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RCE 2021 > General Neurology > Flashcards

General Neurology Flashcards

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1
Q

Lateral Medullary Syndrome/Wallenberg

A 
Vessel: PICA or vertebral
Ipsilateral ataxia
Ipsilateral dysphagia
Ipsilateral face/contralateral body dec pain/temp
Ipsilateral Horner's
Vertigo/nystagmus
Hiccups
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2
Q

Findings in lateral medullary syndrome

A

Vitals - ?AF, BP maybe up
CN - Horner’s (ptosis, miosis, anhydrosis), face pain/temp, dec corneal reflex, dec gag reflex, nystagmus (fast AWAY from lesion), hoarse voice
Motor - normal strength/reflexes
Sensory - contralateral pain/temp
Coordination - ipsilateral dysmetria and dysdiachokinesia
Gait - ataxic
Other - hiccups

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3
Q

Medial Medullary Syndrome

A

Vessel = anterior spinal artery
Ipsilateral tongue weakness
Contralateral arm/leg weakness
Contralateral body vibration/proprioception

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4
Q

Midbrain lesion/Weber’s

A 
Vessel = PCA
Ipsilateral CN3 palsy (ptosis, mydriasis, diplopia)
Eye down and out
Contralateral hemiplegia (face, arm, leg)
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5
Q

ACA

A

Contralateral leg weak and numb

Contralateral grasp reflex

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6
Q

Left MCA stroke - superior branch

A
  • Broca’s aphasia (expressive, non fluent)
  • R weakness face and arm > leg
  • Gaze deviation to the left
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7
Q

Left MCA stroke - inferior branch

A

Wernicke’s aphasia - receptive/fluent
R cortical sensory loss
Right pie in the sky visual loss

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8
Q

Left MCA - main branch M1

A
  • Global aphasia
  • Right weakness face and arm >leg
  • Right cortical sensory loss
  • Right pie in the sky
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9
Q

R MCA superior branch

A

Left weakness face and arm >leg

Gaze deviation to Right

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10
Q

R MCA inferior branch

A

Left cortical sensory loss
Left hemineglect
Left pie in the sky

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11
Q

R MCA main branch

A

Inferior and superior mix

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12
Q

PCA stroke

A

Contralateral homonymous hemianopia

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13
Q

Pure motor stroke

A

Localizations: posterior limb internal capsule, corona radiata, midbrain cerebral peduncle, pons
Artery: ant choroidal, small MCA/PCA branch, basilar
Symptoms
- Contralateral face, arm and leg weak

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14
Q

Pure sensory stroke

A

Localization: thalamus
Artery: thalamoperforators from PCA/MCA
Sx
Contralateral face, arm, leg sensory symptoms

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15
Q

Outpatient Management of TIA/non disabling stroke

A
  • Presenting after 24 hours
  • CT head or MRI head (ideally CTA/MRA arch to vertex)
  • BW: INR/PTT, glucose, lipid, A1c
  • ECG
  • Holter 24 hr plus - if think cardioembolic = 2 weeks
  • TTE if mechanism unknown
  • Start single antiplatelet
  • If already on anti platelet could switch to another
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16
Q

Acute Stroke in ER Management

A
  • Symptoms <24 hour
  • Eval for TPA or EVT
  • ABC, NIHSS, Evaluate/treat seizures
    Sx <4.5 hour = CT head ?tpa
    Sx <6 hour = CT, CTA arch to vertex ?EVT
    Sx 6-24 hr = CT, CTA, CTP if eligible for late window EVT
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17
Q

TPA for Acute Stroke

A 
Inclusion
- Ischemic stroke, DISABLING deficit (NIHSS6+, aphasia, hemianopia, visual/sensory extinction, weak against gravity), >18 yo
- Time from last known well <4.5 hr
Exclusion
- Any source of active hemorrhage
- Hemorrhage on bring imaging
- DOAC use
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18
Q

EVT for Acute Stroke

A
  • Can be in addition to TPA or for those not eligible
    Inclusion
  • > 18 yo, disabling sx, func independent, life expectancy >3 m
  • <6 hr from last known well
  • CT head small-mod ischemic core
  • CTA occlusion in anterior circulation of proximal large vessel (not in posterior circulation, consider basilar)
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19
Q

Acute Stroke BP Management

A
  • TPA = <180/105 x 24 hr
  • TPA and EVT = <180/105 x 24 hr
  • No TPA <220/120
  • EVT only - no targets
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20
Q

Acute Stroke Antiplatelets immediate

A

ASA 160 mg (sometimes DAPT)
IF not on anti platelet, no TPA and no bleed on CT

IF TPA - wait 24 hr before starting ASA (no DAPT)

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21
Q

High risk TIA/Minor stroke antiplatelets

A
  • If non cardioembolic
  • Plavix and ASA 21-30 d then mono therapy
  • Minimal loading dose Plavix 300-600 and 160 ASA
  • Ideally within 12 hours as soon as brain imaging done
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22
Q

Antiplatelets severe intracranial atherosclerosis

A

TIA/stroke in last 30 days PLUS
70-99% stenosis in major intracranial vessel
Consider DAPT x 3 mos then single

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23
Q

Stroke while on antiplatelets

A

On ASA –> Plavix

On Plavix –> ASA/dipyridamole

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24
Q

Stroke and Carotid Stenosis

A

TIA/non disabling + ipsilateral 50-99%

  • Get CTA
  • Stroke expert ASAP

TIA/non disabling + ipsilateral 70-99%

  • CEA either within 48 hr or 2 weeks
  • CEA > CAS if >70 yo

Symptoms <50%
- Max medical management

Asymptomatic/remote >6 m + 60-99%

  • If life expectancy >5 yr = evaluate by stroke expert
  • Maybe CEA/CAS
  • Max medical
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25
Stroke and AF Med choice
- DOAC >warfarin - Bridge with anti platelet (not heparin) - Mechanical valve OR mod-sev MS = warfarin only
26
Stroke and AF Timing
TIA <1 d Mild/small <8 - 3 days Mod 8-15 - 6 days Severe/large 16+ - 12 days Delay if: hemorrhagic transformation, mod-large infarct, high NIHSS, uncontrolled HTN, coagulopathy Early if: mechanical heart valve, intracardiac thrombus, hypercoagluable
27
Stroke Secondary Prevention
``` BP - Past stroke/TIA BP<140/90 Lipids - Check level, start statin, LDL<2/50% drop DM - Test, A1c 7% or less Diet - High fruit/veg, low fat dairy/fibre, plant protein - Na <2 g/day - Exercise mod 4-7 d/week - Stop smoking, alcohol F<10, M<15 - Weight BMI 18.5-25 ```
28
Stroke PFO
If stroke due to PFO, closure with anti platelet recommended if: - 18-60 yo - Stroke non lacunar - Specialist thinks PFO most likely cause
29
Post stroke depression
- 1st year highest risk - screen patients - if more than mild tx CBT, IPT, SSRI (tx min 6-12 mos)
30
Patient comes in with major stroke >24 hr after symptoms started
Single anti platelet only
31
Dissection causing stroke
- If EXTRAcranial carotid or vertebral dissection = anti platelet or anticoagulant - Heparin or warfarin - can choose either - Usually x3-6 mos (repeat CTA to see if resolved) - No evidence for DOACs, duration - No evidence for anticoagulation with INTRAcranial dissection
