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263 Cards in this Set

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What are the causes of unilateral anosmia
Trauma

Tumor
What are the causes of bilateral anosmia
Virus

Allergy

Smoking

Trauma
You see Argyll Robertson pupil in which disease
Tabes Dorsalis - NEUROSYPHILLIS
Lesion causing Argyll Robertson pupil involves _
Descending pupilloconstrictor fibers
Argyll Robertson pupils present as _

How do pupils react to light?
Small irregular pupils

Pupils constrict to accomodation but DO NOT react to light
Adie pupil is caused by a lesion in _
Ciliary ganglion
How does Adie pupil presents

How do pupils react to light
Unilateral or bilateral dilated pupils

Constricts poorly to light but better to accomodation, pupil redilates slowly, light-near dissociation
Afferent pupillary defect is also called _
Marcus Gunn Pupil
In Marcus Gunn pupil there is lesion in _
Optic pathway anterior to optic chiasm
Which disease would you see Marcus Gunn pupil with
Optic neuritis
Perception of relative dimming of the light stimulus compared to "good" eye resulting in bilateral enlargement of pupils - this is called _
Marcus Gunn pupil
Unequal pupils is called _
ANISOCORIA
Facial nerve supplies _
Muscles of facial expression

Taste to anterior 2/3 of the tongue

Stapedius muscle
If patient has weakness or paralysis of 1/2 of the face and you know facial nerve is involved - is it lower motor neuron or upper motor neuron damage? - what is the location of injury?
Lower motor neuron - peripheral nerve or brainstem (pons)
Patient has weakness of the lower quarter of the face, you know facial nerve is involved - what is the location of injury and is it upper or lower motor neuron damage
Upper motor neuron- lesion is above the pons - innervation of upper face is bihemispheric
When you inject cold water in patients ear, eyes deviate _ and nystagmus is _
Eyes deviate toward the injection and nystagmus is to OPPOSITE SIDE (COWS)
When you inject warm water in patients ear, eyes deviate _ and nystagmus is _
Eyes deviate away from the injection and nystagmus is to SAME SIDE (COWS)
If patient presents with hoarseness, swallowing dysfunction and deviation of uvula -which CN's involved?
IX and X
Which way is uvula deviated when there is damage to CN IX and X
Uvula deviates AWAY from side of weakness
In damage to CN XII where does tongue point
Tongue points to SIDE OF WEAKNESS
If there is symmetric change to reflexes - what are the possible diagnoses
Polyradiculopathy

Peripheral neuropathy

Myelopathy
If there is asymmetric change to reflexes what are the possible diagnoses
Radiculopathy

CNS pathology
What is the level of reflex for biceps and brachioradialis
C6
What is the level of reflex of triceps reflex
C7
What is the level of reflex of patellar reflex
L4
What is the level of the reflex of Achilles reflex
S1
Signs of cerebellar damage
Ataxia

Dysdiadochinesia

Nystagmus
Patient cannot heel walk - which muscle is weak? which nerve?
Anterior tibialis

L5
Patient cannot toe walk - which muscle is weak ? which nerve?
Gastrocnemius/Soleus

S1
Patient cannot tandem walk - which condition does he have?
Ataxia - could be damage to cerebrum, brainstem, cerebellum or spinal cord
RHOMBERG TEST - this test relies on 3 major systems interacting together. You need 2 of them to maintain your balance - name 3 systems
Vision

Posterior columns/position sense

Vestibular
If patient has positive RHOMBERG TEST - which diseases are possible
Peripheral neuropathy

Spinal cord disease

Vestibular dysfunction
Are paresthesias normal in elderly
NO
What type of hypotension occurs in elderly
Orthostatic hypotension
In hyperthermia there is _ peripheral vasodilation
INCREASED
Which stages of sleep are reduced in elderly
Stage IV and REM sleep
Which medications can increase risk of falls
Benzodiazepines

Other sedatives and antidepressants
Those fibers are poorly myelinated,primarily sensory and autonomic, symptoms of damage include burning, tingling, numbness and pain
Small fibers
Fibers are heavily myelinated, primarily motor and sensory, symptoms include weakness, vibratory and position sense loss, numbness and areflexia
Large fibers
Types of peripheral neuropathies
Peripheral symmetric polyneuropathy

Mononeuropathy

Mononeuropathy multiplex

Plexopathy

Radiculopathy
Symptoms and signs of peripheral neuropathy
Weakness

Areflexia

Cramps

Ataxias

Deformities

Numbness

Pain

Spasms

Trophic changes

Autonomic dysfunction
Decreased sensation is called _
Hypesthesia
Increased sensation is called _
Hypersthesia
Unpleasant, abnormal sensation produced by normal stimulus is called _
Dysesthesia
Perverted abnormal sensation like burning,prickling, formication (crawling)
Paresthesia
Name autonomic neuropathies
Diabetes Mellitus

Amyloid

Guillain Barre syndrome

Porphyria

Thallium poisoning
Which diseases cause mononeuropathy multiplex
Diabetes mellitus

Vasculitis - RA, polyarteritis nodosa

Trauma

Plasma cell dyscrasia

Leprosy

Sarcoidosis
Which diseases would give you palpably enlarged nerves
Inherited - Charcot Marie Tooth disease, neurofibromatosis

Leprosy

Amyloid

Acromegaly

Chronic inflammatory demyelinating polyneuropathy
Name acute idiopathic inflammatory polyneuropathy
Guillain Barre syndrome
Guilliam Barre syndrome causes _ paralysis
Ascending
What is pathology in GB syndrome
Axonal degeneration

Segmental demyelination

Lymphocytic infiltration
Patient presents with paresthesias, weakness, areflexia, facial diplegia, autonomic instability - diagnosis?
GB syndrome
Patient presents with weakness - what is your differential diagnosis
Poliomyelitis

Myelitis

Diphtheria

Tick paralysis

Heavy metal poisoning

Botulism

Toxin

Porphyria

HIV
Patient presents with GB syndrome - which workup do you do
H&P

LP

EMG

Serology

Toxicology
Treatment for GB syndrome
Supportive care

Plasmapheresis

IV IgG

DO NOT give steroids
Poor outcome predictors in patients with GB
Older age

Rapid onset

Ventilator

Severely reduced distal cMAP on EMG
Most common complication of chronic renal failure - presents as painless progressive symmetric sensorimotor peripheral polyneuropathy - patient will complain of burning, cramping, crawling, itching, creeping which is worse at night - RESTLESS LEGS
UREMIC POLYNEUROPATHY
Treatment for uremic polyneuropathy
Renal transplant

