Flashcards in Neuro Deck (177):
MCA Stroke symptoms
Contralateral paralysis and sensory loss in face and upper limb. Aphasia if stroke is dominant lobe (left) or hemineglect if nondominant (right side). Homonymous hemianopsia (loss of visual field on opposite side of stroke in each eye so left side has right field loss in both eyes so eyes deviate to left)
How do you know what side of the brain speech is controlled by?
Determined by handedness where right handed ppl have left brain dominant
ACA stroke symptoms
motor/sensory loss of contralateral lower limb. can have urinary incontinence
PCA stroke symptoms
Ipsilateral sensory loss of face 9th and 10th CN, contralateral sensory loss of limbs, limb ataxia. Contralateral sensory loss of limbs. Limb ataxia
Best initial/most accurate test for stroke?
Initial: CT scan, Accurate: MRI
Tx for stroke
3-4.5 for ischemic/TIA-aspirin; if on aspirin, add dipyramidole or switch to clopidogrel
Hemorrhage: nothing, but control BP and reverse anticoag
What drug is essential for all stroke patients?
Statin regardless of LDL level
Appearance of hemorrhage vs ischemic on CT scan
Follow up tests for stroke to find cause
2) EKG and Holter if EKG normal
3) Carotid duplex
Strongest risk factor with strokes
Major causes of intracerebral vs subarachnoid hemorrhage
Intracerebral-uncontrolled HTN, Subarachonid-Sacular/ berry aneurysm or AV malformation rupture
Tx for stroke with evidence of AFIB
Long term anticoagulation (eg warfarin, dabigatran, rivaroxaban)
Strict contraindication tPA
Hemorrhagic stroke, stroke/head trauma 185/110, Platelet1.7 INR, PT>15, Increase PTT
Basal ganglia hemorrhage neurologic findings?
Contralateral hemiparesis and hemisensory loss, homonymous hemianopsia, gaze palsy
Cerebellum hemorrhage neurologic findings?
Medial vermis-vertigo and nystagmus
Later vermis-dizziness, ataxia, and weakness
-Ataxia, nystagmus, facial weakness, occipital headache and neck stiffness
Thalamus hemorrhage neurologic findings?
Contralateral hemiparesis and hemisensory loss, nonreactive miotic pupils, upgaze palsy, eyes deviate Towards hemiparesis
Cerebral lobe hemorrhage neurologic findings?
Contralateral hemiparesis (frontal lobe), contralateral hemisensory (parietal lobe), homonymous hemianopsia (occipital lobe), eyes deviate away from hemiparesis, high incidence of seizures
Pons hemorrhage neurologic findings?
Deep coma and total paralysis within minute with pinpoint reactive pupils.
Rebleeding in 1st 24 hours and cerebral vasospasm after 3 days (prevent with nimodipine)
Cushing reflux to increased ICP?
Hypertension, bradycardia, decreased resp rate
When is imaging done for tension, migraine, cluster?
Unsure of diagnosis or recent started syndrome indicates head CT or MRI
Test pseudotumor cerebri and tx.?
CT or MRI to exclude mass and opening pressure >250 on LP. Tx. acetazolamide to decrease CSF and stop offending medication if applicable
Test giant cell?
Best initial: ESR. Most accurate: Biopsy
Tx/prophylaxis tension headache?
NSAIDs/acetaminophen as tx and no prophylaxis
Tx./ prophylaxis migraine headache?
tx. Triptans, IV antiemetics (chlorpromazine). Prophylaxis >3 attacks/month: propranolol
Tx./prophylaxis cluster headache?
tx.100%o2 as abortive, subcutaneous sumitriptan, octreotide. prophylaxis: verapamil, phenytoin, ergot prednisone
Tx. protocol 1,2,3 for trigeminal neuralgia?
3) Gamma knife surgery
When is shingles vaccine indicated?
What electrolyte does not cause seizures?
Tests before EEG with 1st unprovoked seizure
CMP (electrolyte, glucose, kidney func, renal function), CT/MRI, Urine drug screen
Tx. of status epilepticus?
2) Phenytoin or fosphenytoin
4) NM Blockade (succinylcholine, vecuronium) followed by intubation and general anesthesia after (propofol or midazolam)
Pheyntoin side effects?
Consequence of prolonged seizure >5 minutes seen in status epilepticus?
Excitatory cytotoxicity (cortical laminar necrosis) especially common in those noncompliant to therapy
Complication of tonic clonic seizure?
Exception to rule where you should not start epileptic drug after single seizure?
