Usmle 3 Neurology

Front 1

Initial stroke management?

Back 1

1. check if > or < 3 - 4.5 hours
2. CT scan to look for bleeding, infarcts, etc
3. if < 3 hours: fibrinolytic therapy
4. if > 3 hours: ASA and permissive HTN
5. If patient has difficulty speaking, must do swallow study before giving anything oral ==> then can give oral ASA, statin
6. NO indication for mannitol in acute setting
7. patient should receive full-dose heparin b/c 2-10% will get DVT

Front 2

what is permissive BP in ischemic stroke? In hemorrhagic stroke?

Back 2

- ischemic stroke: up to 220/120
- hemorrhagic: ~140; can use Nicardipine (CCB) given IV to control BP

Front 3

If pt undergoes TPA, next step?

Back 3

- don't give heparin, ASA, until 24-48 hours after for DVT ppx
- control BP ~180/105 with IV labetalol, nicardicpine, sodium nitroprusside

Front 4

MMSE dementia cut off?

Back 4

- less than 24 points is 82% specific for dementia

Front 5

initial presentation of dementia workup?

Back 5

- 20% have reversible cause thus academy of neurology recommends following tests: CBC, Chem7, glucose, B12, depression screen, B12, LFTs
- only test for syphilis in those that have RF, prior hx, or live in high risk area

Front 6

dementia sx due to hypoTH?

Back 6

- macrocytosis (nl=80-100), hyponatremia, bradypsyche (slowed thought process), slowed speech, delayed ankle reflex

Front 7

Medial medullary syndrome?

Back 7

- occlusion of vertebral artery or branch ==> contralateral paralysis of arm and leg, contralateral tactile, vibrating position sense, tongue deviation to injured side

- tongue deviation: each half of tongue pushes to other side, so weak left side means tongue is pushed to left

Front 8

Right Lateral midpontine syndrome?

Back 8

The loss of pain and temperature sensation on the right side of his face and left side of his body suggest injury to the spinothalamic tract on the right and the sensory division of CN 5 on the right side. The lack of a direct and consensual corneal response from stimulation of the eye on the right is also consistent with a 5th nerve sensory loss on the right. Motor weakness of the muscles of mastication, diminished jaw jerk and the pointing of the jaw to the right is consistent with injury to the motor fibers of the 5th nerve on the right; hence, both motor and sensory divisions of CN 5.

Motor examination indicated weakness and incoordination of the right arm and leg which is consistent with injury to the right cerebellar hemisphere or in this case the right middle cerebellar peduncle.

The short circumferential branches of the basilar artery at mid-pontine levels serve the middle cerebellar peduncle and in the tegmentum the motor and sensory root of the trigeminal nerve and the nearby spinothalamic tract.

Front 9

Wallenberg syndrome?

Back 9

- lesion of lateral medulla ==> ipsilateral Horner syndrome, loss of pain and temperature sensation of face, weakness of palate, pharynx, vocal cords, cerebellar ataxia,
- loss of pain and temperature on contralateral side of body

http://en.wikipedia.org/wiki/Lateral_medullary_syndrome

Front 10

Lesion of central midbrain?

Back 10

- many different syndromes are possible: Weber's, Benedikt's, Calude's, Nothragel, Parindaud
- common in all: oculomotor paresis, CN III fx abnormalities
- may happen: cerebellar ataxia, contralateral hemiplegia

Front 11

Sx of hypoCa2+

Back 11

- muscle spasms, hand contractures ==> repetitive tonic-clonic sz

Front 12

who's at risk for hypoCa2+

Back 12

- pts with renal or hepatic failure, hypothermia, shock who receives blood transfusion ==> unable to metabolize citrate to lactate ==> citrate binds to calcium
- NOTE: serum Ca2+ levels may be normal b/c deficit is of ionized calcium
- thus give ppx of 10cc of 10% calcium gluconate for 500ml of pRBC

Front 13

When to give sodium bicarb?

Back 13

- if levels are extremely low (5mEq/ml or less)

Front 14

C/I to tPA?

Back 14

- presence of internal bleeding, bleeding diathesis (plt <100,000), recent extracranial surgery or trauma in past 14d, hypodensity in > 33% of arterial territory of CT, intracranial hemorrhage on CT, intracranial surgery in last 3 mo, BP >185/110

Front 15

After acute stroke tx, what evaluation is done to determine etiology?

Back 15

- carotid duplex U/S or MRA or CTA
- ECG
- TTE or TEE

Front 16

CSF of traumatic LP?

