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400 Cards in this Set
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Strange smell followed by LOC, jerking movements, and loss of bowel/bladder control
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Simple partial seizure w/ secondary generalization
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Strange smell, automatisms, LOC
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Complex partial seizure
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Rx for cluster headache (2)
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100% O2
SubQ triptans |
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Prophy for cluster headaches (3)
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Verapamil
Lithium Ergotamine |
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Headache that awakens pt from sleeping and whoosing in ears
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Pseudotumor
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Rx for pseudotumor
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Acetazolamide
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Possible MRI findings in pseudotumor
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Empty sella
Slit-like ventricles |
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Why is an MR venography obtained in pts with potential pseudotumor?
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Cerebral venous sinus thrombosis can present similarly (and also has elevated opening pressure), so must be excluded
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Pathophys of fever
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Cytokine activation
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Athlete in heat w/ temp >105, AMS, dehydration, hypotension, tachy
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Heat stroke
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Pathophys of heat stroke
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Failure of thermoregulatory center
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Large blood with no RBCs on UA
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Rhabdomyolysis (due to muscle breakdown)
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Pathophys of malignant hyperthermia
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Uncontrolled efflux of calcium from sarcoplasmic reticulum
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Inadequate fluid and water replacement during physical activity
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Heat exhaustion
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Cool skin, low BP, confusion, and muscle spasms after intense physical activity
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Heat exhaustion (thermoregulatory apparatus is intact)
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Rx for heat exhaustion
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Remove from heat to prevent hyperthermia
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Most common presenting sign of craniopharyngioma (other than bitemporal hemianopsia) in children vs. adults
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Children: growth retardation
Adults: sexual dysfunciton |
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Rx for subdural hematoma w/ midline shift
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Emergent neurosurg consult for hematoma evacuation
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Cause of foot drop
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Inability to dorsiflex the foot
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What is festinating gait and what disease can it indicate?
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Slow onset of movement followed by short shuffling steps
Parkinson's |
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3 causes of foot drop
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Neuropathy
L5 radiculopathy Trauma to common peroneal nerve |
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Rx for Lambert Eaton syndrome
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Plasmapheresis and immunosuppresants
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Pathologic findings in MS
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Perivascular inflammation and destruction of myelin in white matter
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Two CSF findings of inflammation
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Oligoclonal bands and elevated IgG index (ratio of IgG to albumin in CSF/ ratio of IgG to albumin in serum)
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Differentiate btwn primary and secondary progressive MS
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Latter was relapsing-remitting at diagnosis
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4th MS subtype
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Progressive relapsing
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6 most common initial MS Sx
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Weakness in 1+ limbs, optic neuritis, sensory Sx, diplopia, vertigo, disturbance of micturition
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What is Lhermitte's sign
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Electric sensation passing down back and into limbs provoked by neck flexion
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Most common disease modifying agent used in MS and three brands
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Interferon beta
Avonex and Rebic (1a) and Betaseron (1b) |
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3 other disease modifying agents
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Glatiramer acetate (Copaxone): synthetic myelin analogue
Natalizumab (Tysabri): Ab against T-cell adhesion molecule alpha-4 integrin Mitoxanitrone (Novanrone): chemo agent |
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Main toxicity of mitoxantrone and consequent dose limit
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Cardiotoxicity, 3 yrs
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Acute MS relapse Rx
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Glucocorticoids
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No meds currently approved for which MS subtype?
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Primary progressive
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Common drugs for MS side effects
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Anti-spastics
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Migraine pathophys
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Trigeminovascular activation, inflammation, and cortical spreading depression
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When is the "worst headache of my life" not an emergency?
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When only quantitatively, not qualitatively
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Empiric Abx for meningitis and what to add if suspicion v. high
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2g ceftriaxone, 1gm vanc +/- amp in immunocompromised pts (for Listeria)
If suspicion high, add glucocorticoids |
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When should an LP be done before CT?
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If CT will take >1hr
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When can Abx be d/c
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No WBCs in CSF or negative cultures after 48hrs
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CSF in viral meningitis
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WBC <100, lymphocytic, nml glucose
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Suspected SAH
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Spin CSF! Traumatic blood will aggregate at bottom so appears clear; SAH: xanthrochromia
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Rx for SAH
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Neurosurg consult to clip or coil aneurysm w/in 2 days
Nimodipine |
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Rx for temporal arteritis
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60-80mg prednisone daily; if biopsy positive, continue for 6-8 wks then taper
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Intention tremors are due to damage where?
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Cerebellar hemisspheres
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Sleep has what effect on Parkinsonian tremor during sleep
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Causes it to cease
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Possible eye side effect of phenytoin
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Nystagmus
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Other toxicites of phenytoin
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Ataxia, dysarthria, lethargy, impaired judgment
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CN cause of hyperacusis
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Facial nerve damage --> paralysis of stapedius muscle (middle ear)
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Abnormality in tandem gait indicates problem is
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Cerebellar
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Atrophy and fasciculations of tongue are from
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CN XI problems (often brainstem disease, e.g. stroke or ALS)
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Loss of ankle jerk reflex
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S1 radiculopathy
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Calorics: warm water in ear will cause
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Nystagmus in both eyes away from stimulated ear
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Horner syndrome acutely after vigorous activity
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Carotid artery dissection
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Most common site of a noncommunicating hydrocephalus
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Aqueduct of Sylvius (connection btwn third and fourth ventricle)
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Tentorium cerebelli is a common site of origin for what kind of tumors?