Symptomatic
Second most common cause of neuropathy
Alcoholism
Pathology of alcoholic polyneuropathy
Direct toxic effect

Nutritional defficiencies - B1, B3, B6, B12, folic acid, Zn
Alcoholic polyneuropathy is symmetric _ polyneuropathy
Sensorimotor
This disease is know to cause mononeuropathy, mononeuropathy multiplex, symmetric sensorimotor polyneuropathy, autonomic neuropathy, thoracoabdominal radiculopathy and amyotrophy
DIABETES
Mononeuropathy and mononeuropathy multiplex in diabetics are caused by _

Which CN's are affected


What other nerves are affeted?
Compression

Infarct - occlusion of vasa nervosum

CN's - III, VI, VII

Peripheral - femoral,sciatic, peroneal, radial, ulnar, median
Which type of neuropathy starts as "glove-stocking" neuropathy
Diabetic symmetric sensorimotor polyneuropathy
Diabetic pseudotabes causes loss of _
position sense
In diabetic polyneuropathy which fibers are affected first
SMALL
Treatment for dysesthetic peripheral polyneuropathy
Desipramine

Amitryptiline

Phenytoin

Carbamazepine

Lidocaine

Baclofen

Mexiletene

Capsaicin

Gabapentin
Which type of neuropathy presents with GI and GU symptoms, impotence, impaired sweating and vascular function
Autonomic neuropathy
In radiculopathy which nerve roots are most frequently affected
THORACIC
Radiculopathy in diabetics is associated with _
Poor diabetic control and weight loss
Diabetics get this - its painful and can resemble herpes zoster ?
Radiculopathy
Painful gradually progressive proximal leg weakness in diabetics with no sensory loss is called _
AMYOTROPHY
Which toxin causes sensorimotor peripheral polyneuropathy, Mees lines and GI symptoms
ARSENIC
Which toxin causes wrist drop
LEAD
Which toxin causes blindness and peripheral neuropathy
MERCURY
Which toxin causes sensory and autonomic findings and alopecia
THALLIUM
Which drug can cause neuropathy and B6 defficiency
Isoniazid - TB drug
Patient presents with vesicular eruption, pain, dysesthesias and numbness - diagnosis?
HERPES ZOSTER - shingles
Herpes Zoster reactivation - SHINGLES - usually affects _
Immunocompromised and elderly
Eruption in the external auditory meatus causing facial paralysis is called _
RAMSAY HUNT SYNDROME
Dysesthetic pain following herpes zoster infection is called _

Treatment
Postherpetic neuralgia

Treatment - difficult - amitryptiline, carbamazepine, capsaicin, gabapentin
Name infectious causes of neuropathies
Herpes zoster

Lyme disease

HIV

Diphtheria

Leprosy
Which autoimmune disease causes cranial mononeuropathies and peripheral polyneuropathies
SARCOIDOSIS
Which disease causes light chain and transthyretin accumulation, small fiber neuropathy and carpal tunnel syndrome
AMYLOIDOSIS
Another name for Charcot Marie Tooth disease
Peroneal muscular atrophy
Type I Charcot Marie Tooth disease is _ type
DEMYELINATING
Type II Charcot Marie Tooth disease is _ type
AXONAL
Stork leg deformity, foot drop, steppage gait, palpably enlarged nerves and peripheral polyneuropathy indicated _ disease
Charcot Marie Tooth disease type I
Which type of Charcot Marie Tooth disease is less severe presents with atrophy and peripheral polyneuropathy
Type II - AXONAL
This disease is caused by abnormal heme metabolism, presents as acute motor neuropathy with autonomic findings, can be precipitated by barbiturates or other drug and is associated with recurrent episodes of seizures, abdominal pain and psychiatric disorders
PORPHYRIA
This disease presents as acute onset facial paralysis, hyperacusis and impaired taste, preceded by pain behind ear - diagnosis?
BELLS PALSY
Unilateral Bells palsy - differential?
DM

Trauma

Tumor

Stroke

GB syndrome

Lyme disease

Ramsay Hunt syndrome
Bilateral Bells palsy - differential
GB syndrome

MG

Basal meningitis

Sarcoidosis

Lyme disease
Recurrent Bells palsy - differential
MS

Lyme disease

Sarcoidosis
Patient presents with Bells palsy - workup?
H&P

CBC, UA, fasting glucose, sed rate

Chest X ray, LP, MRI

EMG with NCS
Patient presents with Bells palsy - how do you treat
PROTECT EYE (eyes doesnt close, need to lubricate or patch), PT, surgery, steroids
Possible complications of Bells palsy
Aberrant regeneration

Hemifacial spasm
This disease occurs in middle age and later life, presents with paroxysms of intense, stabbing, shooting pain in V2/V3 distribution, pain is recurrent and last for several weeks at time, can be triggered by shaving, brushing teeth, mouth movements or cold stimulus, could be mistaken for sinus disease or tooth abscess
TRIGEMINAL NEURALGIA
Possible causes of trigeminal neuralgia
Tumor

Vascular

MS

Idiopathic
How would you diagnose trigeminal neuralgia
H&P

MRI
How do you treat trigeminal neuralgia
Meds - phenytoin, carbamazepine, clonazepam, baclofen, lamotrigine

Surgery - Jannetta procedure, Gasserian ganglion block
Horners syndrome is caused by _
Interruption of sympathetic innervation
Causes of Horners syndrome
Stroke

Cervical spinal disease

T1 radiculopathy - Pancoasts tumor

Neck pathology - thyroiditis

Carotid artery dissection

Cavernous sinus pathology - aneurysm

Orbital pathology
How do you diagnose Horners syndrome
H&P

Cocaine

Hydroxyamphetamine
Name two major brachial plexopathies
Klumpke palsy

Erbs palsy
This condition causes severe pain followed by weakness - commonly involves axillary, long thoracic, suprascapular nerves - UPPER TRUNK OF BRACHIAL PLEXUS, sensory symptoms involve axillary distribution - treatment - PT+ meds, prognosis - 89% improve in 3 years, 5% recur - NAME CONDITION
Idiopathic brachial plexitis - PARSONAGE-TURNER SYNDROME
Shoulder dislocation would result in damage to which nerves
AXILLARY AND MUSCULOCUTANEOUS
This condition causes paresthesias and dysesthesias in the hands particularly first three digits, pain is worse at night and patients shakes their hands to take pain away, there is atrophy of thenar eminence - DIAGNOSIS
CARPAL TUNNEL SYNDROME
Possible causes of carpal tunnel
Trauma

