Neuro Flashcards
(80 cards)
1
Q
MS
-autoimmune inflammatory condition involving 3 pathophysiological hallmarks:
A
MS
- degeneration of CNS myelin
- sclerosis / plaque formation
- axonal loss
2
Q
MS
Name 4 predisposing risk factors
A
MS
- northern latitude
- smoking
- vit D deficiency
- viruses (EBV, measles, HSV)
(also more common in females but men have more severe course)
3
Q
Pathophysiology of MS
immune mediated destruction of _____ which causes disruption in _____ and death of ________
A
destruction of myelin
disruption of nerve conduction
death of neurons/axons
4
Q
MS
Name 4 common triggers of MS relapses
A
- trauma
- emotional stress
- pregnancy
- heat
5
Q
MS
Name the 4 subtypes of MS
-which one is most common?
A
- Remitting-relapsing: initial onset of symptoms, with remission and exacerbations (85-90% of cases)
- Primary-progressive: steady decline from onset (10-15% of cases), no relapse/remission
- Secondary-progressive: initially remitting/relapsing with steady decline in function (65% of pts with RRMS after 15-20 years)
- Progressive-relapsing: progressive from onset with superimposed relapses
6
Q
MS
Name the common early symptoms of MS
A
- paresthesia of face, trunk, limbs
- weakness
- visual disturbance (diplopia, blurred vision)
- urinary symptoms (incontinence)
- fatigue (90%)
- impaired gait
7
Q
MS
Name some common cognitive changes with MS
A
- DEPRESSION* (50%)
- apathy
- emotional lability
- problems with memory, attention, concentration
- poor judgement and planning
8
Q
MS
What are 3 systems to assess during physical exam?
A
- complete neuro
- eye
- MSK
9
Q
Multiple Sclerosis
Imaging of choice?
Lab:
- 90% will have _________ bands on electrophoresis
- 2/3 will have persistently elevated _______
What vitamin deficiency has similar symptoms?
A
MRI
90%: oligoclonal IgG bands
2/3: persistently elevated IgG
-B12 deficiency
10
Q
MS first line medication: _______
Drug class? Route? Effect on vaccines? Common side effects? Important to monitor for?
A
INTERFERON
- immunomodulator
- weekly injectable (avonex IM, rebif sc)
- will lessen immune response to live vaccines
- flu-like (fever, chills, myalgia), injection site reaction
Monitor for depression!
11
Q
MS first line po medication for RRMS ______
Drug class?
Route?
Effect on vaccines?
Common side effects?
A
Tecfidera (dimethyl fumarate)
- antineoplastic immunomodulator
- po
- NO live vaccines
- side effects: flushing, GI, drop in lymphocytes
12
Q
MS Patient education topics:
A
- smoking cessation
- heat sensitivity
- vision: rest eyes periodically
- activity, exercise and rest
- fluid restriction and pelvic floor exercises: for bladder symptoms
13
Q
Impact of pregnancy and breastfeeding on multiple sclerosis?
A
- pregnancy and breastfeeding are PROTECTIVE (may stabilize or remit in pregnancy)
- 20-40% will have relapse postpartum
-should stop immunomodulators 2-3 months before conception
14
Q
What is the most common cause of vertigo?
A
BPPV
15
Q
What is the triad of symptoms in Menieres?
A
- tinnitus
- hearing loss
- vertigo
16
Q
What is the vestibular neuritis often preceded by?
A
-viral infection
vertigo is often sudden and severe
17
Q
Vertigo
What are some common medications that can cause vertigo?
