Exam Flashcards
(332 cards)
1
Q
1st seizure after 30 yo…
A
rule out tumor!
2
Q
Absence Generalized Seizure
A
Petit Mal, brief loss of consciousness
No post-ictal Sx
no recollection of events
3
Q
Tonic-Clonic Generalized Seizure
A
Grand Mal, rhythmic jerking of muscles
4
Q
Todd’s Paralysis
A
usually unilateral paralysis after seizure temporarily
suggests FOCAL onset
5
Q
1 SEIZURE TRIGGER
A
MISSED MEDICATION
6
Q
Absence seizure classically on EEG*
A
3 cycle per second spike and wave activity
can be precipitated by hyperventilation
7
Q
status epilepticus
A
seizure greater than 30min
OR serial seizures without return to previous LOC in between
8
Q
most common cause of status epilepticus
A
prolonged febrile seizure
9
Q
status epilepticus Tx
A
Airway
Breathing
Circulation
Dextrostix and Draw blood: glu, lytes, Ca, Mg, BUN, NH3, gases. D25W IV
10
Q
Seizure Tx*
A
try lorazepam, diazepam, or paraldehyde first (1-2 repeats)
PERSISTS then use longer-acting anticonvulsant: phenytoin, phenobarbital
11
Q
Neonatal seizure treatment
A
phenobarbital = first line
12
Q
Tx seizures in pts already on phenytoin or phenobarbital
A
booster doses of 5 mg/kg, subsequent based on severity
13
Q
Sublingual Anticonvulsant
A
Lorazepam (Ativan) - also IV
14
Q
Rectal Anticonvulsant
A
Diazepam (Valium) - also IV
15
Q
What should you watch for w/AED
A
Hypotension
respiratory depression
16
Q
Agents to control intracranial pressure if seizures >60min
A
Mannitol
Dexamethasone
17
Q
why is phenytoin a helpful maintenance AED
A
lack of CNS depressing action, except at high levels
18
Q
generalized seizure medications
A
barbiturates
phenytoin
valproic acid
ethosuximide
19
Q
dose-related side effects of phenobarbital and phenytoin
A
sedation and ataxia
20
Q
complications of longterm use of phenytoin
A
gingival hyperplasia
hirsutism
lymphadenopathy
21
Q
idiosyncratic risk of phenobarbital and phenytoin
A
hepatotoxicity
rash
lupus-like syndrome (phenytoin)
22
Q
Valproic acid treats
A
generalized, partial seizure, myoclonic
useful in mixed seizure disorders
23
Q
dose related side effects of valproic acid
A
sedation, GI upset, THROMBOCYTOPENIA, hyperammonemia
24
Q
Worst idiosyncratic complication of valproic acid
A
fulminant hepatotoxicity
greatest risk: children <2yo, children on mult AED
25
what is Ethosuximide (Zarontin) used to treat?*
absence (petit mal) epilepsy
26
idiosyncratic reactions of ethosuximide
rash
| blood dyscrasias
27
first line treatments for partial seizures
phenytoin (also generalized)
valproic acid (also generalized)
carbamazepine
28
Carbamazepine effective against
partial seizures
| secondary generalized seizures
29
idiosyncratic reaction of Carbamazepine
leukopenia
aplastic anemia
rash
Stevens-Johnson Syndrome
30
Infantile Spasms tx
ACTH
31
MRI findings w/seizures
streaky linear or wedge shaped (white matter) lesions extending from ventricles
32
most common primary headache
tension HA
33
Red Flags for worrisome secondary headache
```
fixed neurological deficits
extreme abrupt onset
papilledema
new onset <5, >50yo
infection
altered consciousness
new in cancer or immunocompromised
```
34
"Worst headache of my life"
aneurysm
35
what kind of headache do young obese women in childbearing years get
idiopathic intracranial HTN (pseudotumor cerebri)
36
What does 50% of those w/temporal arteritis get?
Polymyalgia rheumatica: pain/stiffness in neck that radiates to hip; steroid tx years; self resolves
37
Most common drug causing medication overuse headache*
Acetaminophen*
38
Who is affected by migraines
more women, 30's
HIGHLY genetic!
very debilitating, hrs to days
39
Migraine HA*
Usually UNILATERAL, throbbing, pulsatile, photophobia, phonophobia, nausea
40
"Pt try to lie down in dark quiet room"
migraines
41
Dx for migraines
clinically, NO imaging
42
Tx for migraines*
everyone needs acute tx!!!*
1st: tylenol, motrin, excedrin
then try: Triptans, Ergots
43
Mechanism of action of triptans and ergots
vasoconstriction
44
Tension HA characteristics*
BILATERAL, pressing/tightening, mild to moderate
NOT aggravated by routine activity (more consistent)
NON-THROBBING, "head fullness", "dull"*
45
Most common reason OTC analgesics used*
tension headaches
46
Tx for tension headaches
simple analgesics (NSAID, ASA, Acetaminophen), more effective w/caffeine
47
What medication should you AVOID in tension headaches?*
TRIPTANS or muscle relaxants
48
"suicide headache"*
cluster HA
49
Cluster HA characteristics
severe orbital, supraorbital/temporal pain
UNILATERAL
Autonomic Sx: ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion
15-180 MINUTES
occur in clusters then remission
50
What do you need to rule out w/Cluster HA?*
Get MRI to rule out brain lesion!