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Meningiomas
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Rx for meningiomas
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Surgery + radiation
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What is dysdiadochokinesia and what causes it?
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Impairment of rapid alternating movements
Cerebellar damage, e.g. MS/cerebellar tumors |
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Frequency of alpha waves and when they are emitted
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8-13Hz
Relaxed adult with eyes closed |
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CSF in bacterial meningitis
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Elevated protein, few RBCs, elevated opening pressure, milky fluid, nml gamma globulin, high WBCs, very low glucose
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CSF in Guillain Barre
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Normal except v. high protein and yellow (from high protein)
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3 CSF findings in SAH
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Xanthochromia/ elevated RBCs (old), high protein (from broken down blood), elevated WBCs (chemical meningitis from irritation from blood)
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Elevated gamma globulin (e.g. elevated %protein without elevation in protein content) is CSF finding typical of
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MS
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CSF in viral meningitis
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Some RBCs/WBCs, elevated protein, nml glucose
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Class of drugs used in secondary progressive MS
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Immunosuppressants, e.g. cyclophosphamide (as well as typical MS drugs)
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Risk of carbamazepine and monitoring required
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Aplastic anemia
CBC |
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Surgical options for refractory trigeminal neuralgia
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Surgical gangliolysis
Suboccipital craniectomy for decompression of trigeminal nerve |
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Rx for pseudotumor with progressive visual field deficits
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Shunting or optic nerve sheath fenestration
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Drugs used to control severe HTN in ischemic stroke
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CCBs (nicardipine)
ACEIs (not aiming for tight control) |
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What is torticollis?
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Focal dystonia of SCM
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What is athetosis and what can it indicate?
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Slow, writhing movements of hands and feet
Huntington's |
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HTN with focal neurologic deficits
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Spontaneous intraparenchymal hematoma (most commonly in the basal ganglia)
SAH would have headache, usually no focal findings |
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4 common sites of spontaneous intracranial hemorrhage
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Basal ganglia, cerebellum, thalamus, pons
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Required for diagnosis of dementia
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Functional impairments
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2 first line drugs for absence seizures
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Ethosuximide
Valproic acid |
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Huntington's that develops in childhood w/ more bradykinesia and rigidity + seizures, myoclonus, dystonia
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Westphal variant
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Anatomy of Huntington's disease
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Neostriatum (atrophy of caudate and putamen)
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2 causes of Sydenham chorea
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Pregnancy, rheumatic fever
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Rx for chorea
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Haloperidol
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Sustained muscle contractions, twisting, and repetitive movements since childhood
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Primary generalized dystonia
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What is opisthotonos
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Rigid spasm of the body w/ back fully arched and heels/head bent back
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Hints that dystonia may be secondary
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Other neuro problems, hemidystonia, dystonia at rest or incl. speech at onset
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3 Rx options for dystonia
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Parkinson's drugs
Targeted Botox/ baclofen DBS of GPi |
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Inheritance of primary dystonia
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Most common type (DYT-1) is AD
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Sensory problems in Parkinson's
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Pain, loss of smell
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Other non-motor problems in Parkinson's
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Dysarthria, stuttering, dementia
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Pathologic finding in PD
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Loss of pigment in substantia nigra, striatal dopamine deficiency (>70% when Sx emerge, >90% at death)
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Worry about other diseases if Parkinson's symptoms +
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Rapid progression
UMN signs Incontinence Cerebellar signs |
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Unilateral PD
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Corciobasal ganglionic degeneration
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PD Sx w/ autonomic instability
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Multiple system atrophy
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PD Sx w/ inability to look down and frequent early falls
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Progressive supranuclear palsy
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Rx options for Parkinson's (5)
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1) Levodopa + carbidopa (Sinemet) +/- COMT inhibitors
2) Dopamine agonists (pramipexole, ropinirole, bromocriptine) 3) MAO-B inhibitors (selegiline, rasagiline) 4) Anticholinergics for tremor 5) Amantadine for tremor and levodopa dyskinesia |
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Progressive ataxia + dysarthria and LMN/UMN signs
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Spinocerebellar ataxia (AD)
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MRI findings of SCA
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Cerebellar atrophy
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Rx for tardive dyskinesia
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Benzos, baclofen, Vita E
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Localization of flaccid quadriparesis
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CST in upper cervical region
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Lack of DTRs or rectal tone
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Spinal shock
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When are steroids indicated for SCIs?
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Adults w/ incomplete SCI if w/in 8 hrs (IV methylprednisone)
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Kids <9 w/ traumatic injury always need
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Cord imaging
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Transient LOC after a head injury is often due to damage where?