A
anticonvulsants antidepressants antipsychotics anxiolytics/sedations anti-HTN nitrates diuretics insulin/hypoglycemic agents
18
Q
Define the difference between central and peripheral vertigo
A
Peripheral: dysfunction in inner ear/vestibular nerve
Central: from brainstem/cerebellar ischemia
eg MS, seizures, migraines, neoplasm
19
Q
Common symptoms accompanying:
- CENTRAL VERTIGO
- PERIPHERAL VERTIGO
A
Central: diplopia, dysphagia, dysarthria, abN motor/sensory exam, paresthesia
Peripheral: vertigo usually severe, no associated brainstem symptoms. May have triad of Menieres
20
Q
Central vertigo on physical exam will have deficits in:
A
-cerebellar function
finger to nose, rapid alternating movement, gait
21
Q
Vertigo
Name 3 systems to assess during physical exam
A
- ENT (to r/o otitis media)
- CVS (carotid bruit)
- Neuro (duh)
22
Q
Nystagmus with Dix-Hallpike maneuver is _____ with central vertigo and ______ with peripheral vertigo
A
central: delayed nystagmus
peripheral: immediate nystagmus
23
Q
Bloodwork for vertigo workup
A
CBC
TSH
Lytes
Syphilis screen
24
Q
Contraindications for Epley’s maneuver
A
- neck fracture/instability
- head injury
- unstable carotid disease
- recent retinal detachment
25
What are three classes of medications to suppress vestibular symptoms of vertigo?
- antihistamines (eg meclizine, gravol, Benadryl)
- Benzos
- antiemetics (eg ondansetron, metoclopramide, prochlorperazine)
* these medications are not routinely recommended or used but can be considered for severe acute vertigo
26
Trigeminal neuralgia
Hallmark features (key descriptors)
recurrent severe paroxysmal episodes of electric shock pain along CN V distribution
27
Trigeminal neuralgia
Risk factors:
- possible link to ____ and ____
- most commonly associated with ______
Risk factors:
-possible link to HTN and migraines
-most common association with MS
28
Trigeminal neuralgia
Describe characteristics of the pain
- description
- timing
- location
- triggers
- associated symptoms
Description: electric shocks, severe, stabbing
Timing: Lasts seconds to 2 min, can occur 0-50x/day, does not typically wake people at night
Common to have continuous dull pain between attacks
Location: over CN V distribution (often V2 or V3)
Unilateral, can be bilat over time (esp with MS), rare to be simultaneous
Triggers: light touch along CN V, chewing, brushing teeth, smiling, shaving, cold air, talking
Associated symptoms: tearing, conjunctival injection, rhinorrhea
29
Trigeminal neuralgia
Diagnostics?
Based on clinical hx
- neuro, ENT, dental/TMJ exam
- MRI to r/o brain lesion as cause of compression
30
Trigeminal neuralgia
First line treatment medication: _______
- precautions
- contraindications
- monitoring
- common side effects
First line Rx: carbemazepine (Tegretol)
Precaution: CYP inducer, test for HLA-B*15:02 in Asians (risk of SJS/TEN)
Contraindications: many drug interactions
Monitoring: serum levels
Side effects: GI (n/v/d), hyponatremia, skin (rash, pruritis), drowsiness, blurred/double vision
**need gradual taper
31
Meningitis
Risk factors/Predisposing conditions
- what age?
- sequelae of what diseases?
- comorbid with what conditions?
Meningitis Risk factors:
-age: (<4, adolescents, university students living in dorms)
- sequela of Lyme disease, dental infection, OM, bacterial sinusitis, Hib, varicella, STI
- penetrating head wound, spinal trauma
- sickle cell, asplenia, Hodgkin’s, Ab deficiencies
32
Organisms most commonly responsible for bacterial meningitis in:
- neonates
- kids and teens:
- adults:
Transmission?
- Neonates: GBS, E. coli, listeria monocytogenes
- 2 to 18: N. meningitidis (nasopharynx entry), S. pneumoniae, Hib
- Adults 19-59: S. pneumoniae, N. meningitidis, Hib
- Adults 60+: S. pneumoniae, L. monocytogenes, N. meningitidis
DROPLET transmission
33
What are some causes of aseptic meningitis?
- virus
- fungus
- non-infectious (eg blood in subarachnoid space)
34
What are the 3 hallmark symptoms (triad) of bacterial meningitis?