Amyloid

Acromegaly

Hypothyroidism

Pregnancy

Structural changes

RA

DM
How do you diagnose carpal tunnel syndrome
H&P

EMG with NCS
This condition causes numbness of medial fourth and entire fifth digits, atrophy of the hand (EXCEPT thenar eminence), entrapment sites are elbow and wrist, Tinel sign is positive, there is loss of dexterity and clawhand deformity - NAME CONDITION
ULNAR MONONEUROPATHY
Causes of ulnar mononeuropathy
TRAUMA

BONY ABNORMALITIES

DIABETES MELLITUS
Diagnosis of ulnar mononeuropathy
H&P

EMG with NCS
Patient presents with wrist drop, finger drop and numbness of posterior lateral hand - DIAGNOSIS
Radial mononeuropathy
Causes of radial mononeuropathy
Trauma

Injection

Fracture

Lead

Diabetes mellitus

Handcuff neuropathy
Foot drop occurs due to weakness of which muscle
TIBIALIS ANTERIOR
This condition causes foot drop, numbness between 1st and 2nd toes and anterolateral leg, tibialis posterior is UNAFFECTED - can be caused by DM, trauma, compression or vasculitis - DIAGNOSIS
FIBULAR MONONEUROPATHY (PERONEAL MONONEUROPATHY)
This condition presents with weakness of all muscles below knee, weak hamstrings, numbness below knee (EXCEPT saphenous nerve) and foot drop - can be caused by trauma, surgery, injection, external compression and masses - NAME CONDITION
SCIATIC MONONEUROPATHY
This condition presents with weakness of quadriceps muscles resulting in difficulty EXTENDING THE KNEE, numbness of medial leg - can be caused by DM, catheterization or hematoma - treat underlying cause, leg brace or PT - NAME CONDITION
FEMORAL MONONEUROPATHY
This condition is due to compression of LATERAL FEMORAL CUTANEOUS NERVE, presents with paresthesias or dysthesias of LATERAL THIGH - caused by obesity, weight loss, tight clothes or tight belts - provide symptomatic treatment, injections or transection of the nerve - NAME CONDITION
MERALGIA PARESTHETICA
In this condition symptoms extend beyond a single nerve or root, muscles affected are iliopsoas, adductors, quadriceps + gluteal, hamstrings and leg muscles - can be caused by tumor, abscess, trauma, obstetric, hematoma, radiation, DM or idiopathic. You can diagnose it by H&P, EMG with NCS or imaging, treat - underlying cause, AFO, rehab - NAME CONDITION
LUMBOSACRAL PLEXOPATHY
The area of skin supplied with afferent nerve fibers by single posterior spinal root
DERMATOME
A group of muscles innervated from single spinal segment
MYOTOME
Area of bone innervated by single spinal segment
SCLEROTOME
In disc herniation _ penetrates _
Nucleus pulposus penetrates annulus fibrosus
Disk herniation usually occurs in what direction
DORSOLATERAL (can be lateral or central)
Large disk herniations will involve multiple nerve roots resulting in _
Cauda equina syndrome or spinal stenosis
In this condition pain is aggravated by Valsalva maneuver, patient has radiating pain and paresthesias, POSITIVE STRAIGHT LEG RAISING TEST, patient is bent forward and lumbar curve is flattened, paraspinal muscle spasms occur - DIAGNOSIS - it most commonly involves which nerve roots
DISC HERNIATION

L5/S1
This condition can be acquired or hereditary and is caused by degenerative arthritis involving facet joints, leads to hypertrophy and osteophyte formation, involved discs become flattened and narrowed, subluxation of facet joints occurs - NAME CONDITION
SPONDYLOLYSIS
Slippage of one vertebra over another is called _
SPONDYLOLISTHESIS
Multiple root involvement, widespread arthritic changes and long standing low back pain indicate _
BONY CHANGES
Patient presents with paresthesia of medial leg and weakness of quadriceps, physical exam confirms quadriceps weakness and depressed knee jerk - DISC LEVEL + ROOT
DISC LEVEL - L 3-4

ROOT L4
Patient presents with paresthesias of anterolateral leg and dorsum of foot. Physical exam reveals weak tibialis anterior, tibialis posterior, hams, toe extensors and gluteal muscles - DISC LEVEL+ ROOT
DISC LEVEL - L4-5

ROOT L5
Patient presents with paresthesia over sole and lateral foot and weak plantar flexors. Physical exam reveals weak gastrocnemius, gluteal muscles, toe flexors and depressed ankle jerk - DISC LEVEL + ROOT
DISC LEVEL - L5-S1

ROOT S1
This condition results from central disc herniation usually involving L4-L5 level, involves multiple roots L5-S3 -causes INTERMITTENT NEUROGENIC CLAUDICATION
CAUDA EQUINA SYNDROME
This condition results from thick scarred arachnoid adhering to pia and dura, caused most commonly by contrast dye and surgery, can be caused by intrathecal agents (dye, anesthetic drugs, steroids, amphotericin B, methotrexate), infections (TB, cryptococcus, syphillis, viral), trauma (spinal surgery, vertebral injuries, disc herniations) and spinal subarachnoid hemorrhage, you diagnose it by H&P, EMG with NCS and imaging, and treat with conservative treatment (manipulation, PT, bed rest, meds - prednisone, NSAIDS, analgesics), chemonucleolysis or surgery - NAME CONDITION
ARACHNOIDITIS
In _ radiculopathy level of hernitation in SAME as root
CERVICAL
Patient presents with shoulder pain and numbness of shoulder- LEVEL
C5
Patient presents with pain and numb thumb and index finger - LEVEL
C6
Patient presents with pain and numb middle finger, pectoral and upper back pain - LEVEL
C7
Patient presents with pain and numb 4th and 5th digits and medial forearm - LEVEL
C8
Patient presents with weak biceps and brachioradialis reflexes - DISC LEVEL + ROOT
C4-C5

