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140 Cards in this Set
- Front
- Back
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What is allesthesia?
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Misplaced localization of tactile stimulus
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Lesions of which location typically cause unilateral apraxias?
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Contralateral premotor frontal cortical lesions
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How does the pseudobulbar palsy syndrome present?
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Dysarthria, dysphagia, hyperactive jaw jerk, gag reflexes
Uncontrollable laughing, crying unrelated to emotional state |
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Lesion responsible for pseudobulbar palsy?
What are common causes? |
bilateral interruption of corticobulbar or corticospinal tracts
PSP, multiinfarct dementia |
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Common causes of myoclonus?
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uremia, cerebral hypoxia, HONK
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Time period before initiation of delerium tremens?
Length? |
3-5 days after cessation of drinking
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Delirium tremens syndrome?
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confusion, agitation, fever, sweating, tachycardia, hypertension, hallucinations
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How long after opiods are discontinued do withdrawal symptoms occur?
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1-3 days after short acting agents
More than a week sometimes in longer acting agents |
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What drug can be used to confirm sedative withdrawal syndrome?
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Pentobarbital
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What is used to treat sedative withdrawal?
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Long acting barbiturate - pentobarbital
Taper over 2 weeks |
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What side effects limit physiostigmine use?
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bradycardia, seizures
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EKG changes from hypercalcemia?
Which muscles are spared by hypercalcemia? |
QT shortening
Bulbar muscles, also tendon reflexes are normal |
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What areas are affected by Wernicke Encephalopathy?
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Neuronal loss, demylination, gliosis in periacqueductal grey
Mamillary bodies, medial thalamus, periacqueductal grey, cerebellar vermis CN III, VI, VIII nuclei |
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What is the most specific CSF finding in hepatic encephalopathy?
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elevated glutamine
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What is the AMS syndrome from dialysis called?
Likely pathogenesis? |
Dialysis disequilibrium syndrome
Hypoosmolality |
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Which transplant immunosuppressants are known for producing encephalopathy?
Signs and symptoms? Imaging findings? |
cyclosporine, tacrolimus
Seizure, tremor, visual disturbances, weakness, sensory symptoms, ataxia Subcortical white matter abnormalities |
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Which opportunistic infections occur within 1-6 months post transplant?
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Listeria meningitis, encephalitis
Chronic meningitis from Crypto or TB Brain abscess from aspergillus, nocardia, toxoplasma |
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Which infections are common beyond 6 months after transplant?
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CMV, Toxo, Crypto, Listeria, Nocardia
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What is a potential cause of CNS lymphoma in the post transplant period?
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Posttransplant lymphoproliferative disorder from immunosuppression
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Which of the three most common adult meningitis bugs affect the convexities? Which the base?
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Convexities - H. Flu, Pneumococcus
Base - Neiserria |
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How often and how long should dex be given in meningitis?
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Every 6 hours for 4 days
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Lab findings in TB meningitis?
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positive PPD in half to two thirds
Increased CSF pressure CSF may cause clot on standing Mononuclear pleocytosis of 50-500 cells - PMNs early CSF protein over 100, sometimes over 500 Glucose low to 20 Positive Acid Fast stain Definitive diagnosis by culture |
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What are the complications of the TB drugs?
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Hepatic dysfunction - isoniazid, rifampin, pyrazinamide
Polyneuropathy - isoniazid Optic neuritis - ethambutol Seizures - isoniazid Ototoxicity - Streptomycin |
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When are corticosteroids reccomended in TB treatment?
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spinal subarchnoid block
Watch out if question in diagnosis - add antifungals if not excluded |
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When does syphilitic meningitis occur relative to primary syphylis infection?
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Within 2 years
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Which nerves are most commonly affected by syphilis meningitis?
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In order
VII, VIII, III V, VI, II |
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Treatment of syphilitic meningitis in pen allergy?
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Erythromycin
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When does neurologic involvement from Lyme typically occur?
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delay of up to 10 weeks
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Neurologic manifestations of Lyme?
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Meningitis
Meningoencephalitis CN, peripheral nerve, nerve root disorders |
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Diagnosis of Lyme diseaes?
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ELISA with Western Blot for confirmation
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What is treatment for Lyme involving CNS?
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Ceftriaxone, Penicillin G or cefotaxime for 2-4 weeks
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Which viral meningitis causes a CSF pleocytosis of 1000 to 10,000 cells?
