ABIM 2015 - Neuro Flashcards
(434 cards)
0
Q
What 2 medication types are associated with increased risk of migraine progression causing Medication Overuse Headache?
A
- Opiates (>8 days/month)
- Barbiturates (>5 days/month)
1
Q
Episodes of brief, electrical shooting pain to the forehead, cheeks, jaw/chin triggered by talking, chewing, touching, brushing teeth in Pts >40 yo 1. Dx? 2. How do you Dx? 3. Rx?
A
- Trigeminal Neuralgia
- Must r/o other causes by MRI
- Carbamazepine (1st line) or combo (at least 3 drugs or combos before considering surgery
2
Q
Unilateral throbbing headache uncommon in those >80 yo with +/- photophobia, phonophobia, nausea with visual changes (30%), unilateral numbness, tingling (face, UEs), dizziness, changes in thinking & speech?
A
Migraine headache +/- aura
3
Q
CSF >250 mm H2O, papilledema, woman of child-bearing age, obese, no obstruction/lesion on brain imaging but c/o headache, visual Sx (diplopia, enlarging blind spot), tinnitus, normal CSF or mildly decreased protein, CN VI palsy (abducens nerve-lateral rectus)1. Dx? 2. Tx?
A
- Idiopathic Intracranial Hypertension (IIH) or “Pseudotumor Cerebri)
- Preg: serial LPs; Acetazolamide (diuretic - stones, paraesthesias, drowsiness); wt-reduction; surgical shunting or “optic nerve fenestration”
4
Q
What agents are used to Rx patients with headaches caused by vasoconstriction?
A
Ca - channel blockers (verapamil); steroids (short-term, high-dose); IV-magnesium (eclampsia/pre-eclampsia)
5
Q
Global, vague headache in older patient associated with malaise and fatigue?
A
Temporal (giant cell) arteritis.
-Check ESR (>80, normal or low); CRP (>2.45)
6
Q
What study should be done when suspecting either SAH (sub-arachnoid hemorrhage), meningoencephalitis, meningeal carcinomatosis, inteacranial HTN or decreased pressure & CT was normal?
A
LP for CSF evaluation (xanthochromia, cytology, etc.)
7
Q
Headache seen in elderly (>63 yo), moderate, throbbing, unilateral/bilateral, awake from sleep, can last 15min - 3 hours, associated with REM sleep cycle. 1. Dx? 2. Rx?
A
- Hypnic headache.
2. Indomethacin (NSAID); lithium; verapamil; can also try coffee and methylsergides
8
Q
A persistent, UNILATERAL headache that lasts >3 months, occurs daily with possible lacrimation, ptosis/miosis, rhinorrhea/sinusitis. 1. Dx? 2. Rx?
A
- Hemicrania continua
2. Indomethacin (NSAID)
9
Q
- What must you do to diagnose a headache with RED FLAG symptoms with suspected aneurysm? 2. What if there is no SAH (Sub Arachnoid Hemorrhage) but an aneurysm is suspected?
A
- CT brain and an LP - if positive for SAH - emergent neurosurgery consult.
- If no SAH but positive evidence for aneurysm - CTA or MRA
10
Q
In what type of headache do neurological Sx last >1 hour?
A
Secondary headache (defined by an underlying disorder rather than by symptoms)
11
Q
What is the most common headache type seen at a PMD’s office or ER?
A
A migraine headache (primary HA) - 90%
Tension HA (5%) Cluster HA (5%)
12
Q
What is required to establish brain death?
A
A POSITIVE apnea test:
- Nasal cannula with 100% O2 while vent is disconnected.
- Measure PO2, PCO2, pH after 10 minutes of observation (ABG).
- If PCO2 >60 mmHg OR >20 mmHg over baseline normal PCO2 (35-45 mmHg), the test is positive.
13
Q
Would you use Aspirin AND Clopidrogrel vs. Aspirin OR Clopidrogrel for secondary prevention of stroke?
A
Use EITHER Aspirin OR Clopidrogrel as the use of both together shows no added benefit and does show an increased risk of bleeding.
14
Q
What is the best neuroimaging modality for a secondary HA caused by suspected skull fracture, subarachnoid/intracerebral hemorrhage or paranasal sinus disease?
A
CT Head
15
Q
Neuroimaging modality sensitive for intracranial pathology
A
MRI brain
16
Q
What’s the next step for a pt suspected of having SAH with normal CT; suspecting meningoencephalitis; meningeal carcinomatosis; disorders of cranial hypertension or hypotension?
A
LP for CSF
17
Q
What is a KEY physical examination component in pts with headache?
A
CN assessment
18
Q
In a case of cervical trauma, a pt presents with Horner syndrome, what should you suspect if you’re not suspecting a hilar lung mass?
A
Dissection of internal carotid or vertebral artery.
19
Q
Fertile, overweight female with symptoms of headache, visual changes (diplopia, blurring, CN IV palsy), tinnitus.
A
Idiopathic Intracranial Hypertension (IIH) also known as Pseudotumor Cerebri or Benign Inteacranial Hypertension.
20
Q
What is considered NORMAL CSF opening pressure?
A
60 mmHg to 250 mmHg
21
Q
How is IIH (Idiopathic Intracranial HTN) treated?
A
•If pregnant: serial LPs, Acetazolamide •If resistant to medical treatment: -Surgical shunting -Optic Nerve fenestration
22
Q
- Pt >40 with unilateral brief episodes of shooting pain in 2nd (maxillary) and 3rd (mandibular) divisions of trigeminal nerve?
- Required test?
- Therapy?
A
- Trigeminal neuralgia.
- MRI of brain WITH contrast.
- Carbamazepine or oxcarbazepine.
23
Q
When should a pt with trigeminal neuralgia be considered for surgical decompression (rhizotomy or microvascular decompression)?
A
Only after having tried 3 (THREE) drugs or drug combinations. (Carbamazepine or oxcarbazepine with baclofen, gabapentin, clonazepam or lamotrigine).
24
What is considered first-line therapy for acute migraine?
Triptans (subcutaneous sumatriptan is the fastest and most efficacious however contraindicated in pts with vascular disorders, uncontrolled HTN and hemiplegic or basilar migraines.
25
What is a migraine headache called when it extends beyond 72 hours?
Status migranosus
26
What are the only effective meds for chronic migraine prophylaxis? (5)
1. Propranolol/Timolol (b-blockers)
2. Amitriptyline
3. Divalproex Sodium
4. Topiramate (can cause kidney stones, contraindicated in stones)
5. Botulinum toxin A
27
Which are the only oral contraceptives that women with migraines (esp. w/aura) should use?
PROGESTIN-ONLY otherwise HIGH risk of stroke!
28
What are the PREGNANCY-SAFE (Category-B) migraine meds?
Acetaminophen, metoclopramide, certain opiates and NSAIDS (but only UNTIL 32 weeks - risk of patent ductus arteriosus "PDA" after that)
29
In which HA type is caffeine ok to use and in which is it not?
Tension HA - caffeine ok.
Migraine HA - caffeine not ok
30
This HA is B/L, steady and is only mild to moderately painful. It can last from 30 min to 7 days, has no features of photophobia, phonophobia, nausea or vomiting?
Tension HA
31
What is used to Rx tension HA's!
Aspirin + Acetaminophen + Caffeine
32
How important are MRI and CT in evaluating a chronic headache in a patient?
Not important, less than (<1%) diagnostic yield.
33
What is the best and cheapest treatment of neuropathic pain?
TCA's (amitriptyline, nortriptyline) rather than pregabalin (lyrica).
34
What is the preferred NSAID for PRIMARY (symptom-defined) headache treatment?
INDOMETHACIN
35
Cerebral aneurysm is suspected, what do you do first?
CT/LP
36
CT/LP positive for SAH, what's the next step?
Consult neurosurgery for intervention (craniotomy, etc.)
37
CT/LP not diagnostic for SAH but high suspicion remains, what's the next step?
MRA or CTA
38
Red flags for SECONDARY HA but no SAH suspected, what's the study of choice?
MRI (if neg., try MRA/MRV, LP, check ESR/CRP
39
Red Flags of SECONDARY HA present but NOT typical for episodic migraine AND occur >15 days/month AND last >4 hours?
CHRONIC migraine, CHRONIC tension, hemicrania continua.
40
Red Flags of SECONDARY HA present but NOT typical for episodic migraine AND occur <15 days/month AND last >4 hours?
CHRONIC cluster, CHRONIC paroxysmal hemicrania, SUNCT syndrome, hypnic HA.
41
Red Flags of SECONDARY HA present but NOT typical for episodic migraine AND occur <15 days/month.
EPISODIC cluster, EPISODIC tension.
42
When is contrast needed on an imaging study such as CT or MRI?
When evaluating for malignant or inflammatory disease.
43
New global and vague headache in older person associated with malaise and fatigue with elevated ESR/CRP.
GCA (Giant Cell Arteritis) "temporal arteritis"
44
HA with ipsilateral Horner syndrome.
Internal Carotid Artery or Vertebral Artery dissection.
45
What is the danger with Reversible Cerebral Vasoconstriction Syndrome (RCVS) "recurrent thunderclap headaches."
Acute Infarction (54%) during episode.
46
Reversible Cerebral Vasoconstriction Syndrome (RCVS) resolves in how long?
12 WEEKS
47
How is Reversible Cerebral Vasoconstriction Syndrome (RCVS) treated in order to prevent the associated moderate risk of acute infarction?
Calcium channel blockers (verapamil or nimodipine), short-term high-dose steroids and IV magnesium (eclampsia and preeclampsia).
48
PRIMARY HA generally respond to what treatments?
Indomethacin (NSAID) and ß-blockers.
49
Fertile overweight woman with headache, papilledema, visual disturbances (blurring, diplopia) and tinnitus, no mass found on imaging and no obstruction to CSF flow?
Idiopathic Intracranial Hypertension (IIH)
50
What cranial nerve palsy is associated with IIH that causes diplopia, convergence disorder due to the inability to abduct the eye?
CN VI (abducens nerve)
51
Polycystic ovarian syndrome, pregnancy, steroid withdrawal, and hypervitaminosis A can all result in this type of headache.
Intracranial hypertension
52
What is the treatment of choice of IIH on pregnancy?
Serial Lumbar Punctures
53
What medication is routinely used for treating IIH in non-pregnant patients? Why is the pain complication with this drug?
1. Acetazolamide
| 2. Kidney stones
54
When trigeminal neuralgia is diagnosed in those >40 (90%) it is caused by? When diagnosed in younger patients?
1. Focal demyelination by vascular compression of the trigeminal root entry zone into the skull at the pons.
2. Multiple sclerosis.
55
What test must be done in a patient who presents with signs of trigeminal neuralgia?
MRI of the brain with contrast
56
A headache that is typically UNILATERAL and lasts from 4-72 hours, pulsating and aggravated by walking is what type of headache?
Migraine headache
57
What is present in up to 80% of chronic migraine headache sufferers?
Medication overuse headache (opiates and barbiturates)
58
That are the three (3) types of medications used to treat migraines?
1. NSAIDS
2. Ergotamines
3. Triptans
59
What medication class is contraindicated for migraine treatment in patients with vascular disorders, uncontrolled HTN and hemiplegic migraine subtype?
Triptans
60
What is a migraine attack called that lasts over 72 hours?
Status migranosus
61
How do you treat status migranosus?
IV NSAIDS (ketorolac) & valproic acid + dexamethasone or IV ergotamine
62
Criteria needed for migraine HA prophylaxis
1. HA more than 2 days/week
2. Impaired lifestyle
3. Prolonged aura/migraine-induced stroke
63
What are the general migraine HA prophylaxis agents?
ß-blockers, antidepressants, anticonvulsants, ca-channel blockers, NSAIDS
PROPRANOLOL, TIMOLOL, AMITRIPTYLINE, DIVALPROEX SODIUM, TOPIRAMATE (kidney stones)
64
Why must FIRST be done in pt with migraine HAs prior to starting prophylaxis?
Ensure that they have avoided use of ACUTE HA MEDICATIONS FOR MORE THAN 10 DAYS PER MONTH (analgesics, decongestants, stimulants). THIS IS CRITICAL
65
Should women with migraines use COMBINED (ESTROGEN/progesterone) oral contraceptives?
NO!!! 2-4 X risk of STROKE, especially in women with AURA
66
When can Triptans be used for migraines in PREGNANCY?
ONLY when benefit OUTWEIGHS risk (stroke)
67
Up to what week can NSAIDS be used in PREGNANCY and why?
Up to 32 WEEKS ONLY due to risk of PATENT DUCTUS ARTERIOSUS after that.
68
What are the safe meds to use in migraine HAs during pregnancy?
Magnesium, acetaminophen, metoclopramide, opiates, prednisone, [NSAIDS (ONLY UP TO 32 WEEKS!!!)]
69
In what single way is the treatment of perimenopausal migraine HAs different?
Ok to use hormone replacement therapy
70
What is different about migraine HAs with AURA than those without?
1. They develop within 1 HOUR of AURA onset
2. Develop over a MINIMUM of 5 MINUTES
3. They last a MAXIMUM of 60 MINUTES
71
BILATERAL mild to moderate pain HA like a band, squeezing on the head, with possible scalp tenderness and cervical soreness, can last from 30 MINUTES to 7 DAYS.
Tension HA
72
UNILATERAL HA, with N/V, visual changes, moderate to severe pain.
Migraine HA
73
What are the common triggers of a tension HA (HAs don't develop nocturnally)?
Stress and sleep disruption
74
When should you do a brain MRI if suspecting a tension HA?
If the CHRONIC (>15 days/month) NOT the episodic subtype.
75
How are TENSION HAs best treated?
Tylenol, NSAIDS (caffeine helps both of these)
76
Which HA types are antidepressants useful for?
MIGRAINE HAs
77
Exquisitely painful temporal or peri-orbital HA with ptosis, lacrimation, conjunctival injection, nasal congestion and rhinorrhea, can occur up to 8 times daily and last from15-180 min, can last weeks to months, is most common in men who are smokers and can be triggered by alcohol.
Cluster HA
78
This headache occurs usually within a few hours of falling asleep.
Cluster HA
79
How are cluster HAs treated acutely? (3 agents)
Inhaled oxygen, subcutaneous sumatriptan and intranasal zolmitriptan.
80
What is the only prophylactic treatment for cluster HAs?
Verapamil
81
Corticosteroids and an occipital nerve block are "transitional prophylactic" (short term use of fast-acting agents) for what HAs?
Cluster HAs
82
Cluster-like HA (episodes of piercing pain associated with conjunctival injection & tearing) however last only 15 minutes and can reoccur 8-40 times per day and responds to NSAIDS (INDOMETHACIN)
Chronic Paroxysmal Hemicrania
83
Cluster-like HA (episodes of piercing pain associated with conjunctival injection & tearing) that last only about 60 seconds and recur 1-30 times per HOUR and may respond to lamotrigine?
SUNCT (Short-lasting, Unilateral Neuralgiform headache with Conjunctival injection and Tearing)
84
What is the study of choice for ACUTE moderate to severe traumatic brain injury?
CT with bone windows (looking for skull fracture)
85
Imaging study of choice for mild traumatic brain injury but with CHRONIC symptoms (no imaging study recommended for mild - 90% of such injuries)?
MRI brain
86
What test MUST be administered to all suspected MODERATE - to - SEVERE traumatic brain injury patients?
Glasgow Coma Scale
87
What are the THREE (3) main categories in the Glasgow Coma Scale?
1. Eye-Opening Response (1-4)
2. Verbal Response (1-5)
3. Motor Response (1-6)
≤8 (severe)
9-12 (moderate)
13-15 (mild)
88
What is DECORTICATE posturing?
FLEXION in response to pain (better than decerebrate)
89
What is DECEREBRATE posturing?
EXTENSION in response to pain (worse than decorticate)
90
Head injury causing transient confusion without amnesia or loss of consciousness and resolves completely within 15 min.
Grade 1 CONCUSSION
91
Head injury causing a transient confusion without loss of consciousness but with a period of AMNESIA and AMS lasting >15 min.
Grade 2 CONCUSSION
92
Head injury associated with a BRIEF (seconds) or PROLONGED (minutes) loss of consciousness.
Grade 3 CONCUSSION
93
When do concussions require CT or MRI imaging!
When they are grade 2 or 3 concussions with persistent abnormalities in examination (cognition, vision, coordination) or symptoms lasting >1 week.
94
When can athletes with a GRADE 1 CONCUSSION return to play?
1. If ALL symptoms clear within 15 min, can return ON THE SAME DAY.
2. If they suffer a 2nd GRADE 1 CONCUSSION on the same day, then only after asymptomatic for 1 week.
95
When can athletes with a GRADE 2 CONCUSSION return to play?
1. If asymptomatic for 1 week and normal neuro exam.
| 2. If they suffer a 2nd GRADE 2 concussion and then only If asymptomatic for 2 weeks and normal neuro exam.
96
When can athletes with a GRADE 3 CONCUSSION return to play?
1. If BRIEF GRADE 3 CONCUSSION, after asymptomatic for 1 week.
2. If PROLONGED GRADE 3 CONCUSSION, after asymptomatic and normal neuroimaging after 2 weeks.
3. If SECOND occurrence, if asymptomatic and normal neuroimaging after 4 weeks.
97
When does a GRADE 3 CONCUSSION not require neuroimaging?
When BRIEF and examination findings are normal WITHOUT persistent symptoms after 1 week or abnormalities on neuro exam.
98
Pain in the head and neck with possible vertigo or imbalance, cognitive, psychological and sleep disturbances that occurs WITHIN 2 WEEKS of a head injury (closed injury or whiplash)
Postconcussion Syndrome (PCS)
99
How is Posconcussion Syndrome (PCS) treated?
SUPPORTIVE measures
100
Direct head injury causing fracture of the TEMPORAL bone and laceration of the MIDDLE MENINGEAL ARTERY with symptoms of HA, AMS, ipsilateral pupillary dilation and rapid neurological decline is caused by? Tx?
1. Epidural hematoma
| 2. Immediate surgical evacuation.
101
Because military personnel have a higher incidence of this condition than civilians, congress has mandated that all military personnel returning from combat be screened for this?
Effects of TBI (Traumatic Brain Injury) such as concussion (10% - 20% incidence) and PCS (Postconcussion Syndrome), a syndrome with HA, Neurological and Psychological symptoms.
102
What is REQUIRED to diagnose Epilepsy?
TWO (2) or more UNPROVOKED seizures
103
Generally, in children and adults over 65, fever, infection, intoxication, drug use or withdrawal, metabolic derangements, sleep deprivation or an acute neurological insult can provoke what?
Seizures
104
What MUST be done for treatment immediately following a seizure?
Stabilizing the patient (airway, vitals, offending cause)
105
In a pt with a seizure, without known seizure history and no available blood glucose level, what must be given?
THIAMINE & GLUCOSE
106
What condition can mimic a seizure?
Syncope with convulsions (Convulsive syncope) which can occur in 5% - 10% of pts with cardiogenic or vasovagal syncope.
107
Family H/O, childhood febrile convulsions, trauma with LOC, CNS infection, brain lesions, prenatal/birth injuries are all RISK factors for?
EPILEPSY
108
What is REQUIRED in ALL pts with a FIRST seizure, abnormal neurologic examination or a partial seizure (affects only one hemisphere with or without LOC)?
NEUROIMAGING
109
What MUST be done in a patient with a seizure in the setting of FEVER, HA, STIFF NECK or AMS (altered mental status)?
Lumbar Puncture
110
What MUST be done in ALL immunocompromised pts with a FIRST seizure?
Brain MRI and a LUMBAR PUNCTURE.
111
How long do epileptic seizures generally last?
1-2 min
112
An aura of lightheadedness and swearing usually indicates what event to come?
Syncope
113
Can you experience incontinence with a TIA, MIGRAINE or VERTIGO?
NO
114
Confusion and Fatigue are usually experienced after which two neurological events?
SEIZURES and MIGRAINES (not so after syncope, TIA or vertigo)
115
Can a person who has had a seizure (single ever, multiple, epilepsy) drive?
NO (variable state to state)
116
What are the three types of partial seizures?
1. Simple
2. Complex
3. Secondarily generalized
117
A focal seizure that DOES NOT IMPAIR AWARENESS?
SIMPLE PARTIAL seizure
118
A seizure that ALTERS CONSCIOUSNESS when spreads to involve one or both temporal lobes?
COMPLEX PARTIAL seizure.
119
What is a seizure called when it spreads to involve BOTH HEMISPHERES diffusely with a generalized convulsion?
SECONDARILY GENERALIZED seizure
120
What is a seizure called when it affects the SENSORY not motor CORTEX with no outward manifestations (no motor involvement)?
Epileptic Aura
121
What part of the brain do most common epileptic auras originate from?
Temporal Lobe (epigastric sensations, déjà vu, intense fear)
122
How long do complex partial seizures last!
1-2 minutes with confusion lasting 5-10 min
123
Blank stare, automatisms (lip smacking, repetitive swallowing, fumbling of the hands) occur in what type of seizures?
Complex partial seizures (alteration of consciousness but no tonic-clonic event)
124
Convulsions that begin as partial seizures, cause impaired awareness, diffuse muscle contraction (tonic) and rhythmic jerking of all limbs (clonic) followed by urinary incontinence and tongue biting and resolve within 1-2 minutes with postictal confusion lasting 10-15 min?
Secondarily generalized tonic-clonic seizure
125
These seizures involve BOTH hemispheres at onset, occur without warning. Example?
1. Primary generalized tonic-clonic seizure.
| 2. Absence seizure (<5 sec)
126
What population is generally affected by Absence seizures (a primary generalized seizure)?
Children and it typically resolves by puberty
127
What are the two types of Epilepsy and how do they present? What is seen on MRI?
1. Temporal lobe epilepsy (focal) - complex, partial seizures with epigastric and psychic auras
2. Idiopathic generalized epilepsy - EEG shows generalized spike-wave activity
3. Hippocampal atrophy
128
A type of epilepsy found in adults that is part of idiopathic generalized epilepsy and presents with "jitteriness" where pts drop things and have muscle jerks.
Juvenile Myoclonic Epilepsy
129
How long is medical therapy usually recommended for pts with juvenile Myoclonic epilepsy to prevent future convulsions?
LIFE-LONG
130
What two mood disorders are seen more commonly in pts with epilepsy?
MAJOR DEPRESSIVE DISORDER
| BIPOLAR DISORDER
131
Anti-Epilepsy Drugs can put epileptic pts at risk for what two conditions?
SUICIDALITY
| OSTEOPOROSIS
132
INITIAL study of choice for pt with new-onset seizure?
Head CT
133
What is most important in diagnosis of epilepsy besides a positive MRI and EEG?
Patient's CLINICAL HISTORY
134
What must be done in patients with epilepsy who don't respond to Anti-Epilepsy Drugs (AED) and prior to considering neurosurgery?
Inpatient Epilepsy monitoring unit admission (continuous EEG 2-7 days, off meds)
135
What are pseudoseizures? Who are they most common in?
Non-epileptic seizures, common in women with h/o child abuse.
136
In what patients SHOULD you start Anti-Seizure Drugs after ONY ONE seizure occurrence?
Pts >65 yrs old
Pts with SIGNIFICANT h/o heat TRAUMA
Pts with FOCAL SEIZURE
137
When MUST anti-seizure drugs be started regardless of EEG, MRI, age or other findings?
After SECOND UNPROVOKED seizure
138
BEFORE starting PHENYTOIN, PHENOBARBITAL, CARBAMAZEPINE, OXCARBAZEPINE or LAMOTRIGINE in these pts, what must be considered and why?
ASIANS with HLA-B*1502 allele (genetic testing)
| Because at higher risk for Stevens-Johnson syndrome
139
What is the danger with TOPIRAMATE?
Renal stones, Glaucoma, Metabolic Acidosis, Heat Stroke, Birth Defects
140
GENERALIZED Epilepsy is treated with what four agents?
Lamotrigine, Leviracetam, Valproic Acid, Topiramate
141
This anticonvulsant exacerbates Polycystic Ovary Syndrome, causes Birth Defects, Weight Gain and Hirsutism?
Valproic Acid
142
Which are the two (2) safest seizure drugs during pregnancy?
Lamotrigine, Carbamazepine
143
These five (5) seizure drugs inactivate OCPs?
Carbamazepine, Oxcarbazepine, Lamotrigine, Phenytoin, Topiramate
144
Cleft Palate is most often seen with this anti-seizure drug?
Topiramate
145
What supplement should ALL women with epilepsy take if planning pregnancy?
Folic Acid
146
When is it appropriate to attempt weaning a pt off anti-seizure drugs?
When seizure-free 2-4 years (30%-40% risk of recurrence)
147
When is epilepsy considered refractory and what can be done?
After failing to control seizures with two drugs. Referral to epilepsy center to assess candidacy for surgery
148
Can hemorrhagic stroke be differentiated from ischemic stroke on clinical exam?
NO
149
Best INITIAl test to assess for hemorrhagic stroke?
Head CT WITHOUT contrast
150
Gold standard for diagnosis of cerebral vasculature?
CT angiography (can't do in pts with renal disease)
151
A neurologic emergency with high SHORT-TERM risk of subsequent stroke?
TIA
152
When after a TIA is a pt at the HIGHEST risk for stroke?
48 hours after TIA
153
Who should be admitted after a TIA?
Pts who score a 3 or higher on ABCD2 (Age Blood pressure, Clinical presentation, Duration of symptoms and presence of Diabetes) or a score less than 3 with visual loss
154
A TIA causing transient visual loss usually indicates what?
Extracranial Internal Carotid Artery (ICA) stenosis
156
Does absence of a lesion on CT exclude the diagnosis of ischemic stroke?
NO!
157
1. The greatest risk for stroke in a pt with large artery atherosclerosis is when the stenosis (ICA) is? 2. The risk of recurrent stroke in such a patient is greatest when? 3. Above what BP?
1. >70%
2. Within the first 2 weeks.
3. >140/80 mmHg
158
Hypertension causes what type of infarcts most often?
Lacunar (pure motor hemiparesis, pure sensory stroke).
159
What is intra-cranial hemorrhage (ICH) most commonly caused by?
HTN
160
Why must REPEAT imaging be done and when, for patients with hemorrhagic stroke?
Because hemorrhage may obscure an underlying tumor, it must be repeated 4-6 weeks after event.
161
What single lab is CRITICAL to determine in an acute stroke evaluation.
Blood Glucose (excludes mimics and hyperglycemia is associated with poor outcome after stroke)
162
What is the ONLY thing that rtPA does?
Improved FUNCTIONAL outcomes at 3 months, NOT with earlier neurological improvement or lower mortality
163
What should be done with ALL patients after receiving rtPA therapy?
Admitted for observation for 24 hours in ICU setting.
164
When are surgical procedures and anticoagulation therapies ok after pt receives rtPA?
AFTER 24 hours of being monitored.
165
What therapy besides rtPA is specifically recommended for ISCHEMIC stroke involving the Middle Cerebral Artery up to 6 HOURS after event?
Intra-Arterial Thrombolysis
166
In a patient with ischemic stroke, when using rtPA, what should the BP be kept under? What if no rtPA was used?
1. rtPA used: <220/120 mm Hg
167
In order to achieve a high BP in pts with ischemic stroke and myocardial ischemia or heart failure is it ok to withhold antihypertensive agents?
NO
168
What antithrombotic agent has shown to improve short-term mortality and recurrence of stroke when used within 48 hours of ishchemic stroke onset?
ASPIRIN Alone
169
What agent can ischemic stroke patients benefit from if their stroke was caused by a-fib after cardiac surgery, mechanical heart valve or an arterial dissection?
Heparin
170
Seizure at stroke onset, ANY previous history of hemorrhagic stroke, major surgery within the last 2 weeks, arterial puncture at non-compressible site within past 7 days, recent systemic hemorrhage and coagulopathy are what?
ABSOLUTE contraindications to use of rtPA for treatment of ischemic stroke.
171
What two agent can be used to achieve the desired blood pressure for patients about to undergo rtPA therapy? (<185/110 mmHg)
IV labetalol or nicardipine ONLY (DO NOT USE nitroglycerine or nitroprusside)
172
In what type of stroke do you WANT to lower blood pressure?
Hemorrhagic stroke ONLY
173
What is the ideal blood pressure target for a patient with hemorrhagic stroke?
<160/90 mmHg
174
What is the immediate danger with hemorrhagic stroke?
Herniation (hematoma/edema)
175
What immediate steps must be taken for stabilization of a pt with ICH PRIOR to surgical decompression?
Intubation AND short-term HYPERventilation AND osmotherapy with MANITO or HYPERtonic Saline
176
What are the FOUR (4) most common risk factors for ICH (subarachnoid and otherwise)?
HYPERTENSION, tobacco, cocaine, avm's.
177
SEVERE HA with change in MS (alertness, consciousness)
SAH
178
What agent is used to prevent vasospasm (causing expansion of stroke) post hemorrhagic stroke (ICH)?
Nimodipine
179
How is further cerebral ischemia prevented post hemorrhagic stroke?
Vasopressors to elevate the Mean Arterial Pressure once no further bleeding is established.
180
HA with ocular engorgement, affecting CN III, IV, V (V1, V2) and sometimes VI?
Cavernous sinus thrombosis (venous stroke)
181
What are the risk factors for Cavernous Sinus Thrombosis?
Systemic Inflammatory Disease, Malignancy, Trauma, Dehydration/Infection, Pregnancy.
182
What are the two imaging modalities of choice for cavernous sinus thrombosis?
CT WITH contrast and MRI Venography
183
Whether in the setting of ICH or not, what are the treatments of choice for cavernous venous thrombosis?
Heparin IV followed by WARFARIN for 6 months.
184
Head/neck pain with partial HORNER's syndrome (no anhidrosis)?
Possible carotid or vertebral artery DISSECTION.
185
Best imaging modality for carotid/vertebral artery dissection?
MRI of the soft tissues of the neck
186
Treatment of carotid/vertebral artery dissection?
IV heparin followed by 3-6 months of po WARFARIN
187
When must an ASYMPTOMATIC cerebral aneurysm be intervened on?
If in ANTERIOR circulation, when >12 mm; if in POSTERIOR circulation, when >7 mm. Otherwise, WATCHFUL WAITING
188
What is the ONLY neurosurgical intervention known to REDUCE MORTALITY at 1 year extending to 10 years post stroke?
Admission to a STROKE UNIT/CENTER
189
Recurrence of strokes is greatest in patients with BP above?
>140/80 mmHg
190
What are the KEY modifiable risk factors in stroke (3)?
HTN, hyperlipidemia and tobacco use.
191
What agents are preferred in stroke patients who have intracranial atherosclerosis? Why?
1. ANTI-PLATELET agents (ASPIRIN, CLOPIDOGREL) 2. Because of mortality associated with WARFARIN in these patients.
192
Best agent to use for stroke prevention in patients with previous stroke (ischemic or ICH, however NOT ICH due to amyloid)?
Warfarin/Dabigatran
193
Best agent to use for stroke prevention in patients with previous stroke AND ATRIAL FIBRILLATION who CANNOT tolerate warfarin/dabigatran?