51
Tx of cluster HA
O2, subQ sumatriptan
| prevention with: verapamil* (CCB)
52
What syndrome can you get w/cluster HA?
Horner's syndrome: ptosis, pupil constriction, anhidrosis unilaterally
53
What exam does every patient w/headaches need?*
Fundoscopic exam!
| and get BP
54
Most important risk for Cerebrovascular disease?*
HTN!
55
Most common aneurysm*
Saccular aneurysm ("Berry")
56
when do you surgically treat carotid stenosis?
>50% occlusion
57
Which population gets cerebral aneurysms more
50-60 yo
| 3x more women
58
Diagnostic test of choice for cerebral aneurysms
MRA and carotid angiogram
| ruptured: CT or LP
59
What Dx should you consider w/Hx of AV malformation?*
Bleeding
prevention is key!!
4/100 people hemorrhage a year!
60
How do you diagnose stroke?
Clinically
61
Which type of stroke is more common?*
87% Ischemic stroke!
62
Ischemic stroke*
infarct WITH sequelae! Don't return to state pre-stroke!
63
Transient Ischemic Attack*
NO infarction and NO sequelae
"mini stroke"
Sx <1hr, abrupt, rapid recovery
URGENT, TREAT LIKE STROKE
64
TIA Tx
find cause
determine therapy
TX RISK factors
65
Penumbra
area from ischemia that is SALVAGEABLE in first few hours
66
Eye stroke
amaurosis fugax from ischemia of ophthalmic a. from carotid
67
Ischemia of middle cerebral artery (Anterior or posterior)*
Anterior: Broca's aphasia
Posterior: Wernicke's aphasia
68
Vertebral or basilar artery ischemia*
affect anterior portion of PONS
| "LOCKED IN" SYNDROME: no mvmt except eyelids
69
What lab test should perform ASAP in stroke patient?*
fingerstick glucose
70
When can you treat ischemic strokes with IV tPA?*
<4.5hr of onset*
71
What are the first 2 things you do with stroke patients?
stabilize patient: CAB
| Establish time of symptom onset: accurate and rapid!
72
Findings most predictive of stroke
facial paralysis
arm drift
weakness
abnormal speech
73
What diagnostic imaging test should you do w/stroke?
CT WITHOUT CONTRAST:
See white - hemorrhage
dark: early "mass effect" infarction --> can convert to hemorrhage
74
Contraindications of tPA
recent surgery, GI bleed, MI, prior ICH, high refractory BP, low platelet, low or high glu
75
When should you get mechanical thrombectomy with strokes?
<24hrs of onset
large clots
should still also get tPA
eg MERCI procedure
76
What should you NOT do in ischemic stroke?
DON'T lower BP! Need to maintain perfusion
| BP is a response, not cause
77
What needs to be acutely managed after treatment of stroke?
Manage Glucose!
| hyperglycemia is independent risk for hemorrhage!
78
Medications for secondary prevention of stroke w/TIA**
Anti-thrombotic
ARB/ACE-I
Statin
ALL PTS (REGARDLESS OF LEVELS)
79
"worst headache of my life"
subarachnoid hemorrhage
80
Intracerebral hemorrhage vs subarachnoid hemorrhage onset
intracerebral: gradual/progressive
subarachnoid: abrupt, severe; widespread; rapidly increasing intracranial pressure
81
Imaging for hemorrhage
Non-contrast CT: detects ALL ICH but 90%SAH
| if CT Neg for SAH, get LP to confirm (blood or xanthochromia)
82
What type of hemorrhage is LP contraindicated in?
Intracerebral hemorrhage
83
Tx for intracerebral hemorrhage
conservative and supportive, monitor ICP, seizure prophylaxis
84
Acute HA w/"Thunderclap"*
Subarachnoid hemorrhage
85
What do you find on PE of subarachnoid hemorrhage
nuchal rigidity
| meningismus
86
Tx SAH
```
surgery (clot removal, decompression craniectomy)
seizure prophylaxis (phenytoin)
```
87
How is Parkinson's Dz characterized clinically from other parkinsonisms
Asymmetric parkinsonism
| Clear/Dramatic benefit from dopaminergic therapy
88
Parkinsonism
syndrome w/any combo of bradykinesia (or akinesia), rest tremor, rigidity, postural instability
TRAP
89
essential tremor
worst with action
90
how to confirm normal pressure hydrocephalus
beneficial response to Large volume CSF tap
91
tremor in Parkinson's
"pill rolling"
improves w/intention
presents unilaterally, can progress to bilateral
92
Cardinal symptom of PD*
Bradykinesia or Akinesia
progresses distal to proximal
classic shuffling gait w/unsteadiness
festination: quick short steps, "unwilling running pace"
93
mainstay of PD Tx
Carbidopa/Levodopa (Sinemet) - replace DA
Levodopa = DA precursor, crosses BBB to CNS
Carbidopa prevents conversion to DA in Periphery to prevent side effects
94
COMT Inhibitors
increases half-life of L-DOPA
95
MAO B inhibitor
reduces breakdown of DA
96
Deep brain stimulator in PD
Targets subthalamic nucleus
97
Most common dementia in pts over 65yo**
Alzheimer's
98
Dementia
progressive loss of cognitive functions that interfere w/patient’s daily living; anterograde amnesia (cannot learn new things).
a decline from the patient’s previous intellectual level.