Family hx, status epilepticus, abnormal EEG or CT lesion
Best test to tell if possibility of seizure recurrence?
Sleep deprivation EEG
What differentiates SAH from meningitis?
Loss of consciousness in 50% and very sudden onset
Best initial/most accurate SAH?
Noncontrast CT, LP showing blood w/ 1:500-1000 WBC to RBC ratio
Head CT w or w/o contrast indications?
CT w/o-suspecting blood. CT w/ cancer or infection
1) Nimodipine, 2) Embolization (coiling), 3) VP shunt (if hydrocephalus develops), 4) Seizure prophylaxis with phenytoin
ASA infarction presentation?
Loss of all function except for the posterior column (position and vibration sensation)
Subacute combined degeneration presentation?
Loss of position and vibratory sensation (ataxic gait, paresthesia, impaired position and vibration sense)
Presentation and Treatment of spinal trauma?
Loss of reflex and motor function, hypotension. IVGlucocorticoids
Brown sequard presentation?
Pain and temp on contralateral side from injury 2 levels below and position and vibratory sense lost on ipsilateral side of injury
Best tx syringomyelia?
Surgical removal of tumor if present and drainage of fluid from cavity.
Best initial/most accurate brain abscess?
CT/MRI initial and biopsy accurate
Empiric tx brain abscess?
Penicillin + metro + ceftriaxone
Tuberous sclerosis symp?
HAMARTOMAS-Hamartomas, Ash leaf, mit regurg, angiofibroma, rhabdomyosarcoma (cardiac), tuberous sclerosis, auto dOm, mental redard, renal Angiomyolipoma, Seizure, shahgreen
Best diagnosis of NF2 acoustic schwannomas
MRI w/ gadolinium
Cafe au lait, neurofibromas (cutaneous), optic gliomas, lisch nodules (iris hamartomas),
Bilateral acoustic schwannomas, meningioma, juvenile cataracts, ependymomas
Sturge Weber presentation?
STURGE (Seizures/Stain, Tram track opposing gyri, Unilateral, Retardation, Glaucoma, Epilepsy)
Tx essential tremor?
1) propranolol 2) anticonvulsant (primodine/topiramate)
TRAPS (Tremor, Rigidity, Akinesia/brady, Postural instability (orthostatic hypotension), Shuffling gait)
What is shy drager (multiple system atrophy)?
Parkinsonism, autonomi dysfunction (cholinergic), widespread neurologic signs (cerebrellar) tx. volume expansion with hydrocortisone
Mild disease parkinsons tx >60 or
>60: amantadine (increases dopamine release from snpc) and
Severe disease w/ inability to care and orthostasis parkinson best initial/most effective therapy
Best initial: dopamine agonists (pramipexole, ropinirole) used with COMT inhibitor (tolcapone/entacopone) to reduce "on/off" phenomenon
Most effective: Levodopa/carbidopa
Best tx to prevent progression parkinson?
MAO inhibitor (rasagiline, selegiline)
Tx of spasticity (painful muscle contractions)?
Baclofen, dantrolene, and tizanadine (alpha agonist)
Mild/intermittent: Iron with
Symptom triad and tx in huntington?
Memory (dementia), Mood (psychosis w/haloperidol or quetiapine), Movement (dyskinesia tx with tetrabenazine)
Fluphenazine, pimozide, clonazepam (Cloning pimp on tour w/ flu). Methyphenidade and ADHD intrinsic to Tourette
LP for MS?
Increase protein, 50-100 WBC, increase IgG, oligoclonal bands
Tx for acute episode vs preventing relapse MS?
Acute-high dose steroids, plasmapharesis (if steroids not effective)
Relapse-B-interferon or Glatiramer
Patient hs worsening neurological defecits with use of chronic suppressive medication for MS with new mutiple white matter lesions. What caused it?
Natalizumab-alpha 4 integrin inhibitor also associated with PML
Diagnostic test/tx ALS?
Test-EMG and CPK (secondary to muscle wasting). Riluzole decreases glutamate buildup in neurons and baclofen treats spasticity. CPAP and BiPAP help with resp difficulties
Characteristics and Most accurate test charcot marie tooth?
Inverted champagne bottle legs, high arch (pes cavus), and motor and sensory loss. EMG
Tx. peripheral neuropathy?
Lateral cutaneous nerve percipitating event and presentation?
Obesity, pregnancy, and sitting with crossed legs. Pain/numbness of outer aspect of one thigh
Peroneal neruopathy pericpitating even and presentation?
