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Flashcards in Central and Peripheral Nervous System Deck (40):

Vertebrobasilar System TIA

Decreased perfusion of posterior fossa

Dizziness, double vision, vertigo, numbness of ipsilateral face and contralateral limbs, dysarthia, hoarseness, dysphagia, projectile vomiting, headaches, and drop attacks


Evaluation of embolic stroke

2. Carotid dopplers
3. ECG, Holter Monitors


Subclavian steal syndrome

Stenosis of subclavian artery proximal to vertebral artery-exercise of left arm causes reversal of blood supply leading ot decreased cerebral blood flow

Vertebrobasilar arterial insufficiency

BP in left arm is less than right arm, decrease pulse in left arm

Upper extremity claudication

Treatment: surgical bypass


Ischemic Stroke Diagnosis, Treatment and Prevention

Diagnosis: CT scan: initial (ischemic=hypodense, hemorrhagic=hyperdense)
ECG, CXR-acute MI or a. fib could be cause
Carotid duplex scan-degree of stenosis
MRA-is definitive test

Hyperventilation or mannitol if cerebral edema present
Acute: airway protection, O2, IV fluids
T-PA within 3 hours unless uncontrolled HTN, bleeding disorder or is anticoagulated, or history of recent trauma, or surgery-do not give aspirin for first 24 hrs,, keep BP less than 185/110
Aspirin if more than 3 hours (clopidogrel if cannot take aspirin)
Keep NPO and elevate head

Do not give antihypertensives unless:
1. Patient is >220/120 or MAP is >130
2. Patient has acute MI, aortic dissection, severe HF, Hypertensive encephalopathy
3. Receiving thrombolytic therapy

Control of : HTN, DM, smoking, hypercholesterolemia, obesity

Surgery-carotid endarterectomy
Symptomatic >50% stenosis
Asymptomatic >60% stenosis


Pinpoint pupils vs. poorly reactive pupils vs. dilated pupils for location of hemorrhagic stroke

Poorly reactive=thalamus


Treatment and diagnosis of intrancerebral hemorrhage

Diagnosis: Ct scan (hyperdense regions)

Treatment: admit to ICU
BP reduction if systolic >160 and diastolic >105 use nitroprusside
Mannitol and diuretics if increased ICP
Surgical evacuation of cerebellar hematomas if present


Diagnosis and treatment of subarachnoid hemorrhage

Diagnosis: Noncontrast CT scan
Perform LP if CT is unrevealing or negative. LP is diagnostic (do not perform if papilledema is present)-xanthochromia is gold standard
Once diagnosed perform cerebral angiogram

Rerupture-24 hrs
Vasospasm-3 days

Surgical clip-coiling or stenting

bed rest in dark room
stool softeners
acetaminophen for analgesia
IV fluids for hydration
Control HTN-lower BP gradually
CCB-nefedipine or nomodipine for vasospasm


Diffuse axonal injury

Most significant cause of morbidity in patients with tramautic brain injuries
Due to traumatic deceleration-vegetative state
Occurs in gray-white matter junction-minute punctuate hemorrhage s with blurring of gray-white interface

Diagnosis: MRI most sensitive


Treatment of Parkinsons

Carbidopa-levidopa:most effective
Bromocriptine, pramipexole: (dopamine receptor agonists)use early on
Seelgiline: (MAO-B inhibitor)

Trihexyphenidyl and benztropine: helps with tremor, do not use in older or demented patients

Amitryptyline: depressed as well

Deep brain stimulation if patient does not respond to medications or severe disease before 40


Diagnosis and treatment of Huntingtons Chorea

Diagnosis: MRI shows atrophy of head of caudate nuclei
DNA testing confirms

no cure
Dopamine blockers help with psychosis and improve chorea. Anxiolytic and antidepressants may be necessary


Physiologic tremor

Caused by fear, anxiety, fatigue
Hypoglycemia, hyperthyroidism, pheochromocytoma
Alcohol withdrawal, valproic acid, lithium, methylxanthines, caffeine, and thephylline

Treat the underlying cause


Essential tremor

Induced or exacerbated by intentional activity

Decreased by alcohol use

treat with propanolol


Cerbellar tremor

happens with action

Associated with ataxia, nystagmus and dysarthia

Improved by rest


Treatment of Tourette's syndrome



Diagnosis and treatment of Alzheimer's

Diagnosis: clinical but can see diffuse cortical atrophy on CT or MRI

Cholinesterase inhibitors: donepezil, rivastigmine and glanatamine

Dietary supplement of ginkgo, lecithin

Vitamin E at megadoses


Diagnosis and treatment of Delirium

Mental status exam >25 (?)
labs: chemistry panel, vitamin B12, thiamine

Treatment: underlying cause


Criteria for brain death

Irreversible absence of brain or brainstem function-unresponsiveness, apnea despite adquate oxygenation and ventilation, no brainstem reflexes (pupils, calorics, gag, cornea, doll's eyes)

Core body temp>89.6 ( cannot be diagnosed in hypothermia)

Imaging study that provides explanation

EEG shows electrical silence


Carotid TIA

Temporay loss of speech, paralysis or parasthesias of controlateral extremity, clumsiness of one limb
Amaurosis fugax transient curtain like loss of sight in ipsilateral eye due to microemboli in eye


Diagnosis and treatment of MS

Diagnosis: clinical
MRI: test of choice-white matter lesions
LP: oligoclonal bands of immunoglobulin G
Evoked potentials: newly remyelinated nerves will conduct sensory impulses more slowly

Acute exacerbations: High dose IV corticosteroids shorten acute attack
Therapeutic plasma exchange for steroid refractory
Resolve within 6 weeks on their own

