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100 Cards in this Set

  • Front
  • Back
spinal cord compression etiology
acute --> trauma, hematoma
subacute --> cancer (lymphoma, multiple myeloma, prostate, lung, breast, kidney, colon), epidural abscess
chronic --> herniated disk
spinal cord compression presentation
back pain (96%)
history of cancer, fever
bowel or bladder dysfunction
insidious onset of mild sensory disturbance
lower limb weakness or rigidity
spinal cord compression diagnosis
plain x-rays are 84-94% sensitive
gold standard is MRI
if MRI is contraindicated --> CT myelogram
spinal cord compression management
high-dose dexamethasone immediately upon suspicion
surgical decompression in trauma, herniated disk or epidural abscess
radiotherapy in case on cancer
syringomyelia etiology
central cavitation of spinal cord
communicating is associated with Arnold-Chiari
non-communicating is associated with trauma or spinal cord tumors
syringomyelia presentation
cervical and upper limb pain and temperature loss
may have lower motor neuron deficits in upper limbs and upper motor neuron deficits in lower limbs
syringomyelia diagnosis and treatment
MRI is gold standard; surgery is unsatisfactory
subacute combined degeneration
B12 deficiency results in
corticospinal --> upper motor neuron signs, flaccid/spastic paralysis
dorsal columns --> ataxia, vibration and propioception deficits, distal paresthesia
diagnosis --> low serum B12 and high methylmalonic acid
treatment --> B12 replacement
anterior spinal artery occlusion
bilateral paralysis
pain, temperature and autonomic loss below lession
conserved vibration and propioception
Brown-Sequard syndrome
ipsilateral upper motor neuron signs below lesion
ipsilateral vibration and propioception loss below lesion
contralateral pain/temerature loss 1-2 levels below lesion
bilateral flaccid paralysis and anesthesia at level of lesion
ipsilateral Horner syndrome if above T1
anterior cerebral artery irrigation
medial surface of frontal and parietal lobes
1 inch of supero-lateral surface of frontal and parietal lobes
anterior limb of internal capsule
caudate nucleus
anterior 4/5 of corpus callosum
anterior cerebral artery stroke presentation
contralateral lower limb paralysis
contralateral lower limb sensory loss
urinary incontinece, behavioral disturbances
middle cerebral artery irrigation
lateral surfaces of frontal, parietal and temporal lobes except superior inch
genu and posterior limb of internal capsule
globus pallidus
putamen
middle cerebral artery stroke presentation
contralateral hemiplegia, contralateral anesthesia
contralateral homonymous hemianopia with eye deviation toward lesion
contralateral central facial paralysis
aphasia if left, apraxia and spacial disturbance if right
posterior cerebral artery irrigation
cerebellum, brain stem, pons, occipital lobe
posterior brain circulation arteries
posterior cerebral artery
basilar artery
cerebellar arteries
paramedian branches
vertebral artery
posterior cerebral artery stroke
contralateral homonymous hemianopia
visual hallucinations
agnosia
associated Weber or Benedikt syndromes
Weber syndrome
results from occlusion of penetrating branches of PCA
contralateral hemiplegia and CNIII palsy
Benedikt syndrome
results from occlusion of penetrating branches of PCA
CNIII palsy with contralateral ataxia or athetosis
paramedian branches of basilar artery stroke
quadriparesis with intact vertical eye movement
PICA stroke
Wallenberg / lateral medullary syndrome -->
lateral spinothalamic --> contralateral pain/temperature loss
trigeminal nucleus --> ipsilateral facial sensory loss
vesticular nucleus --> vertigo, nystagmus, nausea
ambigus nucleus --> dysarthria, dysphagia, gag reflex
inferior cerebellar peduncle --> ataxia
descending sympathetics --> Horner syndrome
Wallenberg syndrome
results from posterior cerebellar artery occlusion
lateral spinothalamic --> contralateral pain/temperature loss
trigeminal nucleus --> ipsilateral facial sensory loss
vesticular nucleus --> vertigo, nystagmus, nausea
ambigus nucleus --> dysarthria, dysphagia, gag reflex
