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Flashcards in Central and Peripheral Nervous System Deck (40)
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1

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

2

Evaluation of embolic stroke

1. ECHO
2. Carotid dopplers
3. ECG, Holter Monitors

3

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

4

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
ECHO
MRA-is definitive test

Treatment:
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

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

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

5

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

Pinpoint=pons
Poorly reactive=thalamus
dilated=putamen

6

Treatment and diagnosis of intrancerebral hemorrhage

Diagnosis: Ct scan (hyperdense regions)

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

7

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

Treatment:
Surgical clip-coiling or stenting

Medical:
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

8

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

9

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

10

Diagnosis and treatment of Huntingtons Chorea

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

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

11

Physiologic tremor

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

Treat the underlying cause

12

Essential tremor

AD
Induced or exacerbated by intentional activity

Decreased by alcohol use

treat with propanolol

13

Cerbellar tremor

happens with action

Associated with ataxia, nystagmus and dysarthia

Improved by rest

14

Treatment of Tourette's syndrome

Clonidine
Pimozide
Haloperidol

15

Diagnosis and treatment of Alzheimer's

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

Treatment:
Cholinesterase inhibitors: donepezil, rivastigmine and glanatamine

Dietary supplement of ginkgo, lecithin

Vitamin E at megadoses

16

Diagnosis and treatment of Delirium

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

Treatment: underlying cause
Haloperidol

17

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

18

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

19

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

Treatment:
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

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

20

Guillain-Barré syndrome diagnosis and treatment

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

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

21

Myasthenia gravis diagnosis and treatment

Diagnosis:
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

Treatment:
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

22

Diagnosis and treatment of Duchennes

Diagnosis: serum creatinine phosphokinase markedly elevated
DNA testing

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

23

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

24

Neurofibromatosis Type II

AD

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

25

Tuberous sclerosis

AD

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

Retinal hamartomas, renal renal angiomyolipomas, and rhabdomyomas

26

Sturge Weber Syndrome

Capillary angiomatoses in pia matter

Facial vascular nevi(port wine stain)

Epilepsy and mental retardation are present

Treat epilepsy

27

VHL

AD

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

Associated with renal cell carcinoma

Associated with pheochromocytomas

28

Dizziness workup

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

29

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

30

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