99
Delirium
ACUTE disorder of global cognitive function
100
what are not affected in dementia, unlike delirium
arousal and alertness
101
Pathological hallmarks of AD*
amyloid plaques in cortical cell*
neurofibrillary tangles in hippocampus* - tau
hippocampal atrophy*
brain shrinkage - granular-vacular degen
102
Vascular dementia - Single infarct in MCA
aphasia, confusion, anosognosia, neglect depending on the hemisphere affected
103
Vascular dementia - Single infarct in ACA
frontal lobe syndrome (disinhibition, poor planning, lack of initiative, poor sequencing)
104
Vascular dementia - Single infarct in PCA
visual distortions, hallucinations, cortical blindness
105
Vascular dementia - Single Thalamic infarct
global cognitive and psychiatric dysfunction
106
goal of pharmacologic therapy in AD
slow disease progression and buy family more time
| medication doesn't work for everyone
107
Triad of normal pressure hydrocephalus
gait apraxia, decline in thinking function, bladder incontinence
CSF tap improves gait but not cognition
(but not every pt has triad)
108
What drug should you use in extreme caution in Dementia w/Lewy Bodies**
anti-psychotics*
serious side-effects in 50%
antidepressants* can cause sudden changes in consciousness
109
What dementia is assoc w/chronic alcoholism
Korsakoff's Syndrome
110
Apraxia
loss or impairment of the ability to execute complex coordinated movements
111
Sx of AD
```
Memory
language
apraxia
visual spatial functioning
personality change
psychiatric dz
impairment judgement
"sun downing"
```
112
Dx of AD
```
progression at least 6 months
anterograde amnesia
multiple cognitive deficits
impairment in function
no other cause
```
113
primary neurochemical change in AD
Reduced amount of acetylcholine
| cholinesterase inhibitor used in treatment - Donepezil, galantamine and rivastigmine
114
memantine
NMDA receptor antagonist - regulates glutamate activity
| in AD: excessive glutamate released from damaged cells --> speed up cell damage
115
vascular dementia
inadequate blood flow to brain
often coexist w/other forms of dementia
multiple infarcts more common
abrupt loss of intellectual sills (AD gradual)
116
Second most common cause of dementia
Vascular dementia
| risk increases steeply w/age
117
Anosognosia
unaware of one's own deficits
118
life expectancy of vascular dementia following stroke
3 years
119
Pick's disease
Frontotemporal dementia
120
FTD
Changes in behavior (disinhibited or apathetic) or problems with language (not understandable)
121
average age of onset of FTD
58 yo
| highly inheritable
122
what protein are lewy bodies made of?
alpha-synuclein
123
Dx between Lewy body Dementia and PD w/dementia**
Movmt 1st: PD
Dementia 1st: LBD
Both involve abnormal alpha-synuclein
124
What is a significant Sx in PDD
Hallucinations
125
most common cause of normal pressure hydrocephalus
idiopathic
| adults over 60yo
126
"magnetic gait" - looks like feet glued to floor
gait apraxia of NPH
127
Huntington's
Progressive, single defective (extra repeats) gene on chromosome 4 - defective huntingtin protein - neurons in certain areas of the brain start to break down.
DOMINANT inheritance
128
Sx of huntington's
to emotional disturbances, loss of intellectual abilities, and uncontrolled movements (chorea)
129
Prion diseases pathology
Infectious protein (prion) folded abnormally --> contact normal protein and it fold weirdly too --> aggregates and plaques/neurofibrils --> brain damage
spongiform encephalopathies
2 year mortality
130
Examples of Prion diseases
Creutzfeldt-Jakob disease (CJD) - rare but most common prion dz
Gerstmann-Sträussler-Scheinker syndrome (GSS),
Fatal Familial Insomnia (FFI) – dont sleep at all; rapid death
kuru - culture eating brains of ancestors
mad cow disease
131
Potential causes of dementia
```
Vitamin Deficiency: B12
Thyroid Disease
Drug and medication intoxication (anti-cholinergics, dopamine blockers, benzos, narcotics)
Pseudo-dementia – depression, anxiety
Chronic Infection
```
132
85% of back pain
non-specific lower back pain - usually improves in a few wks
133
what should you consider w/new onset back pain after 50 yo
malignancy
134
What's important to ask in back pain?
IV Drug use - infection
135
cauda equina syndrome
compromised canal below L1
most commonly from herniated nucleus pulposus
urinary retention, dec sphincter tone, Perineal/Saddle paresthesia
EMERGENCY*
136
radiculopathy
dysfunction of nerve root
Pain, sensory impairment, weakness, decreased DTR in a nerve root distribution
non-emergent, eg sciatica
137
spinal stenosis
Narrowing of spinal canal that results in bony constriction of cauda equina
pain walking or standing
138
how does pain decreased in spinal stenosis*
sitting or spinal flexion*
| (increase w/spine extension)*
139
ankylosing spondylitis
Inflammatory arthritis of the spine (Seronegative spondyloarthropathy)
squaring of vertebral bodies and syndesmophytes
can have fusion
140
what is ankylosing spondylitis characterized by?*
Morning stiffness, improved with exercises/activity**
pain wakes you up at night
can have extraskeletal manifestation: uveitis. psoriasis, IBD
141
Waddell's sign
Psychologic distress contributing to back pain symptoms
| fake back pain/intensity
142
alternative classification of low back pain
mechanical
non-mechanical
visceral dz
(w/ or w/o radiculopathy)
143
ROS Red flags for back pain
Constitutional symptoms: Unintentional weight loss, Fever/night sweats
Systemic disease: History of malignancy, IV drug use
Bowel or bladder symptoms (retention or incontinence)
144
PE Red flags for back pain
Saddle anesthesia
Loss of anal sphincter tone (LATE finding)
Major motor weakness in the lower extremities
Elevated temperature
Vertebral tenderness
Limited spinal range of motion
Neurologic findings persisting beyond one month
Pain not reproducible by exam concerns me….
145
steroid effect on lower back pain
NO EFFECT
146
L4 Lumbar Disc Herniation
Decreased/absent patellar reflex, Knee strength
Medial foot
+ SLR
147
L5 Lumbar Disc Herniation
Weakness of great toe and foot dorsiflexion (EHL)
Dorsum of foot
+SLR
148
S1 Lumbar Disc Herniation
Decreased plantar flexion, lateral foot, buttock, posterior thigh, calf
Calf atrophy
Diminished Ankle reflex
+SLR
149
what happens to pts w/lumbar disc herniation in 4 weeks?
80% go asymp
150
Spondylosis
```
Osteoarthritis of the spine
“wear and tear” of the spine
Bone spurs
Disc space narrowing
morning stiffness
```
151
Spondylolysis
Defect or stress fracture in pars interarticularis
Most common at L5-S1
worry w/young HS athletes
152
"Scotty dog" on XRAY**
Spondylolysis
153
Spondylolisthesis
Defect or fractures of bilateral pars interarticularis resulting in slippage
154
what structures do meningitis more commonly affect?
arachnoid mater and the CSF in the subarachnoid space and cerebral ventricles
155
common causes of bacterial meningitis in ADULTS
Neisseria meningitidis
Streptococci pneumonia
Listeria monocytogenes
156
common causes of bacterial meningitis in INFANTS <30 days
group B streptococcus
Listeria monocytogenes
Escherichia coli
157
What to do w/suspected meningitis
immediate Abiotic tx within 3hours to prevent mortality
158
#1 cause of bacterial meningitis for ALL age groups*
Streptococcus pneumoniae
159
bacterial meningitis cause of older/immunocompromised
Listeria monocytogenes
160
bacterial meningitis presentation*
sudden onset and severe
Fever, nuchal rigidity, change in mental status, headache
Nausea, vomiting, photophobia
Sx 3-7 days post exposure
161
Kernig's sign
pt resist extension of knee
| sign for meningitis
162
Brudzinski Sign
stiff neck causes hips/knee flex when neck is flexed
| sign for meningitis
163
viral meningitis
more common than bacterial
less severe
USUALLY self limiting: recovery 7-10days
164
how to tell viral or bacterial meningitis
Lumbar puncture
165
#1 cause of viral meningitis
enteroviruses: Echoviruses, coxsackieviruses, etc.
| 85% of cases
166
what tests to order in meningitis?
blood culture
CSF studies
PCR
167
bacterial meningitis CSF
Cloudy, high neutrophils, low glu, high protein, pos gram stain
168
what to do in meningitis when you see focal neuro deficits or papilledema?
CT scan FIRST
| DONT do LP w/increased intracranial pressure*
169
Tx for bacterial meningitis for 1mon-50yo
vancomycin and 3rd gen cephalosporin
170
Tx for bacterial meningitis for >50yo
ampicillin (covers Listeria), vaco, 3rd gen cephalosporin
171
encephalitis
acute inflammation of the brain associated with neurological dysfunction
usually complication from viral infection
onset: 2-12days after
172
common causes of encephalitis
Arbovirus: WNV (severe and growing)
HIV
Influenza
Herpes viruses: HSV1 and HSV2
173
What test is recommended in all patients w/suspected encephalitis?*
Lumbar Puncture, unless contraindicated
| if suspect increased ICP, then CT first
174
What do you do w/suspected increased ICP?
CT/MRI
175
Tx for excephalitis
treat cause!
| supportive, freq eval
176
What infections is brain abscess often associated w/?
Direct spread:
Sinusitis, otitis media, dental infection, mastoiditis
Occasionally from distant spread (hematogenous):
Lung, skin, pelvic
177
Clinical signs of brain abscess
HEADACHE, Rapid course, Convulsions, Hemiplegia, fever
178
What is a brain abscess considered and why could a LP be contraindicated?
space occupying lesion --> inc ICP -->can herniate brain stem w/LP
179
where is brain abscess most commonly located?*
epidural space
180
How to Dx brain abscess
MRI best
| aspiration by needle (gram stain and culture)
181
venous sinus thrombosis
uncommon, life threatening
| clot forms in cavernous sinus
182
what can be caused by venous sinus thrombosis
Increased pressure, decreased perfusion, and leaking of blood into interstitial space --> Cerebral edema, hemorrhage, and increased ICP
183
how to dx venous sinus thrombosis
MRV
184
Tx venous sinus thrombosis
early anticoag
| corticosteroids can decrease inflammation
185
Transverse myelitis
Demyelination of BOTH SIDES of one section of the spinal cord due to an inflammatory process;
leads to sensory and motor changes below the lesion as well as autonomic dysfunction
186
Causes of transverse myelitis
Idiopathic, Infection (Lyme), post vaccination, MS, RA, SLE (Lupus)
50% had a recent URI
187
Tx of transverse myelitis
Short course of high dose corticosteroids:
| Methylprednisolone 1,000 mg 3-5 days
188
What brainstem reflex testing uses warm and cold water in the ear and watching eye movement?
