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Flashcards in Neuro/Neurosurg Deck (165):

Location of post dural puncture HA

bifrontal or occipital


What is the tx for severe/persistent post dural puncture HA?

epidural blood patch


What is the classical aura associated with migraines?

bilateral homonymous scotoma- bright flashing, crescent-shaped images with jagged edges


Tx for migraines

sumatriptan or dihydroergotamine 9DHE)- 5HT1 receptor agonist


Prophylaxis for migraines

1st line- TCAs and propranolol (most effective); 2nd line- verapamil, valproic acid/topamax, methylsergide


Most common HA



Presentation of temporal arteritis

constitutional symptoms, HA, visual impairment (25-50% b/c ophthalmic artery involved, optic neuritis, amaurosis fugax, blindness), jaw pain when chewing, tenderness over temporal artery with absent temporal pulse, polymyalgia rheumatica (40%)


Tx of temporal arteritis

high-dose prednisone immediately. If visual loss, admit and IV steroids. Do not wait for Bx results. Temporal artery biopsy. If confirmed, Tx 4 weeks then taper and maintain steroids 2-3 years. ESR levels reveal effective Tx.


What is amaurosis Fugax?

Transient monocular blindness caused by temporary lack of blood flow to the retinas. Classically presents in TIA


Signs and symptoms of cluster HA

Unilateral. Excruciating periorbital pain. Begins few hours after pt goes to bed and lasts 30-90min. awakens pt from sleep. Worse with etoh.ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, and eyelid edema


Acute tx of cluster HA

supplemental O2 or sumatriptan


Prophylaxis for cluster HA

verapamil, steroids


Cause of pseudo tumor cerebri

Results from increased resistance to CSF outflow at arachnoid villi


S/Sx of Pseudotumor cerebri

:young obese woman with papilledema without mass, HA, elevated CSF pressure, deteriorating vision, may have slit-like ventricles, normal scan;
H/A worse when lying down
Papilledema: postural visual field problems (when leaning forward)


MCC of SAH overall vs. sporadic

overall- trauma
sporadic= congenital berry/saccular aneurysm rupture


LP findings in SAH

LP diagnostic. LP shows blood in CSF, xanthrochromia (yellow color that results from RBC lysis and is gold standard of diagnosis of SAH).


Diagnosis of SAH

noncontrast CT. If no papilledema, CT negative, and clinical suspicion high, do LP. LP diagnostic. LP shows blood in CSF, xanthrochromia (yellow color that results from RBC lysis and is gold standard of diagnosis of SAH).
➢ Once SAH diagnosed, order cerebral angiography.


Tx of SAH

surgery – clipping. Medical – bed rest, stool softeners, analgesia, IV fluids, HTN – lower gradually, nifedipine (ca channel blocker) for vasospasm which lowers incidence of cerebral infarction by 1/3rd


MCC of viral encephalitis



EEG findings of viral meningitis

slow wave activity


CSF findings in bacterial meningitis vs viral

•Bacterial Meningitis
➢ CSF: ↑ protein, PMN predominate, ↓ glucose, ↑ opening pressure

Viral meningitis
➢ CSF: ↑ lymphocytes, slight ↑ protein, normal glucose and opening pressure


Acute Bacterial Meningitis- neonates

tx-cefotaxime + ampicillin + vanc


Acute Bacterial Meningitis- children > 3 mo

N. meningitides
tx- cefotaxime + vanc


Acute Bacterial Meningitis- adults

S. pneumoniae
tx- cefotaxime + vanc


Acute Bacterial Meningitis- elderly

S. pneumoniae
tx- cefotaxime + ampicillin + vanc


Acute Bacterial Meningitis- immunocompromised

Listeria monocytogenes


acute bacterial meningitis prophylaxis for close contacts

rifampin or ceftriaxone


Orders needed with acute stroke

Non-contrast CT brain, ECG, CXR, CBC, platelet count, PT, PTT, serum electrolytes, glucose


lateral medullary/Wallenberg findings

✦ Ipsilateral: ataxia, vertigo, cranial nerve weakness (eg, dysarthria, dysphagia, dysphonia, weakness of facial muscles and tongue)
✦ Contralateral: motor weakness (eg, hemiparesis, quadriparesis), homonymous hemianopsia with basilar-PCA lesions
✦ Horner’s