ASPIRIN (325 mg) or asa+clopidogrel
194
Best agent to use for stroke prevention in patients with previous stroke WIHOUT a-fib who CANNOT tolerate warfarin/dabigatran?
ASPIRIN (81 mg)
195
What is the preferred agent for subsequent stroke prevention in patients with PERIPHERAL ARTERY DISEASE?
CLOPIDOGREL (plavix)
196
What do you treat a pt with for whom aspirin and optimal risk factor management did not prevent recurrent stroke?
Clopidogrel OR ASPIRIN + DIPYRIDAMOLE
197
When is ASPIRIN + CLOPIDOGREL used together in stroke prevention?
In patients who had cardioEMBOLIC stroke (not a-fib), have vascular stents or previous h/o MI.
198
What are the two interventions of choice (equivalent) for pt's with SYMPTOMATIC ICA stenosis >70% and why?
Internal Carotid Endarterectomy or Angioplasty with Stenting, because risk of 2-year recurrent stroke with SYMPTOMATIC ICA stenosis >70% is >26%
199
What is the preferred intervention for MCA (middle cerebral artery infarction) affecting >50% of its territory?
Hemicraniectomy within 48 HOURS
200
What is the current recommendation for Patent Foramen Ovale as it is a risk for Ischemic Stroke in young people?
Aspirin OR Warfarin, NOT CLOSURE.
201
Best chance for optimal functional recovery after stroke?
INTENSIVE REHABILITATION
202
What is the STRONGEST predictor of long-term disability after stroke?
SEVERITY of INITIAL neurologic deficit.
203
What is the major risk factor for dementia?
Aging
204
What can be a precursor to dementia, presenting as a loss of cognitive ability that exceeds the age-related memory loss but does not interfere significantly with daily activities?
Mild Cognitive Impairment (MCI) - progresses to probable Alzheimer's disease at the rate of 10%-15% per year. DOES NOT interfere with occupational or social functioning.
205
What score on a Mini Mental State Examination constitutes dementia?
A score of 22 or less.
206
Besides PASSIVITY (sitting quietly while spouse speaks) what reflexes can be abnormal in dementia?
Grasp, rooting and snout reflex.
207
What are the three most common types of dementia?
Alzheimer's, Parkinson's and Vascular
208
A rapidly progressive dementia (weeks to months) is suggestive of what type of dementia?
Paraneoplastic or Crutzfeldt-Jakob disease.
209
What lab not tested for routinely in the evaluation of dementia should be tested for when the dementia is rapidly progressive, age of onset is less than 60, there is systemic cancer, infection or inflammatory, autoimmune disease, immunosuppressed states or syphilis?
CSF
210
What is the KEY pathologic agent in Alzheimer's disease?
B-amyloid protein (its pathologic cleavage
211
What chromosome is affected in Alzheimer's dementia?
Chromosome 21
212
In the setting of an acute ischemic stroke, what is the BEST medication to use?
Aspirin 160 mg
213
In the setting of acute ischemic stroke due to post-cardiac surgery a-fib, prosthetic valve or dissection, what is the BEST medication to use?
Anticoagulant such as heparin
214
What do lamotrigine, (lamotigine + valproic acid), carbamazepine, oxcarbazepine and phenytoin have in common?
They can all cause RASH, Steven Johnson's Syndrome and Toxic Epidermal Necrolysis (TEN)
215
What patients are must susceptible to the adverse effects (Steven Johnson's and TEN rashes) from using phenytoin, carbamazepine, oxcarbazepine and lamotrigine?
ASIANS
216
What do valproic acid, gapapentin and pregabalin all have in common?
Cause weight gain
217
How does topiramate affect weight?
Causes anorexia
218
What is the lifespan of a patient diagnosed with Alzheimer's disease?
5-15 years
219
Diffuse brain atrophy, widening of sulci, enlargement of ventricles?
Alzheimer's disease
220
Neurofibrillary tangles, amyloid-containing neuritic plaques and granulovacuolar degeneration of neurons?
Alzheimer's disease
221
What medications slow down the disease progression of Alzheimer's disease?
NONE
222
What are the effects of medications such as CHOLINESTERASE inhibitors DONEPEZIL, RIVASTIGMINE, TACRINE and GALANTAMINE?
Improve cognitive function
223
What adjunct meds are there for Alzheimer's disease (added to the cholinesterase inhibitors (donepezil, rivastigmine, tacrine and galantamine)?
Memantine, Vitamin E, Selegiline
224
What meds are optimal for treating depression in Alzheimer's patients?
SSRI's
225
PSychosis, paranoia, agitation and violent behavior in Alzheimer's patients are treated with what?
Tranquilizers and sedatives
226
What meds should be AVOIDED in Alzheimer's disease?
Dopamine antagonists, anticholinergic drugs
227
What is the second most common cause of dementia?
Lewy Body Dementia
228
What dementia affects >80% of patients with Parkinson's?
Lewy Body Dementia
229
Cognitive impairment with psychiatric features, hallucinations and abnormal dream enactment behavior?
Lewy Body Dementia
230
Eosinophilic Intracytplasmic Accumulations of Alpha-synuclein
Lewy Body Dementia
231
How do you treat ewy Body Dementia?
As with Alzheimer's Dementia - cholinesterase inhibitors
232
What must you be careful of when prescribing the cholinesterase inhibitor TACRINE to an Alzheimer's patient?
Monitor for HEPATIC TOXICITY
233
Although all anti-epileptic drugs (AEDs) are teratogenic, which is most and which two are least?
MOST teratogenic: valproic acid (6-17%)
| LEAST teratogenic: lamotrigine & carbamazepine
234
What drugs and in what progression are used to treat status epilepticus?
Lorazepam, Phophenytoin (phenytoin can cause necrosis), Phenobarbital, Valproate, Propofol.
235
What anti-epileptic drugs affect oral conreaceptive pills?
ALL of them
236
Which anti-epileptic drugs are safe for breastfeeding?
ALL of them
237
Dementia associated with significant behavioral deterioration such as disinhibition, impulsivity, obsession and loss of verbal fluency?
Frontotemporal Dementia (Pick's Disease)
238
Abnormal accumulation of TAU proteins in neurons or glia due to a mutation in the TAU protein on chromosome 17?
Frontotemporal Dementia (Pick's Disease)
239
What is typically seen on a head CT of a patient with Vascular Dementia?
Cerebral Ischemia (from previous stokes, etc.)
240
The TRIAD of COGNITIVE DECLINE, GAIT IMPAIRMENT and URINARY INCONTINENCE in the setting of NORMAL CSF pressure is seen in?
Normal Pressure Hydrocephallus
241
How do you treat Normal Pressure Hydrocephalus (NPH)?
Ventricular Shunt placement.
242
Movement disorders involve the "ExtraPyramidal" motor control system at the center of which is a group of nuclei: substantial nigra, putamen, caudate, globes plaids, thalamus and the sub thalamic nucleus, all of which comprise the?
Basal Ganglia
243
What is the MAJOR risk factor for Parkinson's disease and what is the defect?
Aging, loss of dopamine.
244
Brain trauma, use of well water, exposure to herbicides and pesticides as well as manganese toxicity as well as genetic inheritance (small) are associated with which movement disorder?
Parkinson's disease
245
LRRK2 gene mutation
Parkinson's disease
246
Tremor at REST, rigidity (cogwheel), bradykinesia, loss of postural reflexes, gait FREEZING?
Parkinson's disease
247
What is seen histologically in Parkinson's disease?
Lewy Bodies
248
Facial masking (expressionless) is seen in?
Parkinson's disease
249
What is the symmetry of Parkinson's disease at onset?
Typically ASYMMETRIC
250
What is the most dangerous motor impairment of Parkinson's disease?
Loss of postural reflexes (postural instability) - causing falls, fractures, etc.
251
What movement disorder can present early on with loss of olfactory function?
Parkinson's disease
252
What testing modality is indicated in diagnosing Parkinson's disease?
Brain MRI
253
Most effective drug to suppress motor effects of Parkinson's disease?
