Neuro

Question 1

ABCD2 Score

Answer 1

• Age >=60
• Blood pressure (HTN)
• Clinical features
  
  • speech disturbance but no unilateral weakness = 1
  • unilateral weakness = 2
• Duration
  
  • >= 10 min = 1
  • >= 60 = 2
• Diabetes

Question 2

Cutoffs for carotid endarterectomy

Answer 2

• >= 70% stenosis within 2 weeks
• some benefit for >= 50 % within 2 weeks
• with symptoms

Question 3

Miller-Fisher variant of Guillain-Barre Syndrome

Answer 3

Ataxia, eye muscle weakness, areflexia but usually no limb weakness.

Question 4

Classic Findings of Guillain-Barre Syndrome

Answer 4

Symmetric ascending paralysis with areflexia

Question 5

Brachial Plexus arises from which spinal levels?

Answer 5

C4-T1

Question 6

Definition: status epilepticus

Answer 6

• 5 minutes of either continuous seizure activity or 2 or more sequential seizures without full recovery of consciousness between the seizures

Question 7

Definition: refractory status epilepticus

Answer 7

• sz continues despite 2 drugs

Question 8

Lorazepam Dose Status Epilepticus

Answer 8

Lorazepam (best IV agent)

• 0.1 mg/kg, max 4 mg IV/IM, may repeat x 1 in 4 minutes
• onset 1-5 min (15-30 min IM), duration 12-24 h

Question 9

Midazolam Dose Status Epilepticus

Answer 9

midazolam (best IM agent)

• 10 mg (0.2 mg/kg) IM x 1, no repeats
  
  • onset 5-15 min, duration 1-6 h
• 5-10 mg (0.1-0.2 mg/kg) IV
  
  • onset 1-5 min, duration 1-6 h
• 0.2 mg/kg intranasal (max 10 mg)

Question 10

Lab work to differentiate between sz and PNES

Answer 10

• prolactin within 20 min of event > 2x ULN predictive or true sz but not perfect
• lactate rises causes WAG acidosis (resolves within 30 min)

Question 11

Approach to sz in known epileptics

Answer 11

• check drug levels, glucose
  
  • if low, give loading dose (PO or IV)
• DC home when stable
  
  • if therapeutic and sz not more freq than expected, DC home
• if can’t check (keppra) and noncompliant, give usual home dose before DC
• If compliant and therapeutic and increased freq/duration of seizures, speak with neurology about adding on agents or adjusting dose
• f/u 1-3 days if changing dose

Question 12

Approach to first-time sz

Answer 12

• plain CT Head, ext lytes, tox screen, CBC, ECG
• if no secondary cause, MTO, DC with f/u, no tx
• children:
  
  • > 6 months, single afebrile sz not requiring tx = DC home with outpt MRI if back to neuro baseline
  • no routine labs needed in complex febrile or afebrile sz, use clinical picture
• neonates:
  
  • full septic workup + extended lytes + abx with any sz
  • lactate, ammonia, amino acids + urine amino acids

Question 13

Parasitic cause of sz in developing world

Answer 13

Neurocysticercosis

• most common cause sz in developing world
• CNS infection by larvae of taenia solium taperworm
• sz from parasite degenerating, leaving fibrosis

Question 14

Baseline rate of aneurysms in gen pop

Answer 14

2-6%

Question 15

Sensitivity of CT (-) for SAH

Answer 15

• CT (-): 98% sens @ 6 h, 90% @ 24 h, 50% @ 1 wk

Question 16

How long does it take for xanthochromia to develop in SAH?

Answer 16

• 12h

Question 17

SAH Treatment

Answer 17

• HOB 30 deg
• glu, temp control, reverse anticoag
• SBP < 140
  
  • labetalol/nicardipine
• nimodipine 60 mg PO Q4h (start within 96 h of onset)
  
  • for vasospasm, risk of which is greatest 2 days-3 weeks

Question 18

Autonomic Dysreflexia

Answer 18

• in patients with spinal lesions/open neural tube defects
• paroxysmal sympathetic + parasympathetic hyperactivity initiated by stimuli below level of lesion
  
  • bladder distension, fecal impaction, fracture
• sweating, flushing, ha, htn, bradycardia, piloerection
• tx is remove stimuli

Question 19

Symptoms of Myesthenia Gravis

Answer 19

• prox muscle weakness relieved by rest
• facial and bulbar muscle weakness
• ptosis, diplopia, internuclear opthalmoplegia
• usually no sensory, reflex, or cerebellar deficits

Question 20

Myesthenia Gravis (Read Through)

Answer 20

Evernote “Chronic Neurological Disorders”

Question 21

Optic Neuritis

Answer 21

• usually monocular, painful vision + colour vision loss over several days
• often preceded by retrobulbar/extraocular muscle pain reproducible by periorbital palpation
• often RAPD (Marcus Gunn pupil)
• hallmark of MS

Question 22

Multiple Sclerosis (Read Through)

Answer 22

“Chronic Neurological Disorders”

Question 23

Lambert-Eaton Syndrome

Answer 23

• weakness that gets better with exercise
  
  • hand grip increases in strength over time
• paraneoplastic syndrome
• no specific treatment, refer neuro/medicine

Question 24

Parkinson’s Disease

Answer 24

• resting tremor
• cogwheel rigidity
• bradykinesias, akindesias
• impaired postural reflexes
• sensory deficits, extremity pain
• cardiac dysrhythmias, orthostatic hypotension, dyskinesias, dystonias from dopaminergic therapy
  
  • sometimes drug holiday/reduction in dose may help, discuss with neuro

Question 25

GBS Syndrome

Answer 25

• symmetric ascending paralysis, no sensory deficit

Question 26

Classic GBS CSF Finding

Answer 26

• cytoalbuminologic dissociation (high protein, low WBC)

Question 27

GBS (Read Through)

Answer 27

“Acute Peripheral Neurologic Disorders”

Question 28

Bell’s Palsy

Important physical exam test

Tx

Dispo

Answer 28

• may be preceded by pain behind ear
• r/o otitis/mastoiditis
• test EOM (should be full)
• prednisone 1 mg/kg daily x 7d
• no benefit to antivirals
• patch eye if incomplete closure, f/u urgent optho
• if can close, artificial tears
• f/u GP or ENT within 7d

Question 29

Ramsey Hunt Syndrome

Answer 29

• HZV of geniculate ganglion
• may also have CN VIII involvement with vertigo, nausea, hearing loss
• prednisone + valacyclovir 1 g TID x 7d

Question 30

Botulism Clinical Syndrome

Answer 30

• descending, symmetric paralysis
• CN + bulbar affected first
  
  • diplopia, dysarthria, dysphagia, blurred vision
  • pupils often dilated, nonreactive –> important to differentiate from myesthenia which has normal pupils
  • may have anticholinergic syndrome
• floppy infant with constipation and weak cry
• no sensory deficit, no pain

Question 31

Botulism (Read Through)

Answer 31

“Acute Peripheral Neurologic Disorders”

Question 32

Vertigo (Read Through)

Answer 32

“Vertigo”

Question 33

Trigeminal Neuralgia

Answer 33

• tic douloureux
• severe pains lasting only seconds
• no pain between episodes
• tx: carbamazepine 100 mg PO BID –> GP to increase, refer to neurologist

Question 34

Seizure Meds that can be measured

Answer 34

• phenytoin (Dilantin)
• carbamazepine (Tegretol)
• valproic acid (Epival)