inferior cerebellar peduncle --> ataxia
descending sympathetics --> Horner syndrome
cerebellar artery stroke
vertigo
vomitting
nystagmus
ipsilateral limb ataxia
stroke diagnosis
initial test is noncontrast CT to diffeentiate between ischemic or hemorrhagic
CT will be normal in ischemic stroke in first 48 hours
if ischemic --> check for embolic sources with echocardiogram, carotid duplex, 24-hour Holter and check for hypercoagulability
if hemorrhagic --> do EKG for inverted T-waves
tPA use in ischemic stroke
use if onset <3 hours in ischemic stroke

contraindications -->
history of intracranial hemorrhage
stroke or head trauma within 3 months
hemorrhage within 3 weeks
surgery within 2 weeks
arterial puncture within 1 week
lumbar puncture within 1 week
BP > 185/110
anticoagulants
thrombocytopenia
PT > 15s
stroke treatment
ischemic --> tPA if onset <3h; then aspirin +- dypiridamole OR clopidogrel +- endarterectomy
hemorrhagic --> nimodipine +- craniotomy or coiling or shunt
seizures/epilepsy etiology
"VITAMINS" -->
Vascular (stroke, bleed, AVM)
Infections (meningitis, encephalitis)
Trauma
Autoimmune
Metabolic (hyponatremia, hypocalcemia, hypoglycemia, hypoxia, drug overdose)
Idiopathic
Neoplasm
pSychiatric
seizures/epilepsy general presentation
sudden onset of convulsions with or without aura
postictal symptoms --> disorientation, sleepiness, aching muscles
associated signs --> incontinence, tongue biting, headache
patients with syncope don’t have postictal symptoms or signs
partial simple seizure
focal deficits without loss of consciousness
partial complex seizure
focal deficits with loss of consciousness
partial seizure with secondary generalization
begins as partial and converts to generalized
generalized tonic-clonic seizure
tonic contractions followed by clonic relaxation of muscles
first line --> valproic
second line --> phenytoin, carbamazepine, lamotrigine
absence seizures
sudden brief loss of consiousness without loss of postural tone
treat with ethusuximide or valproic
atonic seizures
sudden loss of postural tone for 1-2 seconds
myoclonic seizures
sudden brief muscle contraction
status epilepticus
recurrent continuous seizures lasting at least 5-30min
epilepsy diagnosis
EEG is test of choice
abnormal EEG alone is not diagnostic (2-18% of population has abnormal EEG)

first rule out reversible causes of seizures checking electrolytes, glucose, toxicology, arterial blood gases and structural lesions with CT or MRI
acute management of seizures
1) secure ABCs
2) evaluate precipitating causes
3) medications in order: lorazepam/diazepam, phenytoin, phenobarbital, midazolam/propofol
maintenance treatment of epilepsy
tonic-clonic --> valproic acid is first OR lamotrigine, carbamazepine, phenytoin
partial --> carbamazepine, phenytoin first OR lamotrigine, valproic second
absence --> ethosuximide or valproic
myoclonic and atonic --> valproic
pregnant --> carbamazepine
vertigo etiology
Meniere
labyrinthitis
positional vertigo
traumatic vertigo
perilymphatic fistula
cervical vertigo
vertigo presentation
patient feels room is spinning without any real movement, nausea and vomitting
differentiate from presyncope which is described as lightheadedness and feeling of blackout
vertigo is neurologic presyncope is cardiologic
central vertigo Vs. peripheral vertigo
central --> gradual onset, absent tinnitus and hearing loss, diplopia, cortical blindness, dysarthria, weakness, vertical nystagmus

peripheral is contrary
Meniere disease
endolymphatic pressure changes
peripheral episodic vertigo 1-8 hours
common causes are syphillis and head trauma
labyrinthitis
follows respiratory tract infection
peripheral vertigo lasts for several days
benign paroxysmal positional vertigo
peripheral vertigo exacerbated by head movements lasts 10-60 seconds
central vertigo
due to cerebellar or brain tumor, bleed, bleed, drug toxicity or multiple sclerosis
vertigo treatment
peripheral --> symptomatic with meclizine or diazepam
Meniere --> low-salt diet and diuretics
benign paroxysmal --> head maneuvers
headache etiology
primary --> migraine (15% of population), cluster, tension
secondary --> hemorrhage, brain tumor, meningitis, temporal arteritis, glaucoma
meningitis headache
accompanied with fever and nuchal rigidity
intracranial hemorrhage headache
associated with nuchal rigidity, sudden onset, severe and without fever
brain tumor headache
deep, dull, aching pain disturbs sleep
posterior brain fossa tumor headache
history of vomitting weeks before, or induced by coughing, lifting or bending
temporal arteritis headache
unilateral pounding, dull headache associated with visual disturbances, jaw claudication, weight loss, arthritis, increased ESR
migraine presentation
pain described as pulsatile, throbbing, unilateral, aggravated by movement
nausea and vomitting
photophobia, phonophobia
may have aura or not
aura --> scintillating scotoma, flashes of light, motor, sensory or visual symptoms
tension headahces presentation
tight, band-like, bilateral headaches
builds slowly, may persist for days and is not exacerbated by movement
may have tightness of posterior neck muscles
cluster headache presentation
excrutiating, unilateral, pulsatile, periorbital headache that begins without warning and peaks in intensity within 5 minutes; lasts 30 minutes to 3 hours, 1-3 times/day for a 4-8 week period; associated with rhinorrhea, reddening of the eye, lacrimation and nasal stuffness
headache diagnosis
clinical history and tests to exclude secondary causes
if severe, sudden onset of first time headache --> head CT
acute management of migraines
mild --> NSAIDs
severe, first line --> triptans (contraindicated in heart disease)
severe, 2nd line --> ergotamine + caffeine
prophylaxis of migraines
first line --> propranolol, timolol, valproic acid, topiramate
second line --> verapamil, tricyclics, SSRIs
treatment of tension headaches
relaxation + acetaminophen/NSAIDs +- muscle relaxant
treatment of cluster headaches
100% O2, prednisone and lithium
may use sumatriptan, ergotamine, verapamil
pseudotumor cerebri etiology
8-10x more common in women
associated with obesity, COPD, Addison, oral contraceptives, tetracyclines, vit A toxicity
pseudotumor cerebri presentation
headache, diplopia, abducens palsy, papilledema
CT/MRI are normal
CSF is normal beyond increase in pressure
pseudotumor cerebri treatment
weight loss
removing offending agent
diuretics (acetazolamide, furosemide)
prednisone may be useful as well as repeated lumbar punctures
trigeminal neuralgia presentation
sudden, severe, sharp pain starts near mouth and progresses towards ear, eye or nostril and lasts few seconds; can be a manifestation of multiple sclerosis or posterior fossa tumors
trigeminal neuralgia treatment
carbamazepine
may also try phenytoin, baclofen or gabapentin
Guillain-Barre syndrome presentation
progressive paralysis
arreflexia
pain or tingling
autonomic instability
history of recent infection (campylobacter, herpes, CMV, EBV)
lack of constitutional symptoms
Guillain-Barre syndrome diagnosis
history + lumbar puncture looking for ↑proteins and normal cell count
(best initial test, 48 hours after onset)
electromyography is most specific
Guillain-Barre syndrome treatment
IV immunoglobulin or plasmapheresis are equally effective
glucocorticoids are not effective
early respiratory support to prevent death
myasthenia gravis presentation
assymetric muscle weakness and fatigability increases with repetition
diplopia, ptosis
dysphagia
no loss of reflexes or sensation
myasthenia gravis diagnosis
best initial test --> acetylcholine receptor antibodies
most specific test --> electromyography (decrease in contraction on repetitive stimulation)
edrophonium test is sensitive but not specific
should do x-ray or CT to exclude thymoma
Eaton-Lambert or botulism difference with myasthenia
Eaton-Lambert and botulism improve weakness with repetitive stimulation
myasthenia gets worse
myasthenia gravis treatment
symptomatic relief --> pyridostigmine, neostigmine + plasmapheresis
thymectomy indicated in postbubertal and <60 with generalized myasthenia
if thymectomy fails then steroids +- azathioprine
mycophenolate is newer immunosuppressive
avoid aminoglycosides
amyotrophic lateral sclerosis presentation
