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1

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)

2

How do you know what side of the brain speech is controlled by?

Determined by handedness where right handed ppl have left brain dominant

3

ACA stroke symptoms

motor/sensory loss of contralateral lower limb. can have urinary incontinence

4

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

5

Best initial/most accurate test for stroke?

Initial: CT scan, Accurate: MRI

6

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

7

What drug is essential for all stroke patients?

Statin regardless of LDL level

8

Appearance of hemorrhage vs ischemic on CT scan

Hemorrhage-white, Ischemic-black

9

Follow up tests for stroke to find cause

1) ECHO
2) EKG and Holter if EKG normal
3) Carotid duplex

10

Strongest risk factor with strokes

HTN

11

Major causes of intracerebral vs subarachnoid hemorrhage

Intracerebral-uncontrolled HTN, Subarachonid-Sacular/ berry aneurysm or AV malformation rupture

12

Tx for stroke with evidence of AFIB

Long term anticoagulation (eg warfarin, dabigatran, rivaroxaban)

13

Strict contraindication tPA

Hemorrhagic stroke, stroke/head trauma 185/110, Platelet1.7 INR, PT>15, Increase PTT

14

Basal ganglia hemorrhage neurologic findings?

Contralateral hemiparesis and hemisensory loss, homonymous hemianopsia, gaze palsy

15

Cerebellum hemorrhage neurologic findings?

Medial vermis-vertigo and nystagmus
Later vermis-dizziness, ataxia, and weakness
-Ataxia, nystagmus, facial weakness, occipital headache and neck stiffness

16

Thalamus hemorrhage neurologic findings?

Contralateral hemiparesis and hemisensory loss, nonreactive miotic pupils, upgaze palsy, eyes deviate Towards hemiparesis

17

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

18

Pons hemorrhage neurologic findings?

Deep coma and total paralysis within minute with pinpoint reactive pupils.

19

SAH complications?

Rebleeding in 1st 24 hours and cerebral vasospasm after 3 days (prevent with nimodipine)

20

Cushing reflux to increased ICP?

Hypertension, bradycardia, decreased resp rate

21

When is imaging done for tension, migraine, cluster?

Unsure of diagnosis or recent started syndrome indicates head CT or MRI

22

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

23

Test giant cell?

Best initial: ESR. Most accurate: Biopsy

24

Tx/prophylaxis tension headache?

NSAIDs/acetaminophen as tx and no prophylaxis

25

Tx./ prophylaxis migraine headache?

tx. Triptans, IV antiemetics (chlorpromazine). Prophylaxis >3 attacks/month: propranolol

26

Tx./prophylaxis cluster headache?

tx.100%o2 as abortive, subcutaneous sumitriptan, octreotide. prophylaxis: verapamil, phenytoin, ergot prednisone

27

Tx. protocol 1,2,3 for trigeminal neuralgia?

1) Carbamazepine/oxcarbamazepine
2) Baclofen/Lamotrigine
3) Gamma knife surgery

28

When is shingles vaccine indicated?

>60

29

What electrolyte does not cause seizures?

Potassium disorder

30

Tests before EEG with 1st unprovoked seizure

CMP (electrolyte, glucose, kidney func, renal function), CT/MRI, Urine drug screen

31

Tx. of status epilepticus?

1) Benzos
2) Phenytoin or fosphenytoin
3) Phenobarbitol
4) NM Blockade (succinylcholine, vecuronium) followed by intubation and general anesthesia after (propofol or midazolam)

32

Pheyntoin side effects?

-AV block
-Hypotension

33

Consequence of prolonged seizure >5 minutes seen in status epilepticus?

Excitatory cytotoxicity (cortical laminar necrosis) especially common in those noncompliant to therapy

34

Complication of tonic clonic seizure?

Shoulder dislocation

35

Exception to rule where you should not start epileptic drug after single seizure?

Family hx, status epilepticus, abnormal EEG or CT lesion

36

Best test to tell if possibility of seizure recurrence?

Sleep deprivation EEG

37

What differentiates SAH from meningitis?

Loss of consciousness in 50% and very sudden onset

38

Best initial/most accurate SAH?

Noncontrast CT, LP showing blood w/ 1:500-1000 WBC to RBC ratio

39

Head CT w or w/o contrast indications?

CT w/o-suspecting blood. CT w/ cancer or infection

40

Tx. SAH?

1) Nimodipine, 2) Embolization (coiling), 3) VP shunt (if hydrocephalus develops), 4) Seizure prophylaxis with phenytoin

41

ASA infarction presentation?

Loss of all function except for the posterior column (position and vibration sensation)

42

Subacute combined degeneration presentation?

Loss of position and vibratory sensation (ataxic gait, paresthesia, impaired position and vibration sense)

43

Presentation and Treatment of spinal trauma?

Loss of reflex and motor function, hypotension. IVGlucocorticoids

44

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

45

Best tx syringomyelia?

Surgical removal of tumor if present and drainage of fluid from cavity.

46

Best initial/most accurate brain abscess?

CT/MRI initial and biopsy accurate

47

Empiric tx brain abscess?

Penicillin + metro + ceftriaxone

48

Tuberous sclerosis symp?

HAMARTOMAS-Hamartomas, Ash leaf, mit regurg, angiofibroma, rhabdomyosarcoma (cardiac), tuberous sclerosis, auto dOm, mental redard, renal Angiomyolipoma, Seizure, shahgreen

49

Best diagnosis of NF2 acoustic schwannomas

MRI w/ gadolinium

50

NF1 presentation

Cafe au lait, neurofibromas (cutaneous), optic gliomas, lisch nodules (iris hamartomas),

51

NF2 presentation

Bilateral acoustic schwannomas, meningioma, juvenile cataracts, ependymomas

52

Sturge Weber presentation?

STURGE (Seizures/Stain, Tram track opposing gyri, Unilateral, Retardation, Glaucoma, Epilepsy)

53

Tx essential tremor?

1) propranolol 2) anticonvulsant (primodine/topiramate)

54

Parkinsons symptoms?

TRAPS (Tremor, Rigidity, Akinesia/brady, Postural instability (orthostatic hypotension), Shuffling gait)

55

What is shy drager (multiple system atrophy)?

Parkinsonism, autonomi dysfunction (cholinergic), widespread neurologic signs (cerebrellar) tx. volume expansion with hydrocortisone

56

Mild disease parkinsons tx >60 or

>60: amantadine (increases dopamine release from snpc) and

57

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

58

Best tx to prevent progression parkinson?

MAO inhibitor (rasagiline, selegiline)

59

Tx of spasticity (painful muscle contractions)?

Baclofen, dantrolene, and tizanadine (alpha agonist)

60

Tx RLS?

Mild/intermittent: Iron with

61

Symptom triad and tx in huntington?

Memory (dementia), Mood (psychosis w/haloperidol or quetiapine), Movement (dyskinesia tx with tetrabenazine)

62

Tourette tx?

Fluphenazine, pimozide, clonazepam (Cloning pimp on tour w/ flu). Methyphenidade and ADHD intrinsic to Tourette

63

LP for MS?

Increase protein, 50-100 WBC, increase IgG, oligoclonal bands

64

Tx for acute episode vs preventing relapse MS?

Acute-high dose steroids, plasmapharesis (if steroids not effective)
Relapse-B-interferon or Glatiramer

65

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

66

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

67

Characteristics and Most accurate test charcot marie tooth?

Inverted champagne bottle legs, high arch (pes cavus), and motor and sensory loss. EMG

68

Tx. peripheral neuropathy?

Pregablin/gabapentin, TCA

69

Lateral cutaneous nerve percipitating event and presentation?

Obesity, pregnancy, and sitting with crossed legs. Pain/numbness of outer aspect of one thigh

70

Peroneal neruopathy pericpitating even and presentation?

High boots and pressure on back of knee. Weak foot with decreased dorsiflexion and eversion (footdrop)

71

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

72

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)

73

Best test/tx for bell palsy?

Test-EMG, tx is prednisone

74

GBS presentation and tests?

Ascending weakness and decreased reflexes, best initial (PFT), EMG most accurate. CSF increased protein normal cell count (albuminocytologic dissassociation)

75

Tx GBS?

IVIG (children) OR plasmapheresis (adults), NOT prednisone

76

Best initial and most accurate test MG?

Best initial-acetylcholine receptor antiboides and most accurate is EMG

77

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

78

Myasthenia crisis tx?

1) Endotracheal intubation
2) Meds (IVIG or plasmapharesis PLUS glucocorticoids) and hold neostigmine or pyridostimine to avoid excess.

79

Workup dementia?

MRI, VDRL/RPR, B12, TSH

80

Tx alzheimers?

Rivastimine, galantamine, donepezil or memantine

81

Tx lewy body

Levodopa or carbidopa

82

Tx frontotemporal

acetylcholine medication

83

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

84

Triggers of vasovagal syncope?

Emotional distress, painful stimuli, and prolonged standing

85

Why do you have peripheral visual field defect?

CN VI palsy (lateral rectus muscle)

86

Symp of diabetic neuropathy?

Peripheral neuropathy (numbness, tingling and feeling of imbalance). Mononeuropathy (CNIII, ptosis and down and out with light reflex/accomodation intact)

87

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

88

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))

89

Wernicke triad?

Encephalopathy, oculomotor dysfunction (ophthalmopletgia) and gait ataxia

90

Korsakoff?

Present with wernicke and irreversible amnesia, confabulation

91

What test may be abnormal in pseudodementia?

Dexamethasone suppression (abnormal) to detect endogenous depression in 50%

92

Alzheimer presentation?

Early insidious short term memory loss followed by later personality changes. May see subcortical atrophy in parietal and temporal lobes predominate.

93

Tx. delirium

Tx underlying condition. Typical or atypical antipsychotics for agitation and benzo for alcohol withdrawal

94

Preservation of what in brain death?

DTR may be present b/c preservation of spinal cord function

95

Most significant cause of morbidity in patients with traumatic brain injuries?

Diffuse axonal injury due to deceleration injury-->vegetative state

96

Most common medications to cause dystonia?

Typical antipsychotics, metoclopramide, prochlorperazine

97

Evaluation of corneal abrasion?

1) Penlight for defect/foreign body identification and pupillary function
2) Fluorosceine after to show corneal staining defect

98

Location and management of brain metastasis?

Location-gray-white junction or watershed zones. Solitary (surgery) and multiple (whole brain radiation)

99

MCC brain abscess from direct spread of head and neck infection?

Viridans or anaerobic

100

MCC brain abscess after nuerosurgery or penetrating trauma direct inoculation?

S. aureus

101

MCC brain abscess from hematongenous spread via endocarditis or osteomyelitis infection?

S aureus

102

What level does spinal cord end at?

L1-L2

103

Presentation of sellar masses?

Bitemporal hemianopsia, headache, diplopia, pituitary hormonal deficiency

104

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

105

Presbycusis symptoms?

High freq hearing impariment difficulty hearing in crowded or noisy environments and trouble hearing high pitched noises

106

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

107

Best test for detecting vasopasm in SAH patients

CT Angiography

108

Aminoglycoside toxicity?

Ototoxicity (hearing loss) by damaging the cochlear cells and in some cases vestibulopathy (motion-sensitive hair cell damage)

109

What are lewy bodies?

Eosinophilic intracytoplasmic inclusions representing alpha-synuclein protein

110

Cause of myasthenic crisis?

1) infection or surgery
2) Pregnancy or childbirth
3) Tapering immunosuppressive drugs
4) Medications (eg aminoglycosides, fluoro, macro, B-blocker)

111

Symptoms myasthenia gravis?

Extraocular (ptosis, dipolia), bulbar (eg fatigable chewing, dysphagia, nasal speech), proximal limb, and resp muscles

112

What does motor control of eye muscles?

LR6SO4R3

113

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

114

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)

115

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

116

What situation is LP contraindicated?

Acute head trauma, signs of intracranial HTN (ie papilledema) or suspicion for SAH. only do w/ NEG CT/MRI

117

What causes conduction velocity to be slowed?

Demyelination. watch out in GBS and MS

118

What causes EMG to show fasiculations or fibrillations at rest?

LMN (peripheral nerve problem)

119

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)

120

Area involved when ignoring one side of body, trouble with dressing

nondominant parietal lobe

121

CN for midbrain, pons, medulla respectively?

CN III/IV-midbrain
V, VI, VII, VIII-pons
IX,X,XI, and XII-medulla

122

Direct spread via otitis media/mastoiditis affected area in brain?

Temporal lobe/cerebellum

123

Direct spread via frontal or ethmoid sinusitis affected area in brain?

Frontal lobe

124

Direct spread via dental infection affected area in brain?

Frontal lobe

125

Bacteremia from other sites of infection, cyanotic, heart disease?

Multple abscesses along distribution of middle cerebral artery (gray-white matter junction)

126

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

127

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

128

Broca and Wernicke aphasia?

Broca-motor aphasia
Wernicke-receptive aphasia

129

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

130

MCA occlusion?

Contralateral hemiparesis and hemisensory loss predominantly in upper limp and face. Homonymous hemianopsia with deviation of eye toward infarct

131

ACA occlusion?

Contralateral hemiparesis and hemisensory predom in lower extremity. Abulia (lack or willor initiative). Dyspraxia, emotional disturbance, urinary incontinence

132

Vertebrobasilar system lesion (supplying brain stem)

-Alternate syndromes with contralateral hemiplegia and ipsilateral CN involvement with possible ataxia

133

Stroke in the VPL nucleus of thalamus?

Unilateral numbness, paresthesias, and hemisensory deficit involving face, arm, trunk, and leg (pure sensory)

134

Lacunar infarction of anterior limb of internal capsule?

Weakness more prominent in lower extremity along with ipsilateral arm and leg incoordination

135

Lacunar stroke at the basis pontis?

Dysarthria-clumsy hand syndrome with hand weakness, mild motor aphasia, no sensory abnormalities.

136

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

137

Sensory symptoms of wallenberg syndrome?

Loss of pain and temp on ipsilateral face and contralateral trunk and limps

138

Ipisilateral bulbar muscle weakness of wallenberg?

Dysphagia and aspiration. Dysarthria and hoarseness

139

Autonomic dysfunction of wallenberg?

Ipsilateral Horner's (PAM), lack of autonomic respiration during sleep

140

Posterior (dorsal) cord syndrome?

Bilateral loss of vibratory and propioceptive sensation, often with weakness, paresthesias, and urinary incontinence or retention

141

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

142

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

143

Ataxic, staggering, wide-based gait area affected?

Cerebellum

144

Magnetic (freezin) start and turn hesitation gait?

Gait apraxia (frontal lobe signs)

145

Short steps, shuffling that is hypokinetic

Parkinsonian

146

Footdrop, excessive hip and knee flexion with slapping quality?

steppage from motor neuropathy commonly the peroneal nerve

147

Unsteady, falling to one side with sensation of ear fullness due to abnormal accumulation of endolymph?

Acute labyrinthitis or meniere disease (vestibular gait)

148

Cause of BPPV?

crystalline deposits (canaliths) in the semicircular canals that disrupt the normal flow of fluid in the vestibular system

149

Meniere disease presentation?

Ear fullness causing unilateral tinnitus and hearing loss with episodic vertigo

150

BPPV presentation?

Brief positional changes causing vertigo WITHOUT neurologic or auditory symptoms

151

Vestibular neuritis vs Labyrinthitous presentation?

Post viral with vertigo. Hearing loss in labyrinthitis and no hearing loss in neuritis.

152

What is otosclerosis?

Bony overgrowth of stapes associated with low-frequency hearing loss found in middle aged 20s-30s

153

Side effect levodopa plus carbidopa?

Somnolence, confusion, hallucinations (older patients), dyskinesia

154

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)

155

Amantadine side effect?

Ankle edema nd livedo reticularis

156

Entacapone or tolcapone side effects?

Dyskinesia, hallucinations, confusion, nausea and orthostatic hypotension

157

Selegeline side effect?

Insomnia and confusion

158

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.

159

Pronator drift is a sensitive and specific finding for what?

UMN disease

160

Right anopsia location of lesion?

Right optic nerve

161

Left homonymous hemianopsia location of lesion?

Right optic tract

162

LUQ anopsia?

Right optic radiation in right temporal lobe

163

LLQ anopsia

Right optic radiation in right parietal lobe

164

Left homonymous hemianopsia with macular sparing?

Right occipital lobe (from PCA occlusion)

165

Lesion causing loss of gag reflex and loss of taste in posterior 2/3rd of tonuge?

CN IX lesion

166

Recurrent laryngeal nerve palsy and hoarseness dysphagia and loss of gag or cough reflex?

CN X lesion

167

CN XI lesion?

Look away from lesion and ipsilateral shoulder droop secondary to loss of innervation of SCM and trapezius

168

CN XII lesion?

Protruded tongue deviates to same side as lesion

169

First line agents of simple seizure?

Carbamazepine, lamotrigine, oxcarbazepine, and levetiracetam

170

First line complex partial/tonic clonic?

Valproate, lamotrigine, levetiracetem

171

First line absence?

Ethosuximide and valproate

172

Secondary seizure tx.

Benzo and/or phenytoin or fosssphneytoin

173

What is hemiballismus (random,violent, unilateral flailing of limbs) caused by?

Subthalamic nucleus lesion

174

Test for peripheral neuropathy?

Nerve conduction studies

175

Tx organophosphate (inhibition of AChE) poisoning?

Atropine or pralidoxime

176

4 Classic signs of basilar skull fracture?

-CSF otorrhea or rhinorrhea, hemotympanum, postauricular ecchymosis, periorbital ecchymosis ("raccoon eyes")

177

#1 sign og increased ICP?

Bilateral dilated and fixed pupils