Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
284 Cards in this Set
- Front
- Back
|
Headache Causes:
_________ nerve endings on extracranial structures that produce referred pain to the head when stimulated Pain stimuli from brain tissue above the tentorium conveyed by the _______ nerve Pain impulses from posterior fossa conveyed by glossopharyngeal, vagus, and first two cervical nerves |
Nociceptive
trigeminal |
|
|
Headache Evaluation:
Must distinguish benign headache from serious or ________ headache ________ helps decide which patients may have benign pain or pain associated with major intracranial lesion |
malignant
History |
|
|
Headache History:
_______,________,________,________ Exacerbating and relieving maneuvers Ominous sign: acute onset of worst headache of his/her life (___________) Suggests ______________ |
Quality, location, duration, course
Thunderclap HA subarachnoid hemorrhage (SAH) |
|
|
________:
throbbing, pressure, jabbing, vice like Location: Especially if pain is __________ in origin - temporal location and temporal arteritis ___________ pain is occipitocervical occasionally associated with retro-orbital pain (unilateral) Multifocal pain is usually a ________ etiology |
Quality
extracranial Posterior fossa benign |
|
|
________: Menses, food, caffeine, alcohol, stress
____________: Worse in morning or awakening from sleep may mean increased intracranial pressure or sleep apnea Associated symptoms: _________ disturbances, nausea, vomiting, nasal congestion, hay fever Other: medications, (especially _________ and OTC meds), family history, past medical history |
Triggers
Diurnal variations Visual analgesics |
|
|
Physical Exam in Acute Headache:
Vital signs, neuro exam, _____ testing, _________ exam Fever: must r/o _________ irritation with Kernig’s and Brudzinski’s Always check ____, besides headache from HTN, can also be present with headaches from - Intracranial hemorrhage, preeclampsia, pheochromocytoma |
vision
fundoscopic meningeal BP |
|
|
Eye exam:
Visual _______ decreased in glaucoma, temporal arteritis, and optic neuritis Visual ______ problems in venous sinus thrombosis, tumor, or aneurysm __________ defects in intracranial masses or optic neuritis Ptosis and meiosis (__________) with acute headache can signify ___________ Papilledema or absent venous pulsations can signify increased __________ |
acuity
fields Pupillary Horner’s syndrome corotid artery dissection intracranial pressure |
|
|
Physical Exam:
Complete neurologic evaluation and mental status exam is mandatory Neuro exam: Motor and sensory systems, gait and cerebellar functions, ________ drift Any abnormality on mental status or neuro exam warrants emergent __________ |
pronator
neuroimaging |
|
|
CT or MRI with:
________ headache in previously well patient, _________ headache disorder, new onset headache in mid or later life, headaches with focal neuro sx, headaches that disturb ______ CT or MRI, and CSF exam with: _________ irritation or impairment of _________ _____ or meningeal infection |
Severe
progressive sleep Meningeal conciousness SAH |
|
|
Patient complaints:
Poor concentration and other vague complaints constant daily headaches, vise like, tight hat band Worse with stress, fatigue, noise and glare Most intense in neck and back of head No focal neuro sx |
Tension HA
|
|
|
Tension headache Treatment
If simple ________ not effective, try anti migrainous meds Relaxation techniques: Hot baths, massage, biofeedback Look for underlying cause of ________ |
analgesia
anxiety |
|
|
Episodic headache disorder with various combinations of neuro, GI, and autonomic changes with dx based on headaches characteristics and associated sx.
PE and lab usually normal 15% in women and 7% in men May begin at any age from early childhood on peaks in adolescence and early adulthood |
Migraine HA
|
|
|
Migraine Headaches Types:
_____ migraine - Migraine without aura ______ migraine - Migraine with aura _____ - Focal neuro sx (visual) that precede the headache |
Common
Classic Aura |
|
|
Symptoms:
Usually pulsating, unilateral, __________ pain With nausea, anorexia, and sometimes vomiting __________,__________, and occasionally osmophobia Diagnosis or migraine requires at lease one of the above, especially if no _____ sx |
frontotemporal
Photophobia, phonophobia GI |
|
|
Migraine Headaches Symptoms:
In children may have __________ pain, sleep disturbance, and motion sickness Onset over age ___ rare, but can have recurrence of migraine that was in remission Can have transient hemiparalysis or hemiplegia in genetic migraines called ______________ |
abdominal
50 familial hemiplegic migraines |
|
|
Familial hemiplegic migraines:
Attacks with major neuro sx Migraine with hemiplegia or ________ Dysfunction outlasts the headache by ___________ |
coma
hours or 1-2 days |
|
|
Migraine Headaches Etiology:
_______(65-91% have family hx) CNS susceptibility to certain stimuli (foods, alcohol) ________ factors Sequential neurovascular events |
Genetic
Hormonal |
|
|
Goals of Treatment:
Treatment of _________ _________ of recurrent headaches Patient information - Tell patient they have migraines Explain that this is a _______ condition Help them understand their role in the treatment process Explain the importance of a headache ________ |
acute attack
Prevention benign diary |
|
|
Treatment Acute migraine:
May be relieved with single agent or combination of agents _________ modification therapy is important Some attacks respond to simple analgesics - Acetamenophin, ASA, NSAIDS (_______) _______ have little use in migraine therapy Overuse of analgesics is common in migraineurs, so monitoring amount of analgesics is important _________ for nausea (also slight sedative effect is beneficial) |
Behavior
Toradol Opoids Antiemetics |
|
|
Treatment Acute migraine:
“Migraine specific” _______ agonists - 5HT1 receptor agonists Effective in alleviating migraines Patients must be instructed in appropriate usage Sumatriptan (Imitrex) Naratriptan (Amerge) Rizatriptan (Maxalt) Frovatriptan (Frova) |
seratonin
|
|
|
Migraine prevention:
Drugs used should be limited to patients who have More than ___ migraines/month Are willing to take _____ meds Adequate trial period should be given, using adequate dosages, before it is considered ineffective |
4
daily |
|
|
___________ migraine (rare):
Blindness or visual disturbances in both visual fields followed by Dysarthria, disequalibrium, tinnitis Perioral and distal paresthesias Transient loss or impairment of consciousness or confusional state All followed by throbbing occipital headache with nausea and vomiting |
Basilar artery
|
|
|
___________ migraine:
Lateralized pain about the eye N and V, diploplia Transient opthalmoplegia of 3rd and 6th nerve may outlast pain for weeks Very rare type of migraine |
Opthalmoplegic
|
|
|
_______ Headache: Is a group of symptoms with specific course
Less than 10% of all headache sufferers More common in men, and onset later in life than migraines Rarely in childhood, and less often a family hx than migraines |
Cluster
|
|
|
Cluster Headache Symptoms:
Pain is extreme Steady, nonthrobbing, retro-orbital on one side of head, may spread to ________ side of face and neck Attacks awake patients 2-3 hours after sleep onset, not relieved by dark quiet area Congestion of ________ and injection of _________ on side of headache (with occasional tearing) ________ on ipsilateral side of the face and forehead May be signs of Horners syndrome (ptosis, meiosis) |
ipsilateral
nasal mucosa conjunctivae Sweating |
|
|
Cluster Headache Symptoms:
Named cluster because symptoms frequently occur over days or weeks with headache free periods of several months to years Very susceptable to _______ as a precipitant, even small amounts Etiology of clusters unknown, but pain distribution suggests _________ nerve dysfunction |
alcohol
trigiminal |
|
|
Cluster Headache Treatment: Abortive (acute headaches) or prophylactic to prevent headaches
May respond to ___ by mask 7-10 L/min for 15 min Effective in 70% of patients within several minutes Preventative medicine - ________, divalporex sodium, _________ (CCB), methysergide (sansert), corticosteroids |
O2
Lithium verapamil |
|
|
Headaches of structural brain disease:
Manifestation of underlying brain disease Seen in ________, TIA’s, intracerebral and subarachnoid hemorrhage Infection seen in _________ - Neck stiffness, + Brudzinski’s and Kernig’s HA from sinusitis, brain tumors, & SAH |
infarction
meningitis |
|
|
Headaches from _________:
Most prominent feature of sinusitis Dull, aching, and non pulsatile Exacerbated by movement, cough, and straining. Improved with decongestants Worse on awakening from prolonged lying down, improved with prolonged standing |
Sinusitis
|
|
|
Headaches from sinusitis
Pain location depends on sinus involved _________: ear, face, dental _______: behind eyes, vertex of skull with tenderness to undersurface of supraorbital rim ________: between or behind eyes, radiating to temples ________: pain to vertex or orbit _______sinusitis: seldom a cause of headaches |
Maxillary
Frontal Ethmoid Spenoid Chronic |
|
|
Brain Tumors
Posterior fossa: headaches especially with __________ if obstuction of CSF occurs Supratentorial tumors less likely to cause headaches but more frequently cause _______, focal defects or altered mental status Increased ____________ does not produce distortion of pain sensitive structures, but headache is from whatever has caused the increased pressure |
hydrocephalus
seizures intracranial pressure |
|
|
Brain tumors (Intracranial Mass Lesions):
Usually due to displacement of vascular structures Posterior fossa cause ________ pain Supratentorial cause ______ Findings are too inconsistant and nonspecific in character Signs of focal diffuse _____________ or increased IC pressure warrants further investigation _________ headache, or new onset in middle or later life requires work up |
occipital
bifrontal cerebral dysfunction Progressive |
|
|
causes 5-10% of strokes Usually due to aneurysm or AVM rupture
No cause found in 20% of cases |
Subarachnoid Hemorrhage (SAH)
|
|
|
SAH:
Sudden onset headache (worst I’ve ever had/____________) Nausea and vomiting Loss or impairment of conciousness which can progress to ______ Confused irritable patient if conciousness is regained with sx of altered mental status _______ rigidity Focal neurologic deficit may suggest site of underlying lesion |
thunderclap headache
coma Nuchal |
|
|
SAH Imaging:
_____ Immediately Preferable to MRI in 1st 24 hours If CT normal with strong suspicion of SAH, must do ________ for blood to R/O SAH Once patient stabilized, may do ___________ to localize source of bleeding and consider for surgery Need bilateral carotid and vertebral angiography because aneurysms can be multiple |
CT
CSF exam angiography |
|
|
SAH TX:
Measures for comatose patients Concious patients confined to bed and advised against straining and exertion _________ treatment for headache and anxiety _________ and stool softners Gradual lowering of ____ if hypertensive but not below diastolic BP of 100mm/hg ________ to prevent seizures _________ management of AV malformations and aneurysms |
Symptomatic
Laxatives BP Phenytoin Operative |
|
|
Distinguished from other headaches because of the shortness of the attacks
(1-2 seconds or less) & the distribution of the pain (along affected nerve root) Usually responsive to treatment with __________ such as phenytoin, carbamazepine, gabapentin, and occasionally baclofen |
Cranial Neuralgias
anticonvulsants |
|
|
_________ neuralgia (tic douloureau):
Stabbing (lancinating), spasmotic, severe pain in one of the divisions of the trigeminal nerve Lasts only seconds Occurs many times/day for weeks at a time Usually provoked by slight _____ to the face such as the lips or gums Small minority of cases associated with ___________, cerebellopontine tumors, aneurysms, ______ Unlike true trigeminal neuralgia, those that are associated with theses conditions have objective findings of neurologic defects Ex: areas of diminished _________ |
Trigeminal
touch multiple sclerosis AVMs sensation |
|
|
Trigeminal neuralgia:
Can be life threatening if it interferes with _______ Treatment: Medical with meds such as __________ If unsuccessful medical treatment, surgical microvascular decompression and/or radiofrequency lesioning of the medial portion of the trigeminal nerve |
eating
carbamazepine |
|
|
_____________ Neuralgia:
Rare and much less common than trigeminal neuralgia Severe stabbing pain from throat to ear Initiated by stimulation of trigger zones such as post pharyngeal wall, swallowing, yawning and/or coughing Treatment is surgical microvascular decompression as medical treatment is ineffective |
Glossopharyngeal
|
|
|
Postherpetic Neuralgia:
1/3 of the cases of _________ produces head pain due to cranial nerve involvement Sometimes, persistant severe burning pain follows the initial illness It may resolve in weeks, or persist from months to years (especially in the ________) |
Herpes zoster
elderly |
|
|
Herpetic Neuralgia:
Localized over the distribution of the cranial nerve, and patients experience severe tenderness even with light touch Most frequent nerve involved is the ____ division of the trigeminal nerve (_________) Geniculate herpes is the ____ nerve and involves pain in the external auditory canal and the pinna _________ syndrome is facial paralysis with geniculate herpes |
1st
opthalmic herpes 7th Ramsay Hunt |
|
|
Occipital neuralgia:
Occipital pain starting at the base of the skull and provoked by neck _______ Tenderness in the region of the occiput and altered sensation in the ____ dermatome Treatment: Soft collar, muscle relaxants, PT, injections of ________, NSAIDS |
extension
C2 analgesics |
|
|
Headache Due to ____________:
Superficial temporal, vertebral, ciliary, and opthalmic arteries are most severely affected Clinical findings: Usually elderly patient Headache with myalgias, malaise, anorexia, weight loss Loss of _______ is the worst and most feared manifestation of this illness Occurs commonly |
Giant Cell (temporal) arteritis
vision |
|
|
Headache Due to Giant Cell (temporal) arteritis:
Physical exam - _________ over scalp and temporal arteries Treatment - ________ 60mg/day at 1st sign Temporal artery ______ immediately Low dose ____ to prevent stroke ESR and patient sx should dictate taper of prednisone ____________ are 17 times more likely in patients with giant cell arteritis |
Tenderness
Prednisone biopsy ASA Thoracic aortic aneurysms |
|
|
Neurologic Exam and Diagnostic Testing: Neuro Hx
Location, quality, and timing of sx PMH, Social Hx Pain generally is due to _________ nervous system problems where aphasia means abnormality of ___ sensory and motor loss means large lesion in the _______ or smaller lesion lower down on the neuraxis Small lesions in spinal cord and brain stem can cause significant neuro problems, where small lesions elsewhere may be ____ |
peripheral
CNS cortex asx |
|
|
Neurologic Exam and Diagnostic Testing: Neuro Hx
Some sx result from lesions at several levels of the nervous system Ex: double vision from _____ lesions Brain stem Peripheral nerves Neuromuscular jct EOM’s Double vision from non focal problems Increased __________ |
focal
intracranial pressure |
|
|
Pace and order of symptoms:
__________ diseases are gradual Alzheimers, Huntingtons, Parkinsons _________ diseases are rapid Stroke, SAH |
Degenerative
Vascular |
|
|
Examination Approach: injury is from one of two possibilities:
_________ pathway structure is disrupted _______ to pathway is disrupted |
Final common
Input |
|
|
In the _______ system the final common pathway includes:
Anterior horn cells Nerve Neuromuscular junction Muscle itself Injury results in dysfunction of the muscle If the efforts to stimulate the final common pathway fail, clinician can conclude the lesion is somewhere in the final common pathway |
motor
|
|
|
Central input to the final common pathway is ______ inhibition
Damage results in _________ of the involved muscle group |
tonic
overactivity |
|
|
Technologic Assessment: Lumbar Puncture
CSF evaluation indicated in specific circumstances Urgent (do not wait for imaging): Acute CNS ________ in the absence of focal neurologic signs Less urgent (wait for brain imaging): Vasculitis, SAH, increased intracranial pressure in absence of ________ on MRI or CT |
infection
mass lesion |
|
|
Lumbar puncture:
Also use for intrathecal therapy for fungal or carcinomatous ________ Symptomatic treatment for _________ from idiopathic intracranial hypertension or SAH |
meningitis
headache |
|
|
Lumbar Puncture:
What to look at in ____ (what to order) - Cell count Differential Protein Glucose Bacterial cultures Color and clarity ~ Cloudy CSF should be centrifuged and examined for ___________ in comparison with water |
CSF
xanthochromia |
|
|
Gram stain
Fungal viral and TB cultures Cryptococcal and other antigens Syphilis Lime titres Malignant cytology PCR for specific viruses Opening and closing pressures |
LP special studies
|
|
|
Lumbar puncture: Contraindications
________ - Tissue infection at puncture site ________ - Known intracranial or spinal mass lesions Increased intracranial pressure due to mass lesions Coagulopathy due to thrombocytopenia, anticoagulation therapy, or bleeding disorders |
Absolute
Relative |
|
|
Transtentorial or foramen magnum herniation
Spinal epidural hematoma Spinal abcess Herniated or infected intervertebral disc Meningitis Reaction to local anesthesia More common ~ Headache and backache |
LP Complications
|
|
|
Helpful in situations where patients cannot be adequately examined or interviewed
They are: Electroencephalography Electromyography Nerve conduction studies Evoked potentials |
Electrophysiologic studies
|
|
|
Electroencephalography:
Mostly used to investigate ________ Documents encephalopathy by documenting slowed background electrical activity in the brain Also used in the evaluation of ________ |
seizures
brain death |
|
|
Electromyography:
Used in the ddx of _______ disease, neuromuscular junction disease, peripheral nerve disease, and anterior horn cell disease Nerve Conduction Studies: Show decreased ________(axonal neuropathy) Show decreased _______(diagnostic of demylenating disease). |
muscle
amplitude velocity |
|
|
Nerve Conduction Studies:
Visual evoked potentials - Used in the evaluation of ___ Asymmetrical slowing of the cortical response to a visual pattern stimulation suggests __________ of the optic nerve and optic visual pathways Brain stem auditory evoked potentials - Helpful in diagnosis of disease of CN ___ or its projections Helpful to dx ______ in infants |
MS
demyelination VIII deafness |
|
|
Imaging:
MRI and CT are ______ in most neurologic diseases Also, many abnormal findings on CT and MRI have no bearing on the neurologic problem responsible for the patient’s symptoms *However, they provide important diagnostic precision for ________ lesions* |
normal
central nervous system |
|
|
Imaging:
_____ is used for most purposes Provides more detail Gets images in horizontal, coronal, and vertical planes simultaneously Used for functional imaging and spectroscopy Good for eval of congnitive and metabolic disorders, _______, and MS ____ has greater accessability, quicker to get, and tolerated better by the patient Detects acute _________ Preferred for _________ |
MRI
epilepsy CT hemorrhages emergencies |
|
|
Imaging:
MRI and CT - Both with __________ are useful in tumors, abcesses, and other processes that alter the blood brain barrier ____: Allows noninvasive visualization of the major vessels of the head and neck |
contrast media
MRA |
|
|
Imaging:
Conventional _________ is used to evaluate intracranial vascular abnormalities Small aneurysms, AVM’s, and inflammation of small blood vessels Non invasive __________ Can define stenotic vessels and with transcranial Doppler can alow characterization of blood flow in intracranial arteries Single photon emission CT helpful in eval of intracranial _______ |
angiography
ultrasonography blood flow |
|
|
PET (positron emission tomography):
Imaging tool that demonstrates _______ abnormalities Useful for evaluating local abnormalities of ___________ & _________ metabolism Expensive and limited to specialized centers PET is useful in defining site of origin of focal ______ Also, may be used to differentiate Alzheimers Dz from other forms of ________, and to gain early dx of Alzheimer’s disease |
metobolic
glucose and oxygen seizures dementia |
|
|
Parkinson’s Disease and Huntington’s Disease
|
Movement Disorders
|
|
|
Signs and symptoms of motor system disease:
_____ disorder - Difficulty with coordination, balance, and rapid movements Normal muscle strength, no muscle wasting Muscle tone increased, with spacticity or ridgidity ____ Disorder - If weakness proximal: climbing or descending stairs, rising from chair, lifting heavy objects over head If weakness distal: stumbling and tripping, problems fastening buttons, and opening locks or doors w/hands |
CNS
PNS |
|
|
Is a hypokinetic (not enough movement) disorder with akinetic/rigid syndrome (increased muscle tone throughout the range of motion)
Will not vary with passive ROM by the examiner Cogwheel rigidity Superimposition of tremor on underlying rigidity |
Parkinson’s Disease (PD)
|
|
|
PD:
Occurs in all ethnic groups Equal ____ distribution Most common variety is _______ Begins mostly between ages ______ Affects up to 1 million people in the US Leading cause of _______ in people over age 65 |
sex
idiopathic 45 and 65 neuro disease |
|
|
4 diagnostic criteria for PD
|
Tremor
Bradykinesia Postural instability Muscle rigidity |
|
|
PD Clinical findings/diagnosis:
Tremor, rigidity, bradykinesia, and postural instability are the cardinal features Tremor - 4-6 cycles/sec Noticed more at ____ Worsened by _____ Less severe during voluntary activity Mostly confined to one ___ for years before it becomes generalized |
rest
stress limb |
|
|
PD Clinical Findings/diagnosis:
Rigidity - Increased _______ to passive movement Characteristically ______ posture seen in many patients Bradykinesia - Most disabling symptom of PD _______ in voluntary movements and reduction in involuntary movements such as swinging arms while walking However, these voluntary movements may be temporarily regained during emergency |