C5

OR

C5-C6

C6
Patient presents with weak triceps reflex- DISC LEVEL + ROOT
C6-C7

C7
Patient presents with weak triceps and finger reflexes - DISC LEVEL + ROOT
C7-C8

C8
Patient presents with weak finger reflex and Horners syndrome - DISC LEVEL + ROOT
T1-T2

T1
Patient has C5 or C6 root compression - DIFFERENTIAL DIAGNOSIS
CARPAL TUNNEL

BRACHIAL PLEXOPATHY

MONONEUROPATHY (RADIAL, MUSCULOCUTANEOUS, SUPRASCAPULAR)
Patient has C7 root compression - DIFFERENTIAL DIAGNOSIS
CARPAL TUNNEL

RADIAL MONONEUROPATHY

BRACHIAL PLEXOPATHY
Patient has C8 root compression - DIFFERENTIAL DIAGNOSIS
BRACHIAL PLEXOPATHY

ULNAR MONONEUROPATHY
This condition presents with episodic blanching (red, white and blue) of fingers precipitated by cold or emotion, idiopathic etiology, symptomatic of disease or medication, it is caused by INCREASED arterial constriction or decrease in intraluminal distending pressure, causes - arterial obstruction, CTD, trauma or medication - TREAT underlying cause, eliminate precipitating factors, sympathectomy usually ineffective - NAME CONDITION
RAYNAUDS PHENOMENON
This condition was first described by Weir Mitchell during civil war, its caused by trauma to nerve resulting in injury to SYMPATHETIC FIBERS - patient presents with persistent, SEVERE, burning dysesthetic pain associated with sudomotor, vasomotor and atrophic changes - TREAT - responds to procaine injections and regional sympathectomy - NAME CONDITION
CAUSALGIA
This condition is caused by blunt trauma to soft tissue and bone, other causes - stroke, MI, angina and DJD, believed to be secondary to autonomic dysfunction. In ACUTE STAGE I - increased temp, increased hair and nail growth, increased blood flow, rubor,edema, decreased range of motion, may last up to 3 months. In STAGE II - DYSTROPHIC - hyperesthesia, cold intolerance, decreased temp, decreased hair growth, brittle nails, pale limbs, cyanotic demineralized bone, STAGE III - ATROPHIC - decreased pain, hyperesthesia, smooth and glossy skin, muscle wasting and contractures - NAME CONDITION - how do you diagnose and treat it
REFLEX SYMPATHETIC DYSTROPHY

DX - H&P, bone scan, thermography, X rays

TREATMENT - sympathetic block (surgical or chemical), regional IV meds, psychological care, PT, TENS unit, manipulation

MEDS - NSAIDS, propranolol, nifedipine, reserpine, guanethidine, prednisone, antidepressants, antiarrythmics, anticonvulsants, phenothiazines and gabapentin
Both MS and GB are demyelinating diseases - how do you differentiate
MS - CENTRAL

GB - PERIPHERAL
This condition is cased by degeneration of ANTERIOR HORN CELLS as result of deletion of hene on chromosome 5q which is responsible for encoding protein called " survival motor neuron" - NO UMN SIGNS - NAME CONDITION - how do you diagnose and treat it
SPINAL MUSCULAR ATROPHY

DIAGNOSIS - H&P, EMG, muscle biopsy

SYMPTOMATIC TREATMENT
This type of muscular spinal atrophy becomes evident in first few weeks of life, common cause for FLOPPY BABY SYNDROME, baby shows decreased intrauterine movement, progressive symmetric weakness, weak cry, swallowing difficulty and respiratory failure - death within few years - NAME CONDITION
WERDNIG HOFFMAN DISEASE
This type of spinal muscular atrophy becomes evident in childhood and presents with generalized weakness, oropharyngeal muscles spared and longer life span
KUGELBERG- WELANDER DISEASE
This disease is caused by degeneration of CST and anterior horn cells, most commonly sporadic but 10% are familial (chromosome 20, AD), some are due to mutation is SOD 1 or alterations of VEGF - NAME DISEASE
AMYOTROPHIC LATERAL SCLEROSIS
Risk factors for ALS
Male and age
Which muscles are spared in ALS
Extraocular and urinary sphincter
How would ALS present
LMN and UMN signs, bulbar palsy

LMN signs - muscle atrophy, weakness, dysphagia, weight loss, cramps and fasciculations

UMN signs - hyperreflexia, spasticity, weakness, gait difficulty, Babinski sign

Bulbar palsy - dysphagia, aspiration, hoarseness
Differential diagnosis of ALS
Cervical spondylosis

Syringomyelia

Anti- GM1 autoantibody

Myelopathies
How do you diagnose and treat ALS, prognosis?
DIAGNOSIS - H&P, EMG, MRI of spine or brain

TREATMENT - suppoortive (vaccinations, nutrition), symptomatic (spasticity meds - diazepam, baclofen, dantrolene), RILUZOLE - new med can extend life by 10%

PROGNOSIS - die from respiratory failure or UTI within 5 years
This condition is caused by chronic progressive TUBULAR CAVITATION of spinal cord, develops after trauma, hematomyelia, cystic degeneration of glioma or ischemia, patient presents with DISSOCIATED sensory loss, shawl like pain and temp loss, atrophy and weakness of hands, paraparesis, fasciculations, hyperreflexia, Babinski sign, bowel and bladder impairment, pain in neck and shoulders, scoliosis and Charcot joints - NAME CONDITION - differential diagnosis, diagnosis and treatment
SYRINGOMYELIA

Diff diagnosis - ALS, MS, spinal cord tumor, cervical spondylosis

Diagnosis - MRI + myelogram

Treatment - surgical, radiation
Dilation of central canal is called _
Hydromyelia
Syringomyelia is associated with _ malformation
Arnold Chiari malformation
This condition is result of B12 defficiency (pernicious anemia), has CNS and PNS features and myelin loss in posterior columns - presents with sensory ataxia, paresthesias in feet, impaired vibration and position sense, UMN signs - spasticity, hyperreflexia and Babinski - NAME CONDITION - how would you diagnose and treat
SUBACUTE COMBINED DEGENERATION

