsi ear ache -Ipsi loss of corneal reflex -***CANNOT WRINKLE FOREHEAD!!! |
|
|
Bell's Palsy DX
|
One of exclusion.
DDX: infectious (with fever = lyme), sarcoidosis, MS, BG |
|
|
Bell's Palsy sxs with Fever??
|
Lyme
|
|
|
Bell's Palsy TX
|
-Prednisone for 24-48 hours of onset
-Acyclovir if linked to HSV -Protect eye from drying -If complete paralysis at day 5->Consult |
|
|
Diabetic Peripheral Neuropathy
|
-Tingling or burning paraesthesias in toes and distal feet
-abnormal pain and temp sensation -reduced achilles tendon reflexes -reduced vib sense in toes -"Sock glove" distribution |
|
|
Diabetic Peripheral Neuropathy TX
|
-Glucose control
-Tricyclic antidepressants for pain-> amitriptyline -Anticonvulsants -> neurontin (Gabapentin), Tegretol, Topamax |
|
|
Guillan-Barre Syndrome
|
Idiopathic polyneuropathy- following minor infections, immunizations (flu), or surgical procedures.
|
|
|
Guillan-Barre Syndrome patho
|
-Due to lymphocytic infiltration and macrophage-mediated demyelination and axonal degeneration
-typically follows Campylobacter, herpes, Mycoplasm |
|
|
Guillan-Barre Syndrome S/S
|
-Symmetric extremity weakness that begins distally and ascends.
-DTR decreased or absent |
|
|
Guillan-Barre Syndrome DX
|
-Electromyogram (EMG), marked slowing of nerve conduction velocities.
-CSF- elevated protein |
|
|
Guillan-Barre Syndrome TX
|
-Close monitoring of respiratory status (resp muscle involvement)
-Plasmapheresis -IV immunoglobulin |
|
|
Myasthenia Gravis- What
|
-Muscle weakness and fatigability, with commonly used muscles
-Improves with rest -Onset usually insidious -***Worse throughout the day! |
|
|
Myasthenia Gravis- Cause
|
Acquired autoimmune disorder that causes a decrease in acetylcholine receptors at the motor endplate.
|
|
|
Myasthenia Gravis- Who
|
Young women (20s), and older men (50s and 60s)
|
|
|
Myasthenia Gravis- S/S
|
-Early stages, affects eye muscles, causing ptosis and diplopia, can be bilateral or uni
-Loss of facial expression, jaw drop, choking on food. -Pts have trouble combing hair, climbing stairs, lifting objects. |
|
|
Myasthenia Gravis- DX
|
-Clinical
-Normal reflex and normal sensory (mostly motor) -Edrophonium test (not done anymore) -Labs: ***CXR to rule out thymoma (thymus tumor) -EMG reveals decrease in action potentials -***Anti-acetylcholine receptor antibodies |
|
|
Myasthenia Gravis- TX
|
-Anticholinesterase (cholinesterase inhibitor drugs) such as pyridostigmine bromide and neostigmine bromide
-Others: prednisone, thymectomy, immunoglobulin, plasmaperesis. |
|
|
Main TX for Myasthenia Gravis
|
Pyridostigmine bromide, neostigmine bromide
|
|
|
Lambert Eaton Syndrome
|
-A/w small cell lung cancer
-defective release of acetycholline -S/S: Muscle strength increases throughout the day (opposite of MG) -confirmed with electrophysiologically -TX: ***Plasmapheresis, immunosuppressant therapy, tumor therapy |
|
|
Cluster Headache
|
-Recurrent episodes of frequent h/a
-Severe, unilateral, periorbital, temple |
|
|
Cluster Headache- S/S
|
-Ipsi: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, ptosis, eyelid edema
-Restlessness or agitation ***Last 30 min to 3 hours and occur 1-8 times per day*** |
|
|
Cluster Headache- RFs
|
MALE
>30 vasodilators (etoh, nitroglycerin) |
|
|
Cluster Headache- Diff DX
|
-Temporal arteritis: r/o with ESR and CRP
-Migraine -Horner's syndrome: NO sweating, cluster headache SWEATING |
|
|
Cluster Headache- TX
|
*O2, 100% at 7-10 liters for 10-15 mins
-Ergotamine tartrate: Dihydroergotamine IM or IV -Sumatripta (Imetrix) -Botox Prophylactic: Prednisone, Verapamil, Depakote, Topamax |
|
|
Migraine- What and Who
|
-Unilateral, aura-associated h/a that lasts 4-72 hours.