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LMCV
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What type of HSV typically causes encephalitis? Meningitis?
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Encephalitis - HSV 1
Meningitis - HSV 2 |
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What areas are affected by HSV encephalitis?
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medial temporal lobes, inferior frontal lobes
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When does meningitis related to HIV typically develop?
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at time of seroconversion
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CSF findings in HIV meningitis?
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mononuclear pleocytosis of up to 200 cells
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Which viruses which typically do not caues encephalitis in non immunocompromised patients cause encephalitis in HIV?
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HSV 2
Varicella |
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What effect does CMV have in AIDs?
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retinitis
polyradiculomyelitis |
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In case of ring enhancing lesion in AIDs patient when should brain biopsy typically be undertaken?
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after 3 weeks of toxo treatment?
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Which fungal infection typically causes PMN pleocytosis?
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Aspergillus
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What should be done for diagnostic purposes in mucurmycosis/
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Biopsy of affected tissue
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How is fungal meningitis treated?
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Amphotericin for 12 weeks
If Coccidioides or no response to IV therapy - Intrathecal ampho If crypto - flucytosine in addition to amphotericin After CSF cultures negative fluconazole for 10-12 weeks Debridement in mucor |
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What is the major side effect with flucytosine?
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Bone Marrow suppression
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When is flucytosine omited in crypto therapy?
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AIDs for bone marrow suppression
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Systemic manifestations of Toxo?
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skin rash, lymphadenopathy, myalgias, arthralgias, carditis, penumonitis, splenomegaly
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Lab diagnosis of Toxo?
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high or rising Sabin Feldman dye test titer
or IgM antibodies to Toxoplasma |
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Treatment for toxo?
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Pyrimethamine and sulfadiazine for 3-4 weeks
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What causes Granulomatous amebic encephalitis?
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acanthamoeba/Hartmanella species
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How is granulomatous amebic encephalitis diagnosed?
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sluggishly motile trophozoites on wet mounts
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In whom does granulomatous amebic encephalitis present?
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chronic illness or immunosuppression
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What are parasitic infections commonly involving CNS?
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malaria
toxo primary amebic meningoencephalitis granulomatous amebic encephalitis cysticercosis angiostrongylus cantonesis meningitis rocky mountain spotted fever |
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Systemic signs, labs consistant with cysticercosis?
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peripheral blood eosinophilia
soft tissue calcification parasites in stool lymphocytic pleocytosis with eosinophils present complement fixaton and heagglutination studies can assist diagnosis |
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When should cysticercosis be treated?
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treat symptomatic neurologic involvemnt or one or more noncalcified intraparenchymal cysts
Intraventricular, subarachnoid, racemose cysts respond poorly to treatment calcified cysts do not require treatment |
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Treatment for cysticercosis?
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albendazole
Praziquantal can be used. Give anticonvulsants if seizures |
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Where is angiostrongylus cantonensis endemic?
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southeast Asia, Hawaii, other Pacific islands
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How is angiostrongylus transmitted?
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ingestion of raw mollusks
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Pathogenesis of Rickettsial involvement of CNS?
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endothelial cell damage leading to vasculitis, microinfarcts, petechial hemorrhage
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Treatment for Rocky Mountain Spotted Fever?
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Doxycycline or chloramphenicol
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What are systemic cancers causing leptomeningeal mets?
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ALL
Non Hodgkins lymphoma Melanoma AML Carcinoma of breast Hodgkin Lymphoma Carcinoma of lung Carcinoma of GI tract Sarcoma |
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What are primary brain cancers causing leptomeningeal spread?
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Medulloblastoma
Pineal tumors |
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What are biochemical markers of cancer spread in CSF?
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CEA, bHCG, AFP specific for leptomeningeal spread
B2 microglobulin, B glucuronidase, LDH isozyme V - may also be elevated in inflammatory disorders |
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How high does blood pressure typically have to be to precipitate HTN encephalopathy?
What increases risk of HTN encephalopathy? |
Over 250/150 if chronic HTN
Concomminant renal failure |
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Clinical signs of HTN encephalopathy?
Imaging? |
retinal arteriolar spasm
Papilledema Retinal hemorrhages Low density areas suggestive of edema in posterior regions of hemispheric WM on CT T2 hyperintensities in same areas on MR |
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Where does hemorrhage from intracerebral contusion typically occur?