Caloric Reflex test
189
what drugs can cause pinpoint pupils, hypoactive bowel sounds and hypotensive
opioids
190
What is the reticular activating system responsible for?
Arousal (alertness)
191
2 principle functions of consciousness
arousal (level) and awareness (content)
192
delirium
acute confusional state characterized by an alteration of consciousness with reduced ability to focus, sustain, or shift attention.
193
what level of consciousness: person can be aroused by moderate stimuli, but then drifts back to sleep
drowsiness
194
what level of consciousness: very mild form of altered mental status in which the patient has inattention and reduced wakefulness.
clouding of consciousness
195
what level of consciousness: more profound deficit that includes disorientation, bewilderment, and difficulty following commands.
confusional state
196
what level of consciousness: severe drowsiness in which the patient can be aroused by moderate stimuli, with drowsiness between sleep states, and then drifts back to sleep.
lethargy
197
what level of consciousness: state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.
obtundation
198
what level of consciousness: only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state
stupor
199
what level of consciousness: state of unarousable unresponsiveness
COMA
200
minimal, but definite, behavioral evidence of self or environmental awareness. Partial preservation of conscious awareness
Minimally conscious state
201
able to arouse but not aware
vegetative state
202
brain death
Absence of brain stem reflexes
| EEG showing electrocerebral inactivity
203
Cerebral cortex function in consciousness
awareness of self and the environment
204
Causes of coma**
```
Herniation syndromes & Various Trauma
Structural/Brainstem lesions
Metabolic
Toxic syndromes
Infections
```
205
Decorticate posturing
Stiff BENT arms towards the body, clenched fists with fingers bent and held on the chest, legs out straight. (Glasgow Coma Scale 3 in motor)
Damage to cerebral hemispheres, internal capsule, or thalamus. May also indicate damage to midbrain.
206
Decerebrate posturing
Arms and legs held out STRAIGHT, toes pointed downward, head and neck arched backwards, muscles tightened and held in rigidity. (GCS 2 in motor)
Indicates brain stem damage, lesions or compression in the midbrain, or lesions of cerebellum
Commonly seen in pontine strokes
207
Which posturing is commonly seen in pontine strokes*
decerebrate posturing
208
CARDINAL FEATURE OF METABOLIC COMA
- Symmetrical nature of the neurologic deficits (from cortical suppression and ARAS disruption)
- Tremor, asterixis, and multifocal myoclonus strongly suggest metabolic coma
- decr muscle tone
- pupils may look abnormal but ALWAYS symmetric, constrict w/light (normal)
209
toxic syndromes - coma
drug overdoses or poisonings
| most important to focus on: PUPIL SIZE, temp, bowel sounds
210
common toxidromes
```
Sympathomimetic
Anticholinergic
Hallucinogenic
Opioid
Sedative-hypnotic
Cholinergic
Serotonin syndrome
```
211
Infections causing coma
```
Bacterial meningitis
Viral encephalitis
Postinfectious encephalomyelitis
Syphilis
Sepsis
Typhoid fever
Malaria
Waterhouse-Friderichsen syndrome
```
212
conditions mistaken for coma
locked-in syndrome: conscious, blink
akinetic mutism: awake, no voluntary mvmt
psychogenic unresponsiveness: pts resist
213
cherry red skin (coma)
carbon monoxide poisoning
214
osler's nodes (coma)
bacterial endocarditis
215
what neuro assessment w/comas
level of consciousness: GCS, arousal
motor responses: tone, reflex, posturing
brainstem reflexes: pupil, cornea, xtraocular
216
GCS <8
severe brain injury
217
What does Glasgow coma scale not assess
brainstem
| assess eyes, motor, verbal
218
FOUR Score <6 predicts...
death!
| considers brainstem, eyes, motor, respiratory
219
pinpoint pupils in coma (but react to light)
pontine lesion
220
significant asymmetric pupils in coma
brain stem, large hemisphere lesion, or ruptured aneurysm
221
pupils unreactive and midsized in coma
death or drugs
222
vestibular-ocular reflex; what does absence indicate?
eyes can't move w/head turn; cant maintain forward gaze
| brainstem lesion
223
caloric reflex test normal findings
eyes moves TOWARD same ear w/cold water
| moves AWAY from ear w/hot water
224
what's usually ordered first w/coma**
CT no contrast
225
pontine lesion characteristics
```
Pin-point, but reactive pupils
Abrupt onset of Coma
Decerebrate posturing or flaccidity
Ataxic Breathing Pattern
BADD!!
```
226
what's even worse than pontine lesion?
bithalamic hemorrhage
227
bithalamic hemorrhage
```
Downward gaze (paralysis of upward gaze)
Small pupils (lack of light pupillary response)
Depressed consciousness/Coma
```
228
What structures are compromised in coma**
ARAS
| Cerebral cortex
229
delirium characteristics*
- Sudden, quick onset, Reversible (acute, transient, fluctuates)
- Affects ATTENTION*
- CONFUSION*: problem w/coherent thinking
- increased vigilance with psychomotor and autonomic overactivity
230
Acute confusional state (delirium)
varying picture of agitation, hallucinations, convulsions, tremor, delusions, and inability to sleep.
emotional disturbance
231
which population more often affected w/delirium
older pts, esp surgical (ICU, hospice)
232
Difference between delirium and dementia**
delirium: affects attention, usu. a cause!
dementia: affects memory
233
Causes of delirium*
```
drugs and toxins
infections
metabolic derangements
brain disorders
systemic organ failures: RESP, LIVER, RENAL, HEART
physical disorders
CONSIDER DRUGS AND STROKE
```
234
cause of post-operative delirium
polypharmacy
235
what should you always check for in delirium?
nuchal rigidity, papilledema, asterixis, nystagmus, pathologic reflexes (Babinski)
236
tests in delirium
CULTURES
EKG: rule out MI
CXR
Pulse ox/abg's
237
DDx in delirium
Depression
Schizophrenia / Psychosis
Dementia
Malingering
238
commonly used Rx for delirium (w/agitation)
Haldol (haloperidol) 0.5 to 1 mg PO or IM q12 hours prn agitation
Ativan (lorazepam) 0.5 to 1 mg PO or IM q6 hours prn agitation
239
most common causes of vertigo*
Benign Paroxysmal Positional Vertigo
Vestibular Neuritis
(other ones: Migraine, Meniere’s Disease, Vascular Causes)
240
What is present w/true vertigo?*
nystagmus
241
what does Purely vertical or torsional nystagmus suggest?*
central lesion
242
central v peripheral lesion in nystagmus and vertigo
central: Sudden onset, constant, nystagmus not suppressed by fixation
peripheral: Brief recurrent attacks/subacute onset, nystagmus suppressed by fixation
243
Vestibular Neuritis*
Inflammation of vestibulocochlear nerve
usu. VIRAL AND SELF LIMITING
Occurs in healthy young people
PE: vestibular imbalance (veer toward affected side), horizontal nystagmus, positive head thrust test (eye moves)
244
labyrinthitis
vestibular neuritis AND unilateral hearing loss
245
Benign Paroxysmal Positional Vertigo
Secondary to calcium debris in posterior semicircular canal
Brief spinning sensation when turning head or tilting head backwards
Brief (seconds), nausea, REPRODUCIBLE
Ear pain, hearing loss, and tinnitus are absent
246
Tx BPPV*
Epley maneuver: remove Ca deposits
| do Dix-Hallpike maneuver first to confirm: pt sit, rapidly lie back, repeat
247
Herpes zoster oticus
Ramsay Hunt, affect facial n.
Acute vertigo, hearing loss on affected side, ipsilateral facial paralysis, ear pain, vesicles in auditory canal (and long facial n.)
Treatment: corticosteroids, acyclovir
248
Ménière's Disease
Excess endolymphatic fluid pressure, Unknown cause
Recurrent attacks of vertigo usually unilateral associated with auditory symptoms (hearing loss, tinnitus, and aural fullness), nystagmus during attacks, gait imbalance
Vertigo is usually severe with nausea and vomiting
Spontaneous, episodic
249
what drug is ototoxic?
aminoglycosides (gentamicin), destroys vestibular system
250
Ménière's Disease Tx
aggressive low-salt diet and diuretics
| avoid caffeine, chocolate, red wine
251
Perilymphatic fistulas
Fistula between fluid filled inner ear perilymph and air filled middle ear
Episodic vertigo and/or hearing loss
CT!
Usu. self limiting
252
Labyrinthine Concussion
Traumatic peripheral vestibular injury following direct concussive head trauma
subside in a few months
253
Cogan syndrome
Rare Autoimmune condition that can cause interstitial keratitis and vestibuloauditory dysfunction
254
EMERGENT causes of vertigo (central lesions - brainstem, cerebellum)*
vestibular migraine
brainstem or cerebellar ischemia/infarct: vertebral a.
wallenberg CVA: specific brainstem infarct, ips horner's, <3 hr for thrombolytics (treat like stroke)
MS
255
acute severe vertigo w/focal neuro signs
stroke
256
acute severe vertigo w/normal neuro exam
otological causes
257
positive head thrust test w/vertigo
vestibular neuritis
w/hearing loss: labyrinthitis
vesicles: ramsay hunt
258
Vertigo lasting >than 20 minutes with unilateral hearing loss
meniere's disease
259
get recurrent attacks of vertigo
TIAs
260
Brief, recurrent, positional changes, specific, reproducible
Dix hall-pike maneuver
Epleys maneuver
benign paroxysmal positional vertigo
261
all vertigo is made worse by what?
head movement
262
vertigo worse w/Worse if coughing, sneezing, etc. (Tullio phenomenon)
perilymphatic fistula
263
vertigo w/recent viral symptoms
vestibular neuritis
264
vertigo treatment
treat underlying cause!
meclizine (Antivert) - good in pregnancy
anti-emetics (Promethazine, metoclopramide), corticosteroids
gait training, vestibular exercises
265
what do central lesions almost always present with?*
other neurological findings: diplopia, dysphagia, weakness, etc.
266
Shortness of breath, palpitations, diaphoresis w/vertigo
cardiac or panic attacks!
267
most common secondary brain tumors
lung, breast metastasis
268
primary brain tumors
Meninges – Meningioma
Glial cells – Gliomas (M/C in adults & children)
-Astrocytoma, glioblastoma, oligodendroma, ependymoma (M/C spinal tumor)
Nerve sheath – Schwannoma, Neurofibroma
Embryonal – Medulloblastoma, neuroblastoma, germinoma, teratoma
Blood vessels - Angioma, Angiosarcoma, etc.
Other: Lymphoma, Epithelial, Pituitary, Pineal gland tumors
269
most common primary brain tumor in adults
gliomas and meningiomas
270
most common primary brain tumor in children
gliomas
271
location of adults brain tumors
70% supratentorial - m/c gliobastoma
272
location of children's brain tumors
70% infratentorial - m/c astrocytoma
273
risk factors of brain tumors
ionizing radiation
| genetics
274
brain tumor presentation
Seizures (focal or generalized)
Focal neuro deficits
Cognitive dysfunction
S/s of increased ICP (triad: HA, nausea, papilledema)
Headache? (tension like)
Supratentorial – Seizures
Infratentorial – HA, vomiting, visual disturbances
275
headaches w/brain tumor
rarely occur in isolation
| from traction on vessels or dura, NO pain receptors on parenchyma
276
Red flags for brain tumors
Acute, new, usually severe HA (especially in ages ≥ 50 years old)
HA changed from previous pattern
HA in elderly or children
HA on exertion, onset at night, or onset in early morning
HA that is progressive in nature
Associated w/ meningismus, fever, or other systemic symptoms
HA w/ new neurologic signs
Precipitation of head pain with Valsalva maneuver (e.g. coughing, sneezing, bending over)
277
Imaging test of choice for brain tumors
MRI w/contrast
278
What do you look for next if positive for brain tumor?
systemic malignancy
279
Tx for brain tumor
surgical resection!
radio/chemotherapy
VP shunt for hydrocephalus
280
non-invasive Tx for brain cancer
```
glucocorticoids to decrease peritumoral edema*
anticonvulsants*
analgesics
DVT prophylaxis if immobile
palliative in mets
```
281
when to avoid corticosteroids in brain tumors
suspicion of lymphoma or malignant gliomas bc screws up biopsy (kills lymphocytes)
282
Astrocytoma (Glioma):
```
M/C primary intracranial cancer – part of brain
-linked to ionizing radiation and rare genetics syndromes
Grade I (pilocytic astrocytoma-cerebellum)=m/c childhood tumor, can be cured if resected – slow growing
Grade II=present as seizure in young adults, resect if possible
Grade III (anaplastic astrocytoma) & Grade IV (glioblastoma)= resect if possible, then radiation +chemo
```
283
Glioblastoma: (grade IV astrocytoma)
Median survival 12-15 months
| -High recurrence rate --> reoperation, carmustine wafer implant, chemo
284
Meningioma:
M/C primary brain tumor (some are benign); often slow-growing
-Extraaxial mass attached to dura
-Tx:
Large-surgical resection curative; otherwise, need radiation to
decrease recurrence
Small-if asymptomatic, watchful waiting with serial imaging
285
Oligodendroma (Glioma):
More responsive and better prognosis compared to astrocytoma
- Tx: surgical resection and radiation +/- chemo
- Median survival >10 years
286
Schwannoma:
- Vestibular; progressive unexplained unilateral hearing loss
- Tx: surgical resection
287
Ependymoma (Glioma):
- Usually in spinal canal
| - Tx: curable with surgical resection
288
Medulloblastoma:
- M/C malignant tumor in children
- Half in posterior fossa
- Tx: surgical resection, radiation, chemo
- 70% have long term survival but have cognitive impairment
289
Primary CNS Lymphoma:
- B cell malignancy; usually occur in immunosuppressed
- May be single mass, multiple masses, or meningeal
- Test for HIV; look at extent of disease (PET or whole body CT), CSF
- Tx: radiation, chemo, methotrexate
290
Pituitary Adenoma:
-Originates from hormone-producing cells in pituitary; nearly all benign
Prolactinoma-prolactin
Acromegaly (adults), gigantism (child)-growth hormone
Cushing's disease-cortisol
-Tx: pharmacologic; surgery if needed +/- radiation
291
Mononeuropathy multiplex
Simultaneous or sequential involvement of noncontiguous nerve trunks.
292
predisposing factors for peripheral neuropathy
```
Diabetes
Vascular disease (peripheral artery disease)
HTN
Hypercholesterolemia
Tobacco/EtOH
```
293
Sx of PNS disorders
weakness
paresthesias/dysesthesias: burning, stabbing, pins/needles, numbness
autonomic dysfunction: coordination, bowel/bladder
(often notice nocturnally); vascular symptoms
294
bilateral or unilateral with: systemic, carpal tunnel, HNP
Systemic: bilateral
| carpal tunnel, HNP: unilateral
295
does neoplastic dz cause peripheral neuropathy?
NOT commonly
296
how to best image herniated disc?
MRI
297
BRACHIAL PLEXITIS tx (trauma, malig, idiopath)
steroids, pain management
298
peripheral neuropathy: "truck driver's hand", cubital tunnel
ulnar neuropathy
| "ulnar claw hand" - late
299
symptoms of peroneal nerve compression
foot drop (cant dorsiflex) and sensory loss in lateral aspect foot and/shin
300
Lateral femoral cutaneous nerve compressionAKA Meralgia Paresthetica
compression at inguinal canal
Paresthesias/hyper-esthesia in anterior lateral thigh.
NO motor involvement!
301
Posterior tibial nerveAKA Tarsal Tunnel Syndrome
Compression at tarsal tunnel (medial ankle)
Pain and sensory disturbance medial aspect of the foot and ankle
least common
302
how does polyneuropathies spread?
distal to proximal
303
most common cause of polyneuropathies
```
diabetes --> damages nerves and vasculature
others:
Peripheral artery disease
B12 deficiency
Hypothyroidism
Alcohol use
Malignancy - especially small cell CA and Multiple Myeloma
Connective tissue disorder
```
304
Guillain-Barré Syndrome (GBS)
Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) - autoimmune
Often occurs few weeks post viral illness (eg flu)
Rapidly progressive “ascending” sensory loss
305
how to Dx GBS
Clinically:
Weakness distally in limbs, bilateral facial weakness
Sensory loss distally
Loss of reflexes
confirm: CSF analysis showing albumino-cytologic dissociation (high protein and no cells)
Slow NCV (only 2wks after onset)
306
GBS Tx
```
Need to act QUICKLY!
IV IG
Plasmapheresis: Removing autoantibodies
Respiratory support may be necessary
DVT prophylaxis
(can cause: cardiac arrhythmias and breathing problems)
```
307
Charcot-Marie-Tooth Disease
NOW called: Hereditary Sensory-Motor Neuropathy
| High arched feet, hammer toes, intrinsic hand/foot muscle atrophy, areflexia, sensory loss
308
pathophysiology of MS
Immune (t cells) cross BBB and activate astrocytes and microglia --> release inflam mediators --> myelin damage --> axonal injury --> damage oligodendrocytes (make myelin)
309
key in MS*
new numbness, tingling, weakness, vision loss or vertigo lasting at least 24 hours
310
Optic neuritis presentation
Blurred vision/vision loss
Color vision loss
Pain with eye movements
311
Types of MS
Relapsing Remitting: Most common
Secondary progressive: 20-40% from RR
primary progressive
312
Relapsing remitting MS
clearly defined attacks of new symptoms (relapses)
Periods of stability assoc w/relapse
disability accumulates w/mult relapse
313
Relapsing remitting MS Tx
Plasmapheresis
| High dose steroid: short term, doesn't help relapse
314
Secondary progressive MS Tx
progressive worsening of neurological function with or without relapses
no Tx
315
McDonald's Criteria
Need at least one symptom lasting at least 24hrs; AND dissemination in time (separated by at least 2 months) and in space (multiple locations)
316
Dissemination in Time
80% positive LP (at least 2 unique oligoclonal bands-IG)
| shown on MRI as enhancing (new) and nonenhancing (old), need MRI taken at least 2 months apart
317
MS Injectable Tx
```
Glatiramer acetate (Copaxone, Glatopa) - reduce relapse
Interferon beta-1a/1b
Peginterferon beta-1a (Plegridy)
(all try to reduce immune cells in CNS)
```
318
most common symptom of neuromuscular disease
weakness
319
Most common disorder of neuromuscular transmission
Myasthenia Gravis
320
Myasthenia Gravis pathophys
Autoimmune disorder
post-synaptic muscle membrane is distorted and simplified, less ACh receptor, AB on membranes receptors (ACh receptor)
AChR antibodies are found in 80-90% affected patients**
321
what can you find anatomically in MG pts?
enlarged thymus -> produce ABs
322
MG Hallmark Sx
```
fluctuating fatigable muscle weakness that worsens with activity and improves on rest
Worsens:
As the day progresses
Prolonged muscle use
Hot temperatures
Stress
Infection
```
323
types of MG
Ocular
| Generalized
324
MG Sx's
Specific muscle weakness, not usually generalized fatigue
2/3 of patients with MG will c/o ocular disturbances: ptosis, diplopia as the initial symptom
Oropharyngeal muscle weakness, difficulty chewing tough or fibrous foods, swallowing, talking – initial symptoms in 1/6 of patients
325
ALS
Nerve cells that control voluntary muscle movements are affected, Motor neurons gradually deteriorate
326
ALS Clinical findings
Upper motor neuron findings:
Slow speech
Brisk gag & jaw jerk, brisk limb reflexes
Spasticity
Lower motor neuron findings:
Atrophy
Fasciculations
Weakness
POS BABINSKI
also cognitive/behavioral changes
327
Most common limb symptom
asymmetric limb weakness
328
muscular dystrophy
```
Group of diseases that causes progressive weakness and loss of muscle mass, no cure
Abnormal genes (mutations) interfere with the production of proteins needed to form healthy muscle - dystrophin
```
329
Duchenne muscular dystrophy
most common m. dys.
X linked recessive disorder, more common males
Gower’s Maneuver- child needs to place 1 hand on the knee to assume an upright position when rising from the floor
Iliotibial bands and heel cords are first to become tight
330
Dx studies of Duchenne muscular dystrophy
Looking for deletion in dystrophin gene
- 30% of patients are negative; muscle biopsy is required to establish absence of dystrophin
Serum CPK levels markedly elevated
EMG - myopathic changes
331
Duchenne muscular dystrophy Tx
PT- goal is to keep joints as loose as possible
| night splints, bracing, surgery, steroids
332
what are patients w/duchenne muscular dystrophy prone to?
fatal pulmonary infections
resp failure
cardiomyopathy