upper motor neuron and lower motor neuron signs concomitantly is unique presentation
fasciculations, tongue atrophy, renervation after denervation on biopsy
also nerve palsies (dysphagia, difficulty chewing, decreased gag reflex, etc)
respiratory involvement with intact cognitive, sensory and autonomic function
amyotrophic lateral sclerosis diagnosis
physical exam + electromyogram
CSF and MRI are normal
amyotrophic lateral sclerosis management
riluzole slows progression
multiple sclerosis presentation
young female with relapsing remitting episodes of
weakness
numbness
tingling
urinary urgency or retention
blurry/double vision
episodes resolve spontaneously
multiple sclerosis diagnosis
clinical diagnosis + MRI of brain and spine
evoked potentials are rarely used
CSF shows mild pleocytosis and mildly elevated proteins
CSF for oligoclonal IgG banding is recommended when clinical suspicion remains after unconfirmatory MRI
multiple sclerosis treatment
remitting relapsing disease --> interferon-B1a, interferon-B1b, glatiramer
secondary progressive disease --> interferon-B1b and mitoxanthrone (2nd-line)
primary progressive disease --> no effective therapy
acute exacerbations --> IV glucocorticoids
spasticity --> baclofen
trigeminal neuralgia --> carbamazepine
bladder hyperactivity --> oxybutynin
urinary retention --> bethanecol
reversible causes of dementia
hypothyroidism
B12 deficiency
hepatic encephalopathy
CNS vasculitis
syphilis
brian abscess
brain tumor
anticholinergics
apnea
trauma
subdural hematoma
normal pressure hydrocephalus
depression
irreversible causes of dementia
Alzheimer (most common)
multifocal leukoencephalopathy
Lewy bodies
frontotemporal degeneration (Pick)
vascular dementia
Creutzfeld-Jakob
dementia definition
memory loss along with impairment of other cognitive functions that interferes with social functioning
Alzheimer
memory loss + aphasia or apraxia or agnosia; inability to make plans and execute them
Pick disease
personality changes precede memory loss; patient lacks insight into condition
dementia with Lewy bodies
fluctuating cognitive impairment
Creutzfeld-Jakob
short, aggressive progression of dementia, myoclonus, ataxia and 14-3-3 protein in CSF
multi-infarct dementia
stepwise progression associated with discrete cerebrovascular events
Binswanger
slowly progressive vascular dementia that affects subcortical white matter
normal pressure hydrocephalus dementia
associated with gait abnormalities early in the course and urinary incontinence
dementia diagnosis
assesment of cognitive impairment with mini mental exam

CBC, electrolytes, calcium, creatinine, liver function tests, glucose, TSH, B12, RPR, HIV

brain imaging in cases of focal deficits, seizures, gait abnormalities
Alzheimer treatment
anticholinestrase inhibitors donepezil, rivastigmine, galantamine improve cognitive function
memantine is disease modifying used in advanced disease alone or in combo
Huntington
chorea + behavioral disturbances (irritability, anger, paranoia, depression)
diagnosed with genetic testing for CAG triplet repeat expansion
cerebral atrophy (cortex, basal ganglia) can be seen in brain imaging
Parkinson etiology
structural lesions in basal ganglia
survivors of encephalitis
neuroleptics (haloperidol, chlorpromazine)
metoclopramide
methyldopa
reserpine
Parkinson presentation
Bradykinesia
cogwheel Rigidity
postural Instability
resting Tremor
"BRITish"
Parkinson+ syndromes
parkinsonism + vertical gaze palsy --> supranuclear palsy
parkinsonism + ataxia --> olivopontocerebellar atrophy
parkinsonism + orthostatic hypotension --> Shy-Drager syndrome
diseases that mimic parkinsonism
severe depression
essential tremor
normal pressure hydrocephalus
Huntington
Parkinson diagnosis
clinical diagnosis
Parkinson treatment with intact functional status
anticholinergics --> amantadine are first-line, then the rest
Parkinson treatment with compromised functional status
initial therapy is carbidopa/levodopa
if dyskinesia, akathisia or on-off --> add pramipexole, selegiline or COMT inhibitor (tolcapone)
essential tremor
improves with alcohol; treat with propranolol