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frontal or temporal poles
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How long does typical post ictal confusion last?
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1-2 hours
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What are causes for prolonged post ictal state?
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Status epilepticus
Underlying structural brain abnormality Underlying diffuse cerebral disorder |
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What are normal neuroopthalmologic changes in aging?
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Impaired Upgaze
Impaired Convergence |
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Gait in Alzheimer's disease?
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Frontal lobe gait disorder with short, slow, shuffling steps, flexed posture, wide base, difficulty initiating walk
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What are acetylcholinesterase inhibitors used in US?
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tacrine, donepezil, rivastigmine, galantamine
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How is frontotemporal dementia differentiated from AD?
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earlier onset
more prominent behavioral than cognitive dysfunction at presentation preferential atrophy of frontal and anterior temporal lobes on CT scan or MR |
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What organs is the infectious prion from CJD present?
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brain
spinal cord eyes lungs lymph nodes kidneys spleen liver CSF |
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What is the second most common dementia after AD?
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Dementia with Lewy Bodies
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How does Lewy body dementia typically present?
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Cognitive decline without early memory impairment
fluctuating cognitive ability, well formed visual hallucinations, signs of parkinsonism, rigidity, bradykinesia |
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Pharmacotherapy for Lewy Body Dementia?
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respond well to anticholinergics
Avoid antipsychotics because patients are more sensitive to EPS |
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Signs, symptoms of corticobasal degeneration?
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rigidty, bradykinesia, postural instability, action tremor
asymmetric cortical mortor and sensory defects Apraxias of eye movement, speech, limbs, Alien hand sign |
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What areas of the brain are affected in AIDs dementia complex?
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white matter
basal ganglia thalamus pons spinal cord |
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What clinical findings are associated with AIDs dementia complex?
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forgetfulness, apathy, social withdrawal
impaired balance, leg weakness, deterioration of handwriting cerebellar ataxia, pyramidal signs - hyperreflexia, extensor plantar responses, weakness in one or both legs, postural tremor, dysarthria Later manifestations: hypertonia, fecal and urinary incontinence, primitive reflexes, myoclonus, seizures, quadriparesis, organic psychosis |
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CSF findings in AIDs dementia complex?
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elevated protein, modest mononuclear pleocytosis, oligoclonal bands
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How long after primary infection does chancre appear in syphilis?
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1 month
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How long after primary infection does secondary syphilis arise?
Manifestations? |
1-6 months
Fever, skin rash, alopecia, anogenital skin lesiosn, ulceration of mucous membranes - neurologic symptoms uncommon |
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What ist he earliest form of symptomatic neurosyphiliis and when does it present?
Manifestations? |
Meningeal syphili
2-12 months after primary infection Headache stiff neck N/V CN II, VII, VIII involvement |
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When does meningovascular syphilis typically occur?
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4-7 months after primary infection
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What are the signs and symptoms of general paresis?
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Gradual memory loss, altered affect, personality, behavior
Followed by global intellectual determiration with trandiosity, depression, psychosis, focal weakness Terminal features - incontinence, seizures, strokes Tremor of face, tongue, paucity of facial expression, dysarthria, pyramidal signs |
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What are signs and symptoms of Taboparesis
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Tabes dorsalis with general paresis
Argyll Robertson pupils, lancinating pains, areflexia, posterior column sensory deficits with sensory ataxia, Romberg sign, incontinence, impotence, Charcot joints, genu recurvatum (hyperextended kneeds) optic atrophy |
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In what types and time course of neurosyphilis are nontreponemal CSF tests falsly negative?
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acute syphillitic meningitis and meingovascular syphilis - conversion later
Late stage tabes dorsalis |
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What is the Herxheimer reaction?
What follow up test for syphilis may indicate retreatment? |
fever and leukocytosis shortly after start of therapy
failure of CSF to return to normal at 6 months |
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On what clinical setting does infection with JC virus typically occur?
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AIDS, lymphoma, leukemia, carcinoma, sarcoidosis, tuberculosis, pharamcologic immunosuppression after organ transplantation
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Course of PML?
Presentation? |
death in 3-6 months
dementia and focal cortical dysfunction ataxia and headache are uncommon and seizures do not occur |
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In what setting does pellagra typically occur and what are affected areas in brain?
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niacin deficiency is typically in alcohol abuse
cerebral cortex, bbasal ganglia, brainstem, cerebellum, anterior horns of spinal cord |
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Clinical presentation of pellagra?
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Diarrhea, glossitits, anemia, erythematous skin lesions
dementia psychosis, confusional states, pyramidal, extrapyramidal, cerebellar signs polyneuropathy, optic neuropathy |
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In whom does dialysis dementia occur?
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patients receiving chronic hemodialysis
Aluminum in dialysate |
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Clinical features, diagnostic features, prognosis of dialysis dementia?
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dysarthria, myooclonus, seizures - intermittent but later permanent
dementia EEG with paroxysmal high voltage slowing with intermixed spikes and slow waves - reversed with diazepam Mean survival 6 months |
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What are imaging signs of dementia pugilistica?
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cavum septum pellucidum
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Clinical findings in vascular dementia?
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pseudobulbar palsy (dysarthria, dysphagia, pseudobulbar affect, focal motor or sensory deficits, ataxia, gait apraxia, hyperreflexia, extensor plantar responses
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What kind of amnestic syndrome is produced by hypoxic injury?
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severe impairment of ability to incorporate new memories
relative preservation of registration and remote memory period of retrograde amnesia preceding insult may occur Lack of concern about impairment may coexist with other watershed syndromes (bibrachial paresis, cortical blindness, visual agnosia) |
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Clinical features of carbon monoxide poisoning?
Lab testing? Imaging? |
Amnestic syndrome from hypoxia, watershed syndromes
affective disturbances frequently associated cherry red discoloration of skin, mucous membranes cardaic arrhythmia Carboxyhemoglobin levels Lucencies in basal ganglia and dentate nuceli on CT |
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In whom does transient global amensia occur?
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middle aged, elderly patients with risk factors for atherosclerotic disease (esp prior ischemic event in posterior circulation)
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How long does transient global amnesia last?
Imaging findings? |
typically lasts for hours - may last for minutes or days
CT or MR with focal thalamic or temporal lobe abnormalities Diffusion weighted MR may show temporal lobe signal abnormalities compatible with cellular edema possibly related to spreading depression |
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What sort of syndrome occurs in transient global amnesia?
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agitation and discomfort regarding memory loss
repeated inquiries about whereabouts, time, nature of what they are experiencing knowledge of personal identity is preserved, remote memories are preserved New memories cannot be formed retrograde amensia for variable period may be present but shrinks as episode resolves |
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How often does an amnestic syndrome emerge after Wernicke's encephalopathy?
Clinical features? |
3/4 of the time
polyneuropathy, nystagmus, gait ataxia inability to form new memories long term memory affected to less extent registration is intact Apathetic patients |
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What areas of the brain are affected in paraneoplastic limbic encephalitis?
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hippocampus, cingulum, piriform cortex, inferior frontal lobes, insula, amygdala
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Clinical syndrome in paraneoplastic limbic encephalitis?
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profound impairment of recent memory - inability to learn new material
remote memory is less impaired registration is unaffected affective symptoms - anxiety or depression are early features commonly Hallucinations, complex partial or generalized seizures |
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CSF findings in paraneoplastic limbic encephalitis?
EEG findings? MR findings? |
mononuclear pleocytosis, mild elevated protein
diffuse slow or bitermpral slow waves and spikes abnormal singal intesity in medial temporal lobes |
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What antibodies are most common with small cell lung cancer in paraneoplastic limbic encephalitis?
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Anti Hu
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What antibodies are most common with testicular cancer in paraneoplastic limbic encephalitis?
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Anti Ta
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What are the intracranial painsensitive structures?
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venous sinuses
Anterior and middle meingeal arteries Dura at base of skull Trigeminal, glossopharyngeal, vagus nerves proximal portions of inernal caorotid artery and branches near Circle of Willis Brainstem periacqueductal gray Sensory nuclei of thalamus |
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What is character of pain caused by intracranial mass?
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dull, steady
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What is a common cause of pain in the first division of the trigeminal nerve?
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postherpetic neuralgia
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What are the most common sites of pain caused by glossopharyngeal neuralgia?
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pharynx
external auditory meatus |
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What typically relieves migraine headache?
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Sleep, vomiting, pressing on ipsilateral temporal artery
Frequency diminished during pregnancy |
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Which primary headache syndrome results often in a horner's syndrome?