-Females, 25-45 yo -Without aura is more common (80%), with aura is classic |
|
|
Migraine- RFs, triggers
|
-Relatives
-Triggers: etoh, ocp, glare, physical exertion, lack of sleep, menses, weather changes, stress, red wine, chocolate, cheese |
|
|
Migraine- S/S
|
-hyperactivity, mild euphoria, lethargy, depression, food cravings.
-Aura: homonymous visual disturbances (scotoma), unilateral weakness, numbness -n/v, photophobia, phonophobia -Worsens with activity |
|
|
Migraine- Abortive Tx
|
Opioids, Prochlorperazine (Compazine), triptans, ergots, NSAIDs
-Sumatriptan: Imitrex: SE chest tightening, flushing, tingling; injection or nasal |
|
|
Migraine- Preventative Tx
|
-BBs (Propranolol or timolol)
-TCA -Depakote (Divalproex) -Topamax -CCB -NSAID -SSRI -MAOi -Gabapentin If h/a limits normal daily activities 3 or more days per month, or a/w a complication. |
|
|
Tension Headaches
|
MC type of primary headache disorder
MC in females, second decade of life |
|
|
Tension Headache- S/S
|
-Diffuse, tight, bandlike, bilateral, mild/moderate pain
-Can last from mins-days, 5-20 per day -Pain does NOT worsen with activity -NO N/V, photophobia, neuro complications -Often upon arising -Muscular tightness or stiffness in neck |
|
|
Tension Headache- Dx criteria
|
Must have 2:
1. Pressing, tightening (not pulsatile) 2. Frontal-occipital 3. Bilateral (but not severe) 4. Not exertional |
|
|
Tension Headache- Tx
|
-NSAIDs, naproxen, ASA, barbiturates, acetaminophen + opioids
-Anti-emetics: Promthazine (Phenergan), Prochloperazine (Compazine), Metoclopramide (Reglan) -Ergots -Tend to be chronic, can use prophylactic tx with tricyclic antidepressant |
|
|
Encephalitis- What
|
-Acute inflammation of the brain parenchyma.
-Peaks in late summer |
|
|
Encephalitis - Etiology
|
*Etiology is typically viral: -Arbovirus (vector = mosquito or tics)-> California enceph, East or West equine enceph, St louis enceph, West nile enceph
-Enterovirus -Varicella-Zoster enceph -HSV enceph -HIV -Rubella/measles |
|
|
Encephalitis - S/S
|
-Febrile illness
-Presents ill: rapid progress to n/v, h/a, myalgias, malaise -Minimal neck stiffness -Altered mental, behavior, personality, motor, sensory, speech, movement. -Confusion, coma, seizures -Lasts 2-3 weeks *Prognosis: from mild illness to rapidly deteriorating course to death |
|
|
Encephalitis- Dx
|
-CT if viral enceph is suspected.
|
|
|
Essential Tremor
|
-Bilateral action tremor hands/forearm, (not rest)
-Any age, enhanced by emotional stress -Isolated head tremor w/o dystonia -Absence of neuro signs ->3 years -can be familial |
|
|
Essential Tremor - Tx
|
-Beneficial response to alcohol
-Propranolol -Primidone -Deep brain stimulation |
|
|
Huntington's Disease Triad
|
-Chorea (involuntary movements)
-Behavioral/psychiatric sxs -Progressive dementia |
|
|
Huntington's Disease - Who
|
-Inherited autosomal dominant with 100% penetrance
-Children have 50% chance -Sxs usually develop after 30 years (30-50) |
|
|
Huntington's Disease - S/S
|
-Choreic movements: increases with (voluntary) movements, increased by emotional stress, disappear with sleep.
-Dementia -Personality changes: agitation, psychosis, irritability, antisocial |
|
|
Huntington's Disease - Dx
|
PE: Brisk reflexes, unable to maintain tongue protrusion
CT/MRI: cerebral atrophy -Dx based on hx, esp fhx, and PE |
|
|
Huntington's Disease - Tx
|
-No cure
-Chorea: Tetrabenazine, Haloperidol, reserpine |
|
|
Parkinson's Disease - What
|
-Adult-onset, progressive, neurodegenerative disease
-Loss of dopaminergic neurons in the substantia nigra |
|
|
Parkinson's Disease - Who
|
-M > F
-Mean age 55 -Drug-induced Parkinsonism can be from dopamine receptor antagonists: antiemetics, antipsychotics, and reserpine. |
|
|
Parkinson's Disease - Triad
|
1) Tremor at rest, pin-rolling, decreases with (voluntary) movement.
2) Rigidity 3) Bradykinesia: Masked facies, dec blinking, impaired swallowing, monotone speech. **Required for dx, most disabling sx*** ALSO: postural instability, shuffling gait, dec arm swing, depression, dementia. |
|
|
Parkinson's Disease - Dx
|
-Clinical, H&P
-CT can be done to r/o DDX: -alzheimer with extrapyramidal features, dementia with lewy bodies, SE of neuroleptic drugs, normal pressure hydrocephalus |
|
|
Parkinson's Disease - Tx
|
*Meds:
***Levodopa is gold standard -Levodopa + carbidopa -Dopamine agonists are second choice: Parlodel, Mirapex, Ropinirole (Requip) -Anticholinergics: helps to decrease movement: mild PD, Benzotropine, trihexyphenidyl -MAO-B inhibitors: inhibits breakdown of dopamine |
|
|
What does levodopa and carbidopa do?
|
-Levodopa is metabolized to dopamine by an enzyme in the brain.-> Can suppress tremor, but is more useful for bradykinesia and rigidity
-Carbidopa prevents levodopa from being converted to dopamine in the bloodstream |
|
|
MC meningitis?
|
Viral
|
|
|
Most important meningitis?
|
Bacterial
|
|
|
Pregnant women and farm workers meningitis?
|
Listeria
|
|
|
Neonates meningitis Etiology
GEL |
Group B strep, e coli, listeria
|
|
|
2 months to 6 years meningitis etiology
|
Strep pneumoniae, Neisseria meningitidis (meningococcus), H flu type b
|
|
|
6 and older (adult)
|
Strep pneumoniae, Neisseria meningitidis (meningococcus)
|
|
|
What type of meningitis occurs in crowded conditions- only type that occurs in outbreaks?
|
Meningococcal meningitis
|
|
|
What type of meningitis occurs with acute otitis media, pneumonia?
|
Pneumococcal meningitis
|
|
|
Which type of meningitis occurs as a complication of a neurosurgical procedure, trauma, or secondary to endocarditis?
|
Staph aureus
|
|
|
Viral meningitis MC in who?
|
Young adults
|
|
|
MC cause of viral meningitis?
|
enteroviruses
-coxsackie -poliovirus |
|
|
Viral meningitis LP
|
Increased pressure
Minimal/no cells Glucose normal to low Increased protein 50-250 |
|
|
Viral meningitis S/S
|
Sensorium is normal
Fever, H/A, stiff neck, photophobia N/V, aches and pains |
|
|
Viral meningitis Tx
|
Most are self-limited, analgesics, antiemetics, abx are not indicated but often initiated
-complete recovery in 7-14 days |
|
|
Bacterial meningitis
|
Emergency, MC in oldest and youngest population
|
|
|
Bacterial meningitis S/S children and adults
|
Fever, AMS, petechial rash, photophobia, stiff neck
|
|
|
Bacterial meningitis S/S neonates
|
Poor feeding, lethargy, irritable, bulging fontanelles.
|
|
|
Bacterial meningitis S/S
|
Fever, h/a, n/v, photophobia, seizures, rigors, sweats, weakness, AMS.
-Brudzinskis (neck flexion) and Kernigs (hip and knee flexion) |
|
|
Bacterial meningitis DX
|
-Get CT before LP
-LP -Gram stain most valuable study- shows elevated WBCs and bacteria |
|
|
Bacterial meningitis LP
|
WBCs >1000
Protein >150 Glucose <40 Lactic acid elevated CRP elevated |
|
|
Bacterial meningitis TX <8 weeks
|
Ampicillin + Cefotaxime (or aminoglycosides such as gent)
-group b strep, e coli, listeria ***NO ceftriaxone (like everyone else) |
|
|
Bacterial meningitis TX >3 months including adults
|
Ampicillin + ceftriaxone
|
|
|
Bacterial meningitis TX immunocompromised/>50/etoh
|
ceftriaxone + vancomycin + ampicillin
|
|
|
Bacterial meningitis TX VP shunt/Neurosurg/head trauma
|
Vancomycin (for skin) + ceftazimide
|
|
|
Bacterial meningitis and Dexamethasone
|
For >1 month and <50, might decrease mortality and morbidity.
|
|
|
Epilepsy def
|
2 unprovoked seizures more than 24 hours apart
|
|
|
Partial Seizures Simple
|
Preserved consciousness
Confined to single locus in brain Often abnormal activity of a single limb Both visible and subjective experiences |
|
|
Partial Seizures Complex
|
Consciousness impaired
Complex sensory hallucinations, mental distortion, staring Automatisms: Chewing movements, lip smacking, stroking, rubbing hands -May or may not remember seizure |
|
|
Generalized Seizures
|
Seizure affects entire brain
Consciousness affected No memory of seizure |
|
|
Generalized Seizure- Tonic Clonic (Grand Mal)
|
Loss of consciousness and then:
-Tonic: All muscles contract, stiffen -Clonic: Jerk or convulsing, grunting/snorting -Followed by postictal period |
|
|
Generalized Seizure- Atonic
|
Patient with significant neurological abnormalities (CP or other mental d/o)
-opposite of tonic -all muscles become floppy or limb -fall to ground; "drop attacks" -quickly recover |
|
|
Generalized Seizure- Absence
|
Brief, abrupt, self-limiting loss of consciousness
-Pts stare, then rapid eye blinking for 3-5 sec -No postictal period -MC in children |
|
|
Generalized Seizure- Febrile
|
Tonic-clonic seizures of short duration and with high fever
-Occurs btwn 6 months and 4 years |
|
|
Seizure Work up
|
EEG
-non-emergent -Prolactin levels can be increased -MRI (or CT) on any adult with new onset seizures |
|
|
Absence Seizure Tx
|
Ethosuximide (Zarontin)
-Valproic acid (Depakote) -Clonazepam |
|
|
Partial (Complex and Simple) Seizure Tx
|
Carbamazepine (Tegretol)
Lamotrigine (Lamictal) Phenytoin (Dilantin) |
|
|
Generalized Tonic-clonic, febrile, atonic Seizure Tx
|
Phenytoin (Dilantin)
Carbamazepine (Tegretol) Lamotrigine (Lamictal) Valproic acid (Depakote) |
|
|
SE of Ethosuximide and Lamotrigine (Lamictal)
|
Stevens-Johnson syndrome
-Slow titration to avoid rash |
|
|
Gabapentin (Neurontin)
|
Usually used as an add-on agent
|
|
|
Phenytoin (Dilantin) Warning
|
Teratogenic: cleft lip and palate and congenital heart dz
|
|
|
Valporic acid (Depakote) Monitor
|
LFTs
May cause thrombocytopenia and bleeding |
|
|
Alternative Seizure TX
|
-Ketogenic diet for children (no carbs)
-Vagus nerve stimulation- Medically-refractory partial epilepsy -Resective surgery: lobectomy, callostomy, lesionectomy |
|
|
Risk of recurrence after 1st seizure?
|
within 2 years 15-70%.
|
|
|
Status epilepticus
|
A single seizure lasting longer than 30 min, or multiple seizures that occur without regaining consciousness between episodes.
-Failure of GABA inhibition -Tonic-clonic is MC and most serious -Life-threatening emergency. -Begin TX if lasts longer than 3-5 min |
|
|
Status epilepticus MCC and MC age
|
-Pt with known seizure disorder who has subtherapeutic levels of antiseizure meds
->50% in young children, and incidence is 2x higher in elderly |
|
|
Status epilepticus S/S
|
-Metabolic changes
-Cardiac changes -Respiratory changes -Renal complications -Cerebrovascular changes -Postictal findings |
|
|
Status epilepticus Causes
|
-Febrile convulsions
-Acute or chronic CNS injury -Idiopathic -Intoxication |
|
|
Status epilepticus DX
|
R/o pseudoseizures (non epileptic seizure)
EEG -Is there underlying cause? *Labs: acidosis, leukocytosis, elevated CK or myoglobinuria (rhabdo) |
|
|
Status epilepticus TX First line
|
5 mins or 2 seizures without full recovery
-Lorazepam (Ativan 2 mg IV) -Diazapam (Valium 5-10 mg IV) -several doses |
|
|
Status epilepticus TX Second line
|
if persists after 5 min
-Fosphenytoin (Cerebyx 20 mg IV) or Phenytoin |
|
|
Status epilepticus TX Third line
|
>20 min, or refractory
-intubated, induce coma with Phenobarbital, Versed (Midazolam), Propofol (Diprivan) |
|
|
Tourette's Syndrome
|
Genetic, boys
-Dx requires both chronic and motor tics, and bouts of tics need to last >1 year -A/w ADHD, OCD, learning disabilities -Tx: neuroleptic drugs |
|
|
ALC- Glascow Coma Scale
|
Eye response- 1-4
Verbal response- 1-5 Motor response- 1-6 *13 or >= mild *9-12= mod *8 or < = severe |
|
|
Coma Causes- Brainstem Hemorrhage Presentation
|
Pontine: Pinpoint Pupils
Cerebellar: Extensor posturing, lost pupillary reflex |
|
|
Coma Causes- Herniations
|
Uncal: Dilated, non-reactive ispi pupil, often associated hemiparesis
Central: loss of brainstem reflexes, decorticate posturing, irreg respirations |
|
|
Other coma causes
|
-Large stroke affecting both cortices
-occult trauma -Increased ICP (htn, brady, irreg respirations) -Toxic-Metabolic: drugs, CO2, uremia, O2, glucose, BP, ammonia, thyroid -> symmetric movement, maintained pupillary reflex, small but reactive pupils. -Infections, TTP |
|
|
Coma work up
|
-Temp, Pulse ox (hypoxic, retaining CO2)
-CT (can be normal in infection and stroke) -lytes, tox, liver, renal function -EEG |
|
|
Concussion and TBI
|
TBI: GCS 13-15, 30 min after injury
Concussion: Blow to head/neck/face -short-lived neuro impairment -functional disturbance rather than structural -May have LOC, but majority occur without LOC and go unrecognized S/S: confusion and amnesia w or w/o LOC, HA, dizziness, vertigo, N/V, insomnia, photophobia, seizures may signify more severe TBI |
|
|
TBI Imaging
|
*CT
-GCS <15, 2 hours after injury -Suspected skull fx -Emesis >2 times ->65 -Amnesia before impact of 30 min -ETOH/drug intox |
|
|
Concussion DX
|
-Mostly clinical
-CT scan normal but done to r/o bleed -MRI can detect subtle findings missed by CT but implications unclear -fMRI, PET may be abnormal |
|
|
Concussion TX
|
-No same day return to play
-Return to play: 24h asymp |
|
|
Post-Concussive Syndrome
|
-3 sxs for >7 days to 3 months
-***HA, Dizziness, Neuro/Psych (personality changes, irritability, anxiety, depression, insomnia) -Cognitive impairment (confusion, forgetfulness, difficulty concentrating) |
|
|
Post-Concussive Syndrome Predisposing Factors
|
Female, PTSD, low educational level, underlying psych disorder
|
|
|
Delirium
|
-Transient global disorder of cognition
-acute confusional state |
|
|
4 Key Features of Delirium
|
-Disturbance of consciousness
-Change of cognition -Develops over short period of time -Caused by medical, intoxication, or medication SE |
|
|
Delirium S/S
|
***Confusion, visual halluc, delusion, difficulty maintaining attention, fluctuating disorientation, sleep-wake reversal, psychomotor changes, dysphasia, tremor, can cause dep and suicidality
|
|
|
Delirium DDX
|
-Metabolic (hypoglycemia, endocrine)
-Withdrawal (etoh, sedative) -Intoxication, Hypoperfusion, hypoxia, intracranial tumor, abscess, bleed, liver, renal failure -Dementia predisposes (25-50% have dementia) |
|
|
Delirium DX
|
-counting back from 20, interview questionaries
-Labs: CBC, lytes, renal and liver, UA, drug levels, tox screen, ABGs, thyroid, vit b12 -Pulse ox -EKG -Head CT |
|
|
Dementia
|
-Slower decline of memory and cognitive function.
-30-50% of elderly >85 -MCC Alzheimer's followed by vascular |
|
|
Dementia Presentation
|
-Gradual and progressive impairment of recent memory and cognition with preservation of remote memory
-Poor social functioning and personality change -Hallucinations, paranoia, delusions -Depression and anxiety common |
|
|
Dementia with Lewy Bodies
|
-Fluctuating cognitive impairment, visual hallucinations, and Parkinsonism
-Onset of dementia within 12 months of onset of PD (close together) -Do not confuse with Parkinson's with dementia, in which dementia occurs later in course of dz |
|
|
Frontotemporal Dementia
|
Prominent behavioral and personality changes
-bipolar-like -Onset mid-50's -Less memory loss -Misdiagnosed as late onset psychiatric disorder |
|
|
Vascular Dementia
|
-Caused by single or multi infarcts, hemorrhages, ischemia/thrombosis.
-Common co-morbidities: DM, HBP, CAD, PVD -Dementia usually within 3 months of event |
|
|
Dementia Diagnosis
|
Hx, mental status testing, PE findings (Parkinson's/Lewy bodies), Vascular dementia gait and dtr abnorms, R/O concurrent illness,
-Head CT or MRI if cognitive decline is recent, hx of stroke, or focal or neuro signs are present ---Vit B12 def, T4/TSH, RPR syphilis |
|
|
Alzheimer's Dementia What and Causes
|
-Usually after 65,
-Changes in tau protein -3 features in anatomy of Alz: 1) Neurofibrillary tangles due to abnormal tau 2) Senile plaques (-amyloid) in the hippocampus 3) Atrophy of cerebral cortex (esp temporal) |
|
|
Alzheimer's Dementia RFs
|
Age, Down's, htn, insulin resistance, obesity, FH, female, low education level, smoking, APOE-4
|
|
|
Alzheimer's Dementia S/S
|
-Insidious onset, progressive, early memory loss, speech difficulties, agnosia (can't recognize faces), acalculia (math), anhedonia, decrease in executive function
*Executive function: complex task performance, problem solving, driving |
|
|
Dementia TX
|
-Treat cause if identified (ie syphilis)
-Vascular dementia: ASA, pentoxifylline |
|
|
Alzheimer's Dementia TX
|
Drug of Choice-> Cholinesterase inhibitor: Donepezil (Aricept)
Rivastigimine (Exelon/Patch) Galantamine (Razadyne) -SE: nv, diarrhea, muscle cramps 2nd Drug of Choice -> Glutamine Receptor Antagonist: Memantine (Namenda) |
|
|
Epidural Hematoma
|
Blunt trauma, temperoparietal skull.
-LOC followed by period of lucidity and subsequent neuro deterioration |
|
|
Subdural Hematoma
|
Traumatic event with LOC
-high speed acceleration/deceleration -60-80% mortality -Crescent-shaped CT -Control ICP |
|
|
MS
|
-Recurrent, occasionally progressive, inflammatory demyelinization of the white matter of the brain and spinal cord
-Course: intermittent, progressive, relapse |
|
|
MS Who
|
-More common in temperate zones of the world and decreases as move toward equator.
-Age: 16-40 -Female |
|
|
MS S/S
|
-Weakness, numbness, tingling, unsteadiness in a limb
-Heat may worsen -Visual: diplopia, monocular vision loss, blurry vision (*optic neuritis!!!) -Spasticity: increased muscle tone, hyperreflexia, limb spasms, loss of dexterity -Upper extremities > lower extremities -Lhermitte's sign is positive- electrical sensation down the back with neck flexion |
|
|
MS DX special tests
|
-MRI more sensitive than CT->may show plaques (Dewson's fingers), multifocal, hyperintense lesions in the periventricular cerebral white matter, brain stem, spinal cord
-Visual Evoked Response (VER)- abnormal in 75-97% -Somatosensory Evoked Potentials (SSEP): abnormal in 72-96% -Brainstem auditory evoked responses |
|
|
MS DX CSF
|
-Increased CSF immunoglobulin levels in 80-90%
-Oligoclonal bands in 70-80% -Increased myelin basic protein |
|
|
MS McDonald DX Criteria
|
->9 lesions
-f/u MRI 3 months later shows new lesion -No better explanation |
|
|
Relapsing-Remitting MS and Secondary Progressive MS
|
-S/S develop in acute relapses followed by recovery
-first 5-10 years -60% develop SP-MS in 15 years, 90% in 25 years -Secondary Progressive: gradual worsening following initial R-R MS |
|
|
MS TX
|
*Drug of choice: Immunomodulating drug: Interferon beta -> Avonex, Betaseron (slows progression of dz and freq of relapses)
*For acute attacks: Methylprednisone IV 1000mg for 5 days followed by tapered oral prednisone *For spasticity: Baclofen (Lioresol) *Neuropathic pain: Gabapentin *Chronic fatigue: Amantadine |
