Neuro Flashcards

Question

ALS

Answer 1

UMN and LMN disease - asymmetric limb weakness and *bulbar dysfunction* - bulbar (medulla) dysfunction - dysfunction of CNs 9-12 (glossopharyngeal, vagus, accessory spinal, hypoglossal) riluzole - glutamate (release) inhibitor, prolongs survival - side effects - dizziness, N, elevated LFTs death within 5 yrs

Answer 2

cord compression = medical emergency - causes - spinal injury (disk herniation, compression fracture), malignancy (lymphoma, breast cancer mets), infection (epidural abscess) - severe low back pain, worse in the recumbent position at night - due to distention of epidural venous plexus when lying down - early - bilateral, LE weakness and absent DTRs - late - UMN signs, paraplegia, bowel/bladder dysfunction - reasons - descending CSTs affected (LE weakness, loss of rectal tone), ascending spinothalamic tract (sensation), descending autonomics (reticulospinal tract, urinary RT) - emergency MRI of spine, IV glucocorticoids, rad-onc/surg consults central cord syndrome - hyperextension injury in elderly pts with pre-existing degenerative changes in c-spine (fall, whiplash) - damage to central portion of anterior spinal cord - CST and LST - weakness in *upper extremities* (because these correlate with the central part of the CST) - can have loss of pain and temp in arms (due to damage to spinothalamic tract) anterior ventral cord syndrome - occlusion of ASA - bilateral spastic motor paresis distal to lesion Brown-sequard - *hemisection* of cord due to penetrating injury - ipsilateral - weakness (LCST), spasticity, loss of vibration sense, and proprioception AT level of injury - contralateral - loss of pain and temp, 2 levels below injury - if this occurs in cervical region - can have ipsilateral Horner syndrome (- compared to complete spinal transection - loss of everything, quadraplegia or paraplegia posterior cord syndrome - causes - MS, vertebral artery dissection - bilat loss of vibratory and proprioceptive sensation, weakness, paresthesias - urinary incontinence/RT spinal cord infarct - abrupt symptoms

Answer 3

ICH - urgent non-contrast CT - headache, AMS Intraparenchymal hemorrhage - BG (putaminal) hemorrhage - almost always involves internal capsule --> contralateral hemiparesis and hemianesthesia - due to hypertensive vasculopathy - involves small penetrating branches --> formation of Charot-Bouchard aneurysms in deep brain structures --> rupture and bleed --> in BG, cerebellar nuclei/cortex, thalamus, and pons - AV malformation - most common cause of intraparenchymal bleed in kids - symptoms - gradual onset - symptoms include - ipsilateral hemitaxia (because corticopontocerebellar fibers decussate twice) - spreading hematoma can lead to coma - non-con CT and decompression imm cerebral amyloid angiopathy - most common cause of lobar/cortical hemorrhage (occipital, parietal) in the elderly (age >60) SAH - CT (and if needed--> get LP) - due to berry aneurysms - will see blood collecting in brainstem and basal cisterns - thunderclap headache, neuro deficits are UNcommon - further evaluation with CT angio SDH - tearing of bridging veins - elderly, alcoholics (cerebral atrophy and increased fall risk) - acute - slow bleed into subdural space, confusion is gradual (1-2d), impaired consciousness, increased ICP signs - chronic - insidious, onset weeks after injury, somnolence, focal neuro deficits epidural hematoma - bleed doesnt cross suture lines - sphenoid bone trauma --> tearing of middle meningeal artery - uncal herniation - *ispilateral* CN3 palsy (down, out, and dilated due to loss of motor and PSNS), hemiparesis - ddx by head CT - urgent surgical evacuation for symptomatic pts

Answer 4

differentiates between nerve and muscle disease

Answer 5

greatest risk factor for both ischemic and hemorrhagic - HTN - because it accelerates atherosclerotic process and promotes thrombi formation - side note - cerebral amyloid angiopathy is the second most common cause of intracerebral hemorrhage (occurs in age >75) if you suspect a stroke - get noncontrast CT head cardioembolic stroke - gray-white junction - if due bacterial endocarditis - you have septic embolism, treat with IV abx - more sudden onset than atherosclerotic stroke - embolic strokes are more likely to bleed than thrombotic strokes ischemic stroke - hypodense region that will become evident >24hrs after event - tpa window - 3.5-4hrs after sx onset (exclusion criteria is long, remember bleeding risk, prior stroke/head trauma in the last 3 mo, and recent intracranial/spinal surgery, BP > 185/110) - stroke and not on ASA - add ASA imm - stroke and on ASA - add clopidogrel (or dipyridamole) - stroke + afib - long term anticoagulation (start outpatient) ischemic stroke with hemorrhagic transformation - deterioration in pts neurologic status - get emergent noncon CT --> urgent surgical decompression intracerebral hemorrhage - focal neuro deficits and signs of increased ICP (vomiting and headache, bradycardia, reduced alertness) - warfarin-associated intracerebral hemorrhage - give vitamin K and prothrombin complex concentrate (contains factors) stroke in young - PFO, IC dissection (trauma!, associated with Horners and varying degrees of hemiparesis), Ehlers-Danlos or Marfans, AVFs, moyamoya disease, drug abuse, hypercoagulable state *********************************************** tx - lifestyle modification. Start asa, statin, and BP reduction.

Answer 6

accumulation of a-synuclein in substantia nigra (BG) --> death of these neurons 2/4 for clinical ddx - resting tremor, rigidity, bradykinesia (hypokinetic, narrow based gait), postural instability - symptoms present asymmetrically... - other signs include mask-like facies tremor - improves with activity (note essential tremor is the opposite) - 4-5 Hz frequency - starts on one hand before the other - treat with trihexyphenidyl (anticholinergic) rigidity - lead pipe or oscillating postural instability - flexed axial posture, loss of balance during turning or stopping, loss of balance when pushed from stationary bipedal stance, frequent falls drugs - levodopa/carbidopa - side effect is somnolence and hallucinations - entacapone - increases dopamine stimulation, side effect is dyskinesia (and other side effects of excess dopamine) - amantidine - dopamine agonist, shown to delay dementia, side effects are ankle edema and livedo reticularis - pramipexole - dopamine agonist (also used in restless leg syndrome) - selegiline - MAOB inhibitor, side effect is insomnia and confusion - note - increased dopamine --> nausea, orthostatic hypotension, dizziness, dyskinesia (long-term use), hallucinations (in order pts) ************************ drug-induced parkinsonism - due to anticholinergics (benzotropine, diphenhydramine) - side note - anticholingerics can improve tremor and rigidity but not bradykinesia Shy-Drager syndrome - degenerative disorder - parkinsonism - autonomic dysfunction (orthostatic hypotension, impotence, incontinence, etc.) - widespread neurologic signs (cerebellar, pyramidal, or LMN) - treat by intravascular volume expansion (fludrocortisone, salt supplementation, a-agonists, compressive stockings)

Answer 7

conus medullaris (UMN and LMN sxs) - note - things that affect the spinal cord can cause UMN and LMN symptoms - back pain with EARLY bladder and rectal dysfunction - symmetric motor weakness, hyperreflexia cauda equina - spinal roots (part of peripheral NS) compressed - radicular pain, *asymmetric LE weakness and hyporeflexia*, saddle anesthesia, LATE bowel/bladder dysfunction causes - cord compression due to mets, disc herniation/rupture, spinal stenosis, infection, tumor, hemorrhage, iatrogenic injury management - emergency MRI, neurosurg eval +/- IV glucocorticoids - neurosurgical emergencies - due to risk of permanent loss of sphincter function

Answer 8

focal dystonia of SCM - dystonia - sustained muscle contraction --> abnormal movements torticollis - congenital, idiopathic, trauma, local inflammation, drug-induced (antipsychotics, metoclopramide, prochlorperazine)

Answer 9

essential tremor, AD - can affect UE, head, voice, etc. - worsens with motion, arms extended, caffeine - resolves during sleep, improves with alcohol consumption - treat with propanolol (or primidone) - orthostatic tremor is a variant of essential tremor - occurs in legs on standing, relieved by sitting down Parkinsons - resting tremor of extremities - basal ganglia dysfunction - progressive loss of dopaminergic neurons in basal ganglia cerebellar (spinocerebellar ataxia, genetic condition) aka intention tremor - usu associated with ataxia (fall towards side of lesion), dysmetria, or gait disorder - tremor increases as hand reaches target physiologic - low amplitude - 10-12 Hz, not visible normally - onset with increased sympathetic activity (drugs, caffeine, anxiety) - worsens with movement, can involve face and extremities

Answer 10

due to damage of contralateral subthalamic nucleus (- involved in the inhibition of movements) thalamic stroke (aka lacunar stroke of thalamus) - certain thalamic nuclei transmit sensory information from the contralateral side of the body and face - stroke - contralateral (total) sensory loss - can also have transient hemiparesis, athetosis, ballistic movements - because neighboring basal ganglia/internal capsule fibers are disrupted - weeks to mo after stroke - thalamic pain syndrome (allodynia)

Answer 11

fetal alcohol syndrome 1) small palpebral fissures 2) *smooth philtrum* 3) thin vermillion border height, weight often < 10% microcephaly + cognitive and behavioral disorders - social withdrawal, delays in motor an lang treatment - early ddx is critical, therapy ******************************* DS is most common genetic cause of developmental delay - flat facial profile, slanted fissures, small low-set ears, clinodactyly, etc. ******************************** Fragile X is the most common inherited reason for ID - XD, CGG repeat - long narrow face, prominent forehead and chin, large ears, macrocephaly, macroorchidism - ADHD, autism - female pts with the mutation may have normal intellect, may have mild ID ******************************** Infections - CMV - ID, sensorineural deafness, blindness, jaundice, HSM, petechiae - rubella - sensorineural deafness, cataracts, HSM, purpura

Answer 12

hypoplastic fingers/nail and cleft lip/palate give ppx vitamin K in first trimester - phenytoin may increase rate of fetal vitamin K degeneration

Answer 13

cerebral contusion - heal without medical intervention diffuse axonal injury - accel/decel injury - coma - head CT may show bleeds at grey-white junction concussion - mild TBI, confusion, amnesia - immediately after - rest for 1 day, reassess - post-concussive syndrome - headache, confusion, amnesia, difficulty concentrating, vertigo, mood alteration, sleep disturbance, anxiety - resolve few weeks to mo following TBI

Answer 14

bugs - Campy (others are Herpes, Mycoplasma, H flu) ascending polyneuropathy after respiratory tract or upper GI infection demyelination of the **peripheral** motor nerves - neuropathic pain flaccid paralysis, absent DTRs and nerve conduction velocities, severe back pain - side note - absent DTRs and paresthesias = signs of NEUROpathy - autonomic symptoms (ileus, BP, heart rate instability, orthostatic hypotension) - respiratory compromise CSF - elevated protein, normal cell count = albuminocytologic dissociation + use EMG for ddx - infiltrating T lymphocytes and macrophages around nerver plasmapheresis and IVIG - and monitor autonomic and respiratory function - assess pts pulmonary function by serial spirometry (FVC is gold std for assessing ventilation, decline in FVC indicates impending respiratory arrest --> tube) typically - spontaneous recovery in a year ************************************ tick paralysis - neurotoxin in tick saliva --> paresthesias, fatigue, ascending muscle paralysis over hrs or days - paralysis can be localized to or more pronounced in 1 leg/arm - examine skin to remove tick --> will result in recovery

Answer 15

lateral *medullary* infarct - due to intracranial vertebral artery - ddx on MRI - give TPA 1) vertigo, falling to side of lesion, nystagmus, ipsilateral limb ataxia 2) abnormal facial sensation, loss of pain and temp in ipsilateral face and contralateral body 3) cranial 9 and 10 involvement - dysphagia, aspiration, hoarseness (- contrast with lateral mid-pontine lesions - affect motor and principal sensory nuclei of trigeminal nerve) 4) autonomic dysfunction - ipsilateral Horners syndrome, intractable hiccups, lack of autonomic respiration

Answer 16

branch occlusion of vertebral or ASA contralateral paralysis or arm and leg tongue deviation TOWARDS lesion

Answer 17

contralateral ataxia and hemiparesis of the entire body (face, trunk, limbs) - variable loss of contralateral tactile and position sense

Answer 18

UMN - leukodystrophies, vasculitis, brain mass in cortext, B12 deficiency (DCML) anterior horn cells - spinal muscular atrophy, ALS, paraneoplastic syndrome, polio peripheral nerves - hereditary primary motor sensory neuropathy - GB - diabetes - amyloid neuropathy (myeloma) - lead poisoning NMJ - MG, LES - organophosphate poisoning - botulism muscle fibers - muscular dystrophies (waddling gait, weak gluteal muscles) - poliomyositis and dermatomyositis - hypothyroidism (+ reduced DTRs) - corticosteroids - HIV myopathy

Answer 19

generalized seizures - triggers - fever, hypoglycemia, sleep deprivation - tongue biting, urinary incontinence, perioral cyanosis - preceding aura, LOC, convulsions, *post-ictal state* vasovagal syncope - prolonged standing, stress - presyncope (lightheadedness, pallor, diaphoresis, nausea) - IMMEDIATE return to baseline cardiogenic syncope (decreased CO in the setting of structural HD) - exertion, dehydration - sudden LOC (no prodrome), immediate return to baseline * ************************* v. s. breath-holding spells - in 6 mo-6yrs - cyanosis, pallor following an upsetting event or minor injury - immediate recovery HOCM (syncope on exertion), orthostatic hypotension (intravascular volume depletion, autonomic instability due b-blockers)

Answer 20

cardiac - valvular insufficiency, perivalvular abscess, conduction abnormalities, mycotic aneurysm neuro - embolic stroke, cerebral hemorrhage, brain abscess, acute encephalopathy or meningoencephalitis renal - renal infarct, glomerulonephritis, drug-induced interstitial nephritis (from therapy) MSK - vertebral osteo, septic arthritis, MSK abscess if you suspect - draw blood cultures, initiate broad-spectrum abx, echo

Answer 21

broad-based gait, impaired heel-to-shin testing posterior circulation issue

Answer 22

treponema pallidum - spirochetes directly damage the dorsal sensory roots --> secondary degeneration of the dorsal columns early - meningitis late - dementia, tabes dorsalis (sensory ataxia, pos Romberg, lancinating pains, reduced DTRs), Argyll robertson pupils (accommodates but doesnt react), dysmetria (overshoot, undershoot of movements), neurogenic bladder tertiary syphilis can cause uveitis other features - decreased concentration, memory loss, dysarthria, tremors, irritability, headaches, personality changes and impaired judgement treat with IV penicillin for 10-14d

Answer 23

JC virus --> demyelinating disease - affects immunocompromised - transplant pts subacute AMS and multifocal neurologic deficits

Answer 24

Wernickes encephalopathy - confusion (encephalopathy), horizontal nystagmus, gait ataxia - due to thiamine deficiency benzos - binds to GABA receptors - slurred speech, ataxia, hypoT, depressed mental status - give flumazenil opioid OD - pinpoint pupils, respiratory depression - naloxone

Answer 25

normal age-related sleep changes - decreased total sleep time, increased nighttime awakenings, phase advance (sleep earlier, wake up earlier)

Answer 26

migraine - due to vasospasm - often pos FHx - unilateral, pulsatile and throbbing - auras (can be paresthesias), photophobia, phonophobia, nausea - basilar migraine - can have basilar aura sxs (vertigo, dysarthria, tinnitus, diplopia) - abortive - triptan, NSAID, acetaminophen, antiemetics, ergots - triptans - serotonin agonist --> vasoconstriction, decreases neurogenic inflammation - preventives - topiramate, divalproate, TCADs, b-blockers - topiramate - can cause renal stones - valproate - hepatotoxic cluster - M>F - onset during sleep - can occur in paroxysms - behind one eye, excruciating, sharp and steady - sweating, facial flushing, nasal congestion, lacrimation, pupil changes - ppx with verapamil, Li - acute attack can be aborted by 100% O2 (or subQ sumatriptan) trigeminal neuralgia - maxillary and mandibular disorders - tx - carbamazepine tension - stress, band-like pattern around head, muscle tenderness in head/neck/shoulders - temporal and occipital regions - use ibuprofen, aspirin, and caffeine to treat kids - headaches are a common complaint - most common = migraines - but will be bifrontal, shorter in duration, other sxs similar - occipital headache is CONCERNING - treat with supportive management --> triptans - image if coordination difficulties, numb/tingling, focal neuro, headache that wakes you from sleep, increasing frequency when would you image - neuro findings - seizures, deficits, changes in consciousness - change in nature - onset age > 40, sudden onset, trauma, present on awakening