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Ascending reticular activating system
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3 grades of concussions
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Grade 1: Sx < 15 min
Grade 2: Sx >15 min Grade 3: LOC |
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Sx of postconcussive syndrome
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Headaches and dizziness
Also: irritable, depression, insomnia, cognitive |
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Return to play guidelines for each of the concussion grades
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Grade 1: 15 min after return to baseline
Grade 2: after 1 wk Grade 3: after 1-2 wks depending on length of LOC (all are longer if 2nd concussion) |
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DDx for stroke-like weakness
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Seizure w/ Todd's paralysis
Complicated migraine |
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Pure motor or sensory strokes localize where?
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Lacunar strokes
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Localization of stroke w/ aphasia, neglect, agonisa, apraxia
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Anterior (carotid) circulation
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Localization of stroke w/ diploplia, vertigo, homonymous hemianopia, crossed findings
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Posterior (vertebrobasilar) circulation
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For non-tPA candidates w/ stroke, give
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ASA
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SAH often has what recent Hx
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Moderate headache (sentinel bleed)
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60% of SAHs occur during
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Sex, trauma, emotional/physical strain, defecation
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2 common systemic complications of SAH
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Hyponatremia and ECG changes (QT prolongation, T wave inversion)
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What is acute communicating hydrocephalus?
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Obstruction of subarachnoid granulations due to blood --> enlarged ventricles --> headache, vomiting, blurry vision, somnolence, syncope
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2 diseases related to aneurysms
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Fibromuscular dysplasia
Polycystic kidney disease |
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2 drugs that cause SAH
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Cocaine
Amphetamines |
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# of grades of SAH, which is best
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5 (based on clinical Sx)
1 is best, 5 is worst |
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Rx for SAH
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Angiography w/ coiling > clipping
Triple H (HTN, hypervolemia, hemodilution) Nimodipine (CCB) |
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Acute change in LOC 1 wk after SAH: imaging algorithm?
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1st: CT for hydrocephalus (to see if need ventriculostomy)
Then, diffusion-weighted MRI for ischemia 2/2 vasospasm; confirm with angiography |
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Risk with a choke hold
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Carotid artery occlusion --> ischemic stroke
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3 causes of carotid artery dissection (tear in wall) (general/pathologically)
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Luminal obstruction
Thromboembolic complications Pseudoaneurysm formation |
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Stroke symptoms + Horner's may indicate what etiology of the stroke?
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Carotid dissection
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AV malformations are associated w/ what type of stroke?
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Intracerebral hemorrhage
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When are carotid dissections stented?
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Only in pts who show no vessel recanalization after 3-6mo
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What is moyamoya disease?
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Idiopathic noninflammatory cerebral vasculopathy; causes progressive occlusion of large arteries at circle of willis (arteries hypertrophy in response to chronic ischemia)
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Difference btwn a partial and generalized seizure
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Partial only relates to one of the cerebral hemispheres, whereas generalized involves both
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Should you treat a first-onset adult seizure?
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Controversial, but usually not; 75% won't recur (only 10-25% go on to epilepsy), and while treatment decreases relapse rate, no evidence that it alters prognosis of epilepsy
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First line for tonic-clonic seizures
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Valproate
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Most common seizure aura
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Sensation of abdominal discomfort
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2 brain areas that must be involved in complex partial seizures
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Basal forebrain and limbic areas
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3 ways to distinguish absence seizures from complex partial seizures
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Absence have no aura, no automatisms (usually), and no postictal confusion
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Bizarre automatisms often indicate seizures where?
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Frontal lobe
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3 classes of auras, based on seizure location
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Abdominal sensation, fear, deja vu: temporal lobe
Electrical sensation, tingling, numbness: parietal lobe Visual changes: occipital lobe |
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How much folic acid should women of childbearing age on AEDs be prescribed?
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4mg daily (to prevent NTDs)
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What is catemenial epilepsy?
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Seizure frequeny can double around menstrual cycle (in 1/3 of women with seizures)
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Unilateral miosis and ptosis in a pt with a headache and recent neck trauma
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Carotid dissection --> Horner syndrome
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What is anisocoria?
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Unequal sizes of the pupils
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What is sick sinus syndrome?
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Bradycardia in which the sinoatrial (SA) node isn't working properly
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Cough or micturition syncope imply what problem?
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Decrease in venous return
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Rx for sick sinus syndrome
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Implantable pacemaker
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Rx for orthostatic hypotension (3 first line and 2 second line options)
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Avoid hypovolemia, electrolyte imbalance, and excess alcohol
Increase salt intake, start fludrocortisone |
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Dysautonomic causes of orthostatic hypotension (7)
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Diabetic neuropathy
Amyloidosis Syphilis SCI Syringomyelia Alcoholic neuropathy AIDP |
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Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is also known as
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Guillain Barre syndrome
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Why is video EEG monitoring needed for pseudoseizures?
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1-3% have organic seizures as well, need to r/o
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Pt treated for temporal arteritis who develops proximal muscle weakness afterwards likely has
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Steroid-induced myopathy! Especially if ESR normal (and already received steroids, the treatment), unlikely to be PMR
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Contralateral hemianesthesia/ dysesthesia can be caused by a stroke where
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VPL nucleus of thalamus (thalamic pain phenomenon)
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HIV pt with multiple demyelinating, non-enhancing lesions w/ no mass effect + hemiparesis and disturbance of speech, vision, and gait
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PML
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Toxo lesions are usually where?
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Basal ganglia
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CSF finding specific for primary CNS lymphoma
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EBV DNA
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Common early side effects of sinemet
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Somnolence, confusion, hallucinations (same w/ dopamine agonists)
Dyskinesia/ motor fluctuations later |
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Common side effect of amantadine
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Ankle edema
Livedo reticularis |
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Cape-like pain and temp loss
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Syringomyelia
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Pathophys of syringomyelia
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Cavitary expansion of spinal cord
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How can anticholinergic meds cause headache/ retro-orbital pain?
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May precipitate acute glaucoma
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Rapidly progressive ascending paralysis with loss of DTRs but no fever or sensory abnormalities
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Tick-borne paralysis
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CSF in tick-borne paralysis
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Normal
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Rx for tick-borne paralysis
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Removal of tick
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New headache (around eye) and halos around lights + non-reactive, dilated pupil and erythematous eye
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Acute angle closure glaucoma
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AMS, tachycardia, coagulopathic bleeding, temp >40.5C (105F)
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Heat stroke (often exertional)
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Neurogenic fever is often caused by abnormalities where?
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Hypothalamus (thermoregulatory mechanism)
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Down and out gaze
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CN III neuropathy
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Best test for acute glacuoma
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Tonometry
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Pronator drift indicates
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UMN disease (exaggerates the strength of the pronators over the supinators)
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Cortical location of motor vs. sensory findings
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Motor: frontal lobe
Sensory: parietal lobe |
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Dysarthria + clumsy hand syndrome
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Lacunar stroke
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Biggest risk factor for lacunar strokes
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HTN
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Pure motor hemiparesis or ataxia-hemiparesis
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Lacunar stroke (posterior internal capsule)
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Pure sensory stroke
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VPL nucleus of thalamus
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Drug approved for ALS and mechanism
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Riluzole
Glutamate inhibitor |
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Findings in Wernicke-Korsakoff syndrome (3 + 2)
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Ataxia, ophthalmoplegia, confusion (Wernicke's)
Plus confabulation and amnesia (Korsakoff's) |
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Most prominent finding in NPH
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Broad-based gait and shuffling, some bradykinesia
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Most common cause of myesthenic crisis
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Infection
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Rx for myasthenic crisis
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Intubation and withdrawal of anticholinesterases for several days (may have induced excess cholinergic Sx)
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Rx for normal pressure hydrocephalus
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Repeated LPs; if improve, VP shunt
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Ipsilateral ataxia (pt falls toward side of lesion) and weakness
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Cerebellar tumor
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Hemiparesis, hemi-sensory loss, homonymous hemianopsia, eyes deviated away from paralytic side
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Putamen hemorrhage
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Most common site of hypertensive hemorrhage
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Putamen (next to internal capsule, so hemiparesis is common)
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Presentation of subarachnoid hemorrhage
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Severe headache WITHOUT focal neuro signs
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Rx for exertional heat stroke
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Evaporation cooling (spray naked pt with lukewarm water and running fans to circulate air)
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Common electrolyte abnormality in subarachnoid hemorrhage
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Hyponatremia (from SIADH and excess ANP --> cerebral salt wasting)
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Pick's disease
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Frontotemporal dementia (may have FH)
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Where is the blood on CT in a pt with subarachnoid hemorrhage
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Sulcai and cisternae
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Child with staring spells, automatism, and post-ictal confusion
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Complex partial seizure (NOT absence if post-ictal)
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Difference btwn typical and atypical absence seizures
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Atypical last longer
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What is Lennox-Gastaut syndrome?
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Childhood seizures of multiple types, impaired cognitive fxn, and slow spike-and-wave activity on EEG
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Decreased strength and sensation only in the LEs and + Babinski
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Spinal cord compression! (UMN signs as well as LMN; no UMN signs in GBS)
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Erythema migrans, headache, arthralgias, myalgias
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Lyme disease
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Work-up of amaurosis fugax
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Carotid duplex (most common site of emboli)
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2 things that can predispose to pseudotumor
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Isotretinoin or Vitamin A toxicity
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When can't you give beta blcokers for essential tremor?
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Pt with bradycardia or severe COPD
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What is primidone
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Anticonvulsant (converts ito phenylethylmalonamide and phenobarb)
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Risk of primidone
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Acute intermittent porphyria (abd pain, neuro and psych abnormalities)
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Test to diagnose acute intermittent porphyria
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Urine porphobilinogen
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Low back pain, bowel/bladder dysfunction, saddle anesthesia, sciatica, LE sensory/motor loss
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Cauda equina syndrome
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How to distinguish cauda equina syndrome from disease in lumbar spine?
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Latter has UMN signs; cauda equina only has lower motor neurons
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Cauda equina syndrome indicates disease where?
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Spinal nerve roots
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Ring-enhancing lesion in brain + fluid collection in maxillary sinus
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Brain abscess (usually strep or anaerobes) 2/2 maxillary sinusitis
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Acute occipital headache, repeated vomiting, gait ataxia, HTN
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Cerebellar hemorrhage
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Pt is very concerned about their impaired memory
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More likely to be pseudodementia than dementia
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What normal neuro finding can brain dead patients still have?
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DTRs (spinal cord finding)
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Parkinsonism + autonomic dysfunction
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Multiple system atrophy
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What is Shy Drager syndrome?
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Multiple system atrophy
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Rx for multiple system atrophy
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Volume expansion (salt, fludrocortisone, alpha agonists)
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Most common site of ulnar nerve entrapment
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Elbow
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Systemic condition that predisposes to carpal tunnel syndrome
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Hypothyroidism
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Ventricles in NPH
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Enlarged
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Side effects of pyridostigmine or neostigmine for myasthenia
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Abdominal cramps, fasciculations, muscular weakness
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Why is neglect usually on the left?
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Involves the right parietal lobe (non-dominant)
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Bilateral trigeminal neuralgia may indicate
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MS
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2 common types of migrainous aura
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Visual and sensory
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Rx for persistent postspinal headache
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Epidural blood patch (pts blood injected into epidural space at site of initial tap)
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Mechanism of triptans
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5HT-1D serotonin receptor agonists
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Contraindication for triptans
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Hx of CAD or HTN
Hemiplegia or blindness as aura |
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All pts with chronic daily headache need
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MRI
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What to avoid to Alzheimer's drugs
|
Don't start 2 at once
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Sense impaired in early AD?
|
Olfaction
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Risk factors for AD
|
Apolipoprotein E type E4
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Degeneration of AD commonly is where?
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Nucleus basalis of Meynert (cholinergic cells project there)
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Motor parkinsonism w/ executive dementia and visual hallucinations
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Lew body dementia
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Occipital lobe hypometabolism
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Lew body dementia
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Atrophy of midbrain
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Progressive supranuclear palsy
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Temporal lobe atrophy and parietal temporal hypometabolism
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Alzheimer's
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Paresthesias in hands and feet, vibratory loss, ataxia, and mental changes
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B12 deficiency
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Pathology of subacute combined degeneration of spinal cord
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Edema and destruction of myelin
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Sensory loss + spastic paresis
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Subacute combined degeneration (lesions in dorsal column and lateral CST)
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2 other lab values in B12 deficiency
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Increased homocysteine, increased methylmalonic acid
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Slowed velocity on NCS means diagnosis is not
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Multiple sclerosis (b/c is a CNS, not PNS problem)
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3 other diseases associated w/ optic neuritis
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Sjogrens, GBS, HIV
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Visual test findings in MS
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Prolongation of visual evoked responses
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ADEM often follows (2 things)
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Infection
Vaccination |
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ADEM can progress to?
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MS (25%)
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Hyperacute ADEM
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Acute necrotizing hemorrhagic encephalomyelitis
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Finding in ADEM
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Perivenular demyelination (inflammatory myelinopathy)
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Rx for ADEM
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Usually nothing: steroids, PLEX, or IVIg if needed
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Don't confuse ADEM with this disease, and how to differentiate
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GBS (prior infection, weakness, urinary incontinence in both, but HEMIparesis and HEMIsensory is ADEM)
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If suspicion for meningitis is v. high, when must a CT still be performed first?
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Focal neuro findings or papilledema
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Most common cause of viral meningitis
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Enteroviruses
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Reduced CSF glucose is what value?
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<40% serum
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MRI in HSV meningitis
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Temporal lobe hemorrhage
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Suspicion of meningitis w/ skin rash
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Neisseria
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Rx for neisseria
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Penicillin or ampicillin + dexamethasone
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Bacterial vs. viral CSF
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Bacterial has higher protein and low glucose, PMN predominance
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Rx for infantile botulism
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ICU (high risk of respiratory depression) and antitoxin human botulism Ig (IV)
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Botulism presentation
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Descending weakness
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Pathophys of botulism
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Inhibition of ACh release by toxin --> presynaptic problem
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Constipation, hypotonia, respiratory difficulties, CN abnormalities and hyporeflexia
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Infantile botulism
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Best Dx test for infantile botulism
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Stool sample
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Foodborne botulism in adults has what Hx?
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Antecedent GI disease (N/V/D)
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Botulism presentation in a baby with reactive pupils and normal DTRs
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Neonatal myasthenia gravis
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HIV pt w/ behavioral changes and lack of coordination
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HIV-associated dementia
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Path findings in HIV-associated dementia
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Cerebral atrophy (esp in frontotemporal region) w/ diffuse myelin pallor
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Testing for CJD
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Periodic short wave complexes on EEG and nml CT
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Description of sensory pain in neurosyphilis
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Lancinating
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4 forms of neurosyphilis
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Asymptomatic
Meningovascular Tabes dorsalis General paresis |
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Rx for toxo
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Pyrimethamine, sulfadiazine, folinic acid
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Prophy for toxo
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Bactrim
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Unilateral unresponsive pupil, impaired corneal sensation, decreased DTRs in legs
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Holmes-Adie syndrome (benign/ normla)
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How to differentiate tonic pupil from CN III palsy?
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Check accommodation (intact in tonic pupil)
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Imaging study for pt w/ papilledema
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CT w/ contrast
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Increased ICP definition
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Pressure >200 (or >250 in obese)
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Rx for refractory pseudotumor
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LP or VP shunt
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Rx for progressive vision loss in pseudotumor
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Optic nerve sheath fenestrations
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Double vision only on horizontal gaze in a pt with CAD
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CN VI palsy (affecting lateral rectus) due to ischemic mononeuropathy)
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Covering one eye resolves double vision indicates
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Binocular double vision (intracranial problem, vs. monocular which is usually an ophtho issue)
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Worsening diploplia on near vision
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Medial rectus problem
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Rx for ischemic CN VI palsy
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Eye patch, prism, botulinum toxin, if no better in 3-6mo: surgery
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Unilateral facial paralysis, hearing loss, and blisters on ear
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Ramsay-Hunt Syndrome
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Ramsay Hunt Syndrome affects which two CNs?
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VII and VIII
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Facial paralysis caused by a stroke usually spares
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Forehead
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Epithelial debris from TM that becomes trapped in middle ear
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Cholesteatoma
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Sensory ganglion of facial nerve
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Geniculate ganglion
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Ramsay Hunt Syndrome is also known as
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Herpes zoster oticus
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Inability to raise upper lip on one side
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Parotid gland tumor (Isolated facial nerve paralysis in one branch is caused by malignancy until proven otherwise)
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Ophtho risk w/ CN VII paralysis
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Exposure keratitis (b/c can't blink/tear, need hourly artificial tears)
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Test for mitochondrial cytopathies
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Serum lactate
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Ptosis + CN III palsy
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Concern for posterior communicating artery aneurysm
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What is MuSK?
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Muscle-specific tyrosine kinase (enzyme critical for aggregating ACh receptors)
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Test in all myasthenia pts (2)
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FVC (to check for respiratory muscle weakness) and TSH
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Pathophys of myasthenia gravis
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ACh receptor Abs bind ACh receptor, prevent ACh from binding, so post-synaptic potentials aren't enough for an AP
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Rx for myasthenia
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Immunosuppressants + anti-cholinesterase inhibitors (latter for symptoms only)
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Type of herniation that causes ptosis?
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Uncal (CN III palsy)
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Type of hearing loss w/ cholesteatoma
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Conductive
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Rx for CIDP
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Steroids, IVIg (1st line if is pure motor CIDP), PLEX
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When to intubate with GBS
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Prophylactic if FVC <15-20mL/kg
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GBS findings
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Areflexia, proximal LE weakness w/ distal sensory changes and ascending progression
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ABs involved in GBS
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Anti-ganglioside
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Most common GBS subtype
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AIDP
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Miller-Fisher GBS subtype
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Areflexia
Ataxia (out of proportion to sensory deficits) Ophthomoplegia CN wekaness > extremities + anti-GQ1b (ganglioside) Abs |
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Acute motor axonal neuropathy (AMAN)
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GBS common in kids
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Acute motor and sensory axonal neuropathy (AMSAN)
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GBS with significant muscle atrophy
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Acute pain autonomic neuropathy
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GBS in which dysrythmias often contribute to mortality
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DDx for acute flaccid paralysis + GI Sx (3)
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GBS
Tick paralysis Botulism (descending) |
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Timing of GBS
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Most severe at 12 days, with improvement from 28-200 days
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LP in GBS
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Albuminiocytologic dissociation (protein up to 400 but no increase in cell count)
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Rx for GBS
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5 days IVIg, 10 days PLEX
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What are Gottron papules?
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Flat-topped raised nonpruritic lesions on MCP, PIP, and DIP joints
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What is a mixed headache?
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Chronic daily headache with episodic exacerbations
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DDx for chronic daily headache (3)
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Primary headache disorder
Cerebral venous sinus thrombosis Increased ICP |
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Best migraine abortive agents (2) in children
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Ibuprofen and acetaminophen are first line
Then sumatriptan nasal spray |
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Migraine is associated with what other disorder?
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Epilepsy (each increases the risk of the other by 2)
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Vertigo w/o headache
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Migraine equivalent
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Diagnostic test for muscular dystrophy
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Muscle biopsy
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Abnormal protein in muscular dystrophy and its function
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Dystrophin (connects cytoskeleton of muscle fiber to surrounding extracellular matrix thru cell emmbrane)
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Other than skeletal muscle, tissue commonly involved in muscular dystrophy and resultant diseases (3)
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Cardiac muscle
Cardiomyopathy --> CHF and arrythmias |
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Elevated blood test in muscular dystrophy
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Creatine kinase
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Drugs for muscular dystrophy
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Steroids to slow muscle degeneration
Anticonvulsants to control seizures/ muscle activity Immunosuppressants to delay damage to muscle cells |
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Why do boys with muscular dystrophy have cognitive impairment?
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Mutant dystrophin in neurons
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Hallmark of tics associated with Tourette syndrome
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Patients have insight into them, and they are suggestible
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Two types of tics (other than motor vs. phonic)
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Simple (blinking, limb jerking, torticollis-posturing, grunting, coughing)
Complex (head shaking, touching, hitting |
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When is a complex tic actually a compulsion?
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If preceded by obsessive thought, anxiety, or fear
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3 meds for tic suppression
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Dopamine receptor antagonists (haloperidol, fluphenazine, pimozide)
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Child with a nighttime seizure w/ sensorimotor manifestations on one side of the face, speech arrest, hypersalivation, and then develops a GTC
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Benign rolandic epilepsy
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When are anticonvulsants indicated for benign rolandic epilepsy?
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Usually only if the child has experienced three or more seizures
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Rx for benign rolandic epilepsy
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Oxcarbazepine or gabapentin
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Most common focal epilepsy in kids vs. adults
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Benign rolandic epilepsy
Temporal lobe epilepsy |
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Infant with severe retardation, recurrent seizures, infantile spasms, hypotonia, and craniofacial dysmorphic features
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Lissencephaly
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2 types of lissencephaly
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Miller-Dieker syndrome (epilepsy, poor feeding, and spasticity)
Isolated lissencephaly sequence (less severe) |
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Child w/ bouts of rapid neck flexion, arm extension, hip and knee flexion, and abdominal flexion, often with arousal from sleep
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Infantile spasms
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3 type of criteria for autism
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Social, communication, and behavioral deficits
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Autism but with normal language development
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Asperger syndrome
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Children with autism develop symptoms before what age?
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3yo
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What is very concerning in a child with developmental problems?
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Prior normal achievement of developmental milestones, but now regressing (could be a progressive neurological disorder) (although children with autism may have some language regression)
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Rate of epilepsy in autism
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25% (vs. 1% in the general population)
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Progressive onset of hearing loss, facial paralysis, headache, and imbalance
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Acoustic nerve meningioma in cerebellopontine angle (CN VII and VIII are there)
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Cell of origin for meingiomas
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Arachnoid villi (mesoderm)
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Most common tumor of cerebellopontine angle
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Acoustic neuroma
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Best test to elucidate etiology of unilateral sensorineural hearing loss?
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MRI of internal auditory canals with gadolinium
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Which primary malignancy can be diagnosed from MRI imaging of brain mets?
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Malignant melanoma (hyperintense on T1 and hypointense on T2)
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Steroid dose for brain tumors
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10mg dexamethasone followed by 4mg q6hrs
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Antibody in myositis
|
Anti-Jo-1
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Where are the lymphocytes on muscle biopsy in polymyositis vs. dermatopyomsitis
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Poly: within fascicles
Dermato: perivascular and perifascicular |
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Rx for inflammatory myopathies
|
Oral prednisone
Add MTX or azathioprine (or IV Ig) if needed) |
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Main association with inflammatory myopathies
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Malignancy (also lung/cardiac problems in 10%)
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Most common acquired myopathy in pts >50
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Inclusion body myositis
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Familial ALS is due to what mutation
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Cu/Zn superoxide dismutase gene (chromosome 21)
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What % of ALS cases are familial (AD)?
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10%
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Diagnostic tests for ALS
|
EMG/NCS
Spine imaging to r/o cervical myelopathy |
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|
Long-term carpal tunnel can cause
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Thenar atrophy
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Rx for carpal tunnel (1st and 2nd line)
|
1st line: rest, splint for immobilization, NSAIDs
2nd line: steroid or lidocaine injections, B6, PT |
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Surgery for carpal tunnel (what is done and what the indication is)
|
Severeing band of tissue
Sx for >6mo |
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Risk factor for brachial plexopathy
|
Radiation
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Decreased dorsiflexion and eversion of the foot
|
Foot drop (peroneal palsy)
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Common cause of peroneal neuropathy
|
Compression at fibular head
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Why do partial palsies recover faster?