Other symptoms in
- neonates
- children and adults
- nuchal rigidity
- fever
- altered LOC
BABIES: high pitched cry, inconsolable, bulging fontanelles, poor feeding, vomiting (vomiting, seizures)
KIDS/ADULTS: sudden onset severe constant headache worse with movement, CNS (vomiting, seizures)
Rash depends on organism --> can be macular, maculopapular, petechia, palpable purpura
35
Assessment for meningitis:
-specific history (besides OLDCARTS) to ask:
- current/recent hx of OM, URI, sinus infection
- chickenpox exposure
- recent dental treatment
- immunizations
- spinal or cranial surgeries
- substance use
- neonates: prenatal history
36
Assessment for meningitis
Physical exam:
- systems to focus on:
- special tests:
- full head to toe exam
- systems of focus: neuro, derm (petechial/ecchymotic rash), ENT (dental disease)
Brudzinski’s (supine, passive neck flexion causes hip flexion)
Kernig’s (supine, pain with extension of flexed knee and hip)
37
CSF findings will show high _____ and -____ and low ______ with bacterial meningitis
high WBC
high protein
low glucose
38
What are some associated complications with bacterial meningitis?
brain damage, hearing loss, learning disability, amputations
39
Before prescribing Carbemazepine, need to test for ________ in _______ (pt demographic) due to increased risk of ___________
- HLA-B*15:02
- Asian patients
- SJS or TEN (toxic epidermal necrolysis)
40
# Define restless legs syndrome
More common in (sex)
-uncomfortable urge to move legs especially at night
2x more common in women
41
Restless legs syndrome
Name some risk factors
including. ....
- chronic diseases?
- medications? 4 class of meds
- pregnancy (third trimester)
- ESRD (25-50% esp with hemodialysis)
- venous insufficiency/varicose veins
- chronic disease: diabetes, anemia, Parkinson’s, MS
- Medications: antiemetics (metoclopramide), antipsychotics, antidepressants (SSRI, SNRI, TCA), antihistamines
42
What is the hypothesized pathophysiology of restless legs?
- neurotransmitter involved?
- low _____ in brain?
What are some triggers?
- basal ganglia dopamine dysfunction
- low ferritin
Triggers:
- ETOH
- sleep deprivation
- caffeine
- long care trips/sitting for long periods
43
URGES mnemonic for restless leg syndrome diagnosis
```
Urge to move the limbs
Rest or inactivity: worsens symptoms
Getting up and moving: relief of symptoms
Evenings: symptoms get worse
Secondary causes must be excluded
```
44
What is first line treatment for moderate to severe RLS?
```
Generic:
Trade:
Classification
Duration of treatment:
Adverse side effects:
Precautions:
Monitoring:
```
Generic: Pramipexole
Trade: Mirapex
Classification: Dopamine Agonist
Therapeutic Indication:
MOA: unknown, stimulates dopamine receptors
Duration (interval) of treatment: short term use as long term can worsen symptoms within a few months
*take until symptoms resolve*
Adverse S/E:
1) Hypotension
2) Dyskinesia
3) Rebound symptoms
Precautions: Avoid abrupt stopping, CNS depressant
Monitoring: renal clearance, BP (orthostatic hypotension)
45
RLS
best to make medications at what time?
How to long stay on treatment?
1 to 2 hours before bedtime
dopaminergic agents: best to limit to short term use
*long term use can worsen symptoms
46
What are some triggers that can lower seizure threshold?
- sleep deprivation, fatigue
- emotional or physical stress
- hypoglycemia
- hyperventilation
- medication withdrawal (benzodiazepines, alcohol)
- hormonal changes (women before or during menses)
Environmental stimuli: blinking lights, fuzzy TV, loud noises, music, odour, being startled
47
Seizures occur when there is an imbalance between excitatory and inhibitory neurotransmitters
Main excitatory neurotransmitter in CNS?
Main inhibitory neurotransmitter in CNS?
Glutamate: excitatory neurotransmitter
GABA: inhibitory neurotransmitter
48
What is the pathophysiological difference between generalized and focal seizures?