32
Symptomatic extra cranial dissection
IV heparin --> LMWH/warfarin x 3-6 mos Repeat CTA to see if resolved Can use anti platelet instead
33
Asymptomatic extra cranial dissection
Antiplatelet
34
Any extra cranial dissection and floating thrombus on CTA
Heparin Then warfarin 3-6 mos Repeat CTA for resolution
35
Intracranial dissection
Antiplatelet
36
Embolic stroke undetermined source
No good evidence for riva or dabi and inc bleed compared to ASA
37
Stroke in <55 yo
Risk factors still HTN, DLD, smoking | Most commonly - cardioembolic and dissection
38
Intracranial Hemorrhage Investigation
CTA - rule out underlying lesion, better than MRA for vascular lesion
39
ICH BP Management
- Assess q15 min x 24 hr - SBP <140-160 for first 24 hr - Prefer 140 if <6 hr ago, on anticoagulant, signs of expansion, presenting SBP <220 Long term target <130/80
40
ICH on anticoagulant
- Reverse anti Xa with PCC - Reverse dabi with idaracizumab - LMWH within 12 hr - protamine - IV UFH - protamine - TXA may reduce volume
41
ICH Neurosurgery
Always call for assessment EVD if dec LOC and hydrocephalus No surgery if stable and no signs herniation
42
ICH Work up
Consider MRI to look for mass/AVM/AVF/amyloid
43
ICH DVTp
IPC then LMWH 48 h after hematoma stable
44
ICH Seizure
If in first 24 hours no need for AED longterm
45
ICH Steroids
HARMFUL, don't use
46
Rest tremor
Idiopathic PD | Other parkinsonism
47
Action tremors
Postural - Enhanced physiologic - Essential - Dystonic Kinetic/intention - Cerebellar disease - Li
48
PD tremor
``` Low frequency Asymmetrical At rest Respond to levodopa Minimal impairment micrographia ```
49
Essential tremor
``` Higher frequency Symmetrical Action/posture Fam hx common Good response to alcohol, no to levodopa Significant impairment Writing messy ```
50
Enhanced physiologic tremor
``` High frequency Small amplitude Symmetrical Postural Enhanced by caffeine, anxiety, stress, TSH, drugs, withdrawal ```
51
Dystonic tremor
``` Dystonia patients when they fight their posture Head and hands Asymmetrical Irregular Postural, not at rest ```
52
Cerebellar tremor
Intention or postural Can also have ataxia, dysdiachokinesia Young --> think MS, Wilson's Stroke -> sudden onset, older, asymmetric
53
Psychogenic tremor
``` Rest/posture/intention mix Irregular Variable freq and amplitude Distractible Entrainable ```
54
Parkinsonism Symptoms
1. Tremor - rest, low amp, thumb 2. Rigidity 3. Akinesia/bradykinesia - slow, fatigue and decrement 4. Postural - hesitant gait (short shuffling, reduce arm swing), freezing
55
Parkinsonism DDx
1. Idiopathic PD 2. Park plus - LBD, PSP, MSA, CBD 3. Vascular - stroke 4. Drug induced - antipsychotics, metoclopramide 5. Genetic - Wilson's 6. Toxins - manganese
56
Idiopathic PD Dx
1. Parkinsonism - akinesia + one of rigidity or tremor 2. Two supportive 3. Absence absolute exclusion 4. No red flags
57
IPD Absolute Exclusion
1. Cerebellar abnormal - MSA 2. Downward vertical gaze palsy/slow vertical saccades - PSP 3. Dx FTD 4. Exclusive lower extremity Parkinsonism x 3 yrs - vascular 5. Tx dopamine receptor blocker - drug induced 6. No response to L dopa 7. Cortical sensory loss, apraxia, aphasia (CBD) 8. Normal functional neuroimaging of dopaminergic system 9. Alternative dx documented
58
IPD Supportive Criteria
1. Response to L dopa 2. L dopa induced dyskinesia 3. Rest tremor of limb 4. Documented olfactory loss/cardiac sympathetic denervation on MIBG scintigraphy
59
Red flags IPD
1. Rapid gait impairment - wheelchair within 5 years onset 2. No progression of motor sx 3. Early bulbar dysfunction 4. Stridor 5. Sev autonomic failure in first 5 yrs 6. Recurrent falls within 3 years onset 7. Anterocollis 8. Absence common non motor sx despite 5 yrs disease 9. Pyramidal signs 10. Bilateral symmetric
60
Typical PD Disease Course
``` Preceding - Anosmia - REM sleep behaviour disorder - Constipation Early - Asymmetric tremor, bradykinesia and rigidity Late - Postural instability/falls - Dementia - Visual hallucinations - Autonomic ```
61
Levodopa/Carbidopa
- PD motor sx - Convert to dopamine in CNS SFx - N/V, ortho HOTN, sedation, confusion, hallucinations - Dyskinesia - Dopa dysregulation (Addiction)
62
Pramipexole
``` PD Motor sx - Dopamine agonist SFx - Ortho HOTN - Sleep attacks - Halluncations - ICD - gamble, sex, shop, eat - Leg swelling ```
63
Trihexyphenidyl
``` Tremor ANTIcholinergic SFx - Dry eyes, blurry vision, dry mouth, constipation, retention - Memory issues ```
64
Selegiline
PD motor sx MAOi inh - HTN crisis tyramine foods - Serotonin syndrome
65
Entacapone
Prolong L dopa COMT inhibitor Orange urine
66
Amantadine
Dyskinesias - Anticholinergic - Insomnia - Levido reticularis - CI if seizures
67
Domperidone
Ortho HOTN Dopamine agonist in gut QT prolong
68
PD Guidelines
- no CT/MRI routine - Ldopa most effective - Regular exercise program - deep brain stimulation - Botulinum for drooling - Ortho HOTN - midodrone, fludrocortisone, domperidone - REM SBD before dx
69
Drug induced parkinsonism
- Symmetric Parkinsonism - Tremor postural - Weeks/mos of onset of drug Think metoclopramide, antipsychotic
70
Vascular parkinsonism
Risk factors, multiple small strokes - Symmetric - Lower body parkinsonism - Falls, pyramidal - Dementia, incontinence - Tremor not common - Poor response to Ldopa
71
MSA
- Symmetrical parkinsonism - No tremor - Early falls, ataxia - Dysautonomia - ortho, ED, incontinent - Pyramidal signs - Stridor - Distal myoclonus - No response to levodopa (orofacial dyskinesia)
72
PSP
- Symmetric parkinsonism - Axial rigid - No tremor - Early falls - Verticular supranuclear gaze paresis - Hyperfrontalis - Sev dysarthria - Mild dementia - Poor response LD
73
CBD
``` Very asymmetric parkinsonism Dystonia Myoclonus Apraxia Aphasia Cortical sensory loss Alien limb No response to LD ```
74
LBD
- Symmetric parkinsonism - Tremor - Early dementia - Fluctuating attention - Visual hallucinations - Hypersensitive to antipsychotics - some response to LD - REM SBD
75
CRAO
Vasculopathy Sudden complete PAINLESS unilateral vision loss Cherry red spot
76
Papilledema
Bilateral disc edema | think intracranial HTN
77
Acute optic neuritis
Young F Unilateral eye pain Vision loss Pale disc = prior optic neuritis
78
Glaucoma
``` Older Poor peripheral vision No pain Eye pressure elevated Large cup to disc ratio Pale disc ```
79
Diabetic Retinopathy
``` Cotton wool spots Microaneurysms Hard exudates Neovascularization Flame hemorrhages ```
80
Hypertensive Retinopathy