Back 16

- RBC > 6,000
- very telling: if 1 WBC per 750-1000 RBCs
- elevated protein, elevated glucose
- WBC/RBC ratio not exceeding 0.01 has 100% NPV for meningitis
- ddx SAH by xanthochromia

Front 17

work up of suspected SAH?

Back 17

- sx: headache, neck pain, vomiting
- CT scan ==> may be neg in 5-10% pts ==> then do lumbar puncture ==> presence of xanthochromia

Front 18

features of opioid withdrawal?

Back 18

- GI sx: cramps, diarrhea, vomiting
- dilated pupils, myalgias, autonomic disturbances - HTN, tachy
- lacrimination/rhinorrhea, sweating
- piloerection, insomnia

Front 19

pt with chronic warfarin use now with trauma? How to reverse quickly?

Back 19

- fresh frozen plasma
- don't use vit K because it's too slow: liver has to use it to synthesize clotting factors

Front 20

Wenicke's triad? Tx?

Back 20

- confusion, ataxia, nystagmus
- 2/2 thiamine deficiency ==> injury of mamillary bodies
- give thiamine; giving glucose only will worsen sx

Front 21

sx that precipitates delirium?

Back 21

- nystagmus

Front 22

Korsakoff's psychosis?

Back 22

- characteristic feature: confabulation
- antegrade amnesia is more common, psychosis, skin crawling
- sequel of Wernicke's

Front 23

superior sagittal sinus thrombus?

Back 23

- associated with trauma, infx, hypercoagulation, vasculitis, nephrotic syndrome, severe hydration, pregnancy
- sx: HA, hemiparesis, papilledema, seizures
- MRI, MRV- hemorrhage in hemisphere white matter thrombus in superior sagittal sinus
- tx: HEPARIN- even if there is hemorrhage on CT b/c bleeding is secondary to venous HTN

Front 24

Lesion of dominant parietal?

Back 24

- usually left hemisphere
- Gertsmann syndrome: acalculia (can't perform simple arithmetic tasks); finger agnosia (inability to name individual fingers), agraphia (impaired writing); right/left confusion- can't distinguish left versus right

Front 25

Lesion of non-dominant parietal?

Back 25

- construction apraxia (can't copy simple drawings)
- dressing apraxia (can't dress self)
- confusion

Front 26

Lesion of dominant temporal lobe

Back 26

- homonymous upper quadrantanopia
- LANGUAGE aphasia
- wernicke's aphasia: incomprehension of spoken or written language

Front 27

Lesion of nondominant temporal lobe

Back 27

- VISUAL disorder, homonymous upper quadrantaopia
- auditory agnosia

Front 28

pt with hx of HA/migraine who now presents with acute HA different from previous?

Back 28

- CT/lumbar puncture to r/o SAH
- don't just treat as another migraine

Front 29

cardinal features of Parkinson's disease?

Back 29

- 2 of 3: tremor, bradykinesia, rigidity
- often asymmetric presentation

Front 30

ddx Parkinson's

Back 30

- look for Parkinson plus syndrome: falls early in course, dysautonomia, poor response to DA therapy

Front 31

MS CSF

Back 31

- oligoclonal bands

Front 32

tx Parkinson's?

Back 32

- start with pramipexole: DA agonist medication
- once sx worsen, use levodopa- save for later b/c of dyskinesia and other side effects
- COMT inhibitor: prolongs effect of levodopa

Front 33

Tx essential tremor?

Back 33

- benzos, primidone (anticonvulsants), propranolol

Front 34

Best way to dx MS?

Back 34

- MRI- demyelination in white matter especially periventricular and subpial white matter of cerebrum, optic nerves, brain stem, spinal cord
- CSF: elevated IgG index but nonspecific, oligoclonal bands don't confirm dx b/c high false positive

Front 35

Tx of MS?

Back 35

- acute: IV methylprednisone-- doesn't prevent future relapses
- prevention of relapse or progression: immunosuppressive drugs (cyclophosphamide, beta interferon, glatiramer acetate)
- plasmapheresis
- repeat MRI in 3 months to monitor
- advise contraception b/c teratogenic

Front 36

MS and pregnancy

Back 36

- decreases relapse during pregnancy but increase in relapse post partum

Front 37

prognostic sx in MS pts

Back 37

- good: early age of onset, female, relapsing form
- initial presentation that are good: sensory sx or CN involvement (esp optic neuritis)
- poor: cerebellum, brainstem, pyramidal sx, internuclear ophthalmoplegia, nystagmus, hemiparesis