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cluster headache
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How often do AVMs caues subarachnoid hemorrhage?
At what age do AVMs typically bleed? Gender distribution? |
roughly 10%
2nd to 4th decade Twice as common in men |
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Where are mycotic aneurysms relative to berry aneurysms on arteries?
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Usually more distal - along course of cerebral arteries
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Where in the vascular system are AVMs most common?
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MCA distribution
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Imaging for AVMs?
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Most are visible with contrast on CT
MR is good for small AVMs especially in brainstem |
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CSF findings in subarachnoid bleed?
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pleocytosis of several thousand WBCs with resultant decrease in glucose
Without pleocytosis there is no dip in glucose |
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How often do multiple aneurysms occur in patients with aneurysms?
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20%
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How can an aneurysmal rupture produce focal neurologic signs in the acute setting?
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rupture or ACA or MCA causes direct jet of blood into brain parenchyma
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Time course of vasospasm subarachnoid bleed?
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Does not occur before day 4
peaks at day 10-14 spontaenous resolution |
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How far should blood pressure be lowered in subarachnoid hemorrhage?
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160/100
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What is etiology of hyponatremia in subarachnoid hemorrhage?
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cerebral salt wasting
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What drug can be used prophylactically to reduce vasospasm?
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nimodipine
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How is vasospasm treated in setting of subarchnoid bleed?
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induced hypertension with phenylephrine or dopamine
Do this after surgical treatment of aneurysm Use prophylactic anticonvulsant because htn raises seizure risk |
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In what patients with subarachnoid bleed is surgery not indicated?
What is optimal timing of surgery? |
stuporus patients or patients in coma
within two days of insult if aneurysm electively if AVM |
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Imaging features in pseudotumor?
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slitlike ventricles
dilation of optic nerve sheath flattening of back of globe 70% have empty sella |
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Triggers for glossopharyngeal neuralgia?
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swallowing, talking (trigger areas around tonxillar pillars)
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Age distribution for postherpetic neuralgia?
Other risk factors? |
does not occur before 50
70% in those over 70 immunocompromise malignant disease (lymphoma, leukemia) |
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Treatment for postherpetic neuralgia?
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TCAs and TCAs combined with phenothiazine
Gabapentin, Tegretol, phenytoin are second line use lidocaine cream, cutaneous patch Use capsaicin cream if tolerated Intrathecal administration of methylprednisolone |
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What is atypical facial pain?
Treatment? |
Chronic boring, unilateral, lower facial pain without cause
Amytriptyline alone or with phenelzine Dilantin is alternative |
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What migraine headache syndrome is inherited by autosomal dominant pattern?
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Familial hemiplegic migraine
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When in a woman's life do migraines tend to remit?
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During pregnancy, after menopause
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What is a useful bedside test for both common and classic migraine?
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reducing headache severity by compressing ipsilateral carotid or superficial temporal arteries
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What foods precipitate migraines?
What are other precipitants? |
Cheeses, meat with nitrate preservatives, chocolate with phenylethylamine, MSG
Fasting, emotion, menses, drugs (OCPs, vasodilators like nitroglycerin), bright lights |
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Contraindications to ergot alkaloids and 5-HT agonists?
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significant hypertension
cardiac disease |
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In whom is prophylactic treatment indicated?
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more than one headache per week
acute episodes difficult to manage poor tolerance or contraindication for ergot alkaloids and triptans |
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What is mean age of onset for cluster headaches?
What is a functional MRI feature of cluster headache? |
25
activation of ipsilateral hypothalamic gray |
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Features of cluster headache?
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unilateral, constant nonthrobbing headache, lasting minutes to less than 2 hours
ipsilateral conjunctival injection, lacrimation, nasal stuffiness, Horner syndrome Always unilateral recur on same side in given patient occur at night awakening patient recur daily often at same time of day for weeks to months |
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Precipitants of cluster headache?
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alcohol and vasodilating drugs
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Prophylactic medication for cluster headaches?
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sustained release verapamil
Ergotamine rectal suppositories or subcutaneous dihydroergotamine at bedtime Prednisone at beginning of cluster cycle 40-80 for 1 week with tapering lithium If chronic rather than episodic use indomethicin |
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Prophylactic treatment of tension headache?
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amitriptyline, imipramine, sometimes propanolol
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