MKSAP Neuro Flashcards
(122 cards)
1
Q
What AEDs increase risk of osteoporosis? Name 4. When should screening start?
A
Phenytoin, Phenobarbital, Carbamazepine, Valproic acid
Should undergo DEXA scan after 5 years of therapy
2
Q
What disease is associated w/ exercise intolerance associated w/ myalgia, mild weakness, and myoglobinuria? How can these patients protect against exercise intolerance?
A
McArdle disease - glycogen storage disease V
They can protect against exercise intolerance by eating carbohydrate-rich diet
3
Q
What is the medical research council muscle scale and when is it used?
A
Scale that evaluates muscle strength of each extremity x 3 movements; maximum score is 60, if <48 = ICU related weakness is diagnosed
4
Q
What AEDs are preferred in pregnancy?
A
Levetiracetam and Lamotrigine (needs dose increase of 50%)
5
Q
What 3 AChe inhibitors are used in mild-moderate Alzheimer’s? What are the contraindications to their use? Name 5.
A
- Donepezil, Rivastigmine, Galantamine
- Sick sinus syndrome, LBBB, uncontrolled asthma, angle-closure glaucoma, ulcer disease; caution with seizures if using donepezil
6
Q
When do you do carotid endarterectomy?
A
> 80% stenosis in patients who have not had a stroke
>70% stenosis in females who have had a stroke; >50% in males who have had a stroke
7
Q
What diagnostic test can be performed in patients w/ mild cognitive impairment to diagnose Alzheimers? What proteins are found?
A
- LP
2. Decreased amyloid-beta-42 peptide, and increased tau protein & p-tau levels
8
Q
What monitoring is needed while on fingolimod?
A
Cardiac (bradycardia w/ first dose), eye exam (macular edema), liver enzymes, CBC (lymphopenia), yearly skin exam (basal cell carcinoma)
9
Q
What disease presents w/ numbness, distal extremity weakness, unsteady gait, areflexia, and atrophy of distal extremity muscles and foreleg muscles?
A
Charcot-Marie-Tooth disease
10
Q
What is St. John’s wort used for? What are some side effects? Name 5.
A
Depression
GI symptoms, dizziness, confusion, dry mouth, photosensitivity, sedation, urinary frequency, anorgasmia, drug interactions
11
Q
What medication can improve functional recovery in severe TBI?
A
Amantadine
12
Q
What presents as subacute severe pain -> resolution of pain -> progressive weakness and atrophy involving the shoulder girdle and upper extremity muscles?
A
Idiopathic brachial plexopathy/Neuralgic amyotrophy/Parsonage-Turner syndrome
It is often triggered by infection or surgery
13
Q
How does reversible cerebral vasoconstriction syndrome clinically present? What are triggers? Name 5. How does it look on imaging? What is the treatment?
A
- Thunderclap headache
- May be triggered by exertion, valsava maneuvers, emotion, or showering/bathing; also vasoactive drugs (sympathomimetic agents, triptans, cocaine, cannabis), anti-depressants, pregnancy, head/neck surgery or trauma
- Mutlifocal constriction of intracranial vessels on MRA or CT angiography
- Calcium channel blockers (verapamil or nimodipine)
14
Q
What are the two first line treatments for MS, and which is preferred in liver disease? What are the side effects? What is the FDA approved therapy for primary progressive MS, and what are the side effects? What is the FDA approved therapy for secondary progressive MS, and what are the side effects?
A
- Interferon beta (avoid in psychiatric disease and liver disease; can cause flu like sx, transaminitis) and glatiramer acetate (can cause injection site reactions, lipoatrophy)
- Ocrelizumab - can cause infections and infusion reactions; increases risk for PML and cancer
- Mitoxantrone - can cause cardiac toxicity and AML; also infection, nausea, oral sores, alopecia, menstrual irregularities, blue discoloration of urine
15
Q
How does cavernous sinus thrombosis present? What is the most common cause?
A
Acute onset headache, proptosis, periorbital edema, painful ophthalmoplegia
Most commonly caused by contiguous spread of infection
16
Q
How does carotid artery dissection present? Vertebral artery dissection?
A
- Orbital pain, partial Horner syndrome, ipsilateral signs of cerebral or retinal ischemia
- Occipital and neck pain; dysarthria, dysphagia, ataxia, and hemifield visual loss
17
Q
What type of CNS tumor is a dural-based tumor w/ a smooth rounded shape with a “tail” tracking along the dura outside the brain parenchyma? What is the treatment?
A
Meningioma
Surgery if symptomatic, observation if small and asymptomatic; no chemotherapy
18
Q
What is needed for staging of primary CNS lymphoma? What is the treatment?
A
Whole body PET or CT, bone marrow biopsy, and testicular U/S
IV methotrexate + rituximab; no surgery
19
Q
How does the paraneoplastic syndrome associated with anti-GAD present? Name 4 findings. What cancers is it associated with?
A
Stiff person syndrome, type 1 DM, ataxia, brainstem encephalitis, parkinsonism, ophthalmoplegia
Thymoma, breast cancer
20
Q
What conditions are associated with intracranial HTN? Name 5. What are the treatment options for idiopathic intracranial HTN? What are the potential side effects of these?
A
- Hypervitaminosis A, tetracyclines, retinoic acid, kidney failure, hypoparathyroidism, addison disease, use of estrogen and progesterone, pregnancy, steroid use or withdrawal
- Acetazolamide (preferred), Topiramate
- Paresthesia, kidney stones, taste perversion; weight loss in topiramate
21
Q
How does intracranial hypotension present? What is the treatment?
A
- Orthostatic headache, thunderclap or subacute; may be associated w/ tinnitus, diplopia, neck pain, nausea, photophobia, and phonophobia
- Autologous epidural blood patch - blood is injected into epidural space
22
Q
What cause of headache presents as diffuse non-nodular pachymeningeal enhancement on brain MRI?
A
Intracranial hypotension
Can also see cerebellar tonsillar descent, subdural fluid collections, decreased ventricular size, and engorgement of pituitary gland
23
Q
What is the preferred treatment for trigeminal neuralgia and what are 3 main side effects? What are 3 alternative medications for treatment?
A
- Carbamazepine - hyponatremia, agranulocytosis, dizziness
2. Oxcarbazepine, Baclofen, Gabapentin, Lamotrigine
24
Q
What are the contraindications for triptans?
A
Uncontrolled HTN, vascular disease (coronary, cerebral, or peripheral), or migraine w/ hemiplegic or brainstem auras
25
What two medications lack vasoconstrictor properties for migraine so may be used for acute migraine in patients w/ vascular disease, migraine w/ aura, and uncontrolled HTN?
Lasmiditan - highly selective 5-HT receptor agonist
| Ubrogepant - calcitonin gene related peptide antagonist
26
What are 3 treatment options for status migrainosus?
Several days of steroids
IV dopamine antagonist + IV benadryl, IV ketorolac, and hydration
IV DHE + anti-emetics
27
What are the 5 meds that can be used in migraine prophylaxis? What are 4 second line agents?
1. Propanolol, timolol, metoprolol, valproic acid, topiramate
2. Atenolol, amitriptyline, venlafaxine, NSAIDs
28
What are erenumab, fremanezumab, galcanezumab, and eptinezumab used for?
Monoclonal antibodies used in migraine prophylaxis
29
How do cluster headaches present? What is the treatment?
1. Cluster headache lasts 15 min to 3 hours, recurs 1-8 times daily over a span of weeks to months; months to years of remission; nocturnal attacks, may be precipitated by alcohol ingestion
2. Oxygen, subcutaneous sumatriptan; Verapamil as long term prevention
30
How does short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) present?
Headache lasting 1 second to 10 minutes, may recur more than 100 times daily; typically no periods of remission
Treat w/ lamotrigine but mostly refractory to medical management
31
How does chronic paroxysmal hemicrania present? What is the treatment?
Headache lasting 2-30 minutes, can recur up to 40 times daily; typically no periods of remission
Indomethacin
32
What is the management for cough headache? What is the management for primary stabbing/ice pick headaches?
1. Indomethacin; Brain MRI since up to half of patients can have a Chiari malformation
2. Indomethacin
33
What are the indications for surgery/drainage in acute vs. chronic subdural hematomas? What is the indication for urgent evacuation of an epidural hematoma? At what size should a cerebellar hemorrhage be evacuated?