DIAGNOSIS - H&P, B12 level - homocysteine and METHYLMALONIC ACID LEVELS, CBC - megaloblastic, hyperchromatic and macrocytic changes

TREATMENT - B12 shots - will arrest process but not totally reverse
This condition is a congenital anomaly - downward elongation of hindbrain into cervical column - caused by cord fixation, developmental arrest or overgrowth of neural tube - associated with spina bifida, hydrocephalus and syringomyelia - in first few years presents as hydrocephalus, in adult onset presents as ataxia, weakness, nystagmus and myelopathic features (Babinski, hyperreflexia) - NAME CONDITION, diagnosis and treatment
ARNOLD CHIARI MALFORMATION

DIAGNOSIS - H&P, MRI

TREATMENT - Surgery
This condition results from failure of closure of the bony spine, most common at lumbosacral level but can occur anywhere along spine or cranium, caused by lack of folic acid or folic acid antagonists (trimethoprim, phenytoin, carbamazepine, phenobarbital, triametrene, primidone). It can range from asymptomatic to dermatological features (overgrowth of hair, sinus, nevus flammeus, pit or lipoma) and neurological features (weakness, atrophy, gait disturbance, urinary and bowel symptoms, sensory loss and areflexia) - NAME CONDITION + DX + TREATMETN
SPINA BIFIDA

Dx - H&P, MRI, CT, Plain X rays

Treatment - prevention (vit A, folic acid), surgical
This is familial and hereditary disease which is localized to chromosome 9&11, caused by defficiency of functional frataxin, onset occurs in 1st or 2nd decade - degeneration of posterior funiculi, lateral CST's, spinocerebellar tracts, dorsal roots and CLARKES COLUMN, presents with areflexia, ataxia, loss of position sense, nystagmus, scoliosis, pes cavus and cardiomyopathy, + BABINSKI - NAME CONDITION + TREATMENT
FRIEDREICHS ATAXIA

Symptomatic treatment
This condition results from progressive degenerative disc changes with bony changes causing pressure on cord resulting in ischemia to cord, patient presents with myelopathic findings - DIAGNOSE by H&P and MRI, treat - surgery or conservative - NAME CONDITION
CERVICAL SPONDYLOLYSIS WITH MYELOPATHY
This condition presents with urinary (and/or fecal) incontinence, failure of erection and ejaculation, paralysis of pelvic floor, sensory loss, reflexes spared - NAME CONDITION AND WHAT OTHER DISEASE DOES IT USUALLY OCCUR WITH
CONUS MEDULLARIS SYNDROME

USUALLY OCCURS WITH CAUDA EQUINA SYNDROME
This condition is caused by HEMISECTION OF SPINAL CORD, presents as IPSILATERAL WEAKNESS AND VIBRATION/POSITION SENSE LOSS + CONTRALATERAL PAIN AND TEMPERATURE LOSS - can be caused by trauma, radiation or tumor - NAME CONDITION
BROWN SEQUARD SYNDROME
This condition is caused by atherosclerosis or dissecting aneurysm resulting in occlusion of artery of Adamkiewicz, there is infarct to anterior 2/3 of spinal cord - patient presents with PARALYSIS + DISSOCIATIVE CHANGES - NAME CONDITION
ANTERIOR SPINAL ARTERY SYNDROME
Occlusion of this artery results in LOSS OF VIBRATION AND POSITION SENSE
POSTERIOR SPINAL ARTERY (both occluded at same time)
This condition is abrupt, occurs after complete or incomplete spinal cord injury, presents with complete paralysis, anesthesia, areflexia and hypotonia - after 3-4 weeks UMN signs may appear - NAME CONDITION
SPINAL SHOCK
This condition results after spinal shock and presents as PERMANENT MOTOR, SENSORY AND AUTONOMIC LOSS- NAME CONDITION
CHRONIC CORD TRANSECTION
This phenomenon lasts typically 15-30 minutes, occurs before, during or after head pain begins - can be visual (scintillating scotoma), paresthesias, weakness, aphasia, vertigo, its a migraine equivalent - NAME PHENOMENON
AURA
Aura phase of migraine is associated with _
REDUCTION IN CEREBRAL BLOOD FLOW
Pain in migraine is generated by _
Sterile neurogenic inflammation
Migraine is neurovascular disorder involving activation of _ - which can result in pain that is referred unilaterally or bilaterally anywhere along trigeminocervical network, can result in pain that is refered to posterior head and neck, can cause reflex activation of cranial parasympathetic nerves leading to sinus like symptoms
Trigeminal nucleus caudalis
Most frequently reported trigger of migraine
STRESS
This type of headache is severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes - can be accompanied on the same side by conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating,miosis, ptosis or eyelid edema - patient is usually young male, pain occurs at night or often same time each day, patient paces or pounds fist or head with attack, may commit suicide -
CLUSTER HEADACHE
In order to be diagnoses with SINUS HEADACHE patient MUST have _
PURULENT NASAL DISCHARGE

PATHOLOGIC SINUS FINDINGS IN TESTS INCLUDING X RAYS, CT OR MRI
Which aspects of history should you elicit when patient presents with headache
QUALITY OF PAIN -aching, pressure, squeezung, throbbing/pounding, sharp/dull

DURATION - over or less than 4 hours

LOCATION

FREQUENCY - twice weekly or less, daily or every other day

INTENSITY - is it getting progressively worse

WARNING - is there aura or prodrome

SLEEP PATTERN

PSYCHOSOCIAL STRESSORS

N/V

MOTION SICKNESS

MEDICAL HISTORY (DM, HTN, stroke, seizure, asthma, heart disease)

AGE OF ONSET

FAMILY HISTORY (motion sickness, headaches)

SMOKING/ALCOHOL/DRUGS

TRIGGERS - sensory stimuli, menses, exercise, valsalva maneuver, chewing

ASSOCIATED SIGNS - CN palsies, Horners, tearing/lacrimation/red eye, diarrhea

MEDS - OTC, caffeine, narcotics, migraine medications

DIETARY FACTORS- fasting, food triggers (caffeine, aspartame, chocolates, MSG)

SINUS DISEASE
Which aspects of physical exam should you elicit when patient presents with headache
VITALS

