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137 Cards in this Set
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What does the presence of Todd's paresis imply?
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The seizure was partial in onset, then secondarily generalized.
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When is imaging indicated for a seizure?
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As a general rule, always get an MRI after any new-onset seizure.
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What percentage of epilepsy patients achieve control with monotherapy?
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70%
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What is the first thing that should be given in status epilepticus, even before drugs?
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100 mg IV thiamine with D5W infusion.
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What should be administered if status epilepticus does not remit with IV lorazepam?
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IV fosphenytoin
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What should be administered if status epilepticus does not remit with IV fosphenytoin?
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IV phenobarbital
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What should be administered if status epilepticus does not remit with IV phenobarbital?
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Induce coma with barbiturates, midazolam, propofol
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Three classic toxicities: phenytoin
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Gingival hyperplasia
Coasening of facial features Ataxia |
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Three classic toxicities: carbamazepine
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SIADH/hyponatremia
Agranulocytosis Diplopia |
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Rare toxicity: vigabatrin
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Irreversible optic nerve atrophy
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Which AED: arrhythmias, hypotension
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Phenytoin
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Toxicities: valproate
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Tremor
Weight gain Hair loss Hepatotoxicity Thrombocytopenia |
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Classic toxicity: lamotrigine
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Stevens-Johnson syndrome
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Seizure features favoring temporal localization
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Gustatory phenomena
Olfactory phenomena Psychic phenomena (deja vu, jamais vu, derealization, etc) |
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Dx: patient with altered consciousness/awareness and automatic behaviors
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Complex partial seizure
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Classic features of a tonic-clonic seizure
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Rigid tone --> symmetric myoclonus
Inconinence Postictal confusion/somnolence lasting minutes to hours |
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EEG finding: absence seizure
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3Hz spike-and-wave forms
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MCC of seizures in childhood
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Febrile seizure
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Dx: teen with myoclonus upon awakening
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Juvenile myoclonic epilepsy
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Optimal treatment: juvenile myoclonic epilepsy
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Valproate
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Dx: seizure syndrome classically exacerbated by sleep deprivation
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Juvenile myoclonic epilepsy
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MCC of intractable complex partial seizures in adults
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Mesial temporal sclerosis
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Features of infantile spasm
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Paroxysmal flexion movements with profoundly disorganized EEG pattern ("hypsarrhythmia")
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Features of Landau-Kleffner syndrome
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Loss of language function + abnormal EEG during sleep
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Features of Lennox-Gastaut
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Cognitive dysfunction, multiple seizures of different types, and 1-to-2 Hz generalized spike-wave forms on EEG
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Treatment of choice: myoclonic seizures
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Valproate
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Treatment of choice: infantile spasm
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Vigabatrin
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Which medications MAY alter the course of Parkinson's disease?
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MAOI-B (selegiline, rasagiline)
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List non-classical Parkinson's features
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Pain
Hypo-/anosmia Sleep disorders Orthostatic hypotension |
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Drugs that can cause essential tremor
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SSRIs
TCAs Beta agonists Lithium Amiodarone Valproate |
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What are the two primary medications used for essential tremor?
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Propranolol and primidone
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What is the primary component of Lewy bodies?
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Alpha-synuclein
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Causes of drug-induced Parkinson's disease
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Antipsychotics
Antiemetics Some Ca2+ channel blockers Amiodarone Some immunosuppressants |
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List common DA agonists used in Parkinson's
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Bromocriptine
Pramipexole Ropinirole Cabergoline |
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Patient diagnosed with Parkinson's doesn't respond to Sinemet: what is the next step?
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Reconsider original diagnosis
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What is the best pharmacologic approach to management of Parkinson's tremor?
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Anticholinergics e.g. trihexyphenidyl
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List some surgical approaches to Parkinson's management
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Pallidotomy/thalamotomy
Deep brain stimulation of GPi |
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Which category of Parkinson's patients respond best to deep brain stimulation?
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Patients that still derive benefit from L-dopa
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Classic triad: Dementia with Lewy Bodies
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1. Dementia
2. Bx abnormalities, hallucinations 3. Parkinsonism |
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Classic S/Sx: progressive supranuclear palsy
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Parkinsonism
Extraocular muscle abnormalities Prominent gait disturbances with frequent falls early on Poor response to L-dopa Marked dysphagia, dysarthria |
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Classic S/Sx: corticobasal degeneration
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Classically begins with clumsiness, stiffness, or jerking of one arm, which then spreads to the ipsilateral leg, then the contralateral limbs
Parkinsonism Alien hand syndrome |
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Classic S/Sx: multisystem atrophy
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1. Parkinsonism
2. Cerebellar ataxia 3. Dysautonomia 4. Partial response to L-dopa |
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S/Sx: ataxia-telangiectasia
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Gait ataxia in childhood, possible with parkinsonisms
Difficulty with saccades Telangiectasia of the face |
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What is the most common presentation of juvenille Huntington's?
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Parkinsonism
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What drug can help with the chorea of Huntington's?
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Tetrabenazine
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MCC of subarachnoid hemorrhage
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Berry aneurysm
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Chronic disease most strongly associated with intraparenchymal hemorrhage
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HTN
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What stroke distribution can cause alexia without agraphia?
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Dominant hemisphere PCA occlusion
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In what type of patient would you expect a venous stroke?
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Coagulopath
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What is the most significant acute neurologic risk in stroke?
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Increased ICP secondary to edema and/or hemorrhage
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Patients with cardioembolic stroke should...
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...be on warfarin.
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Patients with TIA/stroke and significant carotid stenosis should...
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...undergo endarterectomy.
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All patients with TIA/stroke who are not on warfarin should...
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...receive antiplatelet therapy.
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LDL goal for TIA/stroke patients
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<100
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What is the main contraindication to anticoagulation after cardioembolic stroke?
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Bacterial endocarditis
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All stroke patients should be admitted and be put on telemetry: why?
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Stroke can be arrhythmogenic; you may also uncover unknown afib or other arrhythmia as a cause of stroke
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Target INR after cardioembolic stroke
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2-3
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Evidence suggests that which antiplatelet regimen has the greatest absolute risk reduction for second stroke?
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ASA + dipyridamole
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During NCS, amplitude corresponds to...
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Number of fibers
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During NCS, conduction velocity corresponds to...
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...myelination.
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Most common initial site of weakness in ALS
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Arm
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____ are a common and often very significant feature in all patients with ALS
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Fasciculations
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What is the classic pattern of spread in ALS?
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UE ---> contralateral UE ---> ipsilateral LE ---> contralateral UE ---> bulbar muscles
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Which muscle groups are spared in ALS?
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Extraocular muscles, as well as bladder and bowel sphincters
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MCC of death in ALS
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Respiratory failure, aspiration pneumonia
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Patients with ALS have a high incidence of cognitive deficits consistent with what process?
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Frontotemporal dementia
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What is the only agent shown to prolong survival in ALS?
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Riluzole
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MCC of radiculopathy
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Degenerative spinal column disease (vertebral bodies, facet joints, or discs)
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Which plexus is more commonly affected in autoimmune plexopathy?
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Brachial
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What intervention has been shown to improve outcomes in Bell's palsy?
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10-day course of prednisolone
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MCC of mononeuritis multiplex outside of diabetes
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Vasculitis
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DANG THERAPIST mnemonic
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Diabetes
Alcholol Nutritional Guillain-Barre Toxic HEreditary Recurrent Amyloid Porphyria Infectious Systemic Tumors |
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____ is effective for CIDP, but not for AIDP.
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Prednisone.
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LEMS tends to involve ____, which are spared in myasthenia gravis.
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Autonomics
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Standard of care for myasthenia gravis
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Pyridostigmine + an immunosuppressant
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Common endocrine causes of myopathy
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Hyperthyroid
Hypothyroid Hyperparathyroid Cushing's |
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Common medication-induced myopathies
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Corticosteroids
Statins Colchicine Hydroxy/chloroquine |
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MCC toxic myopathy
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Alcohol
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MCC inflammatory myopathy in childhood
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Dermatomyositis
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MCC inflammatory myopathy age >50 years
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Inclusion body myositis
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Classic pattern of involvement: inclusion body myositis
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Weakness of UE flexors and knee extensors, often asymmetric; dysphagia is also very common
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Deranged cell line: dermatomyositis
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Humoral immunity
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Deranged cell line: polymyositis
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Cell-mediated immunity
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Classic histology: inclusion body myositis
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Beta amyloid and hyperphosphorylated tau protein (the same as in Alzheimer's)
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Which inflammatory myositis is associated with significantly elevated risk of malignancy?
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Dermatomyositis
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Treatment: inclusion body myositis
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No known treatment; does not respond to steroids, immunosuppressants, etc.
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Inclusion body myositis has inclusions found in what other two neurologic diseaes?
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ALS and frontotemporal dementia
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Any patient with rapid deterioration from a condition that has the potential to affect respiratory muscles should be monitored with...
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Frequent bedside FVCs and NIFs
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At what FVC is intubation indicated?