Disease modifying:
Interferon B, glatiramer acetate

Baclofen and dantrolene for muscle spasticity
carbamazepine or gabapentin for neuropathic pain
Treat depression if indicated


Guillain-Barré syndrome diagnosis and treatment

CSF analysis-elevated protein, but normal cell count (WBC and RBC) normal glucose
Electrodiagnostic studies: decreased motor nerve conduction velocity

monitor pulmonary function-mechanical ventilation may be necessary
Adminster IV immunoglobulin if significant weakness, plasmapharesis may reduce severity of disease


Myasthenia gravis diagnosis and treatment

Acetylcholin receptor Ab test of choice
EMG shows decreased response to repetitive stimuli
CT of thorax to rule out thymoma
Edrophonium (tensilon) test: AChE cause improvement of symptoms but high false positive rate

AChE inhibitors: pyridostigmine (sympotmatic)
Thymectomy: symptomatic or complete remission
Corticosteroids: no response to AChE inhibitors
Azothioprine and cyclosporine are alternatives
Plasmapharesis: if all else fails or respiratory failure
IV immunoglobins for acute exacerbations

Monitor FVC: 15 ml/kg (1L) indication for intubation

Avoid: aminoglycosides, tetracyclines, B-Blockers, Antiarrhythmis, quinidine, procainamide and lidocaine


Diagnosis and treatment of Duchennes

Diagnosis: serum creatinine phosphokinase markedly elevated
DNA testing

Prednisone increases strength in muscle function, pulmonary function and may reduce risk of scoliosis
surgery to correct progressive scoliosis


Neurofibromatosis Type I

AD: cafe au lait spots, neurofibromas, CNS tumors (gliomas, meningiomas), axillary or inguinal freckling, iris hamartomas (Lisch nodules), bony lesions

Complications: scoliosis,, pheo, optic nerve gliomas, renal arterty stenosis

Seizures, mental retardation, short height, marcocephalic

surgically excise symptomatic neurofibromas


Neurofibromatosis Type II


bilateral acoustic neuromas (MRI)
multiple meningiomas, cafe au lait spots, neurofibromas, and cataracts


Tuberous sclerosis


Cognitive impairment, epilepsy, and skin lesions (facial angiofibromas, adenoma sebaceum)

Retinal hamartomas, renal renal angiomyolipomas, and rhabdomyomas


Sturge Weber Syndrome

Capillary angiomatoses in pia matter

Facial vascular nevi(port wine stain)

Epilepsy and mental retardation are present

Treat epilepsy




Carvernous hemangiomas of brain or brainstem, renal angiomas and cysts in multiple organs

Associated with renal cell carcinoma

Associated with pheochromocytomas


Dizziness workup

Audiogram if vestibular symptoms present
CT scan/MRA if TIA suspected
MRI of posterior fossa if structural lesion suspected


Central vs peripheral vertigo

Central: gradual onset
Other brainstem findings present: weakness, hemiplegia, diplopia, dysphagia, dysarthria, facial numbness-look for cardiovascular risk factors
Nystagmus can be biderictional or vertical
patient responds to every tilt test

Peripheral: cochlear or retrocochlear
Abrupt onset
Nausea and vomiting, head position has strong effect on symptoms, no other brainstem deficits except tinnitus/hearing loss
Tilt test can only be performed once because patient will be refractory
NO peripheral nystagmus
Use MRI to rule out ischemic event


Benign positional vertigo

Semicircular canal dysfunction
Vertigo is experienced only in specific positions or change in position
Lasts for a few moments

Treat with Meclinzine


Ménière's disease

Triad of vertigo, tinnuitis and hearing loss
Nystagmus in acute attack

Attacks lasts for hours to days and recur several months or years later

Hearing loss becomes permanent

Treat with sodium restriction and diuretics, anticholinergics or antihistamines


Diagnosis and treatment of vasovagal syncope

preminitory symptoms: pallor, diaphoresis, lightheadedness, nausea, dimming of vision, roaring in the ears

Tilt table study can reproduce symptoms

Treatment: Assuming supine posture and elevating the legs
B blockers and disopyramide


Orthostatic hypotension diagnosis and treatment

Positive tilt table test

Premonitory symptoms: lightheadedness, nausea...

treat with sodium intake and fluids
Consider fludrocortisone


Treatment of Complex partial seizures

Consciousness impaired, postictal confusion
Automatisms: involuntary repetitive movements-lip smacking or chewing
Olfactory or gustatory hallucinations

Phenytoin and carbamazepine


Treatment of simple partial seizures

consciousness remains intact

Phenytoin and carbamazepine


Treatmetn of tonic clonic seizures

1. Sudden loss of consciousness
2. rigidity
3. musculature jerking
4. Postictal confusion and drowsiness
5. tongue biting, vomiting, apnea and incontinence

Phenytoin and carbamazepine


Absence seizure treatment

Valproic acid or ethosuximide


Treatment of status epilepticus

establishing airway

Give: IV diazepam, IV phenytoin, and 50 mg dextrose

Treat resistant cases with IV phenoarbital


Workup of seizure

Check anticonvulsant levels
CBC, calcium, sodium, glucose, BUN, LFTs, urinalysis

EEG-normal EEG in first seizure is lower risk of recurrence
CT scan
MRI with and without gadolinium
LP and blood cultures if febrile


Treatment of seizure

History of seizures:
Loading dose of anticonvulsant (add second if not controlled) continue for 2 years then slowly taper down and confirm with lack of seizure on EEG

First seizure
EEG and neurology consult-first steps
Normal EEG-do not treat
Antiepileptic drugs started if EEG is abnormal, brain MRI is abnormal patient is status epiepticus
Pregnancy test before prescribing