3 Inclusion criteria for tPA

>/= 18 yo
Clinical diagnosis of stroke with NIH stroke scale score < 22

Time of onset of stroke known and is < 3-4.5 hours (defined as completely free of any stroke symptom)


➢ Symptoms of a TIA associated with carotid disease:

o Loss of vision in 1 eye
o Clumsiness or weakness on 1 side of the body
o Problems with speech


➢ Symptoms of a TIA associated with the vertebra-basilar system

o Vision problems affecting both eyes
o Vertigo
o Ataxia
o Diplopia
o LOC or temporary amnesia


TIA tx

ASA and antiplatelet medications


Broca's aphasia

Fluency- nonfluent
Repetition- abnormal
Comprehension- normal
Naming- abnormal


Transcortical motor Aphasia

Fluency- nonfluent
Repetition- good
Comprehension- good
Naming- Abnormal


wernicke's aphasia

Fluency- fluent
Repetition- abnormal
Comprehension- abnormal
Naming- abnormal


Transcortical sensory aphasia

Fluency- normal
Repetition- normal
Comprehension- abnormal
Naming- abnormal


Conduction apahsia

Repetition- abnormal
Comprehension- normal
Naming- abnormal


Lhermite phenomenon

seen in MS`– neck flexion produces brief fatiguable electric shock sensations in the spine, legs, or arms


Clinical diagnostic criteria for MS

2 episodes of symptoms and 2 white matter lesions


CSF evaluation in MS

elevated cell count consisting mainly of lymphocytes, elevated myelin basic protein concentration, elevated IgG /oligoclonal bands


MS tx

high dose IV steroids for acute attack., IFN-beta, natalizumab (small risk of PML reactivation) cyclophosphamide, baclofen for spasticity, carbamazepine or gabapentin for neuropathic pain. Daily injections of glatiramer acetate (4 AA-myelin basic protein immunologic decoy).


T/F: sensation is intact with GBS



GBS dx

CSF – elevated protein, normal cell count ➢ Cytoalbuminologic dissociation: ↑ CSF protein, nl cell count; NCV-decreased motor nerve conduction velocity


GBS tx

plasma exchange and IVIG
➢ Never give Corticosteroids


pathology in Vit B12 neuropathy

➢ Demyelination in posterior columns, in lateral corticospinal tracts and spinocerebellar tracts


➢ Classic symptom of lead toxicity

foot drop


Most commonly affected area in cervical radiculopathy

C6 and C7


Most commonly affected area in lumbar radiculopathy



Wernicke Encephalopathy: symptoms

ophthalmoplegia, ataxia, global confusion, and nystagmus


Korsakoff Psychosis symptoms

mental status changes, confabulation, and anterograde and retrograde amnesia
Usually irreversible


S/Sx of peripheral vertigo

sudden onset, severe n/v, severe intensity, no associated neuro findings, unilateral nystagmus, positional change has a great effect, pt falls to the same side as the lesion


abnormal sensation of motion that is elicited by certain provocative positions that triggers specific nystagmus

benign paroxysmal peripheral vertigo


BPPV diagnosis

Dix-Hall pike manuever



watchful waiting, vestibulosuppressant medication, vestibular rehabilitation, canalith repositioning, and surgery


vertigo, nystagmus, hearing loss; attacks last minutes-hours

Meniere's disease


How does Central Vertigo differ from peripheral vertigo?

other brainstem symptoms are present (weakness, hemiplegia, diplopia, dysphagia, facial numbess); gradual onset, mild intensity, mild n/v, associated neuro findings, mild nystagmus, position change has mild effect, no refractoriness, patient falls to same side as lesion, nystagmus multidirectional and vertical.


causes of central vertigