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498 Cards in this Set
- Front
- Back
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What is trigeminal neuralgia also known as?
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"Tic douloureux"
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What are the episodes of trigeminal neuralgia like?
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brief episodes of stabbing facial pain
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What part of the trigeminal nerve is tic douloureux associated with?
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2nd and 3rd division
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How is pain exacerbated with trigeminal neuralgia?
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by touch
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What is trigeminal neuralgia thought to be associated with?
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pathophysiology unknown
-thought to be associated w/ aneurysms, AV malformations, demyelination, dental procedures, localized meningeal irritation, or tumor |
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Who is trigeminal neuralgia more common in?
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women
50s and older (rare under 30 years of age) |
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If facial pain occurs under age 30, then what other condition should you be thinking about?
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multiple sclerosis
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What are the S/S of trigeminal neuralgia?
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-Lancinating, electric-shock, severe stabbing type pain
-Pain is unilateral (97%) |
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How long does trigeminal neuralgia pain generally last?
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seconds to minutes
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What may happen after a trigeminal neuralgia attack?
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dull pain/numbness over attack area afterwards lasting minutes to hours
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Does trigeminal neuralgia pain typically wake a patient from sleep?
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no
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How is the diagnosis for trigeminal neuralgia made?
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from history (PE almost always normal)
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What are the possible pain triggers of trigeminal neuralgia? (15)
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Cold weather
Breeze/wind Brushing teeth, flossing Combing hair Chewing food Hot or cold drinks Talking Shaving Washing, touching the face Putting on clothes wearing a hat Smacking the lips Putting on make-up Swallowing/coughing Rubbing the eyes or skin of the face or nearby scalp |
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What diagnostic procedure need to be considered with trigeminal neuralgia?
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CT/MRI if suspicious for MS, tumor, or aneurysm
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What lab needs to be considered with trigeminal neuralgia if suspicious of varicella or herpes titer?
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CBC (considering infectious cause)
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What is the treatment of choice for trigeminal neuralgia?
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Carbamazapine (Tegretol)
-Usual dose is 400-800 mg/day -monitor CBC for aplastic anemia -avoid UV light |
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What meds can be used to treat trigeminal neuralgia?
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Carbamazapine
Baclofen Clonazepam Gabapentin Valproic Acid Amitriptyline |
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Besides meds, how can trigeminal neuralgia be treated?
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-precutaneous transovale needle techniques (3)
*Gamma Knife |
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What happens with glossopharyngeal neuralgia?
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Marked by repeated episodes of severe pain in the tongue, throat, ear, and tonsils, which can last from a few seconds to a few minutes
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Who does glossopharyngeal neuralgia more commonly occur in?
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women slightly > men
usually starts in 40's, 50's |
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What are the S/S of glossopharyngeal neuralgia?
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Lancinating, stabbing “electric-like” pain occurring in the posterior pharynx, ear, neck, tonsils (pain can be quite debilitating causing patients to stop eating and drinking)
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How long does the pain for glossopharyngeal neuralgia last?
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seconds to minutes
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What are the triggers for glossopharyngeal neuralgia? (11)
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Cold and hot drinks
Swallowing Coughing Chewing Speaking Clearing the throat Touching inside ear canal Touching the side of the neck Tooth infection Laughing, yawning Brushing teeth |
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What imaging technique is done for glossopharyngeal neuralgia?
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CT/MRI (MRI preferred)
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How is glossopharyngeal neuralgia treated?
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-Carbamazapine = DOC
-Surgical microvascular decompression for intractable pain -Acupuncture, biofeedback |
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What is the etiology of postherpetic neuralgia?
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complication of resolving shingles (varicella)
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How is postherpetic neuralgia defined?
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pain in area where the rash from shingles has been resolved for 3 months
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What percentage of patients who develop shingles will suffer from postherpetic neuralgia?
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15-20%
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Who gets postherpetic neuralgia? (2)
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elderly
immunocompromised |
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What are the S/S of postherpetic neuralgia?
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Constant burning or stinging pain, in area where patient had the rash of shingles
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What types of drugs can help to lessen and in some cases prevent postherpetic neuralgia?
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antiviral agents
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Which cranial nerve if involved with shingles are patients more likely to develop postherpetic neuralgia?
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first division of trigeminal nerve
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What meds can be used to treat postherpetic neuralgia?
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Pregabalin
Gabapentin Capsaicin cream (topical) Lidocaine patch (topical) Amitriptyline (TCA) Nortriptyline (TCA) Imipramine (TCA) Desipramine (TCA) Phenytoin (anticonvulsant) Carbamazepine (anticonvulsant) |
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Besides medications, what are the other treatment options for postherpetic neuralgia?
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-Transcutaneous electric nerve stimulation (TENS)
-Biofeedback -Nerve block -eliminate nuts from diet -Increase non/low-fat milk products such as yogurt to the diet (foods high in lysine) |
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Where on the body may TMJ pain radiate?
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head (ex. headache)
dental ears face (ex. swelling) mandible neck/upper back |
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Is TMJ pain usually continuous or episodic?
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generally transient and episodic, resolving in most patients without serious long-term effects
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Who is TMJ most commonly seen in?
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women > men
ages 20-50 (rare in children) |
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What are the diagnostic studies that can be done for TMJ?
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Panorama
Plain x-rays CT MRI |
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What is bruxism?
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grinding your teeth
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When should TMJ patients be referred to an oral surgeon immediately?
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trauma/locked jaw
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How can a patients TMJ pain be treated?
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-NSAIDs (anti-inflammatory)
-benzodiazepines (reduce muscle spasm, anxiety) -Warm moist compresses to TM joint -Corticosteroid injection -Massage of muscles of mastication -Use of TENS units |
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What are glomus jugulare tumors?
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Rare, slow-growing, hypervascular tumors that arise within the jugular foramen of the temporal bone
-Small collections of paraganglionic tissue -Derived from embryonic neuroepithelium in close association with the autonomic nervous system |
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What is the most common tumor of the middle ear?
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glomus tumor
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Who are glomus jugulare tumors more common in?
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women > men
40-70 years old |
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Is glomus jugulare tumors more common on the left or the right side?
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left
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What are the S/S of glomus jugulare tumors?
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-Conductive hearing loss
*Pulsatile tinnitus -Ear fullness, otorrhea, hemorrhage, bruit, and the presence of a middle ear mass can also be present -Involvement of the inner ear: vertigo and sensorineural hearing loss |
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Is ear pain common with glomus jugulare tumors?
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no
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What cranial nerves may be involved with glomus jugulare tumors?
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IX-XI (hoarseness/dysphagia)
-but usually follows one year after the initial symptoms of hearing loss |
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What do glomus jugulare tumors less commonly produce? (3)
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Facial nerve palsy
Hypoglossal nerve palsy Horner syndrome |
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What does an otoscope exam reveal with glomus jugulare tumors?
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characteristic, pulsatile, reddish-blue tumor behind the tympanic membrane that often is the beginning of more extensive findings
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What diagnostic procedures can be done for glomus jugulare tumors?
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audiogram
CT w/ contrast (bone destruction) MRI w/ contrast (tumor extent) arteriography (internal carotid artery) |
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What does an audiogram show with glomus jugular tumors?
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-Usually see conductive hearing loss early
-Mixed hearing loss (conductive and sensorineural) as tumor progresses -Sensorineural becomes more prominent as tumor progresses and enlarges |
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What is the TOC for glomus jugulare tumors?
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*surgerical excision
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What are the Tx options for glomus jugulare tumors?
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Surgical excision
Embolization Radiotheraphy Gamma knife beta-blockers, anti-hypertensives(catecholamine-type tumors) |
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Is Bell's palsy mononeuropathy or polyneuropathy?
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mononeuropathy
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Which cranial nerve is Bell's palsy limited to?
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facial nerve (CN VII)
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Is Bell's Palsy unilateral or bilateral?
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unilateral
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How may patients describe their their facial sensation with Bell's palsy?
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"numbness"
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What is the onset of Bell's Palsy?
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Begins abruptly but may progress over hours to days
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What S/S may accompany Bell's palsy?
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unilateral facial weakness
Pain surrounding ipsilateral ear numbness Impairment of taste Impairment of lacrimation Hyperacusis Drooling Difficulty speaking difficulty chewing food |
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Who is Bell's Palsy more common in (epidemiology)?
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women slightly more than men
Bimodal peak - 30’s and 80’s Rare under age 10 |
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What is the possibility of recurrence with Bell's Palsy?
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10-20% (usually w/in 10 years)
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How many people does Bell's Palsy affect in a lifetime?
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1 in 65
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What is the superior method of imaging the course of the facial nerve with Bell's Palsy?
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MRI
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How is Bell's Palsy treated?
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-Treat underlying cause
-50-60% of the cases spontaneously resolve -Oral Prednisone with or without Acyclovir if begun soon after onset of symptoms -treat symptoms |
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How can symptoms for Bell's Palsy be treated?
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artificial tears (lacrimation)
fluids, good dental care (dry mouth) soft foods (chewing problems) |
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What is the prognosis for Bell's Palsy?
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-varies from early complete recovery to substantial nerve injury with permanent sequelae
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What happens with Parkinson's disease?