Generalized: originate within and engage both hemispheres
Focal: originate in one hemisphere --> can spread
49
Name 4 types of generalized seizures
tonic clonic
absence (petit mal)
atonic
myotonic
50
What are the difference in features between absence and focal onset impaired awareness seizures?
Absence (“petit mal”): brief loss of consciousness with minimal/no loss of muscle tone
● Lasts seconds 5-10 seconds
● Often mistaken for “daydreaming” (cannot be interrupted)
● Can be accompanied by lip-smacking, eyelid twitching
● No preceding aura or postictal confusion
● Clusters, can frequently have >20/day
● Onset in childhood
Focal Onset Impaired Awareness Seizures
(Complex Partial Seizures): seizure activity with impaired loss of consciousness
● Lasts 1-2 min
● Sudden onset of blank “daydreaming” stare that cannot be interrupted
● Often accompanied by automatism (eg lip-smacking, chewing, fumbling, rubbing hands)
● Can have brief postictal confusion
51
Describe features of focal onset aware seizures (simple partial seizures):
Focal Onset Aware Seizures (Simple Partial Seizures): seizure activity without loss of consciousness. Commonly known as “auras”
● Brief (<1 min)
Common descriptors:
● Rising abdominal sensation (roller coaster)
● Anxiety, fear, joy, “déjà vu”
● Numbness, tingling
● Flashing lights, unusual smells
52
History questions to ask during assessment of seizure disorder:
History is key! From patient and a witness if possible
Assess for:
- description of symptoms (often the first symptom is the most helpful clue - video is helpful)
- past medical hx of childhood seizures, head trauma, infection, systemic disorders (malignancies, fluid/electrolyte imbalance eg hypoglycemia), neurological disease, stroke
- family hx of seizures
- provoked or unprovoked? (use of drugs and alcohol, sleep deprivation)
In patients with known epilepsy on antiepileptic medications:
- adherence to medications (most common cause of breakthrough seizure)
- medication interactions
- concurrent use of alcohol or substances, illness (fever, vomiting)
53
How is status epilepticus defined?
Seizures lasting ______ with no ___________
Repeated seizures lasting >5-10 min with no intervening periods of normal neurologic function
54
What is the most common cause of seizures in people with epilepsy?
missed anti-epileptic medication
55
Alcohol use > _____ drinks/day increases seizure risk
3 drinks/day
56
Anti-epileptic drugs are usually started after the _____ seizure
second
57
What should be included in routine follow up of seizures?
Also what 3 areas of preventative screening?
- medication compliance
- -mental health/suicide risk (increase risk with some AEDs)
- CBC, LFTs, Cr, [drug]
- annual drug levels if on stable dose and no seizures
screening for:
- contraception/plan for pregnancy
- bone density (osteopenia and osteoporosis with long term AED use)
- dental care
58
Stevens Johnson Syndrome and Toxic Epidermal Necrolysis can happen ____ months after initiation of AEDs
four months!
carbamazepine/oxcarbezepine
phenytoin
lamotrigine
59
Seizures
Pregnancy considerations with AEDs
- folic acid supplement of _____/day if wanting to conceive:
- impact of AEDS on oral contraception
Folic acid: 4 mg/day
Oral contraception less effective (esp if on enzyme-inducing AEDs eg phenytoin, carbamazepine, topiramate)
60
Focal impaired awareness seizures (complex partial) often begin in _____ lobe
temporal lobe
61
Dizziness is often separated into 3 categories:
-define each
Presyncope: lightheaded, "nearly fainting" from decreased cardiac output or blood flow to brain
Vertigo: illusion of movement "spinning" "whirling"
-central vs peripheral
Disequilibrium: instability with walking
62
Name common causes of disequilibrium
```
• peripheral neuropathy
• musculoskeletal disorder interfering with gait
• vestibular disorder
• cerebellar disorder
and/or cervical spondylosis
```
63
Name common causes of presyncope
Presyncope
• cardiac dysrhythmias
• coronary heart disease
congestive heart failure
64
Name common causes of non-specific dizziness
```
Nonspecific dizziness
• psychiatric disorders (anxiety, depression, panic disorder)
• Hyperventilation
• Head trauma / whiplash
Hypoglycemia
```
65
What 2 categories of medications have a high chance of causing dizziness?
antidepressants
| anticholinergics
66
What are the most helpful physical exam findings during assessment of dizziness?