resistance
flexed Slowness |
|
|
PD Clinical Findings/diagnosis:
Other signs - ________ face with widened palpebral fissure Infrequent blinking and fixed facial expression ________ of scalp and face __________(flutter of closed eyelids) Tremor about the mouth and face _______ sign Drooling Soft, quiet voice _________ (decrease in size of letters written in sentences or words) Shuffling gait, loss of arm swing, difficulty in stopping, propensity to fall |
Immobile
Seborrhea Blepheroclonus Myerson’s Micrographia |
|
|
PD Differential Diagnosis:
_____ (hypokensia and slight tremor) ________ (expressionless face, reduction in activity) These two disorders co-exist so may be difficult to differentiate May require trial of antidepressants to differentiate ______ disease - Early age of onset Keyser-Fleischer rings Hepatitis _________ disease - Family history Accompanying dementia |
Old age
Depression Wilson’s Huntington’s |
|
|
PD Treatment – drug treatment not required early in disease, but should be discussed w/patient
Medical Measures - _________: helpful if mild sx w/no disability Improves all clinical features of Parkinsonism but MOA unclear Side effects- Restlessness, confusion, depression, skin rash, edema, nausea, constipation, anorexia, postural hypotension, cardiac arrythmias. SE’s unusual with usual dose of ________ |
Amantadine
100 mg/BID |
|
|
PD Treatment: Anticholinergic drugs (______)
Helpful in relieving tremors and rigidity Started in small dose with increases in increments until benefits occur or side effects limit further increases Side effects- Dry mouth, nausea, constipation, palpitations, arrythmias, urinary retention, confusion, agitation, restless, drowsiness, mydriasis, increased IOP’s Contraindications- BPH, narrow angle glaucoma, obstructive gastrointestinal disease |
Cogentin
|
|
|
PD TX: ________
converted to dopamine SE- N/V, diarrhea, tarditive dyskinesia, facial ticks, choreathetoid movements ______ phenomenon: 4-6/day cycles the drug will work for a matter of time then not anymore thought to be due to falling plasma levels |
Levodopa
on/off |
|
|
PD TX: Levodopa/Carbidopa (_______)
Carbidopa prevents levodopa breakdown When given together, amount of levadopa given for beneficial effects can be less Result is fewer side effects, with exception of “off and on” phenomenon or dyskinesias Sinemet started in small dosages of __________ and increased depending on response Contraindications- Psychotic illnesses Narrow angle glaucoma Concomitant MAOI usage Use with care in _____, may worsen disorder |
Sinemet
25mg carbidopa and 100mg levodopa TID PUD |
|
|
PD TX: ________ agonists (Permax and Parlodel)
Dopamine agonists which acts on dopamine receptors SE- Anorexia, nausea, vomiting, constipation, postural hypotension, digital vasospasm, dyskinesias, headache Some reports of pericardial, plural, or pulmonary fibrosis Pergolide and bromocriptine have been replaced by other agents because of theses side effects Newer meds are ________ & ________ (Requip and Mirapex) Lower incidence of dyskinesias and “off and on” phenomenon |
Dopamine
pramipexole and ropinerole |
|
|
PD TX: COMT inhibitors
Catecholamine–0–methyltransferase inhibitors reduce the metabolism of levodopa to methyldopa leading to longer plasma levels and more dopamenergic stimulation of the brain ________ & ________ currently available Adjunct to levodopa in patients with response fluctuations or inadequate response who have failed other adjunctive therapies Given _____ with Sinemet but Sinemet dosages may have to be reduced up to 1/3 to avoid dyskinesias |
Tolcapone and entacopone
TID |
|
|
PD TX: COMT Inhibitors
Side effects are diarrhea and rare cases of ____ with tolcapone _____ should be ordered every 2 weeks for the 1st year of patients receiving tolcapone Entacapone is the preferred agent because of no liver toxicity and no need for LFT’s ______ is the commercial preparation consisting of levodopa/carbidopa combined with entacapone |
FHF
LFT’s Stalevo |
|
|
PD General Measures:
_______ & _______ therapy Aids to daily living: Rails Banisters Larged handle table utensils Non slip table mats Non slip surfaces in bathrooms Voice amplification devices |
Physical and Speech
|
|
|
PD Surgical measures:
Thalamotomy or pallidotomy for patients who are unresponsive to medical treatment or have intolerable side effects to meds _________: surgical procedure to destroy the globus pallidus to relieve involuntary movements or muscular rigidity ___________: ablation of selected portion of the thalamus to relieve tremors |
Pallidotomy
Thalamotomy |
|
|
PD: ______________
High frequency electrical thalamic stimulation supresses the rest tremor of PD Bilteral stimulation of the subthalamic nuclei or globus pallidus internus may benefit all the features of PD Advantages - Is reversible Causes minimal or no damage to the brain *Is the preferred surgical approach to treatment* |
Deep Brain Stimulation
|
|
|
PD: Secondary Causes
__________ Parkinsons- Mostly ________ medications Provoke a bradykinetic/rigid syndrome Examples: Established as a cause~ Phenothiazines and butyrophenones Metaclopramide (_______) reserpine Reported as a cause~ Lithium Phenytoin ACE inhibitors |
Drug Induced
neuroleptic Reglan |
|
|
PD: Secondary causes
________ Disease- Inclusion bodies found in vacuoles of injured neurons 3 types exist based on where they are found When found only in brain stem there is no difference between Lewy body Dz and PD |
Lewy Body
|
|
|
PD: Secondary Causes
_________ Parkinsonism- Signs of PD Microangiopathic changes in basal ganglia ______ Parkinsonism- Carbon monoxide intoxication causing bilateral necrosis of the basal ganglia Chronic esposure to _______ Parkinsonian sx after usage of street drug _____ |
Vascular
Toxic manganese MPTP |
|
|
Huntington’s Disease:
Progressive autosomal dominant neurodegenerative disorder affecting motor function, cognition, and behavior Characterized by _______ & ______ Occurs throughout the world in all ethnic groups 5 cases/100,000 population Clinical onset between ______ years of age _______ outcome within 15-20 years from onset |
chorea and dementia
30 and 50 Fatal |
|
|
Huntington’s Clinical findings:
Initial sx are abnormal movements or ________ changes Earliest mental changes are _________- Irritability Moodiness Antisocial behavior Psychiatric disturbances Eventual dementia |
intellectual
behavioral |
|
|
Huntington’s:
_________ initially fidgetiness or restlessness Eventually choreiform movements and dystonic posturing Progressive ________ and akenesia sometimes occurs with dementia |
Dyskinesia
rigidity |
|
|
Huntington’s Imaging:
________ demonstrates cerebral atrophy of caudate nucleus ____ shows reduced glucose utilization in an anatomically normal caudate nucleus |
CT scan
PET |
|
|
Huntington’s DDX:
________with no family hx of Huntingtons should not be attributed to Huntingtons _________ causes of chorea: Stroke SLE Paraneoplastic syndromes Infection with HIV Medications In younger patients, after Strep infection- Rare, called _________, self limiting |
Chorea
Non genetic Sydenham’s chorea |
|
|
Huntington’s Treatment:
No cure, can’t halt progression, treatment is _________ Dopamine receptor blocking agents such as _________ or __________ may control dyskinesia or behavioral problems _________ (antipsychotic) for behavioral disturbances |
symptomatic
phenothiazines or haloperidol Clozapine |
|
|
_________ Syndrome
Motor Tics are involved in 80% of the cases 20% have phonic tics Usually all patients develop combination of motor and phonic tics |
Tourette’s
|
|
|
Tourette’s: Tics
1st noted in childhood between ages 2 and 15 _______ tics- Face, head, and shoulders Sniffing, blinking, frowning, shoulder shruging, head thrusting Can be self mutilating (biting lips, tongue, pulling hair) _______ tics- Grunts, barks, hisses, throat clearing, cough _________ – obsene speech utterances _________ – repitition of speech of others |
Motor
Phonic Coprolalia Echolalia |
|
|
Tourette’s:
Chronic disorder with relapses and remissions ___________ behaviors which may be more disabling than tics PE: normal except for ____ ________ disturbances due to cosmetic and social embarassment |
Obsessive-compulsive
TICS Psychiatric |
|
|
Tourette’s Treatment:
_________ is DOC _________ (Klonopin) may be helpful and avoids the long term side effects of haloperidol ________ is a dopamine-blocking drug related to Haldol that may be helpful in patients who have not responded to Haldol |
Haloperidol
Clonazepam Pimozide |
|
|
Cerebrovascular Disease: disorders of the arterial and venous circulatory system of the central nervous system
_________: Onset of abrupt sx due to inadequate blood flow (ischemic stroke) or hemorrhage into the brain tissue (parenchymal hemmorhage) or surrounding space (subarachnoid hemorrhage). most frequent cause of morbidity in developed countries |
Stroke
|
|
|
Types of stroke: Ischemic stroke
_________ stroke is thrombotic or embolic occlusion of major artery _______ ischemia is from inadequate cortical profusion (after cardiac arrest or V-fib) ___________ (CO poisoning or asphyxiation) can cause stroke, but is rare |
Focal ischemic
Global Isolated cerebral hypoxia |
|
|
Hypertension
Diabetes Hyperlipidemia Cigarette smoking Cardiac disease AIDS Drug abuse Heavy alcohol usage Family history |
Risk Factors for Stroke
|
|
|
Ischemic Strokes: ________ ischemia
can result from thrombotic or embolic occlusion of vessel that reduces blood flow to tissue Also can be due to diminished systemic profusion Prolonged ischemia results in infarction Results in necrosis of neurons, glia, and endothelial cells |
Cerebral
|
|
|
Ischemic Strokes: Global cerebral ischemia
from __________ or ______ Some neurons more sensitive to global ischemia - Hippocampus (learning and memory) Perkinje cells of cerebellum Deeper layers of cerebral cortex Pure hypoxia causes lethargy and confusion but rarely irreversible brain injury |
Cardiac arrest or V fib
|
|
|
Ischemic Stroke: Etiology
______ abnormalities- Atherosclerosis, vasculitis, vasospasm, compression (tumor), fibromuscular dysplasia (moyamoya dz), dissection ________- Cardiogenic (atrial fib, mural thrombus, valvular vegetations, myxoma), fat, air, paradoxical, hypercoaguable state, homocystinuria, protein C or protein S deficiency |
Mural
Embolism |
|
|
Ischemic Stroke: Etiology
___________ accounts for 2/3 of strokes Embolization of plaque to distal vessel Insitu thrombus Certain sites of cerebral vasculature are more prone to plaque development ____________ make up most of the remaining 1/3 A-fib, mural thrombus, myxoma, valvular vegetations |
Athroschlerosis
Cardiogenic emboli |
|
|
Cerebral Edema: Intercelluler (________) or interstitial (________)
Intercellular develops in ischemic neurons when __________ fail Vasogenic occurs due to damage to __________ cells, disrupting BBB and allowing macromolecules (plasma proteins) to enter the interstitial space Fluid accumulates over 3-5 days after ischemic stroke and can increase brain water content by 10% leading to transtentorial herniation and death |
cytotoxic
vasogenic ion channel pumps endothelial |
|
|
______: Transient neurologic defect due to reduced blood flow lasting less than 24 hours and followed by full functional recovery
Most resolve within 1 hour Those that last longer should be worked up for alternative explanation Complete stroke means infarction, in TIA there is no infarction |
TIA
|
|
|
TIA:
Maximal clinical deficit in TIA occurs at onset of symptoms Symptom progression in TIA is called __________ Factors contributing to this are- Propagation of a ________ Progession of cerebral edema or hemorrhage to an _________ Hypotension, fever, hypoxemia, or hypoxia may also worsen the condition |
Stroke in evolution
thrombus infarction |
|
|
Lacunar Stroke:
A cerebral lacunae is a small deep infarction involving the penetrating branch of a large cerebral artery Associated with _________ In normotensive patients may be result of microathroma of penetrating arteries of basal ganglia or thalamus Clinical syndrome: Usually pure motor _________ Sometimes includes weakness and ataxia with hemiparesis known as _________ |
chronic hypertension
hemiparesis Ataxic hemipareisis |
|
|
Major Stroke Syndromes: Internal Carotid Artery
TIA’s in the anterior circulation affect the retinal artery or MCA Retinal artery symptoms: _________ vision in one eye or monocular blindness (__________) Retinoscopy (fundoscopy) shows refractile arterial spots which are ________ crystals that have become detached from cholesterol plaque |
Graying out
amaurosis fugax cholesterol |
|
|
Major Stroke Syndromes: Internal Carotid Artery
Most anterior circulation TIA’s are from significantly _______/_______ ICA Others are caused by ____________ Others from spontaneous arterial _______ |
stenotic/ulcerated
cardiogenic embolism dissection |
|
|
Major Stroke Syndromes: Internal Carotid Artery
Arterial occlusion of ICA results in _________ hemiplegia and hemisensory loss of the MCA territory _________ accompanies the occlusion and deficit depends on collateral circulation Clinical recognition of ICA stenosis may be unreliable, because _______ doesn’t distinguish external carotid from ICA |
contralateral
Headache bruit |
|
|
Major Stroke Syndromes: ___________ artery
Embolism causes most of these Main MCA occlusion causes contralateral hemiplegia, hemianesthesia, and homonymous (lateral) hemianopsia with gaze away from the hemiplegic side |
Middle Cerebral
|
|
|
Major Stroke Syndromes: Anterior cerebral artery
Occlusion of the ACA distal to the anterior communicating artery causes weakness and sensory loss in the contralateral ___ Other manifestations: _______________ ______ – akinetic mutism if bilateral (decrease in movement, speech, thought, and emotional reactions) |
leg
Urinary incontinence Abulia |
|
|
Major Stroke Syndromes: ___________
Dizziness (vertigo), diploplia, ataxia, sensory and motor sx, drowsiness Difficult to differentiate vertebrobasilar vertigo from labyrinthine but isolated positional vertigo is more likely to be labyrinthine |
Vertebrobasilar ischemia
|
|
|
Major Stroke Syndromes: Occlusion of ______________
Occlusion of these arteries and/or their branches (PICA, AICA, and SCA) cause specific problems Acute infarction of the cerebellum from occlusion of any of these causes - Swelling in the posterior fossa Obstruction of the 4th ventricle Obstructive hydrocephalus |
vertebral or basilar artery
|
|
|
Major Stroke Syndromes: Occlusion of vertebral or basilar artery
_______ artery occlusion produces massive brain stem dysfunction and is often fatal If medulla is spared, the _______ syndrome can occur: Quadriplegic Can only communicate by means of ___________ |
Basal
locked in vertical eye movements |
|
|
Major Stroke Syndromes: ____________ occlusion
Contralateral hemiparesis Hemisensory loss Amnesia Hemianopsia Central vision spared due to collateral vessels from MCA |
Posterior cerebral artery
|
|
|
Major Stroke Syndromes: Central Venous Thrombosis
Occlusion of the ______ sinus due to hyperviscosity or hyercoagulability Common in _________ Clinical picture: Papilledema, headache, or seizures Diagnosis based on imaging showing hemorrhagic infarcts in parasagittal distribution ____ or ____ often shows the filling defect |
sagittal
pregnancy MRA or CT |
|
|
Diagnosis of Stroke: Two questions
What is the ________? Focal ischemic/thrombotic or embolic Global ischemia/hypoprofusion Hemorrhage Where is the ______? |
mechanism
lesion |
|
|
Diagnosis of stroke: Physical Exam
Determines lesion _________ Identify clues to pathogenesis _________ exam - BP, cardiac rhythm Opthalmoscopy - _______ & _______ emboli Information regarding severity and chronicity of HTN _________ in cerebral venous thrombosis |
localization
Cardiovascular Platelet and cholesterol Papilledema |
|
|
Diagnosis of Stroke: Lab
_____ _____ Coag screen _______ profile _________ profile necessary in young person with venous sinus thrombosis |
CBC
ESR Lipid Hypercoagulable |
|
|
Diagnosis of Stroke
____ is most reliable test for differentiating ischemic stroke from hemorhage Limitation is that only 5% of ischemic strokes are visible in 1st 12 hrs ____ is used to verify infarct if diagnosis remains in doubt Anterior circulation best assessed with duplex ultrasound or ____ |
CT
MRI MRA |
|
|
DDX:
TIA’s vs __________ migraines Some _______ are followed by hemiparesis Acute onset of stroke differentiates it from other brain lesions Strokes and seizures can co-exist Generally, stroke rarely manifests with an alteration of _________ |
hemiplegic
seizures conciousness |
|
|
Treat HTN
Smoking cessation Treatment of DM Treatment of hyperlipidemia |
Stroke Prevention
|
|
|
Stroke Prevention: TIA
Strong risk factor for stroke 5% risk per year Antiplatelet therapy with ____, _________(ticlid), or _________(plavix) prevents secondary events Hospital admission for new onset and recurrent TIA’s Imaging studies should be performed and decision made for medical or surgical rx |
ASA
ticlopidine clopidogrel |
|
|
Stroke Prevention: Carotid stenosis
Asymptomatic _______ or _______ of less than 60% can be treated with antiplatelet therapy Bruit of more than 70% stenosis requires _________ to reduce stroke risk 60%-70% treatment decision made on case by case basis |
bruit or stenosis
endarterectomy |
|
|
Stroke Prevention:
Atrial Fib - Treat with _________ to INR of 2-3 Prosthetic Heart Valve - Long term ________ Bacterial endocarditis - Do not anticoagulate as risk of ___________ from septic embolism is high |
coumadin
anticoag cerebral hemorrhage |
|
|
Stroke Management: General measures
Emphasis initially is to reduce the risk of complications from ________(pneumonia, DVT, UTI) Early intervention by PT, OT, and speech therapy Careful observation of ________ ability helps reduce mortality Aggressive Rx of ____ & ____ Prevention and treatment of _________ may reduce extent of stroke Awareness and treatment of post stroke ________ enhances rehab |
immobility
swallowing HTN and DM hyperthermia depression |
|
|
Stroke Management: Anticoagulants
___________ therapy is treatment of choice to prevent recurrance _________ is important in atrial fib, recent MI’s and thrombus propagation _______ necessary before starting heparin to make sure there is no intracerebral or subarachnoid hemorrhage Coag studies, platelet counts, and tests for hypercoag states before therapy starts Uncontrolled HTN (SBP > 200 mm/hg) or active _____ is contraindication to anticoagulants |
Antiplatelet
Anticoagulation CRANIAL CT PUD |
|
|
Stroke management: Thrombolysis
Consider in patients who present within __ hrs of onset IV __________ Risks and benefits must be explained to patient so decision be made rapidly Risk is 6% for intracranial hemorrhage Benefit is 50% chance of little or no disability at 6 mo with rt-tpa and 38% chance without it Careful monitoring of BP and no ________ or ____ for 24 hours post rt-pa therapy |
3
rt-pa (recombinant tissue-type plasminogen activator) anticoagulants or ASA |
|
|
Stroke Management: Cerebral edema
Only in large hemispheric infarct will cerebral edema be enough to cause _________ If herniation, intubation and hyerventilation cause transient ____________ to reduce intracranial pressure _______ used also, but is transient in its effect |
herniation
vasoconstriction Mannitol |
|
|
Management of Stroke: Stroke rehabilitation
The majority of deaths from stroke are from _______ complications rather than neuro complications Pneumonia Sepsis MI DVT _______ optomizes recovery and decreases medical complications |
medical
Rehab |
|
|
Intracerebral Hemorrhage:
May be diffuse (SAH) or focal intraparenchymal Accounts for 20% of all strokes Causes of spontaneous ICH - __________: HTN, Amyloid aniopathy, AVM’s, drugs (amphetamines, cocaine, anticoagulants, thrombolytics) and tumors ______: Congenital aneurysms (85%), mycotic aneurysm, AVM’s |
Intraparenchymal
SAH |
|
|
Intracerebral Hemorrhages: Hypertensive ICH
Occur at same sites affected in ______ infarcts Clinical findings help localize the site _________ severity correlates with size Diminished ________ ________ - More prominent in acute phase of ICH than in ischemic stroke |
lacunar
Headache alertness Seizures |
|
|
Intracerebral hemorrhages: Lobar hemorrhage
Mostly in ________ distribution unlike hypertensive hemorrhage Smaller than hypertensive ICH’s More ______ prognosis Causes _________: AVM’s or sympathomimetic drug ingestion ________: congophilic amyloid angiopathy Signs tend to develop more slowly |
peripheral
benign Young persons Elderly |
|
|
Intracerebral hemorrhage: Diagnosis, management, and prognosis
____ is test of choice (MRI less sensitive in early stage) Management: depends on size and location Acutely the mass effect is much greater than in an infarct, with greater risk of ___________ Chronically prognosis is better in __________ than ischemic stroke |
CT
herniation and death hemorrhagic |
|
|
Intracerebral hemorrhage: Treatment
Directed at reducing ________ By medical decompression with __________ or ________ By ________ decompression (rarely) - Urgently in cases of cerebellar hemorrhage where patient at risk for sudden deterioration from obstructive hydrocephalus or from direct pressure on brain stem |
mass effect
hyperventilation or mannitol surgical |
|
|
Intracranial anneurysms: Three types
________ - Eratic dilations of large arteries Usually basilar or intracranial carotid Rarely rupture but compress structures causeing local neurological dysfunction Not usually accessible for surgical repair ______ - In bacterial endocarditis where septic emboli lodge in vessels Multiple and in distal arterial tree Can be repaired surgically if no response to antibiotic therapy |
Fusiform
Mycotic |
|
|
Intracranial anneurysms: Three types
______ - Berry aneurysms Form at arterial bifurcations 80% located in anterior circulation Arise from congenital defect in the arterial media and elastic lamina and from gradual deterioration due to hemodynamic stress Higher incidences in ________ disease patients and in _______ syndrome 6% of population have saccular aneurysms Incidence of rupture only 10/100,000 pts 33% of those die before hospital, 20% in the hospital 30% recover without disability |
Saccular
polycystic kidney dz Marfan’s |
|
|
________: a chronic condition of seizures with sudden and usually unprovoked attacks of subjective experiential phenomena, altered conciousness, or involuntary movements
|
Epilepsy
|
|
|
_______- are from abnormal brain electrical activity and are a common sign of brain dysfunction
Can occur during the course of many medical or neurologic illnesses where brain function is temporarily deranged (symptomatic seizures) Self limited and do not persist if underlying disease corrected Can occur as reaction of brain to physiologic stress |
Seizures
|
|
|
Those with limited part of the cerebral hemisphere involved are _______ or _______ seizures
Diffuse cerebral cortex involvement seen in _________ seizures Seizures are dynamic and may evolve: Simple partial into _______ Partial into _______________ |
partial or focal
generalized complex partial secondary generalized clonic tonic seizures |
|
|
__________ seizures occur when epileptic electrical discharge remains limited to a focal area of the cortex
Normally patients can interact with environment Limitations imposed on specific brain functions only May be sensory and/or psychological phenomena 60% have auras Location of focus is important for diagnosis and helps direct diagnostic testing |
Simple partial
|
|
|
Simple partial seizures:
Can also occur with _____ signs Clonic (jerking) tonic (stiffening) movements of a body part Face and hand often involved due to large cortical representation Clonic movements progress in orderly sequence (“__________”) that reflects homunculus representation produce contralateral flexion and elevaton of the arm with turning of the head and eyes and tonic extension of the ipsilateral arm (“_________”) Other signs include speech arrest, vocalization, and eye blinking |
motor
Jacksonian march fencer’s posture |
|
|
Simple partial seizures:
May be followed by __________ state of the involved area _______ may follow simple partial motor seizure Numbness, a sensory seizure _______, and occipital lobe seizure |
post ictal depressive
Weakness Blindness |
|
|
________________:
Impair consiousness and produce unresponsiveness Or, altered conciousness and automatisms such as lip smacking, chewing, swallowing, other erratic behavior Preceded by _____(de ja vu, visual) |
Complex Partial Seizure
aura |
|
|
____________:
Begin diffusely and involve both cerebral hemispheres simultaneously Subdivided according to presence and character of motor manifestations during the seizure |
Generalized seizures
|
|
|
Generalized seizures: _____________
Abrupt LOC with tonic extension of trunk and limbs (tonic phase) Accompnied by epileptic cry which is air forced across contracted vocal cords This is followed by the clonic phase Symmetric bilateral muscle jerking Some patients will have only a tonic or clonic phase |
Generalized tonic/clonic seizures (grand mal)
|
|
|
Generalized seizures: Tonic/clonic
Generally there is __________, but fecal incontinence is rare Seizure lasts about 90 seconds usually, followed by post ictal phase Post ictal phase: 15-30 minutes of __________ state Followed by headache, muscle soreness, mental dullness, lack of energy and mood changes lasting up to __ hours |
urinary incontinence
lethargic confused 24 |
|
|
Transient physiologic changes of Clonic/Tonic seizures:
Blood _______ Lactic acidosis Elevated __________ levels Increased levels of _________, prolactin, corticotropin, cortisol, and growth hormone |
hypoxia
catecholamine creatine kinase (CK) |
|
|
Compications of C/T seizures:
_____ trauma ________ compression fractures Shoulder dislocation Aspiration pneumonia ________ - Acute pulmonary edema, cardiac arrythmias, suffocation |
Oral
Vertebral Sudden death |
|
|
Generalized Seizures: _____________
Mostly in children Sudden momentary lapses in awareness Staring with rhythmic blinking Occasionally small clonic jerks of hands or arms Last 10 seconds with no post ictal period Behavior and awareness returns to normal immediately |
Absence seizures (petit mal seizures)
|
|
|
Generalized seizures: ____________
Rapid recurring brief muscle jerks Bilateral or unilateral Ranges from small movements of face and hands to massive spasms of head, limbs, and trunk Repeated myoclonic seizures may build to general clonic-tonic seizures Occur in clusters after waking, or when falling asleep |
Myoclonic seizures
|
|
|
Febrile seizures:
The most common cause of convulsion (seizure) in children is _______ Epidemiology: Affects 3-5% of all children under age 5 Occurs between ages 6 mo and 4 yrs Can occur in kids up to 7 years 30% have more than one attack Recurrence greatest if seizure occurs before age __ or there is family hx of febrile seizures |
FEVER
1 |
|
|
Febrile seizures:
Usually no long term consequences But, may increase the risk of developing ________ later Low in most children (2-3%) Higher (10-13%) in those who- Have _______ or focal seizures Have a family history of afebrile seizures Are neurologically _______ before the 1st febrile seizure |
epilepsy
prolonged abnormal |
|
|
Febrile seizures _____ cause:
Mental retardation Poor school performance Behavior problems |
do not
|
|
|
Benign partial epilepsy of childhood with Central-Midtemporal Spikes:
One of the most common epileptic syndromes in childhood 15% of all peds epilepsies Begin between ages 4 and 13 Occur mostly at _______ Parents see only _________ activity Focal episode is usually missed |
night
tonic-clonic |
|
|
Benign partial epilepsy of childhood with Central-Midtemporal Spikes:
When occurring during day- Focal episodes are one sided facial twitch, ______ arrest, drooling, ________ of the face, teeth, gums tongue and inner cheek May be very minor and go unnoticed May progress to hemi clonic-tonic activity ____ distinctive for eliptiform discharges over the central and mid-temporal regions Prognosis- Good, with resolution by mid to late adolescents Treated with __________(Tegretol) which prevents further attacks |
speech
paresthesias EEG carbamazepine |
|
|
__________________:
Most common epileptic syndrome in adults (40% of epileptic cases) Begins in late childhood or adolescence Mostly complex partial, some which generalize Arises typically from medial temporal limbic structures but can be from cavernous malformations, cortical dysplasia, glial tumors and *scars from previous _________ or __________* |
Temporal Lobe Epilepsy
head injuries or encephalitis |
|
|
______________:
Chances relate to severity of injury Severe head injury defined as Cerebral contusion Intracerebral or intracranial hematoma Unconcciousness or amnesia lasting more than 24 hours Persistant abnormalities on neuro exam |
Post traumatic epilepsy
|
|
|
Post traumatic seizures:
Majority develop seizures within ____ years of injury But new onset seizures can occur up to 5 yrs later 2/3 of patients have partial or secondarily generalized seizures No increased risk with _____ head injuries such as contusion or hematoma |
1-2
mild |
|
|
Diagnosis of Epilepsy:
________ is the most important diagnostic test for epilepsy Useful in: Diagnosis Classification of seizures Identifying epileptic syndromes Making therapeutic decisions |
EEG (electroencephalogram)
|
|
|
Seizure DX: EEG
With clinical findings EEG patterns showing ______ or _______ are support the diagnosis of epilepsy Focal epileptiform discharges in __________ Generalized epileptiform discharges in __________- No interictal abnormalities on EEG’s can prove or disprove epilepsy Can only establish diagnosis by EEG tracing during a clinical attack (hard to do) Also 2% of normal people may have _______ EEG’s In children, this may be a marker of a genetic trait |
spikes or sharp waves
focal epilepsy generalized epilepsy abnormal |
|
|
Diagnosis: EEG
40% of epileptic pts may show epileptical waveforms on _______ Chance of this is enhanced by ___________ 24 hours before test Pt sleeps during some of the EEG recording ______ EEG’s increase yield of positive tracing |
initial EEG
sleep deprivation Serial |
|
|
Diagnosis: Imaging
____ identifies structural brain pathology that may be associated with seizures (in concert with EEG) Should get MRI on all patients over ___ Also, MRI in all children with- _______ seizures Abnormal neuro findings Focal _______ wave abnormalities on EEG |
MRI
18 partial slow |
|
|
Diagnosis: PET and SPECT (single proton emission computed tomography)
70% of patients with temporal lobe epilepsy have focal __________ areas on interictal PET scans that correspond to the epileptogenic focus Abnormalities on PET and SPECT often seen even when ____ is normal |
hypermetabolic
MRI |
|
|
Diagnosis: Other tests
________, _________, & ______ are useful baseline before meds started __________ screens in young adults with new onset seizures (blood and urine screens) ____ if suspicion of meningitis or encephalitis ____ in any young person with 1st generlized seizure if there is fam hx of arrythmia, unexplained death, or episodic unconciousness Also, EKG in any patient with ________ or valvular dz |
Electrolytes, LFT’s, and CBC
Substance abuse LP EKG arrythmia |
|
|
movement disorders
migraine syncope panic disorder hyperventilation TIA alcoholic blackout hypoglycemia |
Seizure DDX
|
|
|
Treatment:
If cause of _________ seizures is corrected, anti-seizure drugs are not needed Also not necessary in adults with _________ seizure with normal lab and clinical findings |
symptomatic
single unprovoked |
|
|
Treatment:
But, patients with focal neuro findings clinically, radiologically, or on EEG will probably have more seizures and may need ______ Also, social considerations may dictate treatment in patients with only one seizure Generally, otherwise normal patients who will probably be non compliant do not need rx _______ seizures should be treated to stop attacks completely |
meds
Recurrent |
|
|
The type of seizure should be defined and the preferred medication should be given in usual doses and then ________ until seizure control is complete or side effects occur
Seizures that are _______ require slow changes in medication doses If seizures persist at toxic levels, or if major side effects occur, select another agent. Do not stop one agent until another has been added Otherwise, ___________ may result. If seizures persist after two agents have been given to toxic levels, consider referral to a specialized center for complex combination therapy and seizure monitoring. Toxic levels of some antiepileptics (particularly phenytoin and carbamazepine) can cause _______ |
increased
infrequent status epilepticus seizures |
|
|
TX of __________:
Carbamazepine Phenytoin Valproate Gabapentin Lamotrigine Topiramate |
Simple & Complex partial
|
|
|
TX of __________:
Carbamazepine Phenytoin Valproate Gabapentin Lamotrigine Topiramate |
Secondarily generalized
|
|
|
TX of __________:
Valproate Carbamazepine Phenytoin Lamotrigine |
Tonic-Clonic
|
|
|
TX of __________:
Ethosuximide Valproate Lamotrigine |
Absence
|
|
|
TX of __________:
Valproate Clonazepam |
Myoclonic & Tonic
|
|
|
Treatment: Surgery
____________: when seizures cannot be controlled by trials of two appropriate single agents or the combination of two agents |
Medically intractable
|
|
|
Special Concerns: ___________
Major generalized motor seizures that follow so rapidly that a new one starts before the patient has recovered from the previous one Can cause permanent _______ Most frequent cause is abrupt ________ from anti-seizure med in known epileptic Other causes: Withdrawal from ____ or other habitual drugs, cerebral infection, trauma, neoplasm, or hemorrhage Status epilepticus requires urgent Rx and cause needs to be identified as soon as seizures controlled |
Status epilepticus
brain damage withdrawal ETOH |
|
|
Special concerns: Status Epilepticus
____________: lasts for hours to days. May be highly focal or involve most of the limb or half the body Causes: Strokes, trauma, neoplasms, encephalitis Severe _________ can produce partial motor and complex partial status epilepticus with complete resolution after hyperglycemia corrected |
Partial motor status
hyperglycemia |
|
|
Special Concerns: Status Epilepticus
__________: Sustained state of confusion Schizophreniform or other bizarre activity Some may be in stuporous state Lasts for hours to days Patients may resist assistance |
Partial Complex status
|
|
|
Special concerns: Status Epilepticus
_________: two types 1. the more common one resembles partial complex status mostly in adolescence or young adults with petit mal history. Lasts less than 30minutes 2. Other type with automatisms and confusion lasts days to weeks Most of these attacks can be halted with IV ________ |
Absence status
diazepam |
|
|
Special Concerns: Psychosocial problems
Incompletely controlled epilepsy creates ________ problems for pts Disorders that cause partial complex seizures are associated with aberrant __________ Frustration, depression, and suicide more frequent among epileptic pts These problems helped most by bringing problem under complete control and encouraging pts to lead normal life |
emotional
personality traits |
|
|
Special Concerns:
Body contact sports avoided unless seizure free for _____ High risk sports to be avoided - High diving, high alpine cimbing, deep water swimming, underwater swimming, boxing __________ restricted unless patient seizure free for specified time period Epilepsy Foundation of America assists patients in social-vocational arenas |
1 year
Drivers license |
|
|
Discontinuing Meds:
Successful drug withdrawal more successful if initial control successful using _________ and EEG and neuro exam normal just prior to stopping meds Seizure free intervals of _____ decrease likelihood of relapse |
monotherapy
4 years |
|
|
________: progressive loss of intellectual function with memory loss as the central feature
produce specific congition deficits: Language, spatial processing, _____(learned motor behavior) and ___________(ability to plan and sequence events) |
Dementia
praxis executive function |
|
|
Two divisions of Dementia:
______ dementia: cerebral cortex affected, causing problems with memory and language. Patients typically show severe memory impairment and aphasia Alzheimer’s ________ dementia: dysfunction of brain beneath the cortex. Mostly changes in personality and attention span with slowed thinking. Huntington’s, and AIDS related dementia |
Cortical
Sub cortical |
|
|
Neurodegenerative dementia:
Most common underlying cause of dementia- ________ disease Frontotemporal dementia Diffuse ________ disease |
Alzheimer’s
Lewy body |
|
|
Most dementia is __________
Potentially correctable causes are less than 10% of all cases: Infection, metabolic, and nutritional diseases must be ruled out All patients should have _________; liver, renal, and thyroid functions; vit ___ levels; and serologic tests for ______ Chronic infection and normal pressure __________ must be ruled out ___ should be performed on all patients with focal neuro signs and in those patients under 65 at onset of dementia |
untreatable
electrolytes B12 syphilis hydro cephalus MRI |
|
|
Causes of potentially reversible _________ impairment include:
Drug effect Depression Thyroid disease Vit B12 deficiency hypercalcemia Subdural hematoma HIV Normal pressure hydrocephalus |
cognitive
|
|
|
___________ testing:
Characterizes the pattern of cognitive and memory loss and helps in DDx _______ exam is bedside or office screening tool that identifies dementia patients Emphasizes ________ & ________, so better for cortical than sub cortical dementia |
Neuropsychological
MMS (mini mental state) memory and language |
|
|
Neuropshchological testing:
Also there are tests for _______ “Show how you would comb hair” “show how you would blow out a match” ________ processing Clock drawing _________(planning and sequencing) Draw set of numbers on page and have the patient connect them in alphabetical-numerical order |
Praxis
Visual spatial Executive function |
|
|
70% of all cases of dementia in the elderly
Incidence increases with age Up to 30% of people over 85 years of age have ___________ |
ALZHEIMER’S DISEASE
|
|
|
AD Pathology:
Progressive loss of ________ neurons Formation of ________(Aß/beta amyoid) in intraneuronal neurofibrillary tangles Neurofibrillary tangles are twisted masses of protein fibers within nerve cells of the cerebral cortex of AD patients |
cortical
amyloid plaques |
|
|
AD: Etiology
Process starts in _________ and spreads to diffuse areas of cortex in the temporal, parietal, and frontal lobes Deficiency of cortical _________ from the loss of neurons in the nucleus basalis is the basis for treatment with centrally acting acetylcholinesterase inhibitors |
hippocampus
acetylcholine |
|
|
AD: Pathogenesis - Two forms
Young onset or ______ form which is rare 3 specific genetic abnormalities are found in this form More common is _______ form that occurs in patients over age 65 |
familial
sporatic |
|
|
AD: Pathogenesis
Autosomal dominant AD (early onset form) like sx seen in pateints with ______ syndrome (Phil 21 trisomy) who are more than 30 years old Suggests that chromosome 21 may harbor a gene responsible for AD Aß is a cleavage product of the amyloid precursor protein, the gene for which is on chromosome 21 This may be important in the pathogenesis of AD Also, apolipoprotein E gene was found to be a suceptability locus for sporadic AD in late onset AD |
Down’s
|
|
|
AD: Clinical features
Early problems in ________ Impaired ________ abilities (lost in familiar surroundings; unable to copy geometric designs on paper) But _______ retained despite advanced cognitive problems Personality changes and behavioral difficulties Wandering, inapproprite sexual behavior, and agitation |
memory
visuospatial social graces |
|
|
AD: Clinical Features
End stage disease characterized by- Near _______ Inability to sit up, hold head up, or track objects with eyes Dfficulty with _______ and swallowing Weight loss, bowel or bladder incontinence, and recurrent respiratory and urinary _________ |
mutism
eating infections |
|
|
AD: Treatment
Acetylcholinesterase inhibitors such as donepezil (________), rivastigmine (_______) and tacrine (______) should be considered They produce modest improvement in cognitive function May also help in ________ & _________ dementia |
Aircept
Excelon Cognex vascular and Lewy-body |
|
|
Diffuse Lewy-body disease:
These patients have clinical _________(slow gait, rigidity, balance problems) and prominent dementia Lewy bodies are pathologic inclusions found in the brain stem, limbic system, and cortex In Parkinson’s disease they are restricted to the ________ only |
Parkinsonisms
brain stem |
|
|
Diffuse Lewy-body disease:
Clinically, visual _________ and cognitive fluctuations are common These pateints demonstrate a marked hypersensitivity to _______ therapy Attempts to treat hallucinations may worsen the __________ symptoms May be the 2nd most common cause of dementia after _________ |
hallucinations
neuroleptic extrapyramidal AD |
|
|
Vascular Dementia (Multi Infarct dementia):
10-20% of elderly dementia pts have findings of focal ______ on MRI or CT with focal signs on PE When dementia begins with stroke, and illness progression is ________, dx of vascular dementia is likely |
strokes
stepwise |
|
|
Vascular Dementia (multi infarct dementia):
Clinically- Early __________ Flattening of ______ ______ disturbances TX is TX of risk factors: ________ control _______ cessation Diet modification __________ (especially in selective settings such as atrial fib) |
incontinence
affect Gait Blood pressure Smoking Anticoagulation |
|
|
Frontotemporal Dementias:
Unlike AD, begins with marked _________ disturbances ______ dz is the classic form and is associated with ____ Patients are frequently socially disinhibited with personality change and compulsive behaviors (peculiar eating habits or hyperorality) In contrast to AD, ________ function is preserved |
behavioral
Pick’s ALS visuospatial |
|
|
Parkinsons Disease:
50 % have _______ by the time they reach 85 (not AD) Effects _________ more so than language or visuospatial processing Thought processes slow down Occurs relatively late in the disease Many patients are taking drugs for PD that can induce ______, so always reduce dosages before diagnosing underlying dementia in PD patients |
dementia
executive function psychosis |
|
|
___________ Disease:
A subacute dementing transmissible illness Onset age 40-75 years of age Incidence 1 in 1,000,000 population 4 forms ________(80-85%), familial (15%), iatrogenic (1%) and variant Pathology: spongiform degeneration in widespread areas of the cortex Incubation: years!!! |
Creutzfeldt-Jakob
Sporadic |
|
|
CJD:
Variants distinguished by - Predominance of cerebellar sx __________ hyperkenesias Visual ______ 90% of CJD patients have ________ fasiculations All forms have relentless progression of _______ and personality changes over weeks to months |
Extrapyramidal
agnosia myoclonic dementia |
|
|
CJD:
Transmittable agent is a _____ protein, invulnerable to routine modes of antisepsis ____ can be tested for 14-3-3 protein, but is not 100% sensitive or specific for CJD Risk factors greatest in _________ & ________ Prevention- Avoidance of contaminated infected _______ tissue, electrodes, and neurosurgical tools Also, can be contaminated by ________ transplants or contaminated cadaveric growth hormone from infected donors No specific treatment |
prion
CSF butchers and medical office staff brain corneal |
|
|
HIV:
HIV gets into CNS through monocytes and microglial system Causes associated nuronal loss, vacuolization, and lymphocyte infiltration Dementia characterized by __________ & ___________ Patients have executive dysfunction, impaired memory, poor ________, and apathy Treatment of HIV (antivirals and reverse transcriptase inhibitors) may slow the progression of dementia |
bradyphrenia and bradykinesia
concentration |
|
|
Infectious agents:
Some infectious agents can cause chronic _________ They can cause subacute or chronic subcortical _________ |
meningitides
dementia |
|
|
Normal-Pressure Hydrocephalus:
Triad of _______(subcortical), _____ instability, and urinary ________ Patients walk with “_____________” Do not lift knees Broad base |
dementia
gait incontinence feet stuck to floor |
|
|
Normal-Pressure Hydrocephalus:
Symptoms evolve over weeks to months Imaging reveals __________ enlargement out of proportion to cortical ________ in the presence of dementia MRI flow studies Radionucleotide cisternography Most important test is _____ removing large amounts of CSF followed by examination of patients gait and cognitive function Removal of 30-40 ml of CSF Should respond with improved _________ & ________ within minutes to hours |
ventricular
atrophy LP gait and alertness |
|
|
Normal-Pressure Hydrocephalus:
Pathogenesis - Derangement of the _____ hemodynamics Etiology and Treatment - Potentially reversible dementia _______ placement effective if normal-pressure hydrocephalus occurs following severe head trauma or SAH Can also follow ____________ or be associated with CNS _____ |
CSF
Shunt meningoencephalitis tumor |
|
|
Infectious Diseases of the Nervous System:
Localized to the CNS as ___________ or _______________ infections Also, CNS manifestation of infections in the rest of the body _______ disease |
abscesses or parameningeal
Prion |
|
|
Brain Abcess: Signs and sx of other space occupying lesions but with more rapid progression
Originate from extracerebral locations: ________ from unknown areas, lungs, or heart __________ (parameningeal sites): otitis, cranial osteomyelitis, sinusitis Sites of ________(recent or remote) or neurosurgical procedures Infections associated with ___________________ |
Blood-borne
Direct extension head trauma cyanotic conginital heart dz |
|
|
Brain Abcess: Pathogens
Mostly aerobic and anerobic _________ gram negative _______ (bacteroides and Prevotella) Infection often polymicrobial Culture is negative in 30% of antibiotic treated patients and 5% of those operated on prior to AB’s |
Streptococci
anerobes |
|
|
Brain Abcess: Diagnosis/presentation
May have no signs of systemic infection ½ with no fever or leukocytosis Neck stiffness rare Most common presenting sx: _______ of recent onset (most common) Followed by (if untreated)- Increased severity Focal signs such as __________ or __________ Followed by coma/obtundation also after _______ surgery |
Headache
hemiparesis or aphasia oral |
|
|
Brain Abcess: SX
May take hours, or days to weeks _______ occur with abscesses involving cortical grey matter _____ is non diagnostic and shouldn’t be performed. Can be normal/may aggravate transtentorial herniation due to rapid expansion of the abscess Contrast ____ or ____ for diagnosis and monitoring |
Seizures
CSF CT or MRI |
|
|
Brain Abcess: Treatment
Antibiotics or antibiotics with _______ or excision _______ if mass effect or if abcess against ventricular surface (rupture into the ventricular system) Surgery in posterior fossa lesion (brain stem compression potential) Antibiotics alone if - Surgically inaccessible _______ abcesses Early cerebritis stage |
aspiration
Surgery Multiple |
|
|
Brain Abcess: Treatment
_________ plus _________ IV If MRSA suspected (post op infection or IV drug usage) use _______ Follow resolution with CT or MRI If med therapy only, continue AB’s for ___ weeks |
Cephtriaxone
metronidazole Vancomycin 8 |
|
|
Subdural empyema
Infection in space separating the dura and arachnoid From direct extension of infected ___________ or less commonly untreated _________ Cortical venous _______ or _________ develops in about ¼ of cases |
paranasal sinuses
chronic otitis thrombosis or brain abscess |
|
|
Subdural Empyema:
Sx initially those of chronic otitis or sinusitis *_________ is universal feature* ______ and obtundation then ensue, followed by progressive mass and brain swelling leading to venous thrombosis or death from herniation DDx is __________ - Nuchal rigidity and obtundation in both But, papilledema and lateralizing defects more common in sub dural empyema |
Lateralized headache
Fever meningitis |
|
|
Subdural empyema:
Diagnosis - Contrast ____ & _____ can be diagnostic for empyema Treatment - prompt _________ high dose IV antibiotics |
CT and MRI
surgical drainage |
|
|
Malignant Otitis Externa:
Mostly in elderly patients with *________* Etiology is ________ Presentation - Rapid progression of _________ Ear pain, facial swelling _________ of the skull base Puralent meningitis with multiple _______ |
diabetes
pseudomonas Ext Otitis Osteomyelitis CN palsies |
|
|
Malignant ext otitis:
Treatment is urgent ______________ or 3rd generation ________ Surgical debridement (with above) Mortality rate is high |
Antipseudomonal penicillin
cephalosporin |
|
|
Spinal Epidural Abscess:
Infection of epidural space about the spinal cord Can cause _______ & ________, but usually responds to treatment Frequency - .05/10,000 hospital admissions in US Higher in _______ |
death and paralysis
IV drug users |
|
|
Spinal Epidural Abscess:
Present with acute or subacute _______ Usually _______(100.4 – 102.2) Focal _____________ of spine Stiff neck and headache Pain may be mistaken for - Sciatica Visceral abdominal process Chest wall pain Cervical disc disease If the condition goes unrecognized here, rapid weakness/paralysis can occur distal to the infection At this point, spinal abcess should be assumed and neuroradiologic dx confirmed and tx started |
back pain
febrile percussion tenderness |
|
|
Spinal epidural Abscess:
Pathogenesis - ________ sites most common source for hematogenous spread, especially in _________ Bacteriology - Gram stain or culture from pus Usually is ________ ___ abcesses account for 25% in high risk pop. |
Cutaneous
IV drug users Staph Aureus TB |
|
|
Spinal Epidural Abcess: Treatment
Penicillenase-resistant penicillen empirically for staph (_______,_______) _________ if MRSA suspected With above, additional gram neg coverage with __________ or _________ Surgical decompression less necessary today due to early dx by MRI Is necessary if neurologic complications occur |
Dicloxacillin, Nafcillin
Vancomycin 3rd generation Ceph or quinolone |
|
|
Cavernous Sinus:
A cavernous sinus thrombosis causes the cavernous sinus syndrome which is characterized by ______ of the eyelids and conjucntivae (______) of the eyes and _______ of the CN’s which course through the sinus |
edema
chemosis paralysis |
|
|
Septic Cavernous Sinus Thrombosis:
Intracranial complication of _________ Most common organism is ________ Diagnosis: Sinus imaging with attention to _________ & ________ sinuses _____ shows absent “flow void” within a vascular structure |
sinusitis
Staph aureus ethmoid and sphenoid MRI |
|
|
Septic cavernous sinus thrombosis: Treatment
Early diagnosis with prompt ________ of the infected paranasal sinus Specific antistaphylococcal agents such as _______ or _______ given IV |
drainage
nafcillen or oxacillen |
|
|
Myelin: Myelin is white and gives the name to the “_______” of the brain
|
white matter
|
|
|
__________: The process by which myelin of the central and peripheral nervous system is damaged or injured
Diseases of the CNS myelin are either acquired or hereditary MS is the most common _______ disease of myelin |
Demyelination
acquired |
|
|
MS: Etiology
Involves autoimmune-mediated inflammatory _________ and axonal injury Earliest event in MS lesion is breakdown of _____ MS also injures CNS neuronal axons which accounts for brain _______ and permanent damage as the disease progresses |
demyelination
BBB atrophy |
|
|
MS: Clinical findings
Highest incidence in ________ Initially - Weakness, numbness, tingling, or unsteadiness in a _____ Spastic paresis Retrobulbar neuritis Diploplia Disequalibrium Urinary _______ or ________ due to sphincter disturbance Symptoms may disappear after a few days but on exam, a residual _______ may be noted |
young adults
limb urgency or hesitancy deficit |
|
|
MS: Clinical Findings (3 forms of dz)
___________(most common) - Months or years after initial episode before new sx develop or original sx recur Then relapses and remissions lead to disability Weakness, spaciticity, and ataxia of limbs with impaired vision and urinary incontinence Findings at this stage include - Optic atrophy; nystagmus; dysarthria; sensory, cerebellar, and pyramidal deficits in some or all of the limbs |
Relapsing remitting disease
|
|
|
MS: Clinical Findings (3 forms of dz)
__________________ - In patients with relapsing remitting dz the clinical course changes to a steady deterioration rather than relapses ________________ - Less common Symptoms are steadily progressive from outset Disability develops at an early stage |
Secondary progressive disease
Primary progressive disease |
|
|
MS: Clinical findings
Diagnosis made only when clinical picture indicates involvement of different parts of the ____ at different times _________ & _________ likely to precipitate relapses Relapses likely ____ months after due to increased demands and stresses of post partum period |
CNS
Infection and trauma 2-3 |
|
|
MS: Imaging
____ most helpful by demonstrating multiplicity of lesions When myelopathy alone presents with no clinical evidence of widespread disease, myelogram or MRI needed to r/o congenital or acquired surgically treatable lesion |
MRI
|
|
|
MS: Lab and other studies
__________ response - Evoked by monocular visual stimulation, by monaural click stimulation, and by electrical stimulation of a sensory or mixed peripheral nerve, is used to detect subclinical involvement of: Visual pathways Brainstem auditory pathways Somatosensory pathways |
Electrocerebral
|
|
|
MS: Lab and other studies
CSF may show ________ and elevated ______ concentration after an acute relapse Elevated ____ in CSF present in many patients |
lymphocytosis
protein IgG |
|
|
MS: Diagnosis
Should not be diagnosed unless there are ____ or more regions of the central white matter affected at different times Diagnosis depends on above along with clinically relapsing remitting course of the disease Or in patients with multifocal white matter dz but only one clinical attack Or two attacks but only one white matter lesion |
two
|
|
|
MS: Treatment
Recovery of acute relapses treated with ___________ High dose _____ mg/day for 7d followed by tapered dose for __ weeks Preceded by __________ 1g IV for 3 days |
corticosteroids
60-80 mg/day for 7 d 3 methylprednisone |
|
|
MS: Treatment
In relapsing remitting or secondary progressive, ________ sub Q daily reduces exacerbation frequency _________ therapy may help arrest the course of secondary progressive MS Treatment for spasticity and neurogenic bladder needed in advanced cases Patients must _____ during periods of acute relapse and excessive fatigue must be avoided at all time |
beta interferon
Immunosuppressive rest |
|
|
_____________: disorders of the motor unit and of the sensory and autonomic peripheral nerves
|
Neuromuscular Diseases
|
|
|
Signs and SX of ________ disease:
Muscle weakness, wasting, fatigue, cramps, fasiculation, pain, stiffness Signs and sx of _________ disease: Decreased sensation (hypoesthesia,hypoalgesia), abnormal sensation (paresthesia), or painful sensations (dysesthesia) |
motor neuron
peripheral nerve |
|
|
Most sx of neuromuscular dz are _________ whereas focal CNS disease is usually __________
Most common acquired motor neuron disease is __________ |
symmetrical
asymmetrical amyotrophic lateral sclerosis |
|
|
Neuromuscular Diseases: Diagnostic Tests (Labs)
_____ _____ _____ _____ |
CK
LDH AST ALT |
|
|
___________: Measurement of electrical activity arising from muscle fibers
Spontaneous activity in a single muscle fiber is called _________ Spontaneous activity of part of all or a motor unit is _________ |
Electromyography
fibrillation fasiculation |
|
|
Dz of the Motor Neuron:
If lower motor neuron only is involved the term ___________ is used Progressive ________ motor neuron disorders that begin in utero, infancy, childhood, or adulthood |
spinal muscular atrophy (SMA)
inherited |
|
|
Bulbospinal muscular atrophy:
Disorder that alters the function of bulbar and spinal motor neurons (bulbar cerebellum, medulla, and pons) Mean onset age ____ years X-linked _______, ________, & _______ weakness Gynecomastia in 50% Dysphagia and dysarthria Widespread ___________ |
30
Facial, tongue, and proximal fasiculations |
|
|
_____________:
Death of upper and lower motor neurons for unknown reasons leading to a progressive loss of the ability to move any of the muscles in the body. Healthy nerves are replaced by hardened tissue Can be acquired (sporadic) or inherited - mostly sporatic |
Amyotrophic Lateral Sclerosis (Lou Gerhig’s Dz)
|
|
|
Sporadic ALS:
80% of all cases of acquired motor neuron disease Present with - Painless progressive ________, usually focal then spreading to contiguous muscle groups Difficulty swallowing, chewing, coughing, and breathing Muscle atrophy/fasiculations Spacticity _______(upper motor neuron signs) Progressive muscle _______ and weakness (lower motor neuron signs) |
weakness
Hyperreflexia wasting |
|
|
ALS is a relentlessly progressive disease that culminates in ________ muscle paralysis
_______ is the drug used in treatment of ALS and may delay progression of the disease only slightly ALS is usually fatal within 3-5 years. Patients with bulbar involvement usually have the ________ prognosis |
respiratory
Riluzole poorest |
|
|
ALS: Lab and other studies
_______ shows changes of denervation ___ (serum) may be slightly elevated _____ is normal |
Muscle bx
CK CSF |
|
|
ALS: Treatment
________ may slow progression of ALS ___________ to help with drooling Braces and walkers for mobility PT for contractures, ________ for spacticity Liquid diet or NG tube feeding for swallowing problems Consider tracheostomy Keep patient comfortable in end stages |
Riluzole
Anticholinerinergics diazepam |
|
|
________ neuropathies one of the most common neuro problems
Can range from mild sensory abnormalities (diabetic neuropathy) to life threatening disorders such as Guillain-Barre syndrome May be mononeuropathies (CTS) or multiple nerve involvement as seen in Diabetic Neuropathy |
Peripheral
|
|
|
Mononeuropathies: Carpal tunnel syndrome
______ nerve compressed at the wrist deep to the flexor retinaculum Symptoms - Numbness, tingling, and burning in palm and fingers supplied by median nerve Thumb, index, middle, medial ½ of ring Pain and paresthesias mostly at ______, awakening patient Pain may radiate to forearm and shoulder Paresthesias relieved by ______ hand |
Median
night shaking |
|
|
Mononeuropathies: CTS
May persist for years causing sensory loss to fingertips and weakness and atrophy to the ________ ______ sign – tapping nerve ______ sign – wrist flexion Precipitating factors – typing, gardening, house painting, etc Predisposing factors - Pregnancy, myxedema, RA |
thenar imminence
Tinel’s Phalen’s |
|
|
CTS: Dx based on sx and NCS and ___
Treatment: _______, rest Injection with __________ ______- Sectioning of transverse carpal ligament decompresses the nerve |
EMG
Splinting corticosteroids Surgery |
|
|
Mononeuropathies: Ulnar neuropathy (Palsy)
Entrapped ______ nerve due to a poorly healed supracondylar fx with boney overgrowth Muscle ______ & _______ more a problem than sensory symptoms Patients complain of atrophy of 1st dorsal interosseous muscle and problems with fine finger movements May be _______ to small finger and lateral ½ of ring finger |
ulner
weakness and atrophy numbness |
|
|
Mononeuropathies: __________
Most common pure sensory mononeuropathy Compression of lateral cutaneous ________ nerve of the thigh as it passes under the inguinal ligament Sx: Numbness or burning to lateral ________ Can be provoked by prolonged standing or walking Usually _______ patients, weight reduction helps Surgical decompression if evidence of blockage at inguinal ligament |
Meralgia Paresthetica
femoral thigh obese |
|
|
Mononeuropathies:
Mononeuritis Multiplex Seen in patients with DM, RA, Leprosy, polyarteritis nodosa ie patients who have underlying peripheral neuropathy (polyneuropathy) Abrupt onset of focal deficit such as _______ or ulnar palsy which is painful Usually due to ________ of cervical or lumbar plexus |
foot drop
ischemia |
|
|
Mononeuropathies: Bell’s Palsy
Facial paresis of LMN type due to inflammatory reaction of ______ nerve near the stylomastoid foramen Clinical findings - Abrupt onset of facial ______, worsening over the following day ____ pain may precedes or occurs with the paresis Face feels “pulled to one side” Ipsilateral restriction of eye ______ Disturbance of ______ Hyperacusis due to involvement of fibers to the stapedius |
facial
paresis Ear closure taste |
|
|
Bell’s palsy:
On PE, if the person can raise _____ eyebrows they do not have Bell’s palsy, but a ______ is a possibility The entire facial nerve is affected before it exits the stylomastoid foramen, so the patient will not be able to elevate the eyebrow |
both
stroke |
|
|
Bell’s Palsy: Treatment
___________is only treatment that may influence outcome Many clinicians prescribe to all BP patients seen within the 1st 5 days of onset Some when palsy is complete or severe pain Treatment _____ mg x 5 days followed by tapering dose over ___ days Protect ipsilateral eye with lubricating gtts and ________ if closure not possible at night Surgical decompression procedures are not beneficial |
Corticosteroids
60-80 10 eye patch |
|
|
Polyneuropathies: Guillain – Barre syndrome (acute inflammatory demyelinating polyneuropathy)
Since polio vaccination advent, GBS is most frequent cause of flaccid ________ throughout the world Presents as weakness or paralysis affecting limbs __________ with loss of muscle stretch reflexes and increased spinal fluid protein without pleocytosis |
paralysis
symmetrically |
|
|
GBS:
Is _______ mediated, following an infectious process in 60% of cases Seen mostly in with: Camphylobacter jejuni Mononucleosis CMV Herpes viruses mycoplasma |
immune
|
|
|
GBS: Signs and Sx
Pins and needles sensation in ____ with _______ pain Weakness within 1-2 days Mostly in legs, but arms and cranial muscles are 1st to be involved Muscle _______ reflexes lost early Weakness progresses rapidly (at peak by 14-30 days) Critical functions such as _________ can be lost rapidly (days to hours) Respiratory insufficiency and swallowing difficulty can be life threatening |
feet
low back stretch respirations |
|
|
GBS: Treatment
___________ (exchange of patients plasma for albumen) shortens time to recovery High dose infusion of human __________ Either treatment equally effective, no need to combine them |
Plasmapheresis
immunoglobulin |
|
|
Polyneuropathies: Diabetic Neuopathy
_______ is most frequent cause of neuropathy in the world Seen in 70% of patients with _________ diabetes Symptomatic neuopathy affects 5-10% of diabetics May be symmetrical polyneuropathies or different plexus or nerve injuries |
Diabetes
long standing |
|
|
Polyneuorpathies: Diabetic Neuoropathy
Polyneuopathy is ________ & ________ with sensory loss in _____ (most common) Prevalence increases with diabetes duration Can be reduced by maintaining ________ control |
distal and symmetric
feet glycemic |
|
|
Polyneuropathies: Diabetic neuropathy
Clinical manifestations - Before sx, PE may show sensation and _______ abnormalities Sx begin insidiously usually In some patients, it begin with starting _______ There is elevated pain, vibratory, and thermal threshold causing dysesthesias Burning, throbbing pain |
reflex
insulin |
|
|
Diabetic neuropathy: DX
Patient with diabetes and clinical picture of neuropathy makes the dx Can document with electrodiagnostic studies Should be made only in the setting of _________ diabetes (usually requiring insulin) Seldom caues ________ |
long standing
weakness |
|
|
Diabetic Neuropathy: Treatment
Correction of _______ to as near normal as possible Painful neuropathy may respond to ____(desipramine) or _________(gabapentin) |
blood sugar
TCA’s anticonvulsants |
|
|
Disorders of Neuromuscular Transmission: _________
Caused by block of neuromuscular transmission by autoantibodies binding to acetylcholine receptors Clinically this leads to weakness and easy ________ |
Myasthenia Gravis (MG)
fatigability |
|
|
MG:
Occurs at all ages In association with thymic tumor, thyrotoxicosis, RA, and SLE Most common in young ______ with HLA-DR3 In older men, most commonly associted with _______ Insidious onset, sometimes discovered by infection that worsens sx Exacerbates before ______ or during ________ |
women
thymoma menses pregnancy |
|
|
MG: Signs and Sx
*Present with ptosis, diplopia, dysphagia or difficulty chewing, respiratory difficulty, and/or limb weakness* Weakness may remain localized or become ________ Sx fluctuate in intensity during the day Relapses and remissions may last for weeks Course is slow and progressive and can be fatal due to ________ problems (ex aspiration pneumonia) |
generalized
respiratory |
|
|
MG: PE
Reveals weakness and __________ of affected muscles EOM’s usually involved causing ______ or ocular palsies with ______ pupils Bulbar and limb muscles weak Sustained activity weakens muscles which restrengthen after brief rest Normal sensation and no reflex changes |
fatigability
ptosis normal |
|
|
MG:
DX confirmed by response to short acting _________ ________ given IV (after test dose) and MG patients will improve stength of weak muscles lasting about 5 minutes _________ can also be given IM and response lasts for about 2 hours |
anticholinergic
Edrophonium Neostigmine |
|
|
MG: LAB and other studies
____ can indicate a disturbance of neuromuscular transmission Assay of serum for increased circulating _______ receptor antibodies (80-90% sensitivity) |
EMG
acetylcholine |
|
|
MG: Treatment
____________ drugs (neostigmine and pyridostigmine) _________ in all patients under age 60 unless weakness confined to EOM’s ____________ in patients who fail to respond to anticholinesterase meds and have had thymectomy Last resort is ________ or IV Ig therapy |
Anticholinesterase
Thymectomy Corticosteroids plasmaphoresis |