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Any combination of tremor, rigidity, bradykinesia, progressive postural instability
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What type of skin condition is common with Parkinson's Disease?
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seborrhea
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Who does Parkinson's disease most commonly occur in?
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men > women
after age 50 |
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Does family history play a factor in Parkinson's Disease?
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in >25% of cases
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What is the pathophysiology of Parkinson's Disease?
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-Slow degeneration of substantia nigra in midbrain
-Dopaminergic neurons degenerate |
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What are the S/S of Parkinson's disease?
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bradykinesia
impaired gait/mobility postural instability resting tremor rigidity |
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What are the S/S of Parkinson's disease that are associated with bradykinesia?
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*Smaller handwriting
*Mask-like stare Infrequent blink Slowed walking and dressing Soft voice trails off |
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What are the S/S of Parkinson's disease that are associated with impaired gait and moility?
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Change in stride
*Short, shuffling steps |
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What are the S/S of Parkinson's disease that are associated with postural instability?
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*Imbalance while walking or standing
*Frequent falls *Stooping forward to maintain center of gravity |
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What parts of the body are affected with resing tremor in Parkinson's disease patients?
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pill-rolling
Hands and feet head, face, lips, tongue, jaw and neck |
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What are the S/S of Parkinson's disease that are associated with rigidity?
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-Affects breathing, eating, swallowing, and speech
-Cogwheel rigidity (jerky) or lead-pipe rigidity (stiff) |
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What are the secondary symptoms of Parkinson's Disease? (11)
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*Akathisia
Cognitive impairment Depression Fatigue *Freezing of movement Impotence Increased salivation Orthostatic hypotension *Paroxysmal drenching sweats *Seborrheic dermatitis Urinary frequency |
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What is included in the differential list for Parkinson's Disease?
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*Lewy body dementia
Drug induced Parkinsonism Toxin-induced Parkinsonism Structural lesions *Normal pressure hydrocephalus CNS infection Other tremor (Rest/essential) |
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With lewy body demintia is the resting tremor often present or absent?
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absent
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What can cause drug-induced Parkinsonism?
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dopamine blocking drugs (ex. Reglan)
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What can cause toxin-induced Parkinsonism?
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manganese poisoning
Wilson's Disease |
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What diagnostic studies are done for Parkinson's Disease?
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MRI of head indicated if atypical presentation
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How is Parkinson's Disease managed?
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Group support
Physical/speech therapy Tools to assist with ADLs: -Hand rails -Cutlery with large handles -Nonslip mats, etc. |
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How is Parkinson's Disease treated if there is no functional deficit?
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No medications needed, general measures only
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How is Parkinson's Disease treated if there is cognitive and functional disability?
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conservative use of Sinemet
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How is Parkinson's Disese treated if there are no cognitive changes?
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Consider selegiline (Eldepryl)
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How is Parkinson's Disese treated if there is mild functional disability with tremor predominant?
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amantadine
anticholinergics: -Trihexyphenidyl Hcl (Artane) -Benztropine mesylate (Cogentin) |
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How is Parkinson's Disese treated if there is moderate to severe functional disability?
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Sinemet SR
dopamine agonists |
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What meds. can be used to treat Parkinson's Disease?
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-Carbidopa/Levodopa (Sinemet)
-Carbidopa/Levodopa sustained release (Sinemet CR) -Levodopa -Bromocriptine mesylate -Ropinirole -Pramipexole -Selegiline HCL -Amantadine -Anticholinergics -Co-enzyme Q10 |
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What types of surgical treatment can be done for Parkinson's Disease?
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Thalamotomy
Pallidotomy Brain stimulation experimental surgery (implantation of fetal substantia nigra tissue in the caudate nucleus) |
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What is the general age of onset for multiple sclerosis?
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<55 years
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Is multiple sclerosis explained by a single pathologic lesion?
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no
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How are multiple foci with multiple sclerosis best visualized?
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MRI
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What is the top disabling condition of young adults in the US?
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multiple sclerosis
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What is the prevalence of multiple sclerosis in the US?
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250,000 - 350,000
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What is the pathophysiology of multiple sclerosis?
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-Focal regions of demyelination of white matter
-Particularly periventricular and subpial white matter |
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What are the risk factors for multiple sclerosis? (6)
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White > Black
*Female > Male (2:1) High socioeconomic status *Northern latitudes Environmental factors (toxins, viruses) HLA histocompatible antigens |
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What are the symptoms that may be present with multiple sclerosis?
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Sensory loss
Optic neuritis Weakness Paresthesias Diplopia Ataxia Vertigo Paroxysmal symptoms Urinary incontinence *Lhermitte sign Dementia Facial palsy Visual loss Impotence Myokymia Seizure Depression |
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What is Lhermitte sign?
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electrial sensation down spine on neck flexion (multiple sclerosis)
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What are the signs that may be seen with multiple sclerosis?
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Decreased pain/vibration/position sense
Decreased coordination/balance Eye exam deficits reflex deficits Charcot's triad |
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What deficits may show up on the eye exam for multiple sclerosis? (5)
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Visual field defects
Decreased visual acuity Optic nerve pallor/optic neuritis Nystagmus Bilateral internuclear ophthalmoplegia |
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If nystagmus is seen with multiple sclerosis is it more commonly vertical or horizontal?
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horizontal
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What are the reflex deficits that may show up with multiple sclerosis? (5)
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*DTRS hyperactive
Spasticity Abdominal reflexes lost Ankle clonus present *Babinski reflex positive |
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What is included in Charcot's triad for multiple sclerosis?
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Intention tremor
Nystagmus Scanning speech |
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What happens with the hot bath test?
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Hot bath exacerbates visual signs of multiple sclerosis (ex. diplopia)
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What is included in the diagnostic criteria for multiple sclerosis?
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-Objective findings on exam consistent with history
-Long white matter tracts predominately involved -Two or more CNS areas involved -Two separate episodes of symptom clusters involving different CNS areas OR progression over at least 6 months -No other explanation for CNS symptoms -Age range 15 to 60 years |
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What are the findings on a MRI for multiple sclerosis? (2)
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*Plaque formation (myelin sheath loss)
*Spotty and irregular demyelination |
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What diagnostic tests can be done for multiple sclerosis? (3)
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MRI (most useful)
CT evoked potentials |
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What diagnostic test is visually the most useful for multiple sclerosis?
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evoked potentials
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What titers are predictive of multiple sclerosis?
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serum titers
-Anti-Myelin oligodendrocyte glycoprotein (anti-MOG) -Anti-Myelin basic protein (anti-MBP) |
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What may the CSF show with multiple sclerosis?
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Mild lymphocytosis
CSF IgG Increased |
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How are acute episodes or relapses of multiple sclerosis managed?
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*Evaluate for provocative event (acute sinusitis, acute bronchitis, UTI)
*Methylprednisolone Taper schedule First: 1000 mg qd for 3 days Next: 500 mg qd for 3 days Last: 250 mg qd for 3 days -Alternative after first 3 days methylprednisolone --> Prednisone for 14 days treat the symptoms |
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What are the new meds. that can be used to slow the progression of multiple sclerosis?
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-Interferon beta-1b (Betaseron)
-Interferon beta-1a (Avonex, Rebif) -Natalizumab IV once monthly (risk of hypersensitivity) -Immunoglobulin IV |
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What are the essentials of diagnosis for myasthenia gravis?
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*Fluctuating weakness of commonly used voluntary muscles
*Symptoms increase with activity *Short-acting anticholinesterases transiently improve the weakness |
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What is the pathophysiology for myasthenia gravis?
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-Neuromuscular autoimmune disease
-Antibodies form to nicotinic acetylcholine receptors -Results in progressive weakness and fatigab |
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What are the S/S of myasthenia gravis?
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Muscle weakness provoked by exertion
*Proximal, asymmetric limb muscle weakness Cranial muscle weakness *Deep tendon reflexes normal |
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What are the labs and diagnostic tests that can be done for myasthenia gravis?
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Anticholinesterase (edrophonium) Test
EMG CT/MRI of neck Thyroid Function Test RF ANA |
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What does the Anticholinesterase (edrophonium) Test result in with myasthenia gravis?
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improved muscle strength
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How can myasthenia gravis be treated?
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Mestinon (neostigmine/ pyridostigmine)
Prednisone Azathioprine (Imuran) Plasmapheresis and IVIG |
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What are the indications for a thymectomy with myasthenia gravis?
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Age <60 years
Inadequately controlled on Mestinon Thymoma discovered |
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Who is amyotrophic lateral sclerosis more common in?
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men > women (only slightly)
50-70 years old fairly low prevalence worldwide |
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What is the etiology of ALS?
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-Idiopathic (most cases)
-Autosomal dominant inheritance in 5-10% of cases |
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What is the pathophysiology of ALS?
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Upper and lower motor neuron degeneration
Affects anterior horn cells 3 Subtypes |
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What are the S/S of ALS?
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*Muscle aches/cramps
Weakness of distal upper limbs *Weakness progresses inferiorly Dysarthria Dysphagia Drooling Muscle fibrillation and atrophy (upper limbs) *Hyperreflexia *Spasticity of lower limbs |
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What diagnostic test is used to make the diagnosis of ALS?
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EMG
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What is the course/prognosis of ALS?
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*Majority of patients die within 1-3 years of diagnosis
-Only 10% survive beyond 5 years |
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How is ALS treated/managed?
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Riluzole (very expensive)
Vitamin E and Vitamin C? Refer to ALS center: -Physical Therapy -Occupational Therapy -Dietitian -Neurologist |
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What bug causes botulism?
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*Clostridium botulinum
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What botulinum toxins are pathogenic in humans?
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*A, B, and E
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Is the receptor binding with botulism reversible?
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no (however receptors are replaced over time)
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What does it mean to the body for botulism to only affect the neuromusclular junction? (3)
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*Prevents presynaptic acetylcholine release
*Results in bulbar palsy and skeletal muscle weakness -Does not cause sensory deficit or pain |
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How is botulism transmitted?
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aerosol spread in biological warfare
wound infection (trauma/heroin) *foodborne |
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What toxin of botulism is found west of the Mississippi?
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A
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What toxin of botulism is found east of the Mississippi?
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B
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What types of foods may cause botulism?
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*Honey (infants)
Improperly preserved canned foods In-ground vegetables Preserved fish (Toxin type E) |
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What is the onset of botulism?
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Sudden onset symptoms following ingestion or exposure by 1-5 days
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What type of paralysis occurs with botulism?
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*Descending symmetric paralysis (starts at top and goes down-->cranial nerves to generalized weakness)
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What are the associated symptoms with botulism?
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N/V
Dizziness Headache Abdominal pain or cramping Diarrhea or constipation Anticholingergic symptoms may also be present |
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What are the early signs of botulism?
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*Bilateral cranial nerve 6 paralysis
Mydriasis w/ sluggish pupil reaction Nystagmus Ptosis Diminished gag reflex Swollen tongue |
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What are the later signs of botulism?
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*Symmetrical descending flaccid paralysis
*Hyporeflexia *Uncoordination *Irregular respirations to respiratory failure |
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What sources need to be tested for a patient with possible botulism?
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Serum
Gastric contents Stool Stool for culture Wound culture suspected food source |
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What is included in the management of botulism? (5)
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*Contact Centers for Disease Control for suspected cases
-Supportive care -Antibiotic use only recommended in wound botulism -Gastric decontamination if very recent ingestion *Antitoxin (from CDC) |
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How can botulism be prevented?
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*Avoid honey in infants under 1 year of age
*DOD pentavalent toxoid vaccine |
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What is the prognosis for botulism if untreated?
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mortaltiy 60% from respiratory failure
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What is poliomyelitis?
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Symptomatic infection caused by poliovirus, which (on rare occasions) may result in paralysis
-All cases in the U.S. are now vaccine associated |
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Who does poliomyelitis most commonly occur in?
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infants or young children
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What are the 3 possible presentations of poliomyelitis?
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-Abortive poliomyelitis: a flulike illness
Fever -Nonparalytic poliomyelitis: an aseptic meningitis that correlates with invasion of the CNS -paralytic poliomyelitis |
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What happens with paralytic poliomyeltitis?
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Paralysis from involvement of motor neurons in the spinal cord
Flaccid paralysis without sensory defects |
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How is poliomyelitis treated?
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-Maintenance of respiration and hydration
-Early mobilization and exercise once fever subsides -Physical therapy *No agent to alter the course of disease :( |
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What is the prognosis for poliomyelitis in the abortive and nonparalytic forms?
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complete recovery
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What is the prognosis for paralytic poliomyelitis?
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variable
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What are 10 causes of headaches that you DO NOT want to miss?
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-Intracranial hemorrhage (“thunderclap headache”)
-Thrombosis -Vasculitis -Malignant hypertension -Arterial dissection -Aneurysm -Infection (abscess, encephalitis, meningitis) -Intracranial masses -Preeclampsia -Carbon monoxide poisoning |
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What are headache "red flags"? (6)
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*Systemic symptoms (fever, weight loss)
-Secondary risk factors (HIV, systemic cancer) -Neurologic S/S -Sudden or abrupt onset -Older age at onset (>50 years) Change in pattern of headaches |
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What are 3 other names of tension headaches?
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stress headache
muscle contraction headache essential headache |
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What percentage of headaches are tension headaches?
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70%
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Who more commonly gets tension headaches?
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Females > males
Occurs at all ages |
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What is the etiology of tension headaches?
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-Multifactorial
-Stress, sleep deprivation, hunger, and eyestrain may exacerbate symptoms |
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How are tension headaches treated?
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-Relaxation techniques: massage, hot baths, biofeedback
-Physical therapy -Local injection of botulinum toxin type A -TCAs or SSRIs -Muscle relaxants (ex.Flexeril) |
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How are acute tension headaches treated?
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non-narcotic analgesics
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Why should the use of NSAIDs in chronic headaches be limited?
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*risk of rebound
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When are depression headaches usually the worst?
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morning
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How are depression headaches treated?
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antidepressants (treat underlying cause)
consider psychiatric consultation |
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What type of headache is more of a nagging headache instead of severe pain?
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depression headache
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What are 8 types of headaches?
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Tension headache
Depression headache Migraine Cluster headache Giant cell arteritis Posttraumatic headache Cough headache Headache associated with tumor |
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What may precede a migraine headache?
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aura (neurological change)
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What are 2 types of auras that may be seen with a migraine headache?
|
-Most commonly scintillating scotoma (flashing lights)
-“Prickling” of fingertips that marches up arm to the face followed by hypothesia or anesthesia of the area |
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What are the essentials of diagnosis for a migraine headache?
|
-Usually pulsatile headache, usually on one side of head
-Nausea, vomiting, photophobia and phonophobia are common -Aura may precede the headache |
|
|
What is the pathophysiology of migraine headaches?
|
-Likely related to serotonin
-Increase then decrease in blood brain catecholamines -Alternating vasoconstriction and vasodilatation |
|
|
What is the epidemiology of migraine headaches?
|
-Females > males
-Most are undiagnosed -Frequently a family Hx of migraine |
|
|
What are 7 types of migraine headaches?
|
Common migraine (without aura)
Classic migraine (with aura) Complicated migraine (with prominent neurologic signs) Basilar migraine Hemiplegic migraine Ophthalmoplegic migraine Menstrual migraine |
|
|
Are migraine headaches episodic or consisitent?
|
Episodic, occurs 1-2 times per month
|
|
|
What are 3 phases of migraine headaches?
|
prodrome
aura headache |
|
|
What symptoms may the prodrome phase include for migraine headaches?
|
-Precedes headache by up to 24 hours
-Excitability and Irritability -Increased appetite and cravings (especially sweets) -Depression -Sleepiness and fatigue -Yawning -Heightened perception to external stimuli |
|
|
What symptoms may the aura phase include for migraine headaches?
|
Visual aura
Hemisensory aura Hemiparesis aura Dysphasia aura |
|
|
What symptoms may the headache phase include for migraine headaches?
|
-Persists for 4 to 72 hours
Location (unilateral in 50%; often frontal in location) -Pulsating, throbbing in 50% -Dull, ache-type in 50% -Relieved with sleep |
|
|
What are 4 symptoms that are strongly correlated with migraines?
|
Nausea or vomiting
Photophobia Phonophobia not wanting to be touched |
|
|
What are 11 general triggers for migraine headaches?
|
Physical exertion
Stress, worry, or anxiety Menstruation Pungent odors Sleep deprivation, fatigue or excessive sleep Glare from the sun or fluorescent lights Weather changes High humidity High altitude Head trauma Drinking cold water |
|
|
What are 5 medications that may trigger a migraine headache?
|
Nitroglycerin
Reserpine Estrogens/ OCPs Hydralazine Zantac |
|
|
What are 6 foods that may trigger a migraine headache?
|
Chocolate
Alcohol Aged cheese Cold food Red wine Monosodium glutamate (MSG) |
|
|
What are 2 indications for CT imaging a migraine headache?
|
-First or worst severe migraine
-Abnormal neurologic exam |
|
|
For migraine w/out aura, what is included under timing and general characteristics?
|
Five episodes or more
Each episode lasts 4 to 72 hrs No evidence of organic headache |
|
|
For migraine w/out aura, what is included under diagnostic criteria?
|
Two of the following:
-Unilateral pain -Pulsating quality to pain -Symptom severity limits daily activities -Provoked by routine level of exertion One of the following criteria: -Nausea -Photophobia or phonophobia |
|
|
For migraine w/ aura, how many attacks must occur?
|
2 or more
|
|
|
What are 3 S/S that are included under visual aura for migraine headaches?
|
Scintillating scotoma
Fortification spectra Photopsia |
|
|
What are 4 S/S that are included under sensory aura for migraine headaches?
|
Paresthesia
Numbness Unilateral weakness Aphasia |
|
|
What are the diagnostic criteria for a migraine w/ aura?
|
Three or more of the following:
-One or more completely reversible aura symptoms -At least one aura develops over 4 or more minutes -Aura duration 60 minutes or less -Headache follows aura within 60 minutes |
|
|
How are migraine headaches treated?
|
-have pt. make a headache diary
-avoidance of triggers -symptomatic Tx -Sumatriptan (Imitrex) -narcotic pain meds. |
|
|
What is included for symptomatic treatment of migraine headaches?
|
-Rest in a dark, quiet room
-Simple analgesic may be effective if taken right away -Vasoconstrictors (Cafergot, Compazine) |
|
|
What 3 ways are triptans available?
|
oral
nasal IM |
|
|
When should triptans be avoided?
|
pregnancy or patients with coronary artery or peripheral vascular disease
|
|
|
How can migraine headaches be prevented? (8)
|
Aspirin
Propranolol TCAs: amitriptyline/imipramine SSRIs: fluoxetine/sertraline Clonidine Verapimil Depakote Topamax |
|
|
What are the 2 types of cluster headaches?
|
Episodic (90%) – remission periods last at least one month
Chronic (10%) – headaches occur for more than one year with remissions lasting <1 month |
|
|
What is the epidemiology of cluster headaches?
|
-More common in men
-Onset in men occurs in ages 20 to 40 -Onset in women peaks in the 60s (more common in black women) |
|
|
What are 4 risk factors of cluster headaches?
|
Tobacco abuse
Family history of headache Head injury Shift work |
|
|
How is the pain of cluster headaches described?
|
Deep pain
Burning or stabbing type pain Excruciating pain ("Suicide Headache") |
|
|
What is the location of cluster headaches?
|
-Unilateral
-Orbital, supraorbital or temporal pain -Radiates to upper teeth, jaw or neck |
|
|
What is the timing of cluster headaches?
|
-At least 5 attacks within 10 days
-Multiple daily episodes may occur (up to 8 per day) -Headaches last 15 minutes to 180 minutes -Usually recur at same time of day each day *May awaken patient from sleep (especially onset of REM) -Remissions for months to years |
|
|
What are the triggers for cluster headaches?
|
Sleep apnea
Vasodilators -Nitroglycerin -Alcohol |
|
|
What S/S are associated w/ cluster headaches?
|
at least one of the following:
-Lacrimation -Ipsilateral facial flushing or sweating -Ipsilateral nasal discharge -Affected eye red with dilated conjunctival vessels -Restlessness, pacing or rocking head in hands -ipsilateral Horner’s Syndrome (ptosis, miosis) |
|
|
How are cluster headaches treated (abortive therapy)?
|
*Sumatriptan (Imitrex)
O2 inhalation intranasal lidocaine intranasal dihydroergotmaine intranasal capasicin Indomethacin |
|
|
How can episodic cluster headaches be prevented?
|
Corticosteroids
Verapamil Anticonvulsants -Depakote -Topamax -Neurontin Indomethacin Methylsergide? |
|
|
How can chronic cluster headaches be prevented?
|
Verapamil
Lithium microvascular decompression surgery |
|
|
What are the nonpharmacologic measures that can help with prevention of cluster headaches? (4)
|
Relaxation techniques
Cognitive-behavior therapy Treatment of comorbid mood disorders Alcohol cessation |
|
|
What is giant cell arteritis (temporal arteritis) closely associated with?
|
polymyalgia rheumatica
|
|
|
What is the average age of presentation for giant cell arteritis?
|
72 years
|
|
|
What is the pathophysiology of giant cell arteritis?
|
-Inflammation of arteries originating from aortic arch
-Infiltration of arterial wall with inflammatory cells -Intima thickening results in lumen narrowing, occlusion |
|
|
What is the onset of giant cell arteritis?
|
insidious over months or sudden
|
|
|
What are the S/S of giant cell arteritis?
|
-Headache/tenderness over temporal or occipital arteries
-Acute visual loss or diplopia -Fever -Malaise -Weight loss -Sore throat -Dry cough -Tongue pain -Jaw claudication -Temporal artery pulse reduction |
|
|
What are the complications of giant cell arteritis? (6)
|
*Sudden vision loss
Polymyalgia rheumatica Jaw claudication Vertebrobasilar artery thrombosis Myocardial Infarction Mesenteric Infarction |
|
|
What are 3 diagnostic studies that can be done for giant cell arteritis?
|
-Increased sed rate (often >100 mm)
-C-Reactive protein increased -Temporal artery biopsy shows chronic inflammation |
|
|
What are 3 nonspecific lab findings for giant cell arteritis?
|
Moderate anemia
Decreased serum albumin Mild hepatic dysfunction |
|
|
What is the treatment for giant cell arteritis?
|
Prednisone
|
|
|
What is the course for giant cell arteritis?
|
-Self limited course over months to years with steroids
-Risk of permanent blindness if untreated |
|
|
What are the symptoms for posttraumatic headaches?
|
*headache
*dizziness Blurred vision Neck pain Fatigue Sleeping problems Cognitive disturbance Tinnitus Balance difficulty Hearing loss Loss taste or smell |
|
|
How are posttraumatic headaches treated?
|
-Optimistic encouragement :)
-Graduated rehabilitation -Avoidance of sports until resolved -Simple analgesics may help |
|
|
How long do posttraumatic headaches last?
|
may continue for weeks or months
|
|
|
What is an exertional headache also known as?
|
cough headache
|
|
|
What are the symptoms of an exertional headache?
|
Bilateral throbbing or pressure headache lasting minutes to 2 days
|
|
|
What are the triggers for an exertional headache?
|
Exercise
Coughing, sneezing, blowing Lifting weight Straining at stool Crying Singing Sexual activity (may peak with orgasm) |
|
|
What must always be ruled out with an exertional headache (RED FLAG)?
|
organic causes
|
|
|
What type of imaging can be done for an exertional headache?
|
MRI
|
|
|
What can be considered as prophylaxis prior to exertion or intercourse for exertional headaches? (2)
|
Ergotamine
Indomethacin |
|
|
CASE (name the headache)
-patient has daily headache x 2 weeks -worse in morning -anhedonia, weight loss -irritability -insomnia |
depression headache
|
|
|
CASE (name the headache)
-55 y.o. man w/ a severe, stabbing headache -surrounds right eye -sharp optic margins seen on fundoscopic exam -eyes are watery on right -nose is runny on right -denies N/V, photophobia, phonophobia |
cluster headache
|
|
|
CASE (name the headache)
-pt has had headache everyday for 1 month after hitting a tree -dull ache over entire head |
posttraumatic headache
|
|
|
CASE (name the headache)
-pt has daily headaches -feels like "tight band around her head" -lights are a little bothersome -pain in upper neck -no phonophobia |
tension headache
|
|
|
CASE (name the headache)
-patient has severe, throbbing headache -unilateral -N/V -photophobia, phonophobia -hard for PA to do the fundoscopic exam b/c it bothers the patient |
migraine headache
|
|
|
CASE (name the headache)
-72 y.o. male with right sided headache -intermittent -fever -jaw pain |
giant cell arteritis
|
|
|
What is the best therapy for TIA/CVA?
|
prevention
|
|
|
What is the difference between a TIA and CVA at onset?
|
cannot really tell the difference at the beginning
|
|
|
Within how many hours does a transient ischemic attack completely resolve?
|
24 hours
|
|
|
When is the risk of a stroke the highest following a TIA?
|
within the first month following a TIA
|
|
|
What is the most common etiology of a TIA?
|
vessel wall embolus
|
|
|
What is the most often source of a vessel wall embolus with TIA?
|
carotid artery
-Related to thrombus formation distal to stenosis |
|
|
What are the possible cardiac sources of a TIA? (8)
|
Atrial fibrillation
Mitral valve stenosis Mitral valve prolapse Calcified mitral annulus Ventricular aneurysm Atrial or ventricular clot Valvular vegetation Atrial septal defect |
|
|
What is the onset of a TIA?
|
abrupt without warning
|
|
|
What are the S/S of a TIA within the carotid territory?
|
-Weakness and heaviness of contralateral arm, leg, or face or combination
-Numbness and paresthesias -Bradykinesia, dysphasia, monocular vision loss on ipsilateral side +/- carotid bruit |
|
|
What are the S/S of a vertebrobasilar TIA (cerebellum)?
|
-Vertigo
-Ataxia -Diplopia -Dysarthria -Dimness/blurring of vision -Perioral numbness/paresthesias -Weakness or sensory complaints on one, both, or alternating sides of the body |
|
|
Are carotid or vertebrobasilar TIAs at a higher risk to cause a stroke?
|
carotid
|
|
|
What conditions with TIA may have an increased risk of stroke? (5)
|
-Carotid TIAs > vertebrobasilar TIAs
-Age > 60 years -Diabetes TIAs that last longer than 10 mins S/S of weakness, speech impairment, or gait disturbance |
|
|
What type of diagnostic/imaging studies can be done for TIAs? (8)
|
*U/S of cerebral circulation
*Doppler U/S of carotid arteries -CT of the head -Arteriography -MR angiography less sensitive than conventional arteriography -EKG -Chest x-ray -echocardiography or Holter monitor |
|
|
What labs can be done for a TIA? (5)
|
CBC
Fasting blood glucose Serum cholesterol Homocysteine level Serologic tests for syphilis |
|
|
How are TIAs treated?
|
-Carotid endarterectomy
-Smoking cessation -Tx of underlying disease (ex. HTN, DM) -Medical therapy aimed at preventing further attacks/strokes -Anticoagulation (Heparin IV until coumadin level is therapeutic; ASA may be used for people who cannot tolerate coumadin) -Embolization from the cerebrovascular system (ASA OR Plavix if intolerant of ASA) |
|
|
What do CVA patients often have a Hx of? (4)
|
HTN
DM valvular heart disease atherosclerosis |
|
|
With CVA, what reflects the region of the brain involved?
|
distinctive neurologic signs
|
|
|
What is the 3rd leading cause of death in the US?
|
CVA
|
|
|
What are the risk factors for a CVA? (10)
|
HTN
DM Hyperlipidemia Cigarette smoking Cardiac disease AIDS Drug abuse EtOH Family Hx *Elevated blood homocysteine level |
|
|
What are the 2 classifications of strokes?
|
infarcts (thrombotic, embolic)
hemorrhages |
|
|
What are 6 major stroke subtypes?
|
lacunar infarct
carotid circulation obstruction vertebrobasilar occlusion intracerebral hemorrhage subarachnoid hemorrhage intracranial aneurysm |
|
|
What size are lacunar infarction lesions?
|
small (usually < 5mm)
|
|
|
Where do lacunar infarctions occur?
|
in distribution of short penetrating arterioles in the basal ganglia, pons, cerebellum, anterior limb of the internal capsule, and less commonly deep cerebral white matter
|
|
|
What are lacunar infarctions most commonly associated with? (2)
|
HTN
diabetes |
|
|
What are the S/S of a lacunar infarction? (4)
|
-Contralateral pure motor or pure sensory deficit
-Ipsilateral ataxia w/ crural paresis -Dysarthria w/ clumsiness of the hand -Deficit may progress over 24-36 hours before stabilizing |
|
|
What type of imaging is used for lacunar infarctions?
|
-Sometimes seen on CT as small, punched-out, hypodense areas
-CT often normal |
|
|
How are lacunar infarctions treated?
|
ASA
control risk factors |
|
|
What is the prognosis of a lacunar infarction?
|
usually good with partial or complete resolution in 4-6 weeks
|
|
|
What is a cerebral infarction?
|
Thrombotic or embolic occlusion of a major vessel
|
|
|
What does cerebral iscehmia lead to?
|
release of excitatory and other neuropeptides that increase Ca++ flux into neurons causing cell death and increasing the neurologic deficit --> cerebral infarction
|
|
|
What type of onset does a cerebral infarction have?
|
abrupt
|
|
|
With cerebral infarction, what may occlusion of the ophthalmic artery cause?
|
amaurosis fugax
|
|
|
With cerebral infarction, what may occlusion of the anterior cerebral artery cause?
|
-Weakness and sensory loss in the contralateral leg
-May see contralateral grasp reflex, rigidity, abulia, or confusion -Urinary incontinence -Behavioral changes and memory disturbances |
|
|
With cerebral infarction, what may occlusion of the middle cerebral artery cause?
|
-Contralateral hemiplegia, hemisensory loss, homonymous hemianopsia
-Eyes deviate to side of the lesion -Global aphasia if dominant hemisphere involved -Drowsiness, stupor, and coma -Dressing apraxia -Constructional and spatial deficits |
|
|
With cerebral infarction, what may occlusion of the posterior cerebral artery cause?
|
-Thalamic syndrome: contralateral hemisensory disturbance followed by development of spontaneous pain and hyperpathia (feels things more strongly)
-Macular-sparing homonymous hemianopsia -Mild, usually temporary hemiparesis |
|
|
With cerebral infarction, what may occlusion of the vertebral artery cause?
|
may be clinically silent
|
|
|
With cerebral infarction, what may occlusion of both vertebral arteries or basilar arteries cause?
|
-Coma with pinpoint pupils
-Flaccid quadriplegia and sensory loss -Variable cranial nerve abnormalities -If hemiplegia is of pontine origin, eyes are often deviated to the paralyzed side |
|
|
With cerebral infarction, what may occlusion of the major cerebellar arteries cause?
|
-vertigo
-N/V -Nystagmus -Ipsilateral limb ataxia -Contralateral spinothalamic sensory loss in the limbs |
|
|
What type of diagnostic imaging/studies is used for cerebral infarction?
|
-CT of the head to exclude cerebral hemorrhage
-CT preferable to MRI in acute stages -Carotid duplex studies -MRI (diffusion-weighted more sensitive) and MR angiography -EKG -echocardiography or Holter monitor |
|
|
What labs may be taken w/ a cerebral infarction?
|
CBC
Sed rate Blood glucose Serologic tests for syphilis Serum cholesterol Serum homocysteine Blood cultures |
|
|
How are cerebral infarctions treated?
|
-Heparin IV
-IV thrombolytic therapy w/in 3 hrs -Coumadin -physical therapy -occupational therapy -speech therapy -use of mechanical aids to assist with ADLs |
|
|
What type of physical therapy can be done for cerebral infarction patients?
|
-Passive ROM to prevent contractures
-Active ROM as recovery progresses |
|
|
Does cerebral infarction have a better or worse prognosis than a cerebral or subarachnoid hemorrhage?
|
better
|
|
|
If a cerebral infarctoin patient has ___ w/in 3 hours, they are 30% more likely to have no disability at 3 months.
|
TPa
|
|
|
What is a intracerebral hemorrhage usually due to? (2)
|
HTN
presence of microaneurysms |
|
|
Where are intracerebral hemorrhages most frequently located?
|
basal ganglia
|
|
|
What is the onset of an intracerebral hemorrhage?
|
suddenly and without warning during activity
|
|
|
What conditions may intracerebral hemorrhages occur with? (8)
|
Leukemia
Hemophilia DIC Anticoagulant therapy Liver disease Cerebral amyloid angiopathy EtOH Brain tumors |
|
|
What are the S/S of intracerebral hemorrhages?
|
-Initial loss or impairment of consciousness
-Vomiting and headache -Focal signs and symptoms -Loss of gaze -Cerebellar hemorrhage (loss of consciousness could lead to death w/in 48hrs) |
|
|
What type of imaging is used for an intracerebral hemorrhage?
|
CT scan without contrast
Cerebral angiography |
|
|
What labs are useful for intracerebral hemorrhages?
|
CBC
platelet count bleeding times LFTs renal function tests |
|
|
What is contraindicated with an intracerebral hemorrhage?
|
*LP (may cause a herniation syndrome)
|
|
|
How are intracerebral hemorrhages treated?
|
-generally conservative and supportive
-Ventricular drainage may be required -Decompression of superficial hematoma -Prompt surgical evacuation of cerebellar hemorrhage -Tx of underlying structural lesions -Trials of recombinant activated factor VII given with a few hours of onset are promising |
|
|
What percentage of strokes are from a subarachnoid hemorrhage?
|
5-10%
|
|
|
What are the S/S of a subarachnoid hemorrhage?
|
-Sudden onset of “worst headache of my life”
-N/V -Loss or impairment of consciousness (obtundation is common) -Altered mental status -Nuchal rigidity and other signs of meningeal irritation -Focal neurologic deficits frequently absent |
|
|
What type of imaging is used for a subarachnoid hemorrhage?
|
*CT immediately
-assess CSF for blood and xanthochromia (if CT normal) -cerebral arteriography (once patient is stable) |
|
|
How are subarachnoid hemorrhages treated in conscious patients?
|
-Confine to bed, avoid exertion or straining
-Treat symptoms (headache, constipation) -Lower BP gradually keeping diastolic > 100 -Phenytoin (prevent seizures) -surgery indicated to prevert further progression |
|
|
What are the essentials of diagnosis for an intracranial aneurysm? (2)
|
-Subarachnoid hemorrhage or focal deficit
-Abnormal imaging studies |
|
|
Where are most intracranial aneurysms located?
|
in anterior Circle of Willis
|
|
|
What type of aneurysms tend to occur at arterial bifurcations with intracranial aneurysms?
|
"berry"
-May be associated with PKD and coarctation of the aorta |
|
|
What are 3 risk factors for an intracranial aneurysm?
|
smoking
HTN hypercholesterolemia |
|
|
What are the S/S of an intracranial aneurysm?
|
-Most are asymptomatic
-May cause focal neurologic deficit from mass effect |
|
|
What type of imaging/diagnostic studies are used for an intracranial aneurysm?
|
CT scan (shows if a bleed occurred)
Angiography (berry aneurysm) EEG EKG |
|
|
What may CSF show with a patient who has an intracranial aneurysm?
|
blood
|
|
|
What is the major aim of Tx for intracranial hemorrhages?
|
to prevent further hemorrhages
|
|
|
How are intracranial aneurysms treated?
|
-surgical clipping or coil embolization
-Ca2+ blockers and IV fluids to reduce vasospasms (can get ischemia from vasospasms) |
|
|
When is the risk of further hemorrhage the greatest with an intracranial aneurysm?
|
within first 6 months
|
|
|
What type of lesions are arteriovenous (AV) malformations?
|
congenital (vary in size)
|
|
|
What condition may be associated with AV malformations?
|
obstructive hydrocephalus (if not allowing CSF to drain as normal)
|
|
|
What are the S/S of supratentorial (AV malformations)?
|
most AV malformations are supratentorial
-S/S of hemorrhage, recurrent seizures or headaches -Abnormal mental status -Meningeal irritation -Increased ICP |
|
|
What are the S/S of infratentorial (AV malformations)?
|
-Often clinically silent
-May lead to progressive or relapsing brainstem deficits |
|
|
What type of imaging/diagnostic studies are used for AV malformations?
|
-CT scan w/out contrast if bleeding present
-Arteriography -EEG |
|
|
How are AV malformations treated?
|
-Surgical treatment to prevent further hemorrhages
-For patients with seizures and no bleeding, anticonvulsants are usually sufficient -Definitive surgical Tx --> excision of AV malformation -Embolization if not surgically accessible -Injection of vascular occlusive polymer -Gamma knife |
|
|
What are 6 conditions that intracranial venous thrombosis is associated with?
|
-Intracranial or maxillofacial infections (ex. sinus infection)
-Hypercoagulable states -Polycythemia -Sickle cell disease -Cyanotic congenital heart disease -Pregnancy |
|
|
What are the S/S for intracranial venous thrombosis? (5)
|
Headache
Focal/generalized convulsions Drowsiness, confusion Increased ICP Focal neurologic deficits |
|
|
What types of imaging are used for intracranial venous thrombosis?
|
CT
MRI MR venography |
|
|
How do you treat intracranial venous thrombosis?
|
-Anticonvulsants
-Dexamethasone (decrease ICP) -Anticoagulation w/ heparin followed by coumadin for 6 months -Catheter-directed thrombolytic therapy with urokinase and thrombectomy |
|
|
What is epilepsy?
|
any disorder characterized by recurrent seizures
|
|
|
What is a seizure?
|
transient disturbance of cerebral function due to an abnormal paroxysmal neuronal discharge in the brain
|
|
|
What percentage of the populations is affected by epilepsy?
|
1%
|
|
|
When do idiopathic seizures generally begin?
|
between 5 and 20 years of age
|
|
|
What are the 8 etiologies of epilepsy?
|
Idiopathic
Congenital abnormalities/perinatal injuries Metabolic disorders trauma tumors Vascular diseases Degenerative disorders (Alzheimer's) Infectious diseases |
|
|
What are 3 types of metabolic disorders that can cause epilepsy?
|
Drug/alcohol withdrawal
Uremia Hyper-/hypoglycemia |
|
|
What etiology of epilepsy is more likely to develop if the dura matter was penetrated and is most important in young adults?
|
trauma
|
|
|
What is the most common cause of seizures with onset at age 60 or older?
|
vascular disease
|
|
|
How are seizures classified?
|
Partial vs. generalized
Simple vs. complex Petit mal vs. grand mal |
|
|
What happens with a partial seizure?
|
Only a restricted part of one cerebral hemisphere has been activated
|
|
|
Is consciousness preserved with simple or complex partial seizures?
|
simple
|
|
|
Is consciousness impaired with simple or complex partial seizures?
|
complex
|
|
|
What are the special sensory symptoms for partial seizures?
|
light flashes or buzzing
|
|
|
What are the autonomic S/S for partial seizures? (4)
|
abnormal epigastric sensations
sweating flushing pupillary dilation |
|
|
What happens with simple partial seizures?
|
Focal motor symptoms or somatosensory symptoms that march to different parts of the limb
|
|
|
What are absence seizures known as?
|
petit mal
|
|
|
How are absence seizures characterized?
|
impairment of consciousness
|
|
|
What autonomic component may be associated with absence seizures?
|
enuresis
|
|
|
What is the onset and termination of absence seizure attacks?
|
abrupt
|
|
|
When do absence seizures almost always begin?
|
childhood
-may be a child in school that the teacher thinks is daydreaming |
|
|
What does the EEG show for absence seizures?
|
bursts of bilaterally synchronous and symmetric 3-Hz spike and wave activity
|
|
|
What happens with myoclonic seizures?
|
Single or multiple myoclonic jerks
|
|
|
What are tonic-clonic seizures also known as?
|
grand mal
|
|
|
What happens during the tonic phase of tonic-clonic seizures?
|
sudden loss of consciousness; patient becomes rigid and fall to the ground; respirations cease
|
|
|
What happens during the clonic phase of tonic-clonic seizures?
|
jerking of the body musculature for 2-3 minutes followed by flaccid coma
|
|
|
What happens during atonic seizures?
|
Loss of consciousness and muscle tone
|
|
|
What are atonic seizures also known as?
|
epileptic drop attacks
|
|
|
What are 4 types of generalized seizures?
|
Absence seizures (petit mal)
Myoclonic seizures Tonic-clonic seizures (grand mal) Atonic seizures |
|
|
What are the essentials of diagnosis for epilepsy?
|
-Recurrent seizures
-Characteristic EEG changes accompany seizures -Mental status abnormalities or focal neurologic symptoms may persist for hours after a seizure |
|
|
What are the prodromal symptoms of epilepsy?
|
Headache
Mood alterations Lethargy Myoclonic jerking Not the same thing as an aura |
|
|
What is the timing for epilepsy?
|
unpredictable
|
|
|
What are the external precipitants of epilepsy? (10)
|
lack of sleep
hunger emotional stress menstruation EtOH fever flashing lights flickering lights music reading |
|
|
Between seizures, is there abnormality on exam for patients with idiopathic epilepsy?
|
no
|
|
|
What are the indications for MRI with epilepsy? (4)
|
Focal neurologic S/S
Focal seizures Progressive disorder New onset of seizures after the age of 20 years |
|
|
What types of imaging/diagnostic studies can be done for epilepsy?
|
MRI
Chest x-ray EEG |
|
|
What labs may be useful for epilepsy?
|
CBC
Blood glucose Liver function tests Renal function tests Serology for syphilis |
|
|
How can you tell if it is a pseudoseizure?
|
-There may be obvious preparation before the pseudoseizure
-Usually no tonic phase -Rarely any injuries -No change in behavior postictally -No EEG changes |
|
|
What is included for the general treatment plan of epilepsy?
|
-Advise patient to avoid situations that may be dangerous
-There may be mandatory reporting to the state health department -Pharmacotherapy for at least 3 years tailored to the type of seizure |
|
|
How are generalized tonic-clonic or partial seizures treated?
|
Phenytoin
Carbamazepine Valproic acid Phenobarbital Primidone Gabapentin Lamotrigine Topiramate |
|
|
How are absence seizures treated?
|
Ethosuximide
Valproic acid Clonazepam |
|
|
How are myoclonic seizures treated?
|
Valproic acid
Clonazepam |
|
|
If seizures continue after administering medication, what should you do?
|
add second drug and slowly withdraw the first drug
|
|
|
How should the dose of medication be titrated for seizures?
|
based on clinical response, not on blood levels
|
|
|
How should seizure medication be discontinued?
|
-Only when patient has been seizure-free for 3 years
-Reduce dose gradually over weeks or months |
|
|
How is epilepsy treated?
|
Medication
Surgical therapy Vagal nerve stimulation |
|
|
What needs to be done for a solitary seizure within 24 hours?
|
EEG
|
|
|
What are alcohol withdrawal seizures?
|
One or more tonic-clonic seizures within 48 hours of withdrawal from EtOH or period of high intake
|
|
|
What type of imaging should be done for alcohol withdrawal seizures?
|
Head CT with new onset or with focal features
|
|
|
What is the most common cause of status epilepticus?
|
poor compliance with medications
|
|
|
What are the possible causes of status epilepticus besides poor compliance with medications?
|
EtOH withdrawal
Intracranial infection or neoplasm Metabolic disorders Drug overdose |
|
|
What is the mortality rate of status epilepticus?
|
20% (MEDICAL EMERGENCY)
|
|
|
How is status epilepticus treated?
|
-Maintain airway
-50% dextrose IV -Diazepam IV (given over 2 mins) -Phenytoin -EEG monitoring -can use fosphenytoin IV -add phenobarbital (if seizures continue) -general anesthesia (if seizures continue) |
|
|
What should be done once status epilepticus is controlled?
|
initiate oral therapy and investigate cause of status epilepticus
|
|
|
What is the most common type of primary brain tumor?
|
gliomas (50%)
|
|
|
What are the types of primary brian tumors? (7)
|
gliomas
Meningiomas Pituitary adenomas Neurofibromas Hemangioblastomas Retinoblastomas Craniopharyngiomas (congenital) |
|
|
What are the S/S of primary brain tumors?
|
-Generalized disturbance of cerebral function
-S/S of ICP -Personality changes -Intellectual decline -Emotional lability -Seizures -Headaches -N/V -Malaise -Brain herniation |
|
|
What are the S/S of brain herniation in the temporal lobe (primary brain tumor)?
|
ipsilateral pupillary dilation
stupor coma decerebrate posturing respiratory arrest |
|
|
What are the S/S of brain herniation in the cerebellum (primary brain tumor)?
|
apnea
circulatory collapse death |
|
|
What are the S/S of primary brain tumors located in the frontal lobe?
|
normally in children
progressive intellectual decline, personality changes, contralateral grasp reflex, expressive aphasia, anosmia |
|
|
What are the S/S of primary brain tumors located in the temporal lobe?
|
seizures with olfactory or gustatory hallucinations, lip smacking, behavioral changes, déjà vu or jamais vu, micropsia or macropsia, auditory hallucinations
|
|
|
What are the S/S of primary brain tumors located in the parietal lobe?
|
contralateral disturbances in sensation, hyperpathia and spontaneous pain, alexia, agraphia, acalculia, constructional apraxia or dressing apraxia
|
|
|
What are the S/S of primary brain tumors located in the occipital lobe?
|
partial field defects, cortical blindness, loss of color perception, prosopagnosia
|
|
|
What are the S/S of primary brain tumors located in the brainstem or cerebellum?
|
cranial nerve palsies, ataxia, nystagmus, sensory deficits, uncoordination, hypotonia of limbs
|
|
|
What types of imaging/diagnostic studies can be done for primary brain tumors?
|
CT
MRI with gadolinium enhancement Arteriography EEG |
|
|
What are 7 types of primary brain tumors?
|
medulloblastoma
meningioma brainstem glioma astrocytoma pineal tumor glioblastoma acoustic neuroma |
|
|
Who are medulloblastomas most commonly seen in?
|
*children
|
|
|
Where do medulloblastomas arise from?
|
roof of 4th ventricle
|
|
|
What are the S/S of medulloblstomas?
|
Increased ICP with brainstem and cerebellar signs
|
|
|
How are medulloblastomas treated?
|
surgery
chemo radiation |
|
|
Where does a meningioma originate from?
|
dura or arachnoid mater
-compresses adjacent structures |
|
|
Are meningiomas usually benign or malignant?
|
benign
|
|
|
Does meningiomas incidence increase with age?
|
yes
|
|
|
How are meningiomas treated?
|
surgery (tumor may recur if removal not complete)
|
|
|
How do brainstem gliomas present?
|
during childhood with cranial nerve palsies and then long tract signs in limbs
-ICP is a late finding |
|
|
How are brainstem gliomas treated?
|
radiation & shunting
tumor is inoperable |
|
|
What is the onset for astrocytomas?
|
Insidious onset of nonspecific complaints and increased ICP
|
|
|
What is the prognosis for astrocytomas?
|
variable
tumor often inoperable by the time it is diagnosed |
|
|
What are the S/S of pineal tumors?
|
-increased ICP
-Sometimes impaired upward gaze -Other midbrain deficits |
|
|
How are pineal tumors treated?
|
shunting followed by surgery
radiation for malignant tumor |
|
|
What are the S/S of glioblastomas?
|
-Increased ICP and nonspecific complaints
-Focal deficits as tumor enlarges |
|
|
What is the prognosis for glioblastomas?
|
*Rapidly progressive with poor prognosis
-Total surgical removal is often not possible -Radiation and chemo may prolong survival |
|
|
What are the S/S of acoustic neuromas?
|
-Ipsilateral hearing loss
-Tinnitus, headache, vertigo -Facial weakness or numbness |
|
|
What are the best diagnostic tests for acoustic neuromas?
|
MRI
auditory evoked potential |
|
|
How are acoustic neuromas treated?
|
excision
|
|
|
What is the outcome for acoustic neuromas?
|
usually good
|
|
|
What is the most common source of metastatic tumors?
|
*lung cancer
Other primary sites: Breast Kidney GI tract |
|
|
What is the Tx for a single metastatic lesion?
|
excision
radiation |
|
|
What is the Tx for multiple metastases?
|
palliative care only
|
|
|
What is the most common spinal intramedullary tumor?
|
ependymoma
|
|
|
What are the types of spinal intramedullary tumors?
|
ependymomas
other types of gliomas |
|
|
What are 2 types of spinal tumors?
|
intramedullary (10%)
extramedullary |
|
|
What are the types of extramedullary spinal tumors?
|
neurofibromas
meningiomas (benign) myelomas metastases (prostate/breast/lung/kidney) |
|
|
What are 3 causes of spinal cord dysfunction?
|
-Direct compression
-Ischemia secondary to arterial or venous obstruction -Invasive infiltration from intramedullary tumors only |
|
|
What are the S/S of spinal tumors?
|
-Insidious onset
-Pain aggravated by coughing or straining -Motor deficits or paresthesias -Localized spinal tenderness |
|
|
What type of imaging can be done for spinal tumors?
|
-Plain x-ray may be normal or may show metastatic deposits
-CT myelography -MRI |
|
|
What type of lab can be done for spinal tumors?
|
CSF removed during myelography is often xanthochromic with increased protein
|
|
|
How are intramedullary spinal tumors treated?
|
Decompression and surgical excision
|
|
|
How are extramedullary spinal tumors treated?
|
Radiation
Dexamethasone for cord swelling |
|
|
What is the prognosis for intramedullary spinal tumors?
|
depends on cause and severity of compression
|
|
|
What is the prognosis for extramedullary spinal tumors?
|
long-term outlook is poor
|
|
|
What is pseudotumor cerebri also known as?
|
benign intracranial hypertension
|
|
|
Is pseudotumor cerebri really a tumor?
|
no
|
|
|
What are the possible causes of pseudotumor cerebri?
|
Thrombosis of transverse venous sinus
Chronic pulmonary disease Endocrine diseases Vitamin A toxicity *Medications (OCPs/Tetracycline) |
|
|
What are the S/S of pseudotumor cerebri?
|
Headache
Diplopia Papilledema |
|
|
What type of imaging can be done for pseudotumor cerebri?
|
-CT shows no mass +/- small ventricles
-MR venography useful to find thrombi |
|
|
What labs are used for pseudotumor cerebri?
|
LP increased opening pressure
CSF is normal |
|
|
What can happen if pseudotumor cerebri is not treated?
|
permanent visual loss
|
|
|
How can pseudotumor cerebri be treated?
|
Diamox (acetazolamide)
Prednisone Repeated LP to remove CSF |
|
|
How is Tx monitored w/ pseudotumor cerebri?
|
checking visual acuity and optic disk, pressure of CSF
|
|
|
What should be done for pseudotumor cerebri with failure of medical therapy? (2)
|
Lumboperitoneal shunt or other shunt
Subtemporal decompression |
|
|
What is included in the differential diagnosis for partial seizures?
|
TIA
rage attack panic attack |
|
|
What is included in the differential diagnosis for generalized seizures?
|
syncope (especially atonic)
cariac dysrhythmias brainstem ischemia pseudoseizures -conversion disorder -malingering |
|
|
What 3 types of AEDs can cause blood dyscrasias?
|
Phenytoin
Carbamazepine Ethosuximide |
|
|
What are 4 CNS infections?
|
Guillain-Barré Syndrome
Viral meningitis Bacterial meningitis Brain abscess |
|
|
What is going on with Guillain-Barré Syndrome?
|
symmetrical sensory, motor, or mixed deficit, often most marked distally
|
|
|
Does Guillain-Barré Syndrome usually have an ascending or descending symmetric weakness?
|
ascending
|
|
|
Is Guillain-Barré Syndrome acute or chronic?
|
Acute or subacute progressive polyradiculoneuropathy
|
|
|
What does Guillain-Barré Syndrome often follow?
|
infections
vaccinations surgical procedures *Campylobacter jejuni |
|
|
What is the main complaint of Guillain-Barré Syndrome?
|
weakness
|
|
|
What are the motor symptoms of Guillain-Barré Syndrome?
|
*weakness
-in the legs, spreading to a variable extent but frequently involving the arms and often one or both sides of the face -muscles of respiration or deglutition may also be affected |
|
|
Are the sensory symptoms of Guillain-Barré Syndrome usually more or less conspicuous than motor symptoms?
|
less
|
|
|
What are the sensory symptoms associated with Guillain-Barré Syndrome?
|
Distal paresthesias
Dysesthesias Neuropathic or radicular pain |
|
|
What are the autonomic symptoms of Guillain-Barré Syndrome?
|
*Tachycardia
*Cardiac rhythm irregularities *Hypotension or hypertension Facial flushing Abnormalities of sweating *Pulmonary dysfunction Impaired sphincter control |
|
|
What laboratory test is done for Guillain-Barré Syndrome?
|
*CSF characteristically contains a high protein concentration with a normal cell content, but this change may take 2 or 3 weeks to develop
|
|
|
What diagnostic procedures are done for Guillain-Barré Syndrome?
|
*Electrophysiologic (nerve conduction) studies may reveal marked abnormalities, which do not necessarily parallel the clinical disorder in their temporal course
-Pathologic examination has shown primary demyelination or, less commonly, axonal degeneration |
|
|
What meds are used to treat Guillain-Barré Syndrome?
|
-IV immunoglobulin
-Low-dose heparin -Marked hypotension may respond to volume replacement or pressor agents |
|
|
Is Prednisone a good drug for Guillain-Barré Syndrome?
|
no (ineffective and may prolong recovery time)
|
|
|
*What therapeutic procedures can be done for Guillain-Barré Syndrome?
|
Respiratory toilet and chest physical therapy help prevent atelectasis
Plasmapheresis -within the first few days -reserved for clinically severe or rapidly progressive cases or those with ventilatory impairment |
|
|
What should be included in the follow-up (monitoring) for Guillain-Barré Syndrome?
|
spirometry
|
|
|
What is the prognosis of Guillain-Barré Syndrome?
|
-Most patients eventually make a good recovery
-Recovery may take many months -10–20% of patients have residual disability -3% of patients have one or more clinically similar relapses |
|
|
When does the incidence for acute viral meningitis peak (months)?
|
*summer and early fall months
|
|
|
What are the causes of acute viral meningitis?
|
*Enteroviruses
HSV type 2 Arboviruses HIV Varicella zoster virus Epstein-Barr virus |
|
|
*What are the symptoms of acute viral meningitis?
|
Headache
Fever Meningeal signs Mild lethargy or drowsiness malaise, myalgia, anorexia, N/V and diarrhea |
|
|
What is the most important diagnostic test for acute viral meningitis?
|
CSF examination
|
|
|
What shows up with CSF examination for acute viral meningitis?
|
Elevated WBCs (25 – 500 cells/µL) with predominant lymphocytes
Normal or slightly elevated protein level Normal glucose Normal or mildly elevated opening pressure |
|
|
What laboratory studies can be done for acute viral meningitis?
|
CSF
PCR amplification of viral nucleic acid Viral culture Serum antibody tests CBC with diff Electrolytes Sed rate C-reactive protein Liver/kidney function tests |
|
|
What is the diagnostic test of choice for Enteroviruses associated with acute viral meningitis?
|
PCR
|
|
|
What months is Enteroviruses
associated with acute viral meningitis most common? |
summer months
|
|
|
What age group does Enteroviruses associated with acute viral meningitis most commonly affect?
|
children under 15 years old
|
|
|
What months is Arbovirus infections associated with acute viral meningitis most commonly seen?
|
summer and fall
|
|
|
Who does HSV-2 meningitis occur in?
|
~ 25% of women and 11% of men at time of initial genital infection
|
|
|
What is the major cause of viral meningitis in adults?
|
HSV-2 meningitis
|
|
|
How is the diagnosis of varicella zoster virus associated with acute viral meningitis made?
|
PCR
|
|
|
How are EBV infections associated with acute viral meningitis diagnosed?
|
serum and CSF serology
|
|
|
What type of palsies are more common in HIV meningitis?
|
cranial nerve palsies
|
|
|
How is acute viral meningitis treated?
|
-Primarily symptomatic with analgesics, antipyretics and antiemetics
-Monitor fluids and electrolytes Oral/IV acyclovir for HSV/EBV/VZV -For enterovirus infections pleconaril is being investigated |
|
|
How can acute viral meningitis be prevented?
|
Varicella vaccination
|
|
|
What is the prognosis of acute viral meningitis?
|
-Excellent for full recovery for adults
-Outcome is less certain in infants and neonates |
|
|
What is bacterial meningitis?
|
Acute purulent infection within the subarachnoid space
|
|
|
What is the most common cause of bacterial meningitis in adults?
|
S. pneumoniae
|
|
|
What are the causes of bacterial meningitis?
|
S. pneumoniae
N. meningitidis Enteric gram-negative bacteria Group B strep L. monocytogenes H. influenzae type b Staph aureus |
|
|
What are the risk factors for S. pneumoniae bacterial meningitis?
|
pneumococcal pneumonia
sinusitis OM alcoholism DM splenectomy open head trauma |
|
|
What is the mortality for S. pneumoniae bacterial meningitis?
|
~ 20% despite antibiotic therapy
|
|
|
What is an important clue for N. meningitidis bacterial meningitis?
|
Petechiae and/or purpura
|
|
|
What can happen with N. meningitidis bacterial meningitis?
|
Disease can be fulminant with death within hours of onset
|
|
|
Which type of bacterial meningitis is increasinly common in patients with chronic diseases like DM, cirrhosis, or alcoholism?
|
Enteric gram-negative bacilli
|
|
|
What group of individuals is Group B Strep bacterial meningitis generally seen in?
|
neonates
|
|
|
What is an increasingly important cause of bacterial meningitis in neonates, pregnant women, patients older than 60, and immuno-compromised individuals of all ages?
|
L. monocytogenes
|
|
|
How do individuals get infected with L. monocytogenes?
|
is foodborne
–coleslaw, milk, soft cheeses, deli meats, etc. |
|
|
What is the classic clinical triad for bacterial meningitis?
|
Fever
Headache Nuchal rigidity |
|
|
What are the S/S of bacterial meningitis?
|
Fever
Headache Nuchal rigidity Decreased LOC from lethargy to coma Nausea/vomiting Seizures Increased ICP Petechial rash meningococcemia |
|
|
What are the S/S of increased ICP for bacterial meningitis?
|
Decreased LOC
papilledema dilated poorly reactive pupils 6th nerve palsies decerebrate posturing |
|
|
What are the disease specific S/S for bacterial meningitis? (2)
|
Petechial rash or
meningococcemia |
|
|
What should be done immediately for bacterial meningitis? (2)
|
blood cultures
empiric antibiotics |
|
|
What does the CSF lab show for bacterial meningitis?
|
Opening pressure > 180
WBCs 10 – 10,000/µL (predominance of neutrophils) Glucose low Protein high |
|
|
What empiric antibiotics should be used for preterm infants to infants < 1 month old for bacterial meningitis?
|
ampicillin + cefotaxime
|
|
|
What empiric antibiotics should be used for Infants 1–3 months old for bacterial meningitis?
|
ampicillin + cefotaxime or ceftriaxone
|
|
|
What empiric antibiotics should be used for Children > 3 months to adults < 55 for bacterial meningitis?
|
cefotaxime or ceftriaxone + vancomycin
|
|
|
What empiric antibiotics should be used for Adults > 55 or any adults with chronic illness for bacterial meningitis?
|
ampicillin + cefotaxime or ceftriaxone + vancomycin
|
|
|
What empiric antibiotics should be used for hospital aquired infection of bacterial meningitis?
|
ampicillin + ceftazidime + vancomycin
|
|
|
What specific antibiotics are used to treat N. meningitides bacterial meningitis?
|
Pen G or ampicillin, ceftriaxone or cefotaxime if PCN resistant
|
|
|
What specific antibiotics are used to treat S. pneumoniae bacterial meningitis?
|
Pen G, ceftriaxone or cefotaxime +/- vancomycin if PCN resistant
|
|
|
What specific antibiotics are used to treat Gram negative bacilli (other than Pseudomonas) bacterial meningitis?
|
ceftriaxone or cefotaxime
|
|
|
What specific antibiotics are used to treat P. aeruginosa bacterial meningitis
|
ceftazidime or cefepime or meropenem
|
|
|
What specific antibiotics are used to treat Staphylococci bacterial meningitis?
|
nafcillin, or vancomycin if methicillin resistant
|
|
|
What specific antibiotics are used to treat L. monocytogenes bacterial meningitis?
|
ampicillin + gentamicin
|
|
|
What specific antibiotics are used to treat H. influenzae bacterial meningitis?
|
ceftriaxone or cefotaxime
|
|
|
What adjunctive therapy can be used for bacterial meningitis?
|
Dexamethasone IV
-has been shown to decrease meningeal inflammation and reduce the risk of neurological sequelae |
|
|
What does a brain abscess present as?
|
an intracranial space-occupying lesion
|
|
|
What may occur as a sequela of ear or sinus infection, a complication of infection elsewhere in the body, or an infection introduced intracranially by trauma or surgical procedures?
|
brain abscess
|
|
|
What are the most common infective organisms of a brain abscess?
|
Streptococci
Staphylococci Anaerobes Mixed infections not uncommon |
|
|
*What are the early symptoms of a brain abscess?
|
Headache
Drowsiness Inattention Confusion Seizures |
|
|
*What are the later symptoms of a brain abscess?
|
Increasing intracranial pressure
Focal neurologic deficits |
|
|
Is there systemic evidence of a brain abscess?
|
may be little or no systemic evidence of infection
|
|
|
Does examination of the cerebrospinal fluid help in diagnosis of a brain abscess?
|
no
|
|
|
What may a lumbar puncture cause if there is a brain abscess?
|
herniation
|
|
|
What types of imaging can be done for a brain abscess?
|
*CT scan of the head characteristically shows an area of contrast enhancement surrounding a low-density core (similar to metastatic neoplasms)
*MRI permits earlier recognition of focal cerebritis or abscess -Arteriography indicates the presence of a space-occupying lesion but provides no clue to the nature of the lesion |
|
|
How do you treat a brain abscess?
|
IV antibiotics, combined with surgical drainage (aspiration or excision)
Dexamethasone may reduce any associated edema -IV mannitol is sometimes required |
|
|
How should brain abscess patients be monitored?
|
*serial CT scans or MRI every 2 weeks and at deterioration
|
|
|
*What are 2 complications of a brain abscess?
|
Seizures
Focal neurologic deficits |
|
|
What is the prognosis of a brain abscess?
|
Abscesses smaller than 2 cm can often be cured medically
|
