Neuro 4

Question 1

Describe difference in presentation of UMN vs. LMN disorder in the face

Answer 1

UMN disorder = weakness of lower face with sparing of upper face

LMN disorder = weakness of upper and lower face

Question 2

Describe the different levels (e.g. muscle, nerve, etc.) that can cause weakness

Answer 2

Muscle, NMJ, peripheral nerve, nerve root, plexus, spinal cord, cerebral hemisphere/brainstem

Question 3

Describe pattern of weakness in primary muscle disorders

Answer 3

• Symmetric proximal muscle weakness that can affect neck muscles

Question 4

Associated signs and sx in primary muscle disorder

Answer 4

• Muscle pain if inflammatory

* Should not cause sensory or reflex deficits

Question 5

Pattern of weakness in NMJ disorder

Answer 5

• Wekness of proximal muscles
• Some characteristically affect extraocular and bulbar muscles
• Fluctuation in degree of weakness (may change hour to hour)

Question 6

Associated signs and sx of NMJ disorder

Answer 6

• Should not show sensory signs or sx

Question 7

Pattern of weakness in peripheral nerve disorder

Answer 7

• Mononeuropathy = weakness in muscles innervated by a single peripheral nerve
• Polyneuropathy = dysfunction occurs first in the muscles of the distal extremities symmetrically

Question 8

Associated signs and sx of peripheral nerve disorder

Answer 8

• May cause numbness, tingling, or pain

Question 9

What does radiculopathy mean?

Answer 9

• Radiculopathy = problem involving a single nerve rooth

Question 10

Pattern of weakness in nerve root disorder

Answer 10

• Causes weakness in the muscles innervated predominantly by fibers from one nerve root

Question 11

Associated signs and sx of nerve root disorder

Answer 11

• Radiating pain and tingling are common

* If the nerve root serves a particular muscle stretch reflex, that reflex may be depressed or absent (e.g. C5 = biceps)

Question 12

Pattern of weakness in plexus disorder

Answer 12

• Multiple muscles in a limb are weak and do not conform to a particular nerve root or peripheral nerve pattern

Question 13

Associated signs and sx in plexus disorder

Answer 13

• Associated sensory signs of reflex loss common

Question 14

Pattern of weakness in spinal cord disorder

Answer 14

• Weakness in a UMN pattern below the lesion (due to interruption of the descending corticospinal tract)
• Weakness in a nerve root pattern at the level of the lesion (mimics radiculopathy)

Question 15

Associated signs and sx in spinal cord disorder

Answer 15

• Sensory loss below lesion due to interruption of acending tracts
• Reflexes below level of lesion are increased and Babinksi usually present
• Bowel and bladder incontinence may occur

Question 16

Pattern of weakness in cerebral hemisphere disorder

Answer 16

• Weakness of the contralateral side in an UMN pattern
• Parasagittal lesions lead primarily to leg weakness
• Lateral lesions lead primarily to face and arm weakness
• Deep lesions may lead to weakness in all 3 parts

Question 17

Associated signs and sx of cerebral hemisiphere disorder

Answer 17

• L hemispheric lesions may cause aphasia and apraxia
• R hemispheric lesions may cause neglect or visuospatial dysfunction
• Brainstem lesions may have accompanying CN findings

Question 18

Describe typical presentation of tension HA

Answer 18

Constant pressure in temporal and occipital region. Band-like pattern. No nausea, vomiting, or photophobia

Question 19

What is a physical exam finding that remains present in brain dead patients

Answer 19

Deep tendon reflexes (spinal cord may still be functioning)

Question 20

What part of the brain is damaged in alcohol neurotoxicity

Answer 20

Cerebellum (specifically the vermis = defect in truncal coordination = wide-based gait and postural instability)

Question 21

Effects of thiamine deficiency in alcohols

Answer 21

Werknicke’s triad = confusion, ophthalmoplegia, ataxia

Question 22

Approved medication used in ALS

Answer 22

Riluzole = glutamate inhibitor

Question 23

How do you diagnose MS?

Answer 23

• Oligoclonal bands in CSF

- MRI brain shows periventricular hyperintense white matter lesions

Question 24

Tx of MS flair

Answer 24

IV glucocorticoids (e.g. methylprednisolone)

Question 25

What is Friedreich ataxia: imaging findings + presentation

Answer 25

♣ Autosomal recessive trinucleotide repeat disorder GAA ♣ Degeneration of cerebellum and spinal cord • Ataxia, muscle weakness (usually arms > legs), loss of vibratory sense and proprioception, diabetes mellitus, hypertrophic cardiomyopathy • Presents in childood with kyphoscoliosis

Question 26

Classic presentation of CJD

Answer 26

Rapidly progressive dementia, myoclonus, and sharp triphasic synchronous discharges on EEG

Question 27

Describe features of vestibular neuritis

Answer 27

♣ Acute unilateral peripheral vestibulopathy (not really inflammation) ♣ Features: • Sudden onset single episode that can last days • Associated with nausea and vomiting • Severe vertigo but no hearing loss

Question 28

Describe features of labyrinth concussion

Answer 28

Sudden onset vertigo as a result of head injury

Question 29

Describe Meniere disease

Answer 29

♣ Increased pressure and volume of endolymph ♣ Features: • Episodic vertigo with nausea and vomiting • Ear fullness/pain • Unilateral sensorineural hearing loss • Tinnitus

Question 30

Describe perilymph fistula vertigo

Answer 30

♣ Results from disruption of the lining of the endolymphatic system ♣ Patients hear a “pop” at the time of sudden increase in middle ear pressure (sneezing, nose-blowing, coughing, straining) followed by abrupt onset of vertigo

Question 31

Describe benign paroxysmal positional vertigo (BPPV)

Answer 31

♣ Results from freely moving crystals of calcium carbonate within one of the semicircular canals ♣ Features: • Brief episodes brought on by head movement • No auditory symptoms

Question 32

Describe typical sx associated with peripheral vs. central vertigo

Answer 32

Peripheral = tinnitus and hearing loss Central = diplopia, dysarthria, and other sx of brainstem dysfunction

Question 33

What are the signs and sx of cerebellar diseas

Answer 33

Dysmetria, intention tremor, dysdiadochokinesia, gait ataxia, truncal ataxia, dysarthria, nystagus

Question 34

What is dysmetria

Answer 34

* Abnormlaity of the range of force of a movement | * Erratic, jerky movmements with over-and undershootin the target

Question 35

What is dysdiadochokinesia

Answer 35

• Abnormality of the rate and rhythm of a movement demonstrated by asking the patient to perform a rapid alternating movement

Question 36

Paraneoplastic cerebellar degeneration is usually associated with what cancers?

Answer 36

Gynecologic or small cell lung cancer

Question 37

Diagnose: sudden onset cerebellar ataxia with associated vomiting and depressed level of arousal

Answer 37

Cerebellar stroke

Question 38

What disease other than Marfan's presents with a Marfanoid habitus?

Answer 38

Homocystinuria

Question 39

Difference in presentation between Marfan syndrome and Homocystinuria

Answer 39

Marfan: - Marfanoid habitus (pectus deformity, tall stature, arachnodactyly, joint hyperlaxity, skin hyperelasticity, scoliosis) - **Normal intellect - Aortic root dilation - Upward lens dislocation Homocystinuria: - Marfanoid habitus - **Intellectual disability - Thrombosis (Homocysteine is prothrombotic, which may lead to premature acute coronary syndrome) - Downward lens dislocation - Megaloblastic anemia - **Fair complexion

Question 40

Most common infectious cause of single brain abscess

Answer 40

Usually direct extension from an adjacent tissue infection Strep Viridans, Staph aureus

Question 41

Describe presentation of Neurofibromatosis type 1

Answer 41

♣ Neurocutaneous disorder characterized by café-au-lait spots, cutaneous neurofibromas (peripheral nerve sheath tumors), optic gliomas, pheochromocytomas, Lisch nodules (pigmented iris hamartomas) ♣ Neurofibromas consist of proliferation of Schwann cells, fibroblasts, and neurites • Appear as soft, nontender, pedunculated cutaneous lesions

Question 42

Describe presentation of neurofibromatosis type 2

Answer 42

``` ♣ Bilateral acoustic schwannomas, juvenile cataracts, meningiomas, and ependymomas ♣ Presentation: • Hearing loss, tinnitus, balance problems, hyperpigmented skin lesions, cataracts ♣ REMEMBER 2’s: • Chr 22 • Bilateral hearing loss • NF Type 2 • Cataracts ```

Question 43

Presentation of acute closure glaucoma

Answer 43

♣ Rapid onset severe eye pain ♣ May see halos around lights ♣ Affected eye will appear injected with dilated pupil that is poorly responsive to light ♣ Can also have tearing and HA with subsequent nausea and vomiting

Question 44

DIfferentiate between Cauda equina syndrome and Conus medularis syndrome

Answer 44

• Cauda equina syndrome o Likely due to disc herniation or rupture, spinal stenosis, tumors, infection, hemorrhage, or iatrogenic injury o Causes LMN signs as the nerve roots are part of the peripheral nervous system o Usually bilateral, severe radicular pain o Saddle hypo/anesthesia o Asymmetric motor weakness o Hyporeflexia/areflexia o Late-onset bowel and bladder dysfunction ``` • Conus medullaris syndrome o Causes both UMN and LMN symptoms o Sudden onset severe back pain o Perianal hypo/anesthesia o Symmetric motor weakness o Hyperrreflexia o Early-onset bowel or bladder dysfunction ```

Question 45

Describe details of paralysis in Guillan Barre vs. tick-borne

Answer 45

• Tick-borne paralysis o Rapidly progressive ascending paralysis over hours to days o Paralysis may be asymmetrical • Guillain Barre syndrome o Ascending symmetrical paralysis over days to weeks

Question 46

Other sx besides paralysis in Guillan Barre vs. tick-borne paralysis

Answer 46

• Tick-borne paralysis o Absence of fever and sensory abnormalities, and normal CSF • Guillain Barre syndrome o Sensation is usually normal to midly abnormal o Autonomic dysfuction (e..g tachycardia, urinary retention, and arrhythmias) occur in 70% of patients o CSF is usually abnormal and may show high protein with few cells

Question 47

Tx of tick-borne paralysis vs Guillain Barre

Answer 47

Tick-borne = removal of tick resutlt in spontaneous improvement in most patients GBS = IV Ig or plasmapharesis

Question 48

Describe presentation of Essential tremor

Answer 48

♣ Occurs at rest and with movement ♣ Usually genetic ♣ Hands > arms > head >> legs

Question 49

Tx of essential tremor

Answer 49

* Beta-blockers * Primidone (barbiturate/anticonvulsant) * Self-medicated with alcohol * Benzodiasepines (clonazepam)

Question 50

Treatment of trigeminal neuralgia

Answer 50

Carbamazepine (anticonvulsant)