1. Acute - hematoma thickness >10 mm, GCS <9, pupil asymmetry/fixation
2. Chronic - hematoma thickness >10 mm, midline shift >5 mm, significant neurological compromise
3. GCS <9, anisocoria, hematoma >30 mL in volume
4. >3 cm
34
What are the differences between absence seizure and focal seizure w/ altered awareness?
Absence seizure does not have aura, lasts <15 seconds, stops abruptly, no post-ictal state, can have multiple daily, and usually precipitated by hyperventilation
Focal seizure can have an aura, lasts >30 s, gradually terminates, has post-ical lethargy, can occur once weekly or monthly, not likely to be precipitated by hyperventilation
35
How can temporal lobe seizures present?
Rising feeling in stomach, deja vu, fear -> staring, arrest of speech or behavior, automatisms, altered smell/taste/hearing
36
What is the most common cause of medication-resistant adult-onset focal epilepsy?
Mesial temporal sclerosis w/ hippocampal atrophy
37
How does juvenile myoclonic epilepsy present?
Myoclonic seizures - may report dropping items from their hands; most have GTCS, 30% have absence seizures
Triggered by sleep deprivation, stress, and alcohol use
38
What are the 3 first line AEDs for focal seizures? 3 first line agents for generalized seizures?
1. Lamotrigine, Levetiracetam, Oxcarbazepine
| 2. Lamotrigine, Levetiracetam, Valproate
39
What are some side effects of phenobarbital? Name 4.
Sedation, hepatotoxicity, rash, pancytopenia, osteoporosis
40
What are some side effects of phenytoin? Name 8.
Sedation, ataxia, tremor, diplopia, bradycardia*, hypotension*, rash, gingival hyperplasia*, cerebellar atrophy*, peripheral neuropathy, osteoporosis*, pancytopenia, hepatotoxicity*
41
What are some side effects of valproic acid? Name 6.
Sedation, ataxia, tremor, diplopia, weight gain*, PCOS*, reversible parkinsonism w/ dementia*, pancytopenia, osteoporosis*, hepatotoxicity*, pancreatitis*
42
What are some side effects of carbamazepine and oxcarbazepine? Name 5.
Sedation, tremor, diplopia, dizziness, hyponatremia, rash, pancytopenia, osteoporosis, hepatotoxicity
43
What are some side effects of lamotrigine? Name 4.
Sedation, ataxia, tremor, diplopia, headache, dizziness, rash
* Rapid titration associated with SJS, TEN, and DRESS
* Preferred in patients w/ depression or psychosis
* Can worsen myoclonus
44
What are some side effects of topiramate and zonisamide? Name 6.
Sedation, ataxia, tremor, diplopia, poor concentration*, word finding difficulty, paresthesias*, weight loss*, anhidrosis, nephrolithiasis*, acute angle glaucoma*, psychosis, cleft lip/palate in fetus
45
What are some side effects of levetiracetam? Name 3.
Sedation, irritability, psychosis, depression, thrombocytopenia (rare)
46
What are some side effects of lacosamide? Name 4.
Sedation, ataxia, tremor, diplopia, PR prolongation/AV block, atrial fibrillation
47
Which AED should be avoided in elderly patients? Patients with hepatic insufficiency? Patients w/ acidosis and nephrolithiasis (2)? What AEDs need to be dose reduced in CKD (3)?
1. Valproic acid
2. Valproic acid
3. Topiramate, Zonisamide
4. Gabapentin, Pregabalin, Levetiracetam
48
Aneurysms of what size in the posterior & anterior circulation can be managed conservatively?
<7 mm in posterior, <12 mm in anterior
49
What is the risk with ICA stenting vs. endarterectomy?
Peri-procedural stroke w/ stenting
| Peri-procedueral MI w/ endarterectomy
50
What type of epilepsy is associated w/ nocturnal complex seizures that awaken people from sleep?
Frontal lobe epilepsy
| Typically associated with underlying structural pathology
51
What test is indicated for patients <45 y.o. w/ ICH related to cocaine use?
Cerebral angiography b/c this case is associated w/ high incidence of vascular anomalies
52
Which BP drugs should be avoided in ICH?
Nitroglycerin or nitroprusside b/c it increases ICP
53
What is the difference between secondary progressive and primary progressive MS?
Secondary progressive begins as relapsing-remitting; relapses later become infrequent, but there is slowly progressive neurologic disability
Primary progressive presents in 5th or 6th decade; steady progression of disability
54
Alemtuzumab, Teriflunomide, Dimethyl fumarate, and Natalizumab are MS treatments. What are the main side effects?
Alemtuzumab - infusion reactions, infections, autoimmune thyroiditis, ITP, nephropathy, skin cancer
Teriflunomide - Lymphopenia, HTN, peripheral neuropathy, transaminitis
Dimethyl fumarate - lymphopenia, GI sx, PML
Natalizumab - PML, HA, chest discomfort; rare infusion reactions, hepatotoxicity
55
What medication can be used in MS to improve walking speed, leg strength, and gait? What is the main side effect and in whom should it be avoided?
1. Dalfampridine
| 2. Seizures; avoid in those with kidney impairment
56
What medication can be used for pseudobulbar affect (uncontrolled fits of laughter or crying) in MS?
Dextromethorphan-quinidine
57
What medication is used for moderate to severe dementia?
Memantine
58
What medication can be used to treat Parkinson disease dementia?
Rivastigmine
59
What type of cognitive impairment presents w/ repeated falls, emotional incontinence (explosive crying, laughter), apathy, and severe cognitive slowing? What is the management for the cognitive impairment?
1. Vascular cognitive impairment
| 2. Donepezil
60
What is found on MRI, EEG, and CSF in CJD?
MRI: increased intensity in DW sequence of basal ganglia and various cortical regions; "hockey stick sign" in posterior thalamus
EEG: periodic sharp wave complexes
CSF: 14-3-3 protein, and elevation of total tau protein
61
Abuse of what substance can cause a relative B12 deficiency and lead to subacute combined degeneration?
Nitrous oxide
62
What is the first line treatment for Parkinson disease in patients <65 y.o. vs. >65 y.o?
Pramipexole, Ropinirole, Cabergoline in patients <65 y.o.
| Levodopa in older patients
63
What medication can be used to prevent dyskinesia in Parkinsons? What medication can improve neurogenic orthostatic hypotension? What medication is used for Parkinson psychosis? What medication is used for rapid relief of sx caused by sudden wearing off of Parkinson medication?
1. Amantadine
2. Droxidopa
3. Pimavanserin
4. Apomorphine
64
How does corticobasal degeneration (parkinson plus syndrome) present? Name 3 features.
Asymmetric parkinsonism, dystonia, myoclonus, cortical sensory deficits, cognitive deficits, and apraxia (impaired motor planning)
MRI shows asymmetric posterior parietal and frontal cortical atrophy
65
What can be used for symptomatic tx for Huntington disease?
Tetrabenazine, anti-psychotics, clonazepam, AEDs
66
What are treatment options for dystonia? Name 5.
Levodopa, BDZs, Baclofen, Anti-cholinergic drugs
| Clozapine, Tetrabenazine, Zolpidem
67
What is uhthoff phenomenon?
Transient worsening of baseline neurologic sx w/ elevations of body temperature
68
Patients age <40 with essential tremor or dystonia should be screened for what?
Wilson disease - ceruloplasmin and 24 hour urine copper
69
What are 3 treatment options for essential tremor?
Propanolol, Primidone, Topiramate
70
What are some drugs that cause action tremor? Name at least 3 categories and 5 drugs.
Beta agonists, stimulants, AEDs, amitriptyline, fluoxetine, cyclosporine, tacrolimus, atorvastatin, steroids, amiodarone, procainamide, levothyroxine, verapamil
71
What syndrome presents w/ intention tremor, ataxia, parkinsonism, neuropathy, and dementia in older men w/ fam hx of intellectual disability in young males and premature ovarian failure in females?
Fragile X-associated tremor/ataxia syndrome
72
In what disease is oculomasticatory myorhythmia (rhythmic movements of eye convergence w/ chewing) found?
Whipple disease
73
What is the treatment for Tourette syndrome?
CBT, address psychiatric co-morbidities
If tics interfere w/ daily activities treat w/ meds - Clonidine (first line); Topiramate, Levetiracetam, Tetrabenazine, Guanfacine
74
What are some treatment options for tardive dyskinesia? Name 4.
Valbenazine - monoamine depleter; first medication to receive FDA approval for TD treatment
Tetrabenazine, Clonazepam, Anti-cholinergic agents, Amantadine, Botox
75
What type of tremor is seen both at rest and w/ action, is position dependent and has a null point at which tremor stops if there is a change in the position of the affected limb?
Dystonic tremor
76
What type of tremor has a coarse proximal tremor at rest that is worse w/ posturing (especially large amplitude), and is most severe during movements? What type of tremor increases in amplitude as the limb approaches the target?
1. Rubral tremor - due to cerebellar outflow disorders (MS, stroke, TBI)
2. Cerebellar tremor
77
What are some secondary causes of facial nerve palsy? Name 5.
Lyme disease, HIV, sarcoidosis, diabetes, vasculitis, malignancy
78
Which drug increases survival in ALS? Which drug slows functional decline?
1. Riluzole
| 2. Edaravone
79
What imaging should all patients with myasthenia gravis have?
CT chest to screen for thymoma
80
What are the 3 main differences in lambert eaton when compared to MG?
Weakness improves w/ exercise, hyporeflexia and dysautonomia are present
81
What disease is associated w/ distal weakness, cataracts, frontal balding, arrhythmias, DM, thyroid disease, and mild cognitive impairment?
Myotonic dystrophy type 1
82
What lysosomal storage disorder has an adult onset form associated w/ proximal and respiratory muscle weakness? How is it diagnosed?
Pompe disease or acid maltase deficiency
| Diagnose w/ alpha-glucosidase activity
83
What are some drugs that are contraindicated in myasthenia gravis? Name 5.
Aminoglycosides, FQNs, magnesium, beta blockers, calcium channel blockers, neuromuscular blocking agents, morphine, barbiturates, hydroxychloroquine
84
What is the first step in management for medically refractive epilepsy?
Video EEG monitoring to determine candidacy for epilepsy surgery
85
How does autoimmune limbic encephalitis present? What antibodies are targeted?
Hyponatremia, myoclonus, limbic encephalitis (amnesia, temporal lobe seizures, confusion)
Antibodies against voltage-gated potassium channel receptor (LGI1, CASPR2, contactin-2)
86
What is the BP goal post thrombolysis after ischemic stroke? What is the next step in management?
BP <180/105 mmHg
| CT or MR angiography to determine candidacy for endovascular therapy
87
What is the leading cause of fatigue, headaches, and difficult to control HTN in patients w/ stroke?
Sleep-disordered breathing - diagnose with polysomnography
88
What are the 2 treatment options for idiopathic transverse myelitis?
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Steroids
Plasma exchange (or cyclophosphamide) if refractory to steroids
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89
How does the miller fisher variant of GBS present and what antibodies are found?
Ataxia, areflexia, and ophthalmoplegia
| Antibodies to GQ1b
90
Which meds can be used to control obsessive-compulsive behaviors in frontotemporal dementia?
SSRIs, TCAs
| Dementia medications are not helpful
91
What is periodic limb movements of sleep and what is the management?
Stereotyped ankle, knee, and hip flexion during sleep
| If not associated w/ a sleep disorder, no treatment is needed
92
What is the first step in treating psychosis in Parkinsons?
Discontinue dopamine agonist
93
How does multiple system atrophy present? Name 3 features.
Parkinonism, cerebellar ataxia, dysautonomia, early postural instability
94
For how long should anti-coagulation and anti-platelet therapy be held after deep ICH secondary to HTN?
30 days
95
What does POEMS stand for?
Polyneuropathy, organomegaly, endocrinopathy, monocloncal gammopathy, skin changes
96
What can be used to treat the behavioral and cognitive symptoms in Lewy body dementia?
Donepezil
97
What is the management of treatment-refractory depression associated with cognitive and functional decline?
Neuropsych testing
98
What disease presents w/ proximal muscle weakness, elevated CK, and biopsy w/ necrosis w/o inflammation? What antibody is found?
1. Immune-mediated necrotizing myopathy
| 2. hmg-coA reductase
99
What monitoring is needed while on Alemtuzumab?
Monthly CBC, Cr, and U/A
Quarterly thyroid function tests
Yearly skin exam
100
What condition is considered in a patient with recurrent spontaneous lobar intracranial hemorrhages?
Cerebral amyloid angiopathy
101
What are the differences between parkinson disease and parkinson-plus syndromes in regards to progression, symmetry of neurologic signs, tremor, timing postural instability, timing of dysautonomia, and response to levodopa?
Parkinson plus has rapid progression, symmetric neurologic signs, no tremor, early postural instability and dysautonomia, and poor response to levodopa
Parkinson disease often has tremor, is slow, asymmetric neuro signs, late onset of postural instability and dysautonomia, and excellent response to levodopa
102
What are treatment options for cataplexy (sudden loss of muscle tone associated w/ laughing or intense emotions) in narcolepsy? Name 3.
Venlafaxine, fluoxetine, atomoxetine, sodium oxybate
103
What lobe does a seizure presenting w/ focal contralateral motor activity (clonic jerking) localize to? Focal contralateral pain, numbness, or paresthesias?
1. Frontal lobe
| 2. Parietal lobe
104
What are some side effects of felbamate? Name 4.
Nausea, vomiting, diarrhea, aplastic anemia, hepatotoxicity
105
What are some side effects of tiagabine? Name 5.
Sedation, ataxia, tremor, diplopia, imbalance, headache, dizziness, acute confusion and encephalopathy
106
What are some side effects of perampanel? Name 3.
Dizziness, headache, sedation, homicidal ideation
107
What presents w/ days to weeks of mild confusion (despite being able to speak and walk), usually in patients w/ hx of generalized epilepsy but sometimes in healthy older adults?
Absence status epilepticus
| EEG shows continuous generalized spike-and-wave discharges
108
What is included in the ABCD2 score for TIA?
Age >60, BP >140/90, clinical sx (focal weakness vs. speech impairment without weakness), duration (>60 min, or less), presence of diabetes
109
What needs to be performed after diagnosis of subarachnoid hemorrhage?
Catheter-based angiography for definitive diagnosis of aneurysms and other causes of SAH
110
What are some absolute exclusion criteria for tPA in patients w/ acute ischemic stroke?
Significant head trauma or prior stroke in past 3 months, non compressive site arterial puncture within 7 days, intracranial neoplasm or aneurysm, recent intracranial or spinal surgery, BP >185/110 despite treatment, active internal bleeding, active bleeding diathesis (plts <100, heparin within 48 hours + high PTT, anti-coagulation + INR >1.7, DOAC use within 48 hours), glucose <50, multilobar infarction with >1/3 of hemisphere involved
111
For how long should anti-platelets be held after stroke w/ hemorrhagic conversion?
7 days
112
What condition is behavioral-variant frontotemporal dementia associated with?
ALS
113
What medications can be used to lessen the wearing off phenomenon in Parkinsons?
Dopamine agonists (pramipexole, ropinirole, cabergoline), catechol-O-methyltransferase inhibitors (entacapone, tolcapone), or monamine oxidase B inhibitors (selegiline, rasagiline, safinamide)
114
What is the treatment for myasthenic crisis with prominent bulbar or generalized weakness?
IVIG or plasmapheresis before steroids
115
What condition has myoedema (muscle mounding after percussion) on exam?
Hypothyroid myopathy
116
What is the treatment for glioblastoma?
Resection if possible, followed by radiation and chemotherapy
Temozolomide, nitrosureas, bevacizumab
117
Which AEDs are preferred in CNS tumors, if AEDs are indicated?
Levetiracetam and lacosamide
118
What is a positive apnea test?
PCO2 >60 mmHg or >20 mmHg increase overbaseline, and no spontaneous respirations
119
Which AEDs cannot be used w/ OCPs due to decreased effectiveness?
Carbamazepine, oxcarbazepine, phenytoin, barbiturates, primidone, topiramate
120
What is the main difference between mild cognitive impairment and dementia?
Dementia causes occupational or social functioning
| Mild cognitive impairment does not cause functional disability
121
What is the management for a patient age <60 with embolic stroke of unknown source and patent foramen ovale?
PFO closure
122
How do you differentiate dementia w/ lewy body from Alzheimer's and other neurocognitive diseases?
REM sleep disorder - most common in dementia w/ lewy bodies