EYE EXAM - pupils, fundoscopic exam

MUSCULOSKELETAL EXAM - jaw, cervical spine (nuchal rigidity, ROM)

NASAL EXAM

NECK EXAM

NEUROLOGICAL EXAM
Patient presents with headache - WORKUP
H&P

NEUROIMAGING - MRI, CT

BLOOD WORK - sed rate, antibodies (ANA, APLA)

LP

BIOPSY

ANGIOGRAM
Name some serious etiologies of headache
BRAIN TUMOR - primary or metastatic

HEMORRHAGE/INFARCTS

INFECTIONS

VASCULITIS

IDIOPATHIC TRANSCRANIAL HTN

ACUTE HYDROCEPHALUS

GLAUCOMA
Name drugs used for SYMPTOMATIC treatment of migraines
OTC ANALGESICS

COMBINATION MEDS

NSAIDS

TRIPTANS

ERGOTS

MIDRIN

OPIOIDS

NEUROLEPTICS
Name drugs used for PREVENTITIVE treatment of migraines
BETA BLOCKERS

CA CHANNEL BLOCKERS

ANTIDEPRESSANTS

ANTICONVULSANTS

METHYSERGIDE

NSAIDS

CYPROHEPTADINE
Name drugs used for symptomatic treatment of CLUSTER HEADACHES
OXYGEN

DIHYDROERGOTAMINE

SUMATRIPTAN

SPHENOPALATINE BLOCK

INTRANASAL LIDOCAINE

INTRANASAL CAPSAICIN

INDOMETHACIN

OPIOIDS
Treatment for TENSION HEADACHE
PSYCHOLOGICAL COUNSELING

MIDRIN

FIORICET, PHRENILIN

ANTIDEPRESSANTS

PT

MANIPULATION
This headache occurs daily or near daily, its refractory, occurs in primary headache sufferer, only relief for headache is irresistible and predictable use of relief medications, those are usually early morning headaches, patient experiences withdrawal symptoms when medications are withdrawn, can also have improvement of headache when medications are withdrawn, prophylactic medications are ineffective, patient can exhibit signs of med abuse - NAME TYPE OF HEADACHE, NAME TREATMENT AND PROPHYLACTC MEDS
REBOUND HEADACHE - eliminate triggers, consider drug rehab, proper diet (avoid fasting and modify diet), encourage proper sleep and use prophylactic meds

PROPHYLACTIC MEDS- beta blockers, antidepressants, NSAIDS, antiserotonin drugs, Ca channel blockers, MOA inhibitors, anticonvulsants
This type of headache presents as sustained, severe migraine which is not terminated effectively by outpatient medications, requires acute therapeutic treatments over day or longer - NAME CONDITION AND TREATMENT
INTRACTABLE MIGRAINE - STATUS MIGRAINOSUS

TREATMENT - should match intensity and severity of headache - parenteral pain therapy, rehydration, control nausea and vomitting, remove provoking factors, support services (psycohological), monitoring
This condition is potentially serious drug related complication - symptoms may vary from mild to cardiac arrest and coma, many cases go undetected, high risk groups - OCD, bipolar, eating disorders and Parkinsons, it is idiosyncratic - not predictable based on dose or duration of therapy, patient can present with neuromuscular, autonomic or neuropsychiatric symptoms - NAME CONDITION
SEROTONIN SYNDROME
Chills, fever, headache, nausea and vomitting, nuchal rigidity, Kernig and Brudzinski signs, Cushings reflex, change in consciousness, coma and increased ICP are all signs of _
MENINGITIS
Bulging fontanelle, irritability, poor feeding, vomitting, drowsiness and fever are signs and symptoms of _ in infants
MENINGITIS
Possible complications of meningitis
Seizures

Deafness

Hydrocephalus

Blindness

Syndrome of INAPPROPRIATE ANTIDIURETIC HORMONE

Mental defficiency
This condition can be sporadic or epidemic, key signs and symptoms - PETECHIAL OR HEMORRHAGIC SKIN RASH, complications include DIC, adrenal hemorrhage or circulatory collapse - NAME CONDITION
MENINGOCOCCAL MENINGITIS
This type of meningitis usually occurs in children under 5, secondary to SINUSITIS, OTITIS MEDIA, SKULL FRACTURE. In adults associated with DM, alcoholism or immune defficiency - NAME CONDITION
H. INFLUENZAE MENINGITIS
This type of meningitis usually occurs in elderly, secondary to infections of lung,ear, sinus or skull. Associated with alcoholism, asplenia or sickle cell disease - now is the most common cause of meningitis - more common in adults than children
PNEUMOCOCCAL MENINGITIS
Prognosis for meningitis
50-100% die without antibiotics

10-30% die with treatment
Treatment for meningitis
ANTIBIOTICS

SUPPORTIVE CARE

DEXAMETHASONE IN CHILDREN

PROPHYLAXIA
This type of meningitis can occur from skin spread, surgery or endocarditis - may result in abscess or thrombosis of venous sinuses
STAPHYLOCOCCAL MENINGITIS
Most common cause of meningitis in newborns
E. coli and group B strep
This infection is now infrequent may affect spinal cord, cortex or brainstem - symptoms include meningeal signs, fever, headache, paralysis (acute asymmetric flaccid), may involve respiratory, limb or bulbar muscles - death rate is 10% due to respiratory failure
POLIOMYELITIS
This disease is caused by a virus - presents with drowsiness, coma, seizure, headache, vomitting, fever. LABS show elevated WBC count, CSF exam shows increased pressure, increased lymphocytes, increased protein but normal glucose - PROGNOSIS, TREATMENT?
ENCEPHALITIS

PROGNOSIS -mental defficiency, seizure, focal deficits

TREATMENT- supportive
This disease enters brain via TRIGEMINAL GANGLION or olfactory bulbs and resides in temporal and frontal lobes - presents with fever, headache, focal seizures, focal signs - aphasia, personality changes, agitation, hallucinations or meningeal signs - WHAT WILL CSF SHOW, PROGNOSIS AND TREATMENT
HERPES ENCEPHALITIS

DIAGNOSIS - CSF - increased WBC, RBC, protein, decreased OR normal glucose, EEG, IMAGING, BRAIN BIOPSY