Front 38

different gaits

Back 38

- shuffling gait: barely picking up feet = parkinson's
- senile gait: "walking on ice;" feet wide apart, knees and hips flexed, arms wide as if expecting to fall
- scissoring gait: circular leg movements, no flexion of knees = spastic paraparesis
- drunken sailor gait- zigzag course = cerebellar ataxia
- steppage gait - excessive elevation of legs, toes touch before heals = distal lower motor neuron dz

Front 39

vasovagal syncope

Back 39

- aka common faint
- 2/2 strong emotional situation
- do upright tilt table test

Front 40

ALS pathology

Back 40

- involves LMN (anterior horn cells, brainstem neurons innervating bulbar muscles), and upper or corticospinal motor neurons

Front 41

ALS sx?

Back 41

- insidious asymmetric weakness in distal limb; cramping with volitional movements that occur early in AM
- weakness: wasting, atrophy of muscles, spontaneous twitching, fasciculation of motor units
- bulbar muscles: difficulty with chewing, swallowing, fasciculations of face and tongue
- preserved: ocular motility, sensory, bowel, bladder, cog fx

Front 42

Binswanger dz?

Back 42

- vascular dementia of white matter ==> apathy, agitation, bilateral corticospinal or bulbar sx

Front 43

tx of ALS

Back 43

riluzole: glutamate inhibitor - prolong survival and delay need for tracheostomy

Front 44

cluster HA sx?

Back 44

- occurs 1-3x daily lasting 30min to 1 hour x 4-8wks
- severe retroorbital pan, lacrimation, conjunctival injection, rhinorrhea, sweating, pallor
- can present as Horner's syndrome
- ddx chronic migraines- migraines have no eye and nasal sx

Front 45

tx of cluster HA?

Back 45

- preventative: verapamil, check ECG
- if verapamil fails, try Li
- acute cluster: sumatriptan; avoid in CAD
- very severe: 100% O2

Front 46

Myasthenia Gravis?

Back 46

- 2/2 Ab to ACh receptor
- fluctuating muscle weakness that worsens throughout day
- usually have double vision 2/2 EOM weakness; also dysphagia and dysarthria
- do CT- check for thymoma

Front 47

Meralgia paresthetics?

Back 47

- very common syndrome 2/2 lateral femoral cutaneous nerve entrapment
- decrease sensation over anterolateral thigh
- 2/2 obesity and tight garmets

Front 48

Creutzfeldt Jakob disease

Back 48

- periodic sharp wave complexes observed on EEG
- 14-3-3 protein in CSF

Front 49

Alzheimer's pathology

Back 49

- decrease ACh 2/2 degeneration of basal nucleus of Meynert and deficiency of acetyltransferase

Front 50

Acetylcholinesterase inhibitors

Back 50

- tacrine, donepezil
- increase behaviors and cog domains in Alz

Front 51

Benign essential tremor genetics?

Back 51

- autosomal dominant inheritance

Front 52

Tx of TIA

Back 52

- tx RF like DM, HTN
- carotid etiology: clopidogrel or ASA but not BOTH- no extra benefit
- warfarin if cardiogenic source

Front 53

tx of carotid stenosis?

Back 53

- 70-99 stenosis: carotid endarterectomy; sometimes 50% even
- else antithrombic meds: ASA or Clopidogrel but not both

Front 54

Pick's disease

Back 54

- frontal lobe dementia
- speech abnormalities: logorrhea, echolia, aphasia, mutism
- impaired executive fx; hyperoral, irritable, disinhibtion
- gliosis, neuronal loss, Pick bodies - silver staining cytoplasmic inclusions

Front 55

Lewy Body dementia?

Back 55

- second most common dementia
- visual hallucinations, parkinsonism, falls are very common
- cytoplasmic inclusions = lewy bodies

Front 56

explain hyperbili in B12 deficiency

Back 56

- intense erythroid hyperplasia ==> erythroid precursors don't mature normally ==> die in bone marrow ==> anemia and indirect hyperbilirubinemia
- see increase LDH = hemolysis

Front 57

subarachnoid hemorrhage symptoms

Back 57

- headache, neck pain, vomiting, hx HTN and presents with HTN
- get CT head
- if CT head neg, get LP

Front 58

ascending paralysis after camping?