Answer 27

mild - acetaminophen, NSAIDS (naproxen has a longer duration than ibu) moderate - weak opioids and non-opioids - codeine, hydrocodone, tramadol severe - short-acting opioids - morphine, hydromorphone - calculate daily dose, convert to long-acting formulation (fentanyl patch, 72hr duration + oxycodone) PLUS short-acting opioids for breakthrough pain glucocorticoid injections can be used as adjunctive therapy if there is incomplete improvement on opioid therapy

Answer 28

ischemia of sensory thalamic nuclei - contralateral loss of sensation and tingling - delayed episodic, severe pain with ongoing paresthesias (Dejerine-Roussy syndrome)

Answer 29

two lobes of the parotid gland - separated by facial nerve = motor to face

Answer 30

axillary nerve injury - fracture of humerus neck, anterior dislocation of humeral head - note anterior dislocation usu due to externally rotated abducted arm - paralysis of deltoid and teres minor, sensory loss over lateral upper arm --> weak shoulder *abduction* - deltoid weakness appreciated at extreme extension Klumpke palsy - sudden upward traction of arm musculocutaneous nerve - biceps, brachialis, coracobrachialis - elbow flexion and forearm supination - sensation of radial aspect of forearm radial nerve - injured in humeral mid-shaft fractures and improperly fitted crutches - radial nerve - responsible for wrist extension and arm extension - triceps innervation comes off proximal to humeral spiral groove ulnar nerve entrapment - most commonly at elbow (wrist less common, forearm can occur in diabetics) - claw hand - weakness of the hypothenar and interosseus muscles Parsonage-Turner syndrome - acute idiopathic brachial plexopathy - acute, severe shoulder pain.... - sometimes - hx of preceding viral infection or vaccination

Answer 31

during forceful FLEXIOn of arm | - audible pop, visible bulge (where biceps muscle retracts into upper arm)

Answer 32

think Marfans or homocystinuria common features - pectus, tall stature, arachnodactylyl, joint hyperlaxity, skin hyperelasticity, scoliosis Marfans - AD - normal intellect - aortic root dilation - upward lens dislocation Homocystinuria - AR - ID - fair complexion - thrombosis (CVA) - megaloblastic anemia - downward lens dislocation - treat with vitamin *B6* and B12 to lower homocysteine levels, PLUS give antiplts or anticoag * ******************************* v. s. Ehlers-Danlos - collagen disorder.... no other similarities to Marfans v. s. PKU (AR) - fair skin, ID, eczema, must body odor - newborn screening - via tanden mass spec (to look for presence of metabolic products of phe) - get quantitative amino acid analysis later in life - will see elevated phe levels

Answer 33

Fabry - a-galactosidase deficiency - angiokeratomas, peripheral neuropathy, asymptomatic corneal dystrophy, renal and HF, thromboembolic events Krabbe - AR, galactocerebrosidase deficiency - ID, blindess, deafness, paralysis, neuropathy, seizures Tay-Sachs - AR, b-hexosaminidase A - ID, weakness, seizures, cherry-red macula

Answer 34

limit second hand smoke, use a pacifier, room-sharing (w/o bed sharing) SUPINE position - to reduce risk

Answer 35

primary CNS lymphoma - EBV DNA in CSF - single ring-enhancing mass - v.s. toxo - *multiple* ring-enhancing masses (side note - pos toxo serology is common in normal people) - v.s. nocardia - brain abscess with ring-enhancing lesions (CD4 < 100) AIDS dementia - cortical and subcortical atrophy and secondary ventricular enlargment cryptococcal meningitis - CSF with elevated opening pressure, low leukocytes with monos, slightly elevated proteins, low glucose - organisms by India ink

Answer 36

vincristine, platinum (cisplatin), taxanes (paclitaxel) stocking-glove pattern, loss of reflexes, loss of pain and temp sensation - can have motor neuropathy -bilateral foot drop (side note - all this except for the the motor neuropathy occurs in diabetic neuropathy)

Answer 37

ACA occlusion - contralateral LE motor and sensory deficits + UMN signs - abulia - lack of will or initiative - dyspraxia, emotional disturbances, urinary incontience lacunar infarct (post limb of internal capsule) - unilateral motor impairment - OFTEN with symptoms improving spontaneously - other features - pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand - small penetrating artery occlusion due to hypertensive arteriolar sclerosis (small-vessel lipohyalinosis) - areas affects - BG, subcortical white matter, pons - pons = dysarthria-clumsy hand syndrome - **because they are small, they wont be seen on CT immediately after stroke** - risk factors - HTN, DM, advanced age, high LDL, smoking - NO cortical signs (aphasia, agnosia, neglect, apraxia, hemianopia) MCA - contralateral motor - conjugate eye deviation TOWARDS infarct - homoymous hemianopia, aphasia (dominant hemisphere L) - hemineglect (non-dominant hemisphere parietal R) PCA - homonymous hemianopia (with macular sparing), alexia without agraphia, visual hallucinations, sensory symptoms (thalamus), 3rd nerve palsy, contralateral motor deficits vertebrobasilar system lesion - contralateral hemiplegia, ipsilateral CN involvement - may have ataxia