PROGNOSIS - 70% fatal

TREATMENT - ACYCLOVIR
This infectious disease shows typical meningeal symptoms, CSF shows high lymphocyte count and protein, normal glucose (EXCEPT mumps, herpes, lymphocytic choriomeningitis, others), bacterial cultures are negative , patients usually recover without sequelae - supportive treatment
VIRAL (ASEPTIC) MENINGITIS
This infectious disease presents with hydrophobia, Negri bodies symptoms begin up to a year after inoculation, get pain and numbness at the site of inoculation, fever, apathy, lethargy, seizure, excitability, spasmodic contractions of pharynx/larynx, fatal in 2-10 days after symptoms begin - prevention through vaccination
RABIES
This infectious disease occurs by direct extension, metastasis or trauma. Causes - Staph, Strep, anaerobes or in immunocompromised - Toxoplasma, fungal, TB. Patient presents with headache, fever, chills, nausea, vomitting, seizures and focal findings. CSF studies are nonspecific, MRI is diagnostic. Treatment with antibiotics or surgery
BRAIN ABSCESS
This infectious disease presents with skin depigmentation and anesthesia, mononeuropathies including ulnar, greater auricular, tibial, peroneal, CN 's V and VII - you diagnose it by H&P and treat with dapsone, rifampin and clofamazine
LEPROSY
Patient presents with pain, fever, neck stiffness, headache and radicular pain and myelopathy. Thoracic region is involved the most. Labs show increased sed rate, increased WBC, CSF shows aseptic meningitis picture, MRI and myelogram were ordered - results pending. Differential diagnosis include GB, transverse myelitis, GB and meningitis
EPIDURAL ABSCESS
This infection is associated with chronic disease - renal failure, DM, transplant and alcoholism
LISTERIA MONOCYTOGENES
What are the causes of bacterial meningitis
Partially treated bacterial meningitis

Trauma

CSF leaks

Mollaret meningitis

Sarcoidosis

Behcet syndrome

Tumor

Fungal
This infection causes basilar meningitis with subacute symptoms of headache, anorexia, 2 weeks to 3 months duration, moderate temperature of 100-102 F, seizure, cranial nerve findings. CSF shows very high protein, increased lymphocytes and decreased glucose
TB meningitis
This infectious disease has unknown cause and initiates generalized granulomatous process, it can affect meninges, cranial or peripheral nerves and muscles. Patient exhibits signs of basilar meningitis. Labs show INCREASED ANGIOTENSIN CONVERTING ENZYME and INCREASED SERUM CALCIUM. Analysis of CSF shows INCREASED PROTEIN, DECREASED GLUCOSE, 10-200 cells mostly lymphocytes, cultures are negative - DIAGNOSIS + TREATMENT
NEUROSARCOIDOSIS

TREATMENT- STEROIDS
This infectious disease is common in Latin America, Mexico, SW USA. Patient exhibits focal symptoms and hydrocephalus. H&P, imaging and biopsy are used to diagnose. DIAGNOSIS + TREATMENT + ORGANISM CAUSING IT
TAENIA SOLIUM (PORK TAPEWORM)

CYSTICERCOSIS

TREATMENT - ANTIBIOTICS, STEROIDS
Patient presents with mononucleosis like symptoms, MRI shows multiple masses and patient exhibits focal findings. History is positive for AIDS. WHICH TESTS TO ORDER + DIAGNOSIS + TREATMENT
ORDER SEROLOGY

TOXOPLASMOSIS

TREATMENT - ANTIBIOTICS
This infectious disease is rare, familial in 10-15%, transmissible. Patient presents with rapid dementia, extrapyramidal and pyramidal signs and STIMULUS SENSITIVE MYOCLONUS. EEG shows PERIODIC SHARP WAVES, CT scan shows atrophy. WHAT TEST SHOULD BE ORDERED, PROGNOSIS, DIAGNOSIS
CREUTZFELD JAKOB DISEASE

DEATH WITHIN 1-2 YEARS

ORDER BIOPSY
This infectious disease is associated with chronic illness and decreased immunity, diabetes mellitus, renal failure, sarcoid, leukemia, lymphoa, lupus and AIDS. Patient presents with subacute symptoms of headache, mental changes and focal findings. DIAGNOSIS + WHAT DIAGNOSTIC PROCEDURE CONFIRMS IT + PROGNOSIS + TREATMENT
CRYPTOCOCCOSIS

DIAGNOSIS BY SPINAL TAP - INDIA INK STAIN, CRYPTOCOCCAL ANTIGEN, INCREASED PROTEIN, DECREASED GLUCOSE, 10-500 LYMPHOCYTES AND FUNGAL CULTURES

PROGNOSIS - FATAL IF NOT TREATED

TREATMENT - ANTIFUNGALS
Patient presents with stiffness, restlessness, irritability, opisthotonis, risus sardonicus and seizure. He also has lockjaw
DIAGNOSIS + PROGNOSIS + TREATMENT
TETANUS

50% MORTALITY

TREATMENT- ANTISERUM, PENICILLIN, SUPPORTIVE, IMMUNIZATION
What is normal CSF pressure
50-200 mm H2O
What is normal CSF cell count
0-5 lymphocytes
What is normal glucose in CSF
1/2 to 2/3 of serum glucose
What is normal protein in CSF
15-45 mg/dl
Analysis of CSF shows normal glucose, increased lymphocytes, increased protein, negative bacterial cultures and negative Gram stain DIAGNOSIS
ASEPTIC MENINGITIS
Analysis of CSF shows decreased glucose, increased PMN's, increased protein, positive cultures and positive stains - DIAGNOSIS
BACTERIAL AND FUNGAL MENINGITIS
Analysis of CSF shows decreased glucose, increased white cells, increased protein, negative cultures, negative stains and positive cytology DIAGNOSIS
TUMOR MENINGITIS
What are the indications for spinal tap
Fever with or without meningeal signs
Unexplained delirium or dementia
Unexplained headache
Diagnostic purposes - subarachnoid hemorrhage, MS, GB, metastatic cancer
What are the contraindications for spinal tap
Coagulopathy - low platelets, anticoagulation

Focal skin infection

Increased ICP with mass lesion

Papilledema itself IS NOT a contraindication
Complications of spinal tap
Headache

Infections

Bleeding

Diplopia (CN VI)