Back 58

- neurotoxin secreting tick
- do a skin exam
- ddx with GBS with normal CSF

Front 59

sx of GBS, etiology, tx

Back 59

- flaccid paralysis and absence of DTRs
- etiology: campy, CMV, EBV, herpes
- plasmapheresis or IVIG if severe disease (e.g. respiratory sx)
- no role for steroids

Front 60

traumatic LP

Back 60

- WBC to RBC is (1:750-1000)
- elevated protein and glucose

Front 61

Wallenberg syndrome

Back 61

- Horner, loss of pain and temp of face, weakness of palate, pharynx, vocal cords, cerebellar ataxia
- LATERAL medulla

Front 62

medial medullary syndrome

Back 62

- vertebral artery --> contralateral paralysis of arm and leg, loss of tactile, vibratory and position sense, tongue deviation to injured side

Front 63

lateral midpontine syndrome

Back 63

- impaired sensory and motor function of CNV w/ limb ataxia

Front 64

medial pontine syndrome

Back 64

- ipsilateral limb ataxia and contralateral eye deviation and paralysis of face, arm, and leg
- variable impairment of touch and position sense

Front 65

central midbrain lesion

Back 65

- many syndromes: weber's, benedikt's, claude, nothnagel, parinaud
- all share oculomotor paresis and other CNIII dysfx and cerebellar ataxia and contralateral hemiplegia

Front 66

delirium with increased MCV

Back 66

- b12

Front 67

pt with bell's palsy, next step?

Back 67

- check ears for HSV
- don't do lyme titers-- lyme doesn't cause bell's, it can cause facial palsy, but see other signs of lyme as well
- just give eye patch and artificial tears
- can give CS and acyclovir

Front 68

impaired balance, impaired upward gaze, which tumor?

Back 68

- pineal --> Parinaud's syndrome: loss of pupillary reaction, vertical gaze paralysis, loss of optokinetic nystagmus, ataxia, headache
- ddx craniopharyngioma where headache and other sx of anterior pit tumor vs pit tumor causing bitemporal hemianopsia but see hormonal dysfx

Front 69

tx of MS prevention

Back 69

- beta-interferon or glatiramer acetate
- need contraception
- relapses reduced in pregnancy but occurred in first 6months postpartum
- get MRI in 3 months to follow course

Front 70

MS good prognosis

Back 70

- early age, female, relapsing form
- initial sx: sensory, CN involvement esp optic neuritis

- bad: cerebellum, brainstem, pyramidal, internuclear ophthalmoplegia, nystagmus, hemiparesis, brainstem, cerebellum, pyramidal system

Front 71

signs of hypoTH

Back 71

- macrocytosis, hyponatremia, bradypsyche, slowed speech

Front 72

AEDs safe for kids

Back 72

- barbiturates, benzos, phenytoin, fosphenytoin

Front 73

dementia with CT showing enlarged ventricles

Back 73

- VP shunt
- look for wide based gaits, loss of urine

Front 74

meralgia paresthetica- which nerve

Back 74

- lateral femoral cutaneous nerve

Front 75

entrapment: femoral nerve, L5 and S1, obturator

Back 75

- femoral: anterior and anteromedial thigh with quadriceps muscle weakness, decreased knee jerk
- L5 and S1: back pain down lateral or posterior aspect of leg, weakness of muscle
- obturator: sensory loss over medial thigh and weakness in leg adduction

Front 76

pt with TIA

Back 76

- tx with clopidogrel > aspirin

Front 77

elevated LDH

Back 77

- marker of hemolysis

Front 78

toddler with suspected CP?

Back 78

- get head CT

Front 79

brain death findings

Back 79

- absence of cerebral and brainstem function
- comatose, absent motor response, absent pupillary light reflex, absent gag, absent rooting, absent corneal and oculovestibular reflexes, absent apnea

Front 80

medications associated with pseudotumor cerebri?

Back 80

- isotretinoin, all trans-retinoic acid, minocycline, tetracycline, cimetidine, CS, danazol, tamoxifen, levo, Li, nitrofurantoin

Front 81

Lewy body dementai vs Alzheimers?

Back 81

- lew body: dementia + 2 of 3: cognitive fluctuation ("mom has good days and bad days"), visual hallucinations, parkinsonism
- bad response to dopamine agonists!
- tx with dopa and ACh-I

Front 82

psychogenic coma

Back 82

- do ear canal cold water irrigation-- normal response: transient, conjugate, slow deviation of gaze to the side of the stimulus followed by saccadic correction to midline

Front 83

vertebrobasilar insufficiency

Back 83

- reduced blood flow to brain secondary to emboli, thrombi or dissection
- vertigo, dizziness, dysarthria, diplopia, numbness
- resolves