Answer 38

ventral brainstem injury

Answer 39

amaurosis fugax - "curtain falling over eye," transient - atherosclerotic emboli from carotid artery - in your differential - cardioembolic disease, giant cell, retinal vein occlusion, retinal vasospasm, papilledema traumatic carotid injuries - mechanism - penetrating trauma, fall with object in mouth (toothbrush, pencil), neck manipulation (yoga, sports) - can be due to fibromuscular dysplasia - internal carotid is posterior to the tonsillar pillars - presents with hemiplegia, aphasia, neck pain, thunderclap headache, Horners - CT or MRA for carotid artery atherosclerosis - workup for TIA - EKG, carotid US, echo to find etiology - initial interventions for carotid artery disease - ASA, statin, BP control, lifestyle changes - stenosis >60% - stent - for symptomatic pts with high-grade stenosis (70-99%) - CEA - pts with disabling neurologic deficits, 100% carotid occlusion, or life expectancy of <5yrs are unlikely to benefit

Answer 40

S aureus, hematologic spread classic triad = fever, focal/severe back pain, neuro findings (starts with nerve root pain, shooting and electric) - suprapubic mass - distended bladder due to urinary RT ddx - elevated ESR, blood and aspirate cultures, MRI spine treat - vanc + ceftriaxone (broad spectrum) - aspiration and surgical decompression

Answer 41

inflammation and edema of facial nerve often due to herpes simplex activation peripheral (lesion below pons) - inability to raise eyebrow or close eye forehead sparing (ability to wrinkle forehead) - suggestive of an intracranial lesion, warrants brain imaging for most pts - partial or complete recovery occurs within 6 mo

Answer 42

oculomotor nerve palsy - mydriasis, ptosis, down and out eye - uncal herniation, p.comm aneurysm - nerve ischemia (DM) - down-and-out gaze with preserved pupillary response - because of which fibers control what and inner fibers are furthest from the blood supply (so are more susceptible to ischemia) nerve compression - mydriasis (PS fibers are on the outside of the nerve)

Answer 43

shearing of subdural veins

Answer 44

3 cardinal findings - unresponsiveness - absence of brainstem reflexes - apnea absent cortical and brain stem functions - note brain stem controls- CNs, vagus nerve (heart), respiratory center (no spontaneous breathing at high PCO2) - SC may still be functioning = DTRs may be present - brainstem reflexes - fixed pupils, no corneal reflex, absent oculovestibular reflexes, no gag, no response to supraorbital pressure isoelectric EEG can be used as a confirmatory test - not necessary though

Answer 45

anterior uveitis - pain and redness, blurry vision, photophobia posterior uveitis - floaters, reduced visual acuity

Answer 46

glucocorticoid-induced - occurs weeks to mo after starting - weakness, without pain - LE muscles are more involved - note glucocorticoids also cause bone loss and hyperglycemia polymyalgia rheumatica - pain and *stiffness* in shoulder and pelvic girdle - can be seen in 50% of pts with temporal arteritis - responds to glucocortoids (low dose) - elevated CK inflammatory myopathies - pain, proximal weakness - skin rash and inflammatory arthritis - elevated ESR and CK statin-induced - elevated CK hypothyroid myopathy - proximal muscles, delayed DTRs, myoedema - elevated CK

Answer 47

improperly canned foods, cured fish inhibits presynaptic Ach release onset 36 hrs after ingestion (GI upset) --> bilateral cranial neuropathies ( blurred vision, diplopia, facial weakness, dysarthria, dysphagia) - symmetric *descending* weakness - diaphragmatic weakness - may need mechanical ventilation EMG - decreased compound muscle APs, repetitive stimulation increases amplitude serum analysis for toxin treat with equine serum antitoxin

Answer 48

treat cholinergic tox (ex organophosphate poisoning) - atropine blocks peripheral effects of Ach at muscarinic receptors - pralidoxime - reactivates AchE

Answer 49

focal neuro findings - *AMS*, CN deficits, fever, behavioral changes - NO rash CSF - lymphocytic pleocytosis, erythrocytosis (due to hemorrhagic destruction of temporal lobes), elevated protein levels - PCR analysis of HSV DNA in CSF (high sensitivity and specificity) brain imaging - temporal lobe lesions (MRI > CT) treat with IV acyclovir

Answer 50

progressive morning headache supratentorial tumors - can cause seizures supra and infratentorial tumors can cause symptoms of increased ICP meningioma - calcified, benign --> complete resection - commonly found in middle-aged women medulloblastoma - peds tumor - nocturnal or morning headaches - cerebellar dysfunction low grade astrocytoma - most common brain tumor in children - dont undergo malignant transformation - px due to mass effect and compression of surrounding structures = seizures glioblastoma - butterfly, central necrosis, serpiginous contrast enhancement CPA angle - acoustic neuroma, meningioma - headache, hearing loss, vertigo, tinnitus, balance problems posterior fossa tumor - can injure glossopharyngeal nerve - loss of gag reflex, taste on post 1/3, loss of pharyngeal sensation - dysfunction of carotid sinus --> increased risk of syncope mets are more common in adults - lung > breast > other > melanoma > colon - mets that will be solitary - breast, colon, RCC - mets that are multiple - lung cancer, malignant melanoma - brain mets are at gray-white junction - sxs of less than 2 mo - give glucocorticoids to reduce swelling + for palliative care - leads to a survival time of 1-2 mo - if prognosis is favorable and there is a single met - surgical resection followed by radiosurgery/radiation - note - primary cns tumors are more common in KIDS

Answer 51

bacterial - fever, increased ICP, meningeal irritation - complications in kids - *hearing loss,* ID, CP, epilepsy (so developmental f/u and audiologic testing is required) Listeria - ampicillin Tb meningitis - subacute presentation - CSF glucose is VERY low - less than 10 herpes meningoencephalitis - can have high RBC and protein levels - reflects temporal lobe hemorrhage

