Neuro

Question 1

CNS involvement: WHERE + symptoms

Answer 1

• Upper motor neuron: Sx in face, arm, leg
  
  • Stroke, brain, neoplasm
• Spinal cord: BL, sensory level, brisk reflexes
  
  • transverse myelitis
• *always consider bowel and bladder w/spinal cord!

Question 2

PNS involvement: WHERE + symptoms

Answer 2

• Radicular pattern: dermatome, e.g., shingle, radiculopathy. Radiculopathy changes with position!
• Neuropathy: Localized to distribution of nerve, weakness, loss of sensation, e.g., carpal tunnel
• Polymyositis: localized to muscle, muscle tenderness. E.g., statin myopathy

Question 3

2 main questions for yourself when pt presents with a HA

Answer 3

1. Primary vs secondary
2. Dangerous to wait?

Question 4

Examples of primary HAs

Answer 4

• Migraine
• Cluster headache
• Autonomic cephalgia
• Tension Type Headache
• Chronic daily Headache
• HA syndrome associated

Question 5

Examples of secondary HAs

Answer 5

• Giant cell arteritis
• Brain infections
• Brain hemorrhage
• Idiopathic, intracranial HTN
• Low CSF pressure
• Car accidents – HA s/t muscle spasms

Question 6

Sx & diagnostics of low CSF pressure HA

Answer 6

• Severe throbbing HA w/bending, lying down
• Nausea
• Normal neuro
• Possible CSF rhinorrhea
• May happen s/t car accidents, surgeries
• Imaging: cerebellum going into foramen magnum. CSF pressure is low, so brain sinks when stand.

Question 7

Tx for Low CSF pressure HA

Answer 7

• Look for CSF leak (often cannot find)
• May heal on their own
• Managed w/pain meds

Question 8

Cluster HA and gender

Answer 8

More women than men

BUT if men have HA, more likely to be cluster

Question 9

Why do people often have visual symptoms (e.g., stars, black, flashes) before syncope?

Answer 9

Retina is highly vascular and metabolic, senses any difference in circulation

Question 10

Types of partial seizures

Answer 10

Simple partial, complex partial, partial seizures with secondary generalization

Question 11

Types of Generalized seizures

Answer 11

• Tonic-clonic (grand mal)
• Absence (petit mal)
• Myoclonic

Question 12

S/S of stroke

Answer 12

• Sudden numbness or weakness of the leg, arm, or face
• Sudden confusion or trouble understanding
• Sudden trouble seeing in one or both eyes (amaurosis fugax – carotid artery plaque lands in central retinal artery then body clears)
• Sudden trouble walking, dizziness, loss of balance or coordination (brain hemorrhage)
• Sudden severe HA w/no known cause

Question 13

2 types of stroke

Answer 13

Ischemic

Hemorrhagic: sudden is almost always vascular

Question 14

Multiple mechanisms of stroke

Question 15

4 cardinal signs of parkinsonism

Answer 15

• TREMOR
• Bradykinesia: most disabling
• Rigidity
• postural instability: late sign

Need 2 for Dx

Question 16

3 clinical types of multiple sclerosis

Answer 16

• Relapsing
• secondary progressive: more insidious
• primary progressive: chronically progressive from onset

Question 17

Tempo of cerebral mass lesions (tumor, subdural)

Answer 17

Progressive but fluctuating

(Cecil)

Question 18

Tempo of seizures and migraines

Answer 18

Episodic course

(Cecil)

Question 19

Tempos of strokes

Answer 19

Abrupt ictal onset with worsening for 3-5 days followed by partial or complete recovery

(Cecil)

Question 20

Acute onset of neuro sx suggests

Answer 20

Vascular cause of seizure

(Cecil)

Question 21

Subacute onset of neuro sx suggests

Answer 21

Mass lesion, e.g., tumor or abscess

(Cecil)

Question 22

Waxing and waning course w/exacerbations and remissions of neuro sx indicates

Answer 22

Demyelinating cause

(Cecil)

Question 23

Chronic and progressive neuro sx suggests

Answer 23

Degenerative cause

(Cecil)

Question 24

What does fatigue indicate, in terms of neuro diagnosis?