Levodopa-Carbidopa (dopamine AGONIST)
254
How long on average do levodopa (dopamine precursor) and dopamine agonists last before "wearing-off" episodes begin to occur? What is used then?
5 years, Amantadine (flu antiviral)
255
Pts with rapidly progressing Parkinson's disease WITHOUT tremor at rest, SYMMETRIC presentation and that do NOT respond to levodopa and with EARLY falling in their course indicates what?
Atypical Parkinson's or "Parkinson's-PLUS" syndrome
256
How long do Parkinson's-PLUS pts typically live?
8-12 years
257
When is the "Pull Test" for Parkinson's considered positive?
When the patient takes more than ONE step backward
258
Most adult CHRONIC ataxia syndromes are caused by? Subacute? Acute?
Chronic: cerebellar degeneration (check B12 and Vit E)
Subacute: Prion disease, paraneoplastic syndrome
Acute: substance intoxication, stroke
259
Most common INTENTION tremor, 50% familial?
Essential tremor
260
What are the symmetries of Essential & Parkinson's tremors?
Essential: bilateral; Parkinson's unilateral
261
What is used to treat Essential tremor?
Propranolol, primidone and Deep Brain Stimulator
262
Adult with TREMOR & DEMENTIA with family history of mental retardation?
Fragile X syndrome
263
Focal or generalized torsional, twisting movement disorder caused by stroke, tumor, infection, Parkinson's, drugs, anoxic insult, birth injury or Wilson's disease?
Dystonia
264
Why must ALL persons with generalized dystonia be trialed on levodopa?
Because (rarely) they may have Dopamine-Responsive Dystonia
265
How is Non Dopamine-Responsive Dystonia treated if Focal? Generalized?
Focal: Botulinum Toxin; Generalized: Baclofen or dopamine depleting drugs (reserpine)
266
What part of the brain is affected in Dystonia?
Basal Ganglia
267
Fatal progressive choreiform disorder affecting the caudate nucleus?
Huntington's Chorea
268
What type of meds are used in Huntington's Chorea?
Dopamine-Depleting drugs (reserpine)
269
What are most dopamine-blocking agents called and what can they cause?
Neuroleptics (tranquillizers); Tardive Dyskinesia
270
What is the term for single, rapid, shock-like muscle jerks (like hiccups) which can be physiologic or caused focally by tumors or stroke? How do you treat?
Myoclonus; anti-convulsants (valproic acid, clonazepam)
271
What is the best agent to use for acute dystonia?
Diphenhydramine
272
What psychiatric diseases are Tourette's syndrome associated with?
OCD and ADHD
273
What meds are used to treat Tourette's?
Alpha-agonists (Clonidine, Guanfacine); Clonazepam; Neuroleptics: Haldol, Risperidone, Olanzepine (can cause TD)
274
Whom does Tourette's syndrome affect mostly?
Males 3:1
275
What is the ONLY reversible (non-iatrogenic) movement disorder that affects the Basal Ganglia if treated early?
Wilson's Disease
276
Young adult presenting with Parkinsonism?
Wilson's Disease
277
How is Wilson's disease treated?
Copper-restricted diet, Copper chelators (penicillamine)
278
How is Wilson's disease cured?
Liver transplant
279
Life threatening disorder manifesting as hyperthermia (>38ºC/>100.4ºF), tachycardia, diaphoresis, labile blood pressure, muscle rigidity or dystonia, elevated muscle enzyme levels (rhabdo w/renal injury) and delirium caused by neuroleptics/antipsychotics?
Neuroleptic Malignant Syndrome
280
How is Neuroleptic Malignant Syndrome treated?
Discontinuation of offending drug and administration of Bromocriptine (dopamine agonist) & Dantrolene (muscle relaxant)
281
Confusion, myoclonus, shivering, diaphoresis after administration of these drugs?
Serotonin Syndrome; OD on serotonergic meds or SSRI+MAOI
282
Iron deficiency, uremia, peripheral neuropathy, DM, RA, pregnancy and fibromyalgia are associated with this dopamine-related, hereditary movement disorder?
Restless Leg Syndrome
283
What are the first-line agents used in Restless Leg Syndrome?
Bromocriptine and Pramipexole (dopamine agonists)
284
Most important test in diagnosing MS?
MRI WITH GADOLINIUM (to differentiate inflammatory MS lesions from non-MS lesions)
285
CNS demyelinating disease involving brain, spinal cord and optic nerves with focal demyelinating white matter plaques associated with inflammation?
MS
286
In MS, acute neurologic symptoms may arise from what? Chronic symptoms?
Disruption of white matter PATHWAYS; Subsequent degenerative changes in BOTH white & gray matter
287
What are the risk factors for MS?
Northern latitudes (BEFORE ADOLESCENCE), low vitamin D levels, EBV exposure in childhood, women
288
What is Neuromyelitis Optica?
"Devic disease" demyelination of optic nerve and spinal cord but unlike MS, it spares the brain, common in non-white women
289
This myelitis occurs typically in childhood, its subacute and often follows an infection
Acute Disseminated Encephalomyelitis
290
What is typically found in CSF of acute disseminated encephalomyelitis?
Significant leukocytosis
291
What is considered an MS flare or relapse?
A newly developed focal demyelinating plaque due to focal inflammation
292
Acute loss of vision and pain with eye movement showing inflammation of the optic nerve is called what and a common presenting syndrome of what?
Optic Neuritis; MS
293
How does myelitis (inflammation of the spinal cord) present in MS?
Sensory or motor symptoms BELOW involved spinal level INCLUDING bladder and bowel function abnormalities
294
How does paralysis present in MS?
Flaccid at first, progressive to spastic
295
What is L'hermitte sign in MS?
Electric shock sensations provided by head and neck movement
296
Eye movement abnormalities such as diplopia, nystagmus and vertigo are seen when MS involves what part of the CNS?
The Brainstem
297
Cortical involvement in MS causes only subtle, chronic symptoms such as?
Cognitive dysfunction and fatigue
298
What is the Uhthoff phenomenon in MS?
A TEMPORARY worsening of any MS symptom with elevation in body temperature
299
Where are the white matter lesions (plaques) seen in MS?
Periventricular and around corpus callosum
300
Elevated CSF OLIGOCLONAL BANDS not present in the serum and elevated IgG?
MS
301
What are the three possible courses of MS?
Primary Progressive, Secondary Progressive and Relapsing-Remitting
302
What is the 10-year risk of MS in a pt with a FIRST replacing demyelinating event, with brain lesions on MRI and in a pt without?
90% vs 20%
303
What is the median time for conversion from relapsing-remitting MS to secondarily progressive MS?
10-15 years
304
Progressive MS from initial symptom, 25% of pts undergo rapid progression (7-years) to requiring gait-assisting devices and 25% very slow progression (not requiring gait-assisting devices > 25 years after)
Primary Progressive MS
305
How many patients with relapsing-remitting MS convert to secondary-progressive MS? over what time period?
2/3 of pts; 10-15 years average
306
What lifestyle modifications are recommended in MS?
Active lifesyle, physical therapy, occupational therapy, calcium+vit D supplementation, immunizations, intermittent urinary catheterization +/- prophylactic antibiotics for UTIs
307
What happens in MS and pregnancy?
Significantly reduced relapse risk in 3rd trimester but significant risk of relapse un the first 3 months after delivery
308
What habit causes a 3x risk in secondary progression of MS?
Smoking
309
What can happen in MS patients who have infections, fever, etc.?
PSEUDO-relapses
310
How are acute relapses treated in MS?
IV steroids for 3-5 days followed by 10-14 day oral taper
311
What can be done for MS pts who do not respond to steroid treatment for acute relapses?
PLASMAPHARESIS
312
What are the 2 first-line DISEASE-MODIFYING agents in treating chronic MS?
Interferon and Glatiramer (equivalent agents)
313
What do the disease modifying agents do in modifying MS?
Direct the immune response AWAY from autoimmunity and protect the blood-brain barrier
314
Why is use of Natalizumab in MS limited?