- positional change in symptoms
- orthostatic BP and HR
- gait
- nystagmus
67
All vertigo (central and peripheral) is worse with ________ and generally accompanied by ____ and ______
worse with movement of head
- accompanied by:
- nystagmus
- postural instability (hard to stay upright)
68
Ear symptoms (tinnitus, hearing loss) is suggestive of _______ vertigo
peripheral
69
Name 3 risk factors for carpal tunnel syndrome
- hobby/work with repetitive wrist/hand movements or use of vibrating tools
- pregnancy
- aging
Conditions that cause edema/inflammation:
- cysts, lesions, masses
- RA, DM, thyroid/endocrine disease
- burn trauma/structural change
- mechanical overuse
- infectious diseases (TB, leprosy)
- genetics (small carpel tunnel space, anatomical anomalies)
70
Carpal tunnel syndrome:
involves the _____ nerve which contains these spinal nerves:
and innervates _______
median nerve
-spinal nerve
C6-8, T1
-innervates forearm, wrist, hand
71
What are some signs and symptoms of carpal tunnel?
- pain (wrist, referred to elbow and /or shoulder)
- tingling, numbness and/or burning (paresthesia) in first 3 radial fingers (D1-3)
- sensation can radiate up to wrists into forearms
- weak grip, dropping objects
- worse at night
72
Describe physical assessment for carpal tunnel
Exam:
- hand: palmar deformity, wasting in hand muscles, bony deformity
- neuro-MSK assessment of hand
- 2 point discrimination: to hand, forearm, upper arm
Special tests:
- Tinel's
- Phalen's x 60 sec (positive = palmar numbness/tingling/pain to D1-4)
- manual compression (positive = paresthesia within 30 sec)
73
What are some non-pharm treatment options for carpal tunnel?
- avoid triggering activities
- stretching
- Frequent rest breaks to rest arms and wrists
- Wrist splints in neutral position overnight for one month
- Ergonomic adaptation
- Carpal tunnel release for severe symptoms
74
What is the first line pharm treatment for carpal tunnel?
Ibuprofen or naproxen (NSAIDs)
75
Bells Palsy
What is it caused by?
etiology unknown
| -most likely reactivation of HSV causing inflammation and compression of CN VII (facial nerve)
76
Risk factors for Bells Palsy?
- diabetes
- pregnancy (third trimester, immed PP)
- HTN
- hypothyroidism
- recent infection
77
Bell's Palsy:
Signs and symptoms:
upper or lower motor neuron?
rapid acute onset
```
unilateral facial weakness
-unable to close one eye
-eye lid sagging
-mouth drooping
may have retro-auricular pain
-may have drooling, decreased tearing, altered taste, sound sensitivity
```
LOWER motor neuron
(sparing of forehead suggests upper motor neuron)
78
Physical exam for Bell's Palsy:
| -pertinent positive and negative findings?
Facial symmetry: drooping mouth, unable to close eye, forehead sparing?
Ears: r/o OM, Ramsay Hunt (herpetic lesions in canal or behind ears)
Neuro: CN - able to close eyes completely? raise eyebrows?
79
Bell's Palsy
Pharm management?
Non-pharm?
Prednisone 60-80 mg daily x 1 week for all patients
Valacyclovir only in severe cases (in conjunction with steroid)
EYE PROTECTION
* eye lubricant
* taping eye shut
* patch at night but only after taping eye shut first
* sunglasses
80
Bell's Palsy
When to refer?
- abnormal neuro exam
- bilateral palsy
- slow progression at 3-4 weeks
- no improvement at 3-4 months