Pain
How do you distinguish traumatic tap from subarachnoid hemorrhage
SUBARACHNOID HEMORRHAGE - CSF IS YELLOWISH/REDDISH WHEN SPUN DOWN

TRAUMATIC TAP - CSF CLEARS WHEN SPUN DOWN
Patient presents with morning headaches - DIFFERENTIAL DIAGNOSIS
HTN

SINUS

REBOUND

TUMOR
Cognitive changes, headache, seizure, vomitting, focal motor and sensory deficits and papilledema should lead you to suspect _
TUMOR
Patient presents with neurological symptoms and you suspect brain tumor - WHAT WORKUP DO YOU DO
H&P

MRI WITH GADOLINIUM

EVOKED POTENTIALS

BIOPSY

SPINAL TAP

BLOOD STUDIES
4 types of gliomas
ASTROCYTOMA

OLIGODENDROGLIOMA

MEDULLOBLASTOMA

EPENDYMOMA
60% of all primary intracranial tumors
ASTROCYTOMA
Prognosis of astrocytoma is best predicted by _
Necrosis and rate of growth
This tumor is mostly seen in children and young adults. Patient presents with CN findings, long tract signs and increased intracranial pressure. Survival is 5-47 months
BRAINSTEM GLIOMA
This neoplasm has 25% incidence in patients with neurofibromatosis, presents with visual and endocrine changes and hydrocephalus
OPTIC NERVE GLIOMA
Which glioma has the worst prognosis
GLIOBLASTOMA MULTIFORME
This tumor constitutes 5% of gliomas, usually affects young adults, located in frontal lobe, 50% of patient would show calcifications on MRI - its a well circumscribed firm tumor
OLIGODENDROGLIOMA
This tumor makes up 5-10% of gliomas and 20-40% of all posterior fossa tumors, 75% occur under age of 16. Its a primitive tumor that arises from FETAL EXTERNAL GRANULAR LAYER, arises from posterior vermis and involves 4th ventricle, it also sheds cells can get TUMOR MENINGITIS WITH THIS. Patient would present with increased intracranial pressure, ataxia, headache, focal findings and altered consciousness
MEDULLOBLASTOMA
This tumor makes up 3% of all gliomas and 10% of all intracranial neoplasms in children. Location is in 4th ventricle, spinal cord or cerebellopontine angle. Patient presents with hydrocephalus + focal findings, 5 year survival 30-40%
EPENDYMOMA
This tumor makes up 0.5% of intracranial tumors, most common in lateral ventricle, takes form of GIANT CHOROID PLEXUS, 50% of symptoms in 1st year, 75% in first decade. Treatment - resection + shunt
CHOROID PLEXUS PAPILLOMA
This tumor makes up 80-90% of cerebellopontine angle tumors and 5-10% of all intracranial tumors, associated with neurofibromatosis - SLOW GROWING TUMOR. Patient presents with hearing loss, tinnitus, unsteady gait and CN V and VII findings
ACOUSTIC NEUROMA
Patient has a tumor at cerebellopontine angle - DIFFERENTIAL DIAGNOSIS
MENINGIOMA

PAPILLOMA

EPENDYMOMA

CHOLESTEATOMA

NEUROMA
This is a round, nodular, vascular, well circumscribed tumor, causes hyperostosis of overlying skull, presents with CEREBRAL EDEMA, constitutes 15% of all intracranial tumors, seen more common in women, clinical features depend on location
MENINGIOMA
This tumor is located in the white matter near the ventricle - can involve frontal lobe, cerebellar vermis, corpus callosum and basal ganglia, spinal seeding is sometimes sees, once rare but the incidence has increased with AIDS, risk for opportunistic infections, survival only slightly better than glioblastoma multiforme
PRIMARY CNS LYMPHOMA
These tumors presents with hydrocephalus, lethargy, vomitting, papilledema and gait disturbance
PINEAL REGION TUMORS
Paralysis of upgaze, convergence/retraction nystagmus and light-near dissociation are all indicative of _
PARINAUD SYNDROME
This tumor often secretes PROLACTIN (or other hormones), symptoms are due to endocrine or mass effect, patient presents with headache, visual changes, CN III, IV or VI problems and endocrine problems
PITUITARY TUMOR
Differential diagnosis for pituitary tumor
CRANIOPHARYNGIOMA

MENINGIOMA

ANEURYSM
First line treatment for prolactinoma
BROMOCRIPTINE
This tumor arises from Rathkes pouch, 6-10% of all childhood tumors. Patient presents with visual disturbance, endocrinopathy, headaches, ICP and papilledema and CN palsies. Diagnose by H&P, MRI/CT and biopsy
CRANIOPHARYNGIOMA
This tumor is derived from PARAPHYSIS, anterior superior location in 3d ventricle - oval or round gelatinous green tumor
COLLOID CYST
This disease is due to HEMANGIOBLASTOMA OF CEREBELLUM - associated with multiple angiomas of the retina, liver and pancreatic cysts, associated with POLYCYTHEMIA
VON HIPPEL LINDAU DISEASE
Which primary cancers most often cause brain metastasis - median survival less than 9 months
LUNG

BREAST

MELANOMA

RENAL

GI
This disease condition can occur both with primary and secondary cancers - multiple levels of CNS involvement, roots, CN's, compression, headache and papilledema - diagnose with H&P, CSF examination and MRI with gadolinium, treat with radiation and intrathecal chemo
LEPTOMENINGEAL CARCINOMATOSIS
This disease presents with fluctuating weakness, ptosis and diplopia, can affect facial and pharyngeal muscles
MYASTHENIA GRAVIS
Differential diagnosis of MG
ALS

MUSCULAR DYSTROPHY

LAMBERT EATON SYNDROME

BOTULISM

ORGANOPHOSPHATE POISONING
Treatment of MG
MEDS - PYRIDOSTIGMINE, NEOSTIGMINE

IV IGG

PLASMAPHERESIS

IMMUNOSUPPRESSIVE DRUGS - STEROIDS, AZATHIOPRINE, CYCLOPHOSPHAMIDE, CYCLOSPORIN

SURGERY - THYMECTOMY
When baby doesnt have myasthenia but has symptoms due to maternal antibodies (weak cry, suck, respiratory insufficiency) its called
NEONATAL MYASTHENIA
Mechanism of action of botulinum toxin
Presynaptic inhibition of Ach release