``` Cotton wool spots Hard exudates Flame hemorrhages AV nicking Copper Wiring Disc Edema ```
81
Infective endocarditis eye
Roth Spot
82
Approach to Diplopia nerves involved
1. CN6 = LR 2. CN4 = SO 3. CN3 = the rest, eyelid, constrict 4. Sympathetics = dilation
83
Cavernous Sinus contains
CN 3,4, V1, V2, 6 and sympathetics
84
Monocular diplopia
Psych or Ophtho
85
Binocular diplopia
Neurology problem
86
Horizontal images
CN 6 palsy
87
Vertical images
CN 4 palsy
88
Oblique images
CN 3 palsy
89
Diplopia worse near
CN 3/4
90
Diplopia worse far
CN 6
91
Diplopia worse looking L/R
CN 6
92
Diplopia worse looking up/down
CN 3/4
93
CN3 Palsy vs Horner's
``` Ptosis - Both Pupil - Horner = miosis - CN3 = mydriasis Anisocoria - Horner worse in dark - CN3 worse in light Diplopia - CN3 down and out Rule Out - Horner - carotid dissection in neck - CN3 PCOMM aneurysm ```
94
Binocular Diplopia
- EOM - thyroid - NMJ - MG - Cavernous sinus - Brainstem internuclear - stroke, MS INO
95
CN3 Palsy ischemic vs compressive
- Both have ptosis and down and out - Ischemic pupil spared, comp mydriasis - Ischemic no pain, comp pain - Ischemic in DM/DM/HTN - Comp in aneurysm
96
CTA for CN3
1. Complete CN3 and pupil spared = no CTA 2. Partial CN3 and pupil spared = CTA 3. Pupil involved = CTA
97
Horner's syndrome
1. Ptosis 2. Miosis 3. Anhidrosis Ddx 1. First order neuron - stroke, demyelinating, tumour - MRI brain 2. Second order - T1 radic, pan coast tumor - MRI C spine/CT chest 3. 3rd order - carotid dissection/aneurysm - CTA neck/brain
98
CN6 Palsy
- Binocular diplopia, horizontal images, worse far, worse looking to same side as palsy Inv - CT/CTA if cavernous sinus - MRI brain with GAD - tumor, inflame, infection - MRI brain with MRV/CTV (for VST) then LP (IIH)
99
Complete Cord Syndrome
- Bilateral sensation below - Bilateral weakness (LMN at level, UMN below) - Bowel and bladder problems - Above C3=respiration - Above T6=auto dysreflexia - If sudden injury may initially be flaccid and absent reflexes Etiology - Trauma - Large disc - Hemorrhage - Abscess - Transverse myelitis
100
Central Cord
- Suspended sensory loss pain/temp - No weakness - No loss vib/prop Etiology 1. Syringomyelia (fluid filled cyst in spinal cord) 2. Intramedullary tumor
101
Anterior Cord Syndrome
1. Bilateral loss pain and temp 2. Bilateral weak 3. Bowel and bladder 4. Normal prop/vib Etiology 1. Spinal cord infarction (ant spinal artery) 2. Disc herniation
102
Posterior Cord Syndrome
1. Bilateral loss prop/vib 2. +/- weakness 3. Pain/temp fine Etiology 1. Syphilis - tabes dorsalis 2. B12 - subacute combined degeneration
103
B12 Def - SCD
1. Anemia, atrophic glossitis 2. Dementia 3. Normal pupils, dec visual acuity 4. UMN weakness - brisk knee reflexes, upping toes 5. LMN weakness - loss of ankle reflexes 6. Loss of vib/prop 7. Can have loss of pain/temp/vib/propr distal 8. Sensory ataxia 9. Positive Romberg
104
Syphilis tabes dorsalis
1. Gummas, LN, aortitis 2. Dementia 3. Argyll Robertson pupils 4. Normal strength 5. Loss reflexes 6. Loss vib/prop 7. Sensory ataxia 8. Positive Romberg
105
Hemi Cord/Brown Sequard
1. Ipsilateral weakness 2. Ipsilateral loss vib/prop 3. Contralat loss pain/temp Etiology 1. Trauma 2. Demyelination - MS
106
Pure Motor Spinal Cord
Asymmetric weakness - UMN only(HTLV) or LMN only (ALS) or both (West Nile/polio)