Because of potential for PML by JC-virus reactivation
315
What is the only ORAL disease-modifying agent for MS?
Fingolimod
316
What is the ONLY disease modifying drug for MS that has shown benefit in Secondary-Progressive MS?
Mitoxantrone
317
What disease-modifying therapy is there for Primary-Progressive MS?
NONE
318
What are BOTOX, Baclofen, Cyclobenzaprine, Tizanidine as well as stretching exercises recommended for in MS?
Symptoms of muscle spasms and painful cramping
319
What is neuropathy pain treated with in MS pts?
TCA (amitriptyline, nortriptyline), gabapentin and pregabalin
320
Which is the ONLY pregnancy SAFE disease-modifying agent for MS?
Glatiramer
321
What two meds can be used to treat fatigue in MS patients? (One is a drug used in Narcolepsy, the other an anti-viral)
Modafinil; Amantadine
322
What is the ONLY drug available for improved mobility in MS patients which acts by increasing conductance through demyelinated axons?
Dalfampridine
323
When is oxybutynin a good choice and when is it a bad choice for bladder dysfunction in pts with MS?
Good: urinary frequency/urgency Bad: urinary retention
324
Presenting symptoms and signs of spinal cord injury usually occur where?
At or Below the level of injury
325
Where does sensation of pain occur with spinal injury?
At site of injury
326
What type of motor deficit does one notice BELOW the level of spinal injury?
Spastic, paralysis, hyperreflexia and extensor plantar responses
327
Involvement of the spinal sensory pathways results in loss of what sensation?
Vibration, pain, temperature, position sense
328
What is the best test to pinpoint the level of injury?
ASCENDING pin-prick evaluation
329
Spinal compression (fracture, neoplasm, abscess, hematoma) is a NEUROSURGICAL EMERGENCY and best diagnosed?
MRI/CT myelography (if MRI is contraindicated)
330
Neck or back pain, followed by weakness, sensory changes and bladder or bowel dysfunction?
Compressive myelopathy (spinal cord compression)
331
How should TRAUMATIC spinal cord compression be treated acutely?
High-dose steroids and spinal stabilization
332
What affords the BEST chance for future ambulation in newly-diagnosed metastatic spinal cord tumors?
EARLY DECOMPRESSIVE SURGERY
333
What are spondylosis and spinal canal stenosis?
CHRONIC compressive myelopathies (spinal cord injury)
334
What is the level of MOST spinal stenosis and disk herniations resulting in groin, thigh, leg and buttock pain, that is increased with activity and improved with rest?
LUMBAR spine
335
What is the treatment for spinal stenosis and disk herniation?
Physical therapy and surgical decompression
336
What are some disease processes that can cause inflammatory myelopathies?
MS, Sarcoidosis, Rheumatologic disease
337
A post-infectious (viral gastroenteritis or URI) syndrome resulting in inflammation of a segment of the spinal cord resulting in back pain, weakness, sensory changes and bowel/bladder dysfunction?
Idiopathic Transverse Myelitis
338
What are the two tests necessary in Idiopathic Transverse Myelitis?
MRI with contrast of the spine and CSF (leukocytosis)
339
How is Idiopathic Transverse Myelitis treated?
IV steroids (plasmapharesis/cyclophosphamide if refractory)
340
What happens if symptoms of Idiopathic Transverse Myelitis linger BEYOND 30 days or recur?
Consider MS
341
Vitamin B12 deficiency, Zinc TOXICITY and Copper deficiency can result in what neurological pathology?
Degeneration of Corticospinal Tracts (vibration, position)
342
How do you test for low vitamin B12 levels?
Low Vit B12 (cobalamin) in serum, low methylmalonic acid level, MACROcytic anemia (MCV >110)
343
Infarction of the Anterior Spinal Artery results in what?
Acute onset of B/L weakness, loss of pain/temp but not vibration/position
344
Best imaging modality to test for spinal vascular disorders?
Angiography
345
Vascular infarcts of the spinal arteries are usually caused by?
Cardiogenic, prolonged hypotension (cardiovascular/aortic surgeries)
346
Congenital genetic myelopathy with finding of VERY LONG CHAIN FATTY ACIDS in the serum?
X-linked adrenoleukodystrophy (adrenomyeloneuropathy)
347
Peripheral neuropathies can affect what types of nerves?
Motor, Sensory, Autonomic
348
What is the symmetry of peripheral neuropathies?
Symmetric with a distal-to-proximal gradient
349
What portion of the peripheral nervous system is affected when there are directly-associated symptoms of orthostatic hypotension, cardiac arrhythmias and sweating?
Autonomic nervous system
350
Most common cause of peripheral neuropathy?
DM
351
Besides conventional laboratory studies such as SPEP, CBC, ESR, fasting glucose, HbA1c, Vit B12 for peripheral neuropathy work-up, what must also be tested if the neuropathy is RAPIDLY progressing?
CSF
352
Large nerve fiber neuropathies can be evaluated additional by what test?
EMG
353
What diagnostic test is best for small-fiber neuropathies (DM)?
Sensory testing for pressure and thermal function
354
Are cramps or fasciculations found in CNS nerve injury?
NO
355
Can atrophy be seen in CNS nerve injury?
NO
356
What are pre-surgical recommendations for carpal tunnel syndrome?
Wrist splints, occupational therapy, steroid injections
357
When is surgery recommended for carpal tunnel syndrome?
When symptoms are progressive ins spite of pre-surgical treatments
358
How can you differentiate a CNS lesion (tumor) from a peripheral lesion (Bell's Palsy) when the face is involved?
CNS: affects LOWER face; Peripheral: UPPER and LOWER
359
Upper and Lower facial muscle paralysis with inability to close eyes tightly, raise eyebrows with hyperacusis, dry mouth and impaired taste?
Bell's Palsy
360
What should be done within the first 72 hours of diagnosing Bell's Palsy?
Prednisone
361
Synkinesis?
Aberrant re-innervation after Bell's Palsy (voluntary smiling causes involuntary eyelid closure)
362
Generalized polyneuropathies beginning at the feet and ascending up the limbs, affecting the hands in a stocking-glove distribution with pain can bee seen in these two common diseases?
DM, alcoholism
363
Which neuropathy becomes more prevalent in poorly-controlled long-standing DM?
Autonomic neuropathy
364
Pt with previously undiagnosed DM or even mild DM with significant weight loss followed by acute severe unilateral leg pain with numbness followed by proximal weakness and atrophy?
Diabetic AMYOTROPHY (L2 to L4 radiculopathy)
365
A hereditary neuropathy with mutation in genes encoding for myelin formation with palpable peripheral nerves, very high foot arches, hammer toes and atrophy of distal extremity muscles (stork legs)?
Charcot-Marie-Tooth (CMT) disease
366
What are the two immune-mediated peripheral neuropathies that attack the nerve roots and peripheral nerves distinguished only by symptom duration?
Gullain-Barré syndrome (GBS) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
367
Recent diarrheal infection with Campylobacter jejuni followed by lower back pain then, rapid-onset symmetric weakness of the upper and lower limbs over days to weeks with only mild sensory loss?
Guillain-Barré syndrome (GBS)
368
Why should Guillain-Barré patients be hospitalized?
Because of high-risk of respiratory failure and dysautonomia (labile blood pressure, constipation, arrhythmias)
369
What is seen in the CSF of Guillain-Barré patients?
Elevated protein count
370
What treatment has absolutely NO effect in Guillain-Barré syndrome?
Steroids
371
How is Guillain-Barré treated?
Either IV IgG or Plasma Exchange 7-14 days from symptom onset
372
How is Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) different than Guillain-Barré?
Evolves more slowly (MONTHS) with progressive but also relapsing-remitting symptoms with PAIN and responds to PREDNISONE as well as IV IgG and Plasmapharesis
373
What is the CSF of patients with Critical Illness Polyneuropathy different than that of Guillain-Barré?
It is NORMAL
374
What are the agents used in treating neuropathic pain such as in DM?