Answer 24

• Not likely to reflect definable dz
• More likely outside of PNS or CNS
• Exceptions: neuromuscular junction DOs such as myasthenia gravis, UMN dz e.g., MS, diseases that cause EPS (e.g., parkinson’s), or impair sleep

(Cecil)

Question 25

Imaging recommended for low back pain, with or w/o radiculopathy?

Answer 25

Not typically necessary unless red flags * Recent significant trauma or minor trauma at \>50yo * Unexplained wt loss * Unexplained fever * Immunosuppression * Hx cancer * Hx prior local surgery * Systemic do, bone or arthritic do * IV drug use * Age \>70yo * Focal neuro deficit w/progressive sx * Duration \>6w * Thoracic spine pain

Question 26

Most common causes of low back pain by age

Answer 26

Mechanical!! * 20-40: muscle strain (back, unilateral, acute onset, worse w/standing and bending) * 30-50: herniated nucleus pulposus (back, unilateral, acute onset w/prior episodes, worse w/sitting and bending) * \>50: OA (back, unilateral, insidious onset, worse w/standing) * \>60: spinal stenosis (leg, bilateral, insidious, worse w/standing) (Cecil)

Question 27

Most common cause of cardioembolic stroke

Answer 27

Afib | (Cecil)

Question 28

Clinical manifestations / neuro deficits in setting of ischemic stroke

Answer 28

* Depends on involved vascular territory * Embolic: usually maximal deficit at onset * Atherothrombotic: may be stuttering onset * “Abrupt onset of focal neuro deficit in distribution of a specific vascular territory” (Cecil)

Question 29

Initial labs for suspected stroke

Answer 29

At ED * Partially to R/O other causes * CBC & PLT * PT/INR, aPTT, Glc, electrolytes, renal function tests, troponin, O2 sat * Urgent ECG * CT or MRI as soon as stable Other tests depend on pt (pregnancy, tox screen, etc)

Question 30

Significance of CBC in evaluation of stroke

Answer 30

WBCs: infective cause, e.g., Infective endocarditis; infection can also cause recurrence of sx in setting of prior stroke

Question 31

Significance of polycythemia in setting of suspected stroke

Answer 31

Hyperviscosity can lead to occlusion of small intracranial vessels

Question 32

Significance of thrombocytopenia in setting of suspected stroke

Answer 32

May reveal underlying coagulation disorder / contraindictation to tPA

Question 33

Significance of glucose in setting of suspected stroke

Answer 33

Hypo and hyperglycemia may cause strokelike sx

Question 34

Significance of impaired renal function in setting of suspected stroke

Answer 34

Risk factor for ischemic stroke, may increase risks of using thrombolytic and anticoagulant agents

Question 35

Significance of electrolyte abnormalities in setting of suspected stroke

Answer 35

Can cause neuro sx, e.g., hyponatremia

Question 36

Brain CT vs MRI in setting of suspected stroke

Answer 36

* CT: more accessible * MRI: more likely to show acute ischemic injury, but not for pts w/metal implants, cardiac pacemakers, difficult in unstable pts

Question 37

Treatments for ischemic stroke

Answer 37

tPA or endovascular therapy (if not tPA candidate)

Question 38

How much time between symptom onset and tPA administration?

Answer 38

\< 3 hours No more than 4.5 hours (Cecil)

Question 39

Primary prevention of ischemic stroke

Answer 39

Healthy lifestyle Treat RFs (afib, HTN, DM, carotid stenosis) (Cecil)

Question 40

Secondary prevention after TIA or stroke

Answer 40

* Lifestyle * Antiplatelet if not C/Is – esp short term dual antiPLT tx (asa & clopidogrel) * Tx risk factors * Stenting or endarterectomy (Cecil)