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10-12mL/kg
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What is it critical to evaluate for when assessing a patient with reported cognitive decline?
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Depression.
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Define "mild cognitive impairment."
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An acquired and persistent deficit in one or more cognitive domains that is more severe than you would expect from aging alone but not severe enough to interfere with social and occupational capacities.
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Age of onset in sporadic Alzheimer's disease correlates with...
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...the number of ApoE4 alleles a person has.
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Alzheimer's plaques: intracellular or extracellular?
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Extracellular
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Alzheimer's severity correlates better with tangle burden or plaque burden?
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Tangle burden
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What percentage of cases of dementia are due to Alzheimer's?
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60%
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Which lobes are most affected in Alzheimer's?
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Temporal and parietal
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Which forebrain nucleus is prominently affected in Alzheimer's?
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Nucleus basalis of Meynert
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Where are neurofibrillary tangles found within neurons?
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Axon hillock
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Most prominent symptom of Alzheimer's
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Memory loss
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Up to 40% of Alzheimer's patients develop...
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...parkinsonisms.
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Associated symptoms in Alzheimer's
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Psychiatric issues
Myoclonus Incontinence Seizures |
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CSF evaluation in Alzheimer's
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Low beta amyloid, high tau
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MOA: memantine
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NMDA antagonist
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Four treatments for Alzheimer's
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Memantine
Galantamine Rivastigmine Donepezil |
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Standard Alzheimer's treatment algorithm
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Start with an AChE inhibitor at time of diagnosis, then add memantine when the dementia becomes moderately severe
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Three key features distinguishing dementia with Lewy bodies from Alzheimer's
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1. Early-onset parkinsonisms
2. Early-onset hallucinations 3. Fluctuations in cognition/mental status |
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Cognitive deficits: DLB vs. Alzheimer's
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Compared to Alzheimer's, DLB patients tend to exhibit fewer memory deficits and more executive functioning deficits
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Neurochemical abnormalities in DLB
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A combination of Parkinson's and Alzheimer's: dopaminergic depletion from substantia nigra and cholinergic depletion from nucleus basalis of Meynert
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Neuropathology: corticobasal degeneration
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Accumulation of tau protein
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Composition: Pick bodies
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Tau protein
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Classic findings: frontotemporal dementias
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Disinhibited behaviors and language deficits ("semantic dementia")
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Dx: rapid cognitive deterioration with frequent myoclonus
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CJD
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Diagnosis: narcolepsy
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Two or most episodes of REM within 15 minutes + mean sleep latency of less than 8 minutes
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Most common PNS manifestation of HIV
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Distal, symmetric peripheral polyneuropathy
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Most common CNS manifestation of HIV
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AIDS dementia: progressive with pronounced apathy and social withdrawal
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Work-up: HIV+ patient with headaches or mental status abnormality
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MR head + LP
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Work-up: HIV+ patient with multifocal brain lesions
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Toxo IgG titer
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MC manifestation: Neuro-lyme
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Subacute or chronic meningitis weeks to months after innoculation, often with spontaneous remission
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Tx: neuro-lyme
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Two weeks IV ceftriaxone
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MC CNS manifestation of tuberculosis
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Basal meningitis with cranial nerve abnormalities
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CSF in CNS tuberculosis
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High opening pressure
High protein Low glucose Lymphocytic pleocytosis |
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Tx: CNS tuberculosis
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Two months of INH, rifampin, ethambutol, and pyrazinamide, then another 7 months of just INH and rifampin
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Which HSV: aseptic meningitis
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HSV-2
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Which HSV: adult encephalitis
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HSV-1
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Which HSV: neonatal encephalitis
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HSV-2
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Classic MRI: HSV encephalitis
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Temporal lobe microhemorrhage
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MCC: fatal encephalitis
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HSV
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Tx: zoster
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Famciclovir or valacyclovir
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Most common structure affected by MS
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Spinal cord (50%)
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"Lhermitte's phenomenon"
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Electric sensation passing down the back and into the limbs upon neck flexion in MS patients
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Most common symptom in MS
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Weakness in one or more limbs (40%)
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Histology: MS plaque
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Perivascular collections of macrophages and CD4+ cells with marked focal demyelination and some axonal damage
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MOA: natalizumab
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Mab against α4 integrin
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The only drug FDA approved for secondary-progressive MS
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Mitoxantrone
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Limiting toxicity: mitoxantrone
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Cardiomyopathy
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MC CNS manifestations of SLE
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Neuropsychiatric: cognitive impairment, psychosis, altered consciousness
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Classic neurologic manifestation of PAN
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Mononeuritis multiplex
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