High boots and pressure on back of knee. Weak foot with decreased dorsiflexion and eversion (footdrop)
Stroke vs bell palsy presentation"
stroke paralyze only lower half of face and can wrinkle forehead. Bell palsy is entire face and CANNOT wrinkle forehead
Presentation bell palsy
Paralysis entire half of face, hyperacusis (no innervation to stapedius), and taste disturbances (loss of sensation to anterior 2/3 of tongue)
Best test/tx for bell palsy?
Test-EMG, tx is prednisone
GBS presentation and tests?
Ascending weakness and decreased reflexes, best initial (PFT), EMG most accurate. CSF increased protein normal cell count (albuminocytologic dissassociation)
IVIG (children) OR plasmapheresis (adults), NOT prednisone
Best initial and most accurate test MG?
Best initial-acetylcholine receptor antiboides and most accurate is EMG
Best initial and best next step treatment MG?
Initial: Neostigmine or pyridostigmine
If not work 60: Prednisone w/ azthioprine tacrolimus cyclophosphamide and mycophenalate used to get patient off steroids before serious adverse events
Myasthenia crisis tx?
1) Endotracheal intubation
2) Meds (IVIG or plasmapharesis PLUS glucocorticoids) and hold neostigmine or pyridostimine to avoid excess.
MRI, VDRL/RPR, B12, TSH
Rivastimine, galantamine, donepezil or memantine
Tx lewy body
Levodopa or carbidopa
CJD tx and signs?
None, Rapidly progressive dementia w/ 2 of 4 clinical (myoclonus, akinetic mutism, cerebellor or visual disturbance, pyramidal/EPS dysfunction), sharp triphasic on EEG or 14-3-3 CSF. Definitive biopsy or PRNP mutation
Triggers of vasovagal syncope?
Emotional distress, painful stimuli, and prolonged standing
Why do you have peripheral visual field defect?
CN VI palsy (lateral rectus muscle)
Symp of diabetic neuropathy?
Peripheral neuropathy (numbness, tingling and feeling of imbalance). Mononeuropathy (CNIII, ptosis and down and out with light reflex/accomodation intact)
Differentiating essential, parkinson, cerebellar, and physiologic tremmor
Essential-resting and intention, hands, worse with caffeine and better with alcohol
Parkinson-restin and improve with intention than restarts, hands and legs, increase with mental tasks
Cerbellar-intention, assoc with ataxia, dysmetria and chronic alcoholic
Physiologic-acute (eg drugs, hyperthyroid, anxiety, caffeine) and not visible under normal conditions. Worse with activity
What is tick borne paralysis?
Ascending paralysis (asymmetrical) more pronouned in 1 leg or arm with ABSENCE of fevery, sensory, and normal CSF. No autonomic dysfunction (unlike majority of patients with GBS (like lack of sweating, urinary retention, orthostasis, arrhythmias))
Encephalopathy, oculomotor dysfunction (ophthalmopletgia) and gait ataxia
Present with wernicke and irreversible amnesia, confabulation
What test may be abnormal in pseudodementia?
Dexamethasone suppression (abnormal) to detect endogenous depression in 50%
Early insidious short term memory loss followed by later personality changes. May see subcortical atrophy in parietal and temporal lobes predominate.
Tx underlying condition. Typical or atypical antipsychotics for agitation and benzo for alcohol withdrawal
Preservation of what in brain death?
DTR may be present b/c preservation of spinal cord function
Most significant cause of morbidity in patients with traumatic brain injuries?
Diffuse axonal injury due to deceleration injury-->vegetative state
Most common medications to cause dystonia?
Typical antipsychotics, metoclopramide, prochlorperazine
Evaluation of corneal abrasion?
1) Penlight for defect/foreign body identification and pupillary function
2) Fluorosceine after to show corneal staining defect
Location and management of brain metastasis?
Location-gray-white junction or watershed zones. Solitary (surgery) and multiple (whole brain radiation)
MCC brain abscess from direct spread of head and neck infection?
Viridans or anaerobic
MCC brain abscess after nuerosurgery or penetrating trauma direct inoculation?
MCC brain abscess from hematongenous spread via endocarditis or osteomyelitis infection?
What level does spinal cord end at?
Presentation of sellar masses?
Bitemporal hemianopsia, headache, diplopia, pituitary hormonal deficiency
Presentation of central cord syndrome?
weakness more pronounced in upper extremities than lower and possible pain and temp sensation loss due to damage of spinothalamic tract seen in hyperextension injuries with preexisting degenerative changes to cervical spine
High freq hearing impariment difficulty hearing in crowded or noisy environments and trouble hearing high pitched noises
Metoclopramide MOA, effect, and side effects?
MOA prokinetic agent that is a dopamine receptor antagonist, treat nausea vomiting and gastroparesis, side effects: agitation, loose stools, drug induced EPS (tardive dyskinesia, dystonic rxns, and parkinsonism) tx. with benztropine or diphenhydramine
Best test for detecting vasopasm in SAH patients
Ototoxicity (hearing loss) by damaging the cochlear cells and in some cases vestibulopathy (motion-sensitive hair cell damage)
What are lewy bodies?
Eosinophilic intracytoplasmic inclusions representing alpha-synuclein protein
Cause of myasthenic crisis?
1) infection or surgery
2) Pregnancy or childbirth
3) Tapering immunosuppressive drugs
4) Medications (eg aminoglycosides, fluoro, macro, B-blocker)
Symptoms myasthenia gravis?
Extraocular (ptosis, dipolia), bulbar (eg fatigable chewing, dysphagia, nasal speech), proximal limb, and resp muscles
What does motor control of eye muscles?
Most common sacular (berry) aneurysm location and symptoms?
Located at branch points of circle of willis. Most commonly ACom and Anterior cerebral . Can present with bitemporal hemianopsia because of optic chiasm compression
Second most common saccular (berry) aneurysm location and symptoms?
Located at PCA and PCom can lead to CNIII palsy (Down and out with blown pupil and no afferent light reflex)
Glucocorticoids vs PMR myopathy?
Glucocorticoid progressive proximal muscle weakness and atrophy without pain or tenderness, lower extremity more with normal ESR/CK, PMR with pain and stiffness in shoulder and pelvic girdle with rapid steroid response and increased ESR with normal CK
What situation is LP contraindicated?
Acute head trauma, signs of intracranial HTN (ie papilledema) or suspicion for SAH. only do w/ NEG CT/MRI
What causes conduction velocity to be slowed?
Demyelination. watch out in GBS and MS
What causes EMG to show fasiculations or fibrillations at rest?
LMN (peripheral nerve problem)
What causes EMG with no muscle acivity at rest and decreased amplitude of muscle contraction with stimulation?
Intrinisc muscle disease as muscular dystrophies and inflammatory myopathies (Eg polymyositis)
Area involved when ignoring one side of body, trouble with dressing
nondominant parietal lobe
CN for midbrain, pons, medulla respectively?
V, VI, VII, VIII-pons
IX,X,XI, and XII-medulla
Direct spread via otitis media/mastoiditis affected area in brain?
Direct spread via frontal or ethmoid sinusitis affected area in brain?
Direct spread via dental infection affected area in brain?
Bacteremia from other sites of infection, cyanotic, heart disease?
Multple abscesses along distribution of middle cerebral artery (gray-white matter junction)
TOF heart disease increased risk?
Bacterial abscess secondary to R-->L shunt w/o bypassing pulm circulation where bacteria typically filtered and removed by phago
Gene mutation in NF1 and NF2 respectively
NF1 tumor suppressor gene codes for neurofibromin on chromosome 17. NF2 tumor suppressor codes for merlin on chromosome 22
Broca and Wernicke aphasia?
Posterior limb of internal capsule (lacunar infarct) clinical presentation?
Unilateral motor impairment (face, arm and to lesser extent leg), no sensory or cortical deficits, no visual field abnormalities
Contralateral hemiparesis and hemisensory loss predominantly in upper limp and face. Homonymous hemianopsia with deviation of eye toward infarct
Contralateral hemiparesis and hemisensory predom in lower extremity. Abulia (lack or willor initiative). Dyspraxia, emotional disturbance, urinary incontinence
Vertebrobasilar system lesion (supplying brain stem)
-Alternate syndromes with contralateral hemiplegia and ipsilateral CN involvement with possible ataxia
Stroke in the VPL nucleus of thalamus?
Unilateral numbness, paresthesias, and hemisensory deficit involving face, arm, trunk, and leg (pure sensory)
Lacunar infarction of anterior limb of internal capsule?
Weakness more prominent in lower extremity along with ipsilateral arm and leg incoordination
Lacunar stroke at the basis pontis?
Dysarthria-clumsy hand syndrome with hand weakness, mild motor aphasia, no sensory abnormalities.
Vestibulocerebellar symptoms of wallenberg syndrome (lateral medullary infarct)?
Vertigo, falling to side of lesion, difficulty sitting upright without support, diplopia and nystagmus, ipsilateral limb ataxia
Sensory symptoms of wallenberg syndrome?
Loss of pain and temp on ipsilateral face and contralateral trunk and limps
Ipisilateral bulbar muscle weakness of wallenberg?
Dysphagia and aspiration. Dysarthria and hoarseness
Autonomic dysfunction of wallenberg?
Ipsilateral Horner's (PAM), lack of autonomic respiration during sleep
Posterior (dorsal) cord syndrome?
Bilateral loss of vibratory and propioceptive sensation, often with weakness, paresthesias, and urinary incontinence or retention
Anterior (ventral) cord syndrome?
Bilateral spastic motor paresis distal to lesion nad loss of pain and temp on both sides below the lesion with intact propioception
Differences in conus medullaris vs cauda equina?
Cauda (peripheral LMN)-hyporeflexia, asymmetric motor weakness and late-onset bowel/bladder dysfunction
Conus-hyperreflexia, symmetric motor weakness, early-onset bowel/bladder dysfunction
Ataxic, staggering, wide-based gait area affected?
Magnetic (freezin) start and turn hesitation gait?
Gait apraxia (frontal lobe signs)
Short steps, shuffling that is hypokinetic
Footdrop, excessive hip and knee flexion with slapping quality?
steppage from motor neuropathy commonly the peroneal nerve
Unsteady, falling to one side with sensation of ear fullness due to abnormal accumulation of endolymph?
Acute labyrinthitis or meniere disease (vestibular gait)
Cause of BPPV?
crystalline deposits (canaliths) in the semicircular canals that disrupt the normal flow of fluid in the vestibular system
Meniere disease presentation?
Ear fullness causing unilateral tinnitus and hearing loss with episodic vertigo
Brief positional changes causing vertigo WITHOUT neurologic or auditory symptoms
Vestibular neuritis vs Labyrinthitous presentation?
Post viral with vertigo. Hearing loss in labyrinthitis and no hearing loss in neuritis.
What is otosclerosis?
Bony overgrowth of stapes associated with low-frequency hearing loss found in middle aged 20s-30s
Side effect levodopa plus carbidopa?
Somnolence, confusion, hallucinations (older patients), dyskinesia
Trihexyphenidyl or benztropine side effects?
Anticholinergic (hot as hare, dry as a bone, red as a beet, blind as a bat, mad as a hatter, and full as a flask)
Amantadine side effect?
Ankle edema nd livedo reticularis
Entacapone or tolcapone side effects?
Dyskinesia, hallucinations, confusion, nausea and orthostatic hypotension
Selegeline side effect?
Insomnia and confusion
EPS effects and treatments?
Acute dystonia (4hour)-tx with benztropine or diphenhydramine, Akathisia(restlessness). tx with benzo. Parkinsonism (4 week) with no effective tx. Tardive dyskinesia (4 months) with no effective tx.
Pronator drift is a sensitive and specific finding for what?
Right anopsia location of lesion?
Right optic nerve
Left homonymous hemianopsia location of lesion?
Right optic tract
Right optic radiation in right temporal lobe
Right optic radiation in right parietal lobe
Left homonymous hemianopsia with macular sparing?
Right occipital lobe (from PCA occlusion)
Lesion causing loss of gag reflex and loss of taste in posterior 2/3rd of tonuge?
CN IX lesion
Recurrent laryngeal nerve palsy and hoarseness dysphagia and loss of gag or cough reflex?
CN X lesion
CN XI lesion?
Look away from lesion and ipsilateral shoulder droop secondary to loss of innervation of SCM and trapezius
CN XII lesion?
Protruded tongue deviates to same side as lesion
First line agents of simple seizure?
Carbamazepine, lamotrigine, oxcarbazepine, and levetiracetam
First line complex partial/tonic clonic?
Valproate, lamotrigine, levetiracetem
First line absence?
Ethosuximide and valproate
Secondary seizure tx.
Benzo and/or phenytoin or fosssphneytoin
What is hemiballismus (random,violent, unilateral flailing of limbs) caused by?
Subthalamic nucleus lesion
Test for peripheral neuropathy?
Nerve conduction studies
Tx organophosphate (inhibition of AChE) poisoning?
Atropine or pralidoxime
4 Classic signs of basilar skull fracture?
-CSF otorrhea or rhinorrhea, hemotympanum, postauricular ecchymosis, periorbital ecchymosis ("raccoon eyes")