Answer 52

severe = GCS < 13, focal neuro deficits, skull fracture, seizure, AMS, prolonged LOC --> head CT wo contrast mild = GCS 13-15 w/ vomiting, headache, brief LOC, high-risk mechanism, severe mechanism (car crash with ejection, passenger fatality, rollover, auto-ped, fall height >5ft, high impact head hit) ---> observe 4-6hrs or head CT wo contrast - concussion is considered mild TBI - why do you get neuroimaging with mild? - bc sxs often overlap with severe TBI minor head trauma (GCS 15) - no head CT

Answer 53

viridans strep, s aureus, gram negative orgs path - adjacent infection (sinusitis, dental infection), hematogenous (will see multiple abscesses at gray-white junction) - bacteremia is also an increased risk in cyanotic HD - where the lungs (filter) are bypassed px - headache (resistant to analgesia), fever (50%), focal neuro deficits, seizure - initially - imaging with show cerebritis - in 1-2 wks - will show ring-enhancing lesion with central necrosis treat - empiric prolonged IV abx (metro, cef, vanc) + aspiration (surgical drainage)

Answer 54

brocas - frontal lobe - Boca - damage means they have expressive aphasia - right hemiparesis - can have gaze deviation to the side of the lesion - awareness of deficit wernickes - temporal lobe - receptive aphasia - right superior visual defect - no awareness of deficit arcuate fasciculus - through the frontal and parietal lobes - conduction aphasia - fluent with phonemic errors repetition impaired in brocas and wernickes aphasia nondominant frontal/temporal lobe lesions - affect emotion - frontal lobe - affects the way person conveys emotion through speech - temporal lobe - inability to comprehend emotion gestures

Answer 55

carotid artery dissection --> ipsilateral (partial) Horners vertebral artery dissection (inferior cerebellar artery occlusion) - lateral medullary (Wallenberg) syndrome - loss of pain/temp over ipsilateral face and contralateral body - vertigo, ipsilateral ataxia - Horner syndrome - due to damage of vestibular nuclei and inferior cerebellar peduncle

Answer 56

affect acomm and pcomm acomm - compress optic chiasm --> bitemporal hemianopia pcomm - 3rd nerve palsy (down and out eye)

Answer 57

lower the birth weight - the greater the risk for intraventricular hemorrhage - vascular perfusion injuries (hypoxia, hypotension, reperfusion of damaged vessels, increased venous pressure, abrupt changes in cerebral flow) - can also lead to IVH - have to do transfontanel US for all newborns with predisposing risk factors - grades 1-4 - grades 3-4 are associated with long-term sequelae

Answer 58

femoral - anterior compartment of thigh - flexion at hip, extension at knee - sensation to anterior thigh and medial leg obturator nerve - medial thigh - adduction - sensation of medial thigh tibial nerve - posterior compartment of thigh, post leg, and plantars - sensation to leg common peroneal (aka fibular) - susceptible to compressive injuries at fibular head (leg crossing, bedrest, cast) --> transient symptoms - worse in thin inds or people who have lost a sig amount of weight - superficial and deep peroneal - anterior and lateral leg - dorsum of foot

Answer 59

pituitary IC nerves - 3-6 cavernous sinus communicates across midline - so unilateral sxs become biateral facial/ophthalmic venous system - no valves - SO adjacent infections can spread to the cavernous sinus --> infectious cavernous sinus thrombosis - get MRI - treat with broad spectrum abx (+ prevention, reversal of cerebral herniation)

Answer 60

inhibits reuptake of NE and serotonin - but has MANY other receptor interactions - anticholinergic sxs - histamine receptors - lethargic - a1 receptors - orthostatic hypotension

Answer 61

sensory ataxia - pos Romberg - peripheral roots, dorsal roots, posterior column cerebellar ataxia - use tandem gait testing - staggering, wide-based gait, truncal ataxia - dysdiadochokinesia, dysmetria or intention tremor, Romberg (romberg tells about vestibular function), nystagmus - muscle hypotonia - pendular knee reflex - can occur in alcoholics (alcoholic cerebellar degeneration) gait apraxia (frontal gait) - start and turn (magnetic) - due to damage to cortico-cortical white matter fibers of frontal lobe - dementia, incontinence, frontal lobe signs - causes - frontal lobes degeneration, NPH Parkinsonian - short, shuffling steppage - due to motor neuropathy - foot drop (because you cant dorsiflex, L5 radiculopathy or common peroneal nerve neuropathy), excessive hip and knee flexion when walking - slapping quality - falls - distal sensory loss and weakness vestibular - acute labyrinthitis, meniere disease - staggering gait + vertigo and nystagmus pyramidal tract or CST - spastic ataxia

Answer 62

neuroleptic = dopamine antagonist fever > 40/104, confusion, muscle rigidity, autonomic instability 1) stop antipsychotics, restart dopamine 2) supportive care 3) dantrolene or bromocriptine * ***************** v. s. lithium tox - tremors, ataxia, AMS, N&V, hypotension v.s. serotonin syndrome - AMS, autonomic instability, and NM excitability (tremor, hyperreflexia, myoclonus)

Answer 63

taenia solium (pig) new-onset seizure cysts at various stages of development - nonenhancing/hypodense lesions, calcified granulomas

Answer 64

pinpoint pupils - descending sympathetic fibers have been destroyed

Answer 65

hypercoagulable conditions - OCPs, malignancy headache, confusion, seizures, focal neuro deficits confirm with MRI (CT will show nothing)

Answer 66

Duchenne and Becker - XR .... - Duchenne - comorbidities are scioliosis, cardiomyopathy - wheelchair-dependent by adolescence, death by 20s-30s due to respiratory or heart failure - can try corticosteroid treatment - Becker - cardiomyopathy - death by 40-50s due to heart failure myotonic dystrophy - AD - CTG repeat - onset - 12-30 - facial weakness, hand grip, myotonia (delayed muscle relaxation, ex pt wont be able to release hand after handshake), dysphagia - comorbidities - arrhythmias, cataracts, balding, testicular atrophy/infertility - death from respiratory/heart failure