107
L5 vs Peroneal Neuropathy
Ankle inversion and hip ABduction strong in peroneal, weak in L5
108
C7 vs radial neuropathy
Radial lesion - Strong pronator teres, triceps - weak BR C7 Lesion - Strong BR - Weak pronator teres, triceps
109
C8/T1 vs Ulnar
Ulnar - FPL (flex thumb), APB (abduct thumb), EIP strong C8/T1 - FPL, APB, EIP weak
110
White on CT
1. Calcium/bone 2. Contrast 3. Blood - acute, hrs to days 4. Melanoma, lymphoma
111
Blood on CT
Hyperdense - hrs to days Isodense - 1-2 weeks Hypodense - 3-4 weeks
112
Rule out SAH with CT head if
Within 12 hrs from onset and read by neuroradiologist | Otherwise need LP
113
T2 and FLAIR MRI
Hyperintense = any pathology | Stroke, tumor, blood, demyelination
114
DWI and ADC
Acute stroke <14 d will be white on DWI and dark on aDC
115
GRE or SWI
Blood of any age or calcium
116
T1 with gad
enhancement = tumor, new demyelinating lesion, infection
117
ALS
Selective loss of pyramidal neurons and motor neurons Die from respiratory failure Bulbar - dysphagia, dysarthria, dyspnea, brisk jaw jerk LMN at level of lesion UMN below lesion
118
UMN findings
Spasticity Hyper reflexia Upgoing toes
119
LMN findings
Atrophy Fasciculations Weakness
120
ALS Dx
MRI C spine | NCS/EMG
121
ALS Tx
Multidisciplinary clinic Riluzole - inc survival 3 mos Edaravone - dec functional decline Sialorrhea - anticholinergic, suction, botox Spasticity - PT, baclofen, botox Cramps - tonic water, gabapentin, baclofen
122
ALS Respiratory Care
``` - FVC baseline and q 3 months Home NIV - Symptoms - orthopnea - SNIP <40, MIP <40 - Upright FVC <65% - FVC sit/supine <80% symptoms - Daytime PCO2>45 - Abnormal nocturnal oximetry/sleep disordered breathing ```
123
Pseudobulbar Palsy
``` UMN lesion in the corticobulbar pathway (medulla and CS tract) Sx 1. Dysphagia 2. Dysarthria 3. UMN findings 4. Pseudobulbar affect Etiology 1. ALS 2. MSA 3. PSP ```
124
Outpatient stroke last 48 hours very high risk features and tx
``` Features: unilateral weakness, language/speech Tx 1. Send to ED stroke centre 2. Imaging within 24 hours 3. ECG Tx DAPT 2-3 wks ```
125
Outpatient stroke 48 hrs-2 weeks high risk
Unilateral weakness, language/speech disturbance See stroke neurologist within 24 hrs Tx DAPT 2-3 wks
126
Outpatient stroke 48 hrs-2 weeks medium risk
No weakness, language/speech change Stroke expert within 2 weeks Tx DAPT 2-3 wks
127
Outpatient stroke >2 weeks
See stroke expert in 1 month | Tx DAPT 2-3 wks
128
Amaurosis Fugax
``` Painless Sudden transient blindness Usually embolic from ipsilateral carotid Monocular Last <5-10 mins ```
129
Bell's palsy Tx
1. Prednisone | 2. +/- acyclovir
130
Motor grading
``` 0 = paralysis 1 = flicker 2 = can't move against gravity 3 = can move against gravity 4 = move against some resistance 5 = complete strength ```
131
LEMS
Anti Ca channel Ab Associated with small cell carcinoma Proximal muscle weakness = incremental response Hyporeflexia or absent
132
Pontine lesion
Pupils small and fixed
133
Triptan and ergot CI
CAD
134
Cauda Equina
Acute - Weakness/paraparesis - Reduced DTRs at knees/ankles - Bilateral sensory loss - urinary retention +/- fecal incontinence - LBP to legs (sciatica) - NO babinski

RCE 2021 (6 decks)

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