Pregabalin, gabapentin, TCA's (amitriptyline), venlafaxine, duloxetine, capsaicin
375
When is it considered a therapeutic failure for a neuropathic pain medication?
>4 weeks without efficacy
376
Dysfunction in BOTH UPPER and LOWER motoneurons in one or more areas of the body with death within 3-5 years of diagnosis?
Amyotrophic Lateral Sclerosis (ALS)
377
Spasticity, hyperreflexia, flaccid paralysis, extensor plantar responses?
UPPER motoneurons
378
Fasciculations, muscle weakness, atrophy, cramps?
LOWER motoneurons
379
What is the ONLY drug that slows down ALS progression (by 3 months)?
RILUZOLE
380
Autoimmune disease which results from an autoantibody blocking postsynaptic acetylcholine receptor OR the muscle-specific tyrosine kinase (MuSK) receptor at the neuromuscular junctions?
Myesthenia Gravis (MG)
381
Fatigable muscle weakness worsening with activity and improves with rest, especially affecting ocular and bulbar muscles?
Myesthenia Gravis (MG)
382
What is the general presenting symptom of patients with Myesthenia Gravis?
Diplopia or Ptosis (bilateral)
383
30% of patients with Myesthenia Gravis (MG) also have a diagnosis of what? 75% have what else?
Thyroid disease; Thymic hyperplasia or Thymoma (CT chest)
384
What cancers are associated with Myesthenia Gravis besides Thymoma?
Breast cancer, Small Cell Lung Cancer and Hodgkin Lymphoma
385
What is the first line therapy for MILD Myesthenia Gravis but does not work well with MG caused by autoantibodies against MuSK receptors?
Pyridostigmine
386
How do you treat SEVERE Myesthenia Gravis (MG)?
Immunosuppression with Prednisone, Mycophenolate Mofetil, Azathioprine, Cyclosporine, Rituximab
387
What is a rescue treatment for patients with refractory Myesthenia Gravis and severe limb weakness or respiratory/bulbar dysfunction?
IV IgG or Plasma Exchange/Plasmapharesis
388
A rare, usually paraneoplastic syndrome caused by autoantibodies against P/Q-type calcium channels at the PRESYNAPTIC neuromuscular junction associated with Small Cell Lung Cancer?
Lambert-Eaton Myasthenic Syndrome
389
How is Lambert-Eaton Myaesthenic Syndrome DIFFERENT than Myasthenia Gravis (MG)?
Activity and exercise IMPROVE (opposite) reflexes and strength
390
Which is the only myopathy in which onset is asymmetric?
Inclusion Body Myositis
391
Very slow progression (years) of a myositis suggests one of two types?
Congenital (dystrophy) or Inclusion Body Myositis
392
Subacute progression (months) of myositis suggests what type of myositis?
Endocrine
393
Acute progression (weeks) of myositis suggests what two types of myositis?
Inflammatory or Toxic
394
What myositis is associated with Frontal Balding, Cataracts and Mental Retardation?
Myotonic Dystrophy
395
What lab should be tested for in myopathy and when will this be normal?
CK level; normal if slowly-progressing myopathy
396
Slowly progressive myopathy with PROXIMAL muscle weakness and cushinoid-appearance?
Steroid-induced myopathy
397
What other endocrinological disorder can cause myopathy?
Thyroid disease
398
What vitamin deficiency can cause a myopathy with myalgia, bone pain, diffuse fatigue and proximal limb weakness?
Vitamin D deficiency
399
What do you look for if suspecting an inherited myopathy (Duchenne or Emery-Dreifuss)?
Family history, genetic testing, muscle biopsy
400
What is found in myotonic dystrophy that is different than other myopathies?
Myotonia (can't release handshake)
401
What type of myopathy mimics Myesthenia Gravis?
Mitochondrial myopathy
402
What types of myopathies are associated with dysmorphic facial and skeletal features with neuropathy and cardiomyopathy?
Congenital (hereditary) myopathies
403
What is the strongest risk factor for Critical Illness Myopathy (which presents exactly like but is more common than Critical Illness Neuropathy)?
IV steroids
404
What is the most common TOXIC myopathy caused by?
Statins or concomitant use of statins with Macrolides (-mycin's), Cyclosporine (anti-rejection, immunosuppressant), Itraconazole and Protease Inhibitors (HIV, Hep C)
405
Pravastatin, Rosuvastatin, Fluvastatin?
Less myopathy risk
406
Most common presentation of intracranial tumors?
Seizures
407
Most common symptom of Frontal Lobe Tumors?
Personality/Behavioral changes
408
Best study for intracranial tumor?
MRI with contrast
409
What is the most common type of brain tumor and where from?
Metastatic (breast, lung, melanoma)
410
What is the most common PRIMARY brain (CNS) tumor?
Glioblastoma Multiforme
411
What is REQUIRED for diagnosis of Glioblastoma Multiforme?
Brain Biopsy
412
Primary CNS tumor that presents without seizures, also needs biopsy for diagnosis like Glioblastoma Multiforme and can also be diagnosed by slit lamp evaluation of the eye and CSF?
Primary CNS Lymphoma (non-Hodgkin lymphoma)
413
How do you manage brain edema in patients with a brain tumor? EXCEPT!?
Steroids; Except if a Primary CNS Lymphoma is suspected
414
What is the first step in the treatment of MOST brain tumors? Except?
Maximal surgical resection; Except in Primary CNS Lymphoma
415
What are common NON-neurological complications of brain tumors?
DVTs and PEs
416
What can occur 6-12 months after radiation therapy for brain tumors and what does it present like?
Delayed Radiation Necrosis - presents like the initial brain tumor (seizures, etc.)
417
Tumor-Associated Immune-Mediated Injury?
Paraneoplastic Syndromes (immune reaction to a primary tumor)
418
ANNA, NMDA, CRMP-5, MA, PCA-1, VGCC?
Paraneoplastic antibodies found in serum and CSF
419
Unexplained, subacute progressive neurologic disorder should raise the suspicion for what?
Paraneoplastic syndrome
420
How early can a paraneoplasic syndrome present PRIOR to the neoplasm being found?
YEARS
421
Suspicion for a paraneoplastic syndrome should prompt what kind of work-up?
PET, CT-chest/abd/pelvis, antibody testing
422
How are paraneoplastic syndromes treated besides addressing the neoplasm?
IV IgG, Plasmapharesis, Steroids
423
Locked-In state is caused by a lesion where?
Brainstem (usually pons)
424
Absence of corneal reflexes indicates damage to what?
Pons (also no response to caloric manuvers) and midbrain
425
Absence of gag reflex, cough, respiration indicated damage to?
Medulla
426
Describe Apnea test for confirmation of brain death
1. Remove from vent, put on 100% NC
2. Baseline ABG with Pco2 40-60 mmHg
3. Repeat ABG at 1 & 5 minutes, watch for spontaneous respirations
4. If Pco2 increased by >20 mmHg AND no spontaneous respirations, test is POSITIVE
5. Need an additional POSITIVE test AT LEAST 6 hours after the first positive test for confirmation of BRAIN DEATH
427
What is the BEST prophylactic agent to use for a woman who experiences migraines in the perimenstrual period?
Mefenamic Acid
428
Should women with migraines use combined oral contraceptive pills?
NO - STROKE!! (x2) (migraine with aura + combined oral contraceptive pills = stroke x8)
429
Should you perform a Lumbar Puncture in a patient with papilledema?
Fuck the Fuck NO!! (herniation)
430
Factor V leiden
Hypercoagulation anomaly resulting in CLOTS
431
What should MOST patients with atrial fibrillation be treated with?
Warfarin
432
What atrial fibrillation patients can be started on ASPIRIN rather than warfarin?
Non-valvular AF,
433
What do ALL patients with stroke or TIA require emergently and why?
Non-contrast head CT to r/o intracranial hemorrhage
434
Patients with TIA have an elevated risk of what in the next 48 HOURS?
STROKE