|
Local sprouting
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Nerve root of peroneal nerve
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L4-L5
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4 types of seizures that are characterized as generalized epilepsy
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Tonic-clonic
Atonic Myoclonic Absence |
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3 types of local epilepsy
|
Idiopathic (syndromes, genetic)
Symptomatic (trigger) Cryptogenic |
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Aura of odd smell only
|
Simple partial seizure
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|
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4 hereditary epilepsies
|
Benign rolandic epilepsy
Febrile convulsions JME Childhood absence epilepsy |
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Prognosis of hereditary epilepsies
|
All but JME resolve spontaneously
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|
Best AED for JME
|
Valproic acid
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Best AED for generalized epilepsy
|
Valproic acid
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Best AED for focal epilepsy
|
Phenytoin or carbamazepine
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|
|
Rx for benign rolandic epilepsy
|
Observe unless seizures worsen
|
|
|
When is a febrile seizure complex (vs. simple)
|
Focal
>15 min Recurs w/in 24 hours |
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|
Most common etiology of febrile seizure
|
HHV6
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Risk of recurrence of single simple febrile seizure
|
30%
|
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Rx for febrile seizures
|
Often intermittent prophy (rectal or oral diazepam only during febrile illnesses)
|
|
|
Common location of pure motor strokes
|
Lacunar (posterior limb of internal capsule)
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|
|
Ipsilateral Horner syndrome, ataxia, and facial P&T loss; contralateral P&T loss in body; dysphagia and dysphonia
|
Lateral medullary syndrome
|
|
|
Structures contained in lateral medulla
|
CN V nucleus, nucleus ambiguus, lateral spinothalamic tracts, CN IX and X
|
|
|
What does nucleus ambiguus contain?
|
Motor neurons of CN IX and X
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|
|
Lateral medullary syndrome is due to occlusion of?
|
Vertebral artery (or PICA, which is a branch of it)
|
|
|
Deposition in cerebral amyloid angiopathy
|
Beta-amyloid protein
|
|
|
HIV pt w/ stroke Sx and a cortical lesion on imaging
|
Bleeding from myocotic aneurysm
|
|
|
Diagnostic test for suspected bleeding from mycotic aneurysm
|
LP for xanthrochromia
|
|
|
Cause of mycotic aneurysm
|
Bacterial emboli from heart --> arterial wall (low virulence organism; high virulence causes meningitis or abscess)
|
|
|
Encephalofacial angiomatosis
|
Sturge-Weber (port wine stain + leptomeningeal angiomas)
|
|
|
Broca's aphasia cause
|
Left MCA infarction
|
|
|
Pts with bleeds <40yo likely have
|
AVMs (aneurysms don't bleed til later)
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|
Aneurysm where can compress CN III?
|
Posterior communicating artery
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|
Cause of transient monocular blindness in carotid artery disease?
|
Embolism to central retinal artery
|
|
|
Gaze deviation indicates
|
Ipsilateral frontal lobe damage
|
|
|
Where are expressive vs. receptive language centers?
|
Expressive: frontal
Receptive: temporal |
|
|
Where do the language centers communicate?
|
Arcuate fasciculus
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|
|
Problem with repetition is a
|
Conduction aphasia
|
|
|
Speech limited to repetition implies
|
Mixed transcortical aphasia
|
|
|
Tunnel vision
|
Conversion disorder or malingering
|
|
|
Concentric constriction (visual field is overall smaller but enlarges as test screen moves away)
|
Neurosyphilis
|
|
|
Lack of red reflex
|
Congenital cataracts
|
|
|
Presence of white reflex
|
Scar or retinoblastoma
|
|
|
Sturge-Weber has a risk of what eye problem?
|
Glaucoma
|
|
|
Rx for CMV
|
Ganciclovir
|
|
|
Acute central scotoma
|
Methyl alcohol intoxication
|
|
|
How to differentiate pappillitis and papilledema?
|
Former has visual loss
|
|
|
Rx for pseudotumor in pregnant woman
|
Repeated LPs
|
|
|
Cause of APD
|
Optic atrophy from optic neuritis
|
|
|
Retinal exam changes from HTN
|
Segmental narrowing of arterioles and nicking
|
|
|
Retinal microaneurysms usually indicate?
|
DM
|
|
|
Most common ocular motor paresis is of
|
CN VI
|
|
|
CN VI nucleus is where?
|
Pons
|
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|
Which CN is most commonly injured w/ facial trauma?
|
CN IV (superior oblique) b/c extends far into orbit
|
|
|
What do pts develop to compensate from CN IV loss?
|
Head tilt
|
|
|
Which CNs are affected by herpes zoster ophthalmicus?
|
CN V ad IV
|
|
|
Diabetic injury to CN III usually spares?
|
Pupillary constriciton (whereas that goes first with compression)
|
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|
INO indicates
|
Mesencephalic or pontine injury
|
|
|
Rapid downward deviation of both eyes followed by slow upward conjugate eye movements
|
Ocular bobbing, usually from pontine damage
|
|
|
Nystagmus while locking at a rotating drum w/ stripes
|
Optokinetic nystagmus (normal)
|
|
|
Which drugs cause a syndrome that can resemble hypertensive encephalopathy?
|
Cyclosporine and tacrolimus (reversible posterior leukoencephalopathy)
|
|
|
Inferior visual field defect
|
Ischemic optic neuropathy
|
|
|
Appearance of ischemic optic neuropathy on retinal exam (early and late)
|
Initially swollen optic nerve, then pale optic nerve
|
|
|
Lantern jaw, prominent nose, spade shaped hands, DM and menstrual problems
|
Pituitary problem, e.g. acromegaly
|
|
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Temporal lobe damage eye findings
|
Superior homonymous quadrantonopsia
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