Answer 67

mesolimbic - antipsychotic efficacy nigrostriatal - coordination of movement - EPS, acute dystonia, akathisia, parkinsonism tuberoinfundibular - hyperprolactinemia - esp risperidone (high affinity for D2 receptors)

Answer 68

AMS and/or neuro deficits sxs at BG > 600 mg/dL (usu >1000 mg/dL)

Answer 69

fever, headache, confusion neuroinvasive WNV --> myelitis --> asymmetric flaccid weakness in limbs

Answer 70

AT3 deficiency - increased risk of spont venous thromboembolism - but usu in femoral and mesenteric veins (cerebral thromboses are less common) homocystinuria - lens dislocation, ID, marfanoid feature, increased risk of arterial and venous thrombi

Answer 71

consider in pts >50 with new onset headaches (temples) fever, weight loss, vision changes, jaw claudication (fatigue, pain with chewing)

Answer 72

loss of transparency of lens - sxs - blurred vision, glare, halos around lights - as cataract progresses - retinal detail may be lost risk factors - age, DM, smoking, chronic sunlight exposure, glucocorticoid use * ********************************** v. s. macular degeneration - which affects central vision, dry (slow, progressive, bilateral) and exudative (unilateral, agressive)

Answer 73

painless loss of vision - due to thrombosis of retinal vein blood and thunder appearance = venous dilation, diffuse hemorrhage, cotton wool spots, disk swelling treatment - if there is no significant macular edema - close observation - macular edema - VEGF inhibitor injection note - central retinal artery occlusion is much more acute - painless monocular vision loss - embolic source - fundoscopic exam will show retinal whitening - tx - ocular massage, anterior chamber paracentesis, revascularization and asa, statin, or warfarin are initiate to prevent future attacks

Answer 74

fluctuating mental status, sundowning aka toxic-metabolic encephalopahty - inattention, confusion, asterixis - asterixis is not always associated with alcoholism many causes - drugs - benzos, antihistamines, muscle relaxers, sedatives - infections - electrolyte disturbances - metabolic derangements - systemic illness - CHF, hepatic failure, malignancy - CNS disturbance - risk factors - advanced age, dementia CMP, CXR, CBC, UA, review med list management - AVOID polypharmacy and physical restraints - maintain normal sleep-wake cycle - so reduce nighttime noises and disturbances - frequent reorientation - treat underlying cause - initial treatment for agitation - low dose haloperidol (can also use quetiapine, risperidone) - -> note prolonged use can increased mortality in elderly

Answer 75

weakness, fatigue, muscle cramps severe hypokalemia (< 2.5) - flaccid paralysis, hyporeflexia, tetany, rhabdomyolysis, arrhythmias causes - diuretic, diarrhea, vomiting, anorexia, hyperaldosteronism EKG - flat T waves, U waves, ST depression, PVCs, etc. ***************************** hypokalemic periodic paralysis - AD - due to defects in ion channels - attacks of flaccid limb weakness (+ decreased DTRs) - starts in early adulthood/adolescence - occurs after awakening - after eating a high carb meal, alcohol, cold weather, exercise - lasts hrs -days - can resolve completely, can leave residual weakness

Answer 76

dominant temporal lobe - medial temporal lobe - memory - lateral temporal lobe --> semantic issue - lost sense of what features make one animal distinct from other animals - note alzheimers - progresses from medial to lateral temporal lobe parietal lobe - astereognosis - inability to identify an object by touch of the hands non-dominant parietal lobe - visuospatial function (drawing intersecting pentagons)

Answer 77

sxs worse at NIGHT compression at forearm if pt also has thenar eminence numbness and weakness of thumb flexion - both nerves branch before the carpal tunnel inability to make OK sign 1) *wrist splint* in neutral position, steroid injection, possible task modification 2) nerve conduction study 3) surg consult

Answer 78

C and A delta fibers are affected - loss of pain and temp reflexes, proprioception, vibration sense intact

Answer 79

loss of motor atonia normally present during REM sleep = pts act out their dreams associated with subsequent onset of neurodegenerative disorders and synucleinopathies (Parkinsons)

Answer 80

uncomplicated acute back pain - usu due to MSK injury or degeneration - give NSAIDs red flags - trauma at onset, prior malignancy, weight loss, fever, IVDA radicular pain - can try epidural steroid injections or TCADs down the line

Answer 81

diabetic neuropathy - painful - give lyrica pupil-sparing third nerve palsy - down and out pupil - due to microvascular infarct of central fibers, peripheral fibers are spared so preserved pupillary reflex (v.s. with herniation, where peripheral PS fibers are compressed)

Answer 82

TIAs - abrupt onset seizures - 2-3min migraine aura - 15-30 min, visual or tingling aura

Answer 83

can look like optic neuritis/MS, but is NOT anti-aquaporin-4 antibodies aggressive - does not respond to treatments for MS - requires more aggressive immunosuppressive therapy

Answer 84

ex - C5-C6 disc herniates --> C6 will be compressed shooting pain C5 C6 - index finger, thumb C7 C8, T1 - ring, little finger

Answer 85

weakness, absent DTRs, sensory deficits = points to peripheral NS problem can be due to arsenic - but this would show cognitive impairment overtime can be due to prolonged diabetes

Answer 86

frequently have dopamine blocking properties | - ondansetron does not

Answer 87

isolated short-term memory impairment - resolves in 24hrs can have MRI abnormalities - bilateral hyperintense hippocampi (on T2 flare) association with migraines reassurance

Answer 88

Rinne - conductive hearing Weber - sensorineural conductive hearing loss - limits sound from reaching inner ear - otitis externa or media - cholesteatoma - chronic, progressive, bulging or dulling of tympanic membrane - trauma - cerumen - ruptured TM - would be visible - altitude/ear pressure changes - otosclerosis - sclerosis of ossicles, normal otoscopic exam sensorineural - disorder of inner ear, cochlea, or auditory nerve - presbycusis - "difficulty tolerating loud sounds that others can hear", subjective tinnitus - Menieres - vertigo, tinnitus, hearing loss - barotrauma - schwannoma - unilateral tinnitus, hearing loss, vertigo - cerebrovascular ischemia

Answer 89

tumor --> parinaud syndrome | - loss of vertical gaze, loss of pupillary light reflex, lid retraction, nystagmus

Answer 90

LE weakness and numbness | - associated with increased reflexes due to CST involvement

Answer 91

neuropathic pain along V2 and V3 pathophys - related to demyelination along trigeminal nerve root (as it enters pons) - due to localized compression (vascular structure) - usually unilateral UNLESS it is due to MS - in which case it would present bilaterally treat with carbamazepine, oxcarbazepine - side effect of carbamazepine - leukopenia, aplastic anemia (CBC in monitoring) - surgery ******************* burning mouth syndrome

Answer 92

due to C. trach A-B --> leading cause of blindness worldwide conjunctival injection, tarsal inflammation, pale follicles (on tarsal conjunctiva, pull eyelid up) - can often have concomitant nasopharyngeal infeciton chronic infection --> scarring + inversion of eyelashes --> lashes rub on eye, cause ulcerations --> blindness oral azithromycin - for trichiasis (ingrown eyelashes), need eyelid surgery to preserve vision

Answer 93

usually due to brainstem lesions findings - strabismus, eye deviation after 4 mo of age (note ocular instability of infancy before age 4mo), asym corneal light reflex or red reflex, deviation on cover test, head tilt (torticollis) usually due to nasal deviation (esotropia) ``` treat with 1 penalization therapy - cycloplegic drops to blur normal eye 1 patch NL eye - prescription eye glases - surgery ``` complications - amblyopia, diplopia

Answer 94

fluorescein exam --> US or CT | - NO MRI

Answer 95

herpes zoster ophthalmicus - VZV - ophthalmic branch (TG) - forehead, eye (conjunctivitis, corneal ulcers) - treatment w/i 72hrs after eruption with high dose acyclovir reduces complication risk herpes simplex keratitis - pain, photophobia, decreased vision - dendritic ulcer, vesiculoulcerative lesions bacterial keratitis - contact lens wearers, corneal trauma - hazy cornea with central ulcer, adjacent stromal abscess - can have hypopyon (pus layers in cornea)

Answer 96

leukocoria (white reflex) - strabismus, decreased vision, ocular inflammation, eye pain, glaucoma, orbital cellulitis mass with calcifications on CT or US highly malignant tumor - death from liver and brain mets

Answer 97

indicates UMN or pyramidal/corticospinal tract disease why - UMN lesions cause more weakness in the supinator muscles compared to the pronator muscles

Answer 98

10+ years of heavy alcohol use degeneration of Purkinje cells (cerebellar vermis) px - wide-based gait, incoordination in legs, postural instability - impaired tandem walking/heel to skin but preserved finger-nose testing dx - CT/MRI will show cerebellar atrophy tx - alcohol cessation, nutritional supplements, ambulatory assistance - this prevents progression but does not reversion * ******************************************** v. s. a diabetic small vessel injury - would present as a polyneuropathy of small fibers (pain and temp) and large fibers (vibration and proprioception) - gait is preserved

Answer 99

damage leads to fixed dilated pupil - nonreactive to light or accommodation Edinger-Westphal nucleus provides PS outflow to eye

Answer 100

vertical diplopia - compensatory mechanism is tucking chin and tilting head away from affected eye

Answer 101

cranial nerve dysfunction ipsilateral to lesion, contralateral motor/sensory weakness

Answer 102

secondary causes include - Fe anemia, uremia, DM, MS, Parkinsons, pregnancy, drugs (antidepressants, metoclopramide) tx - for mild/intermittent - Fe supplement if needed, supportive measures (leg massage, heating pads, exercise), avoidance of aggravating factors (sleep deprivation, meds - severe - pramipexole and ropinirole (dopamine agonists), gabapentin is second line

Answer 103

in recovering opioid addicts - still use IV morphine - FOLLOWING discussion of risks/benefits - methadone (slow onset) is used for chronic pain - rather than acute pain IV ketorolac (NSAID) - used for short-term treatment of severe pain

Answer 104

most commonly caused by degenerative joint disease - disc herniation and osteophytes compress cord - other factors include - hypertrophy of ligamentum flavum, bulging of intervertebral dsics, spondylolisthesis (displacement of vertebral body relative to another) flexion opens up canal - pain worse with walking = neurogenic claudication dx - MRI tx - PT and exercise

Answer 105

useful to identify areas of high bone turnovers - metastatic disease, suspected fractures, osteomyelitis

Answer 106

trimus, painful spasms - other sxs - sweating, dysphagia, labile BP, tachy toxin blocks release of inhibitory neurotransmitters - glycine and GABA tx - debride wound, abs, human tetanus Ig AND tetanus toxoid *************************************** botulism - impaired Ach release

Answer 107

cocaine/amphetamine - causes hemorrhagic or ischemic stroke | - will show up on noncon CT

Neuro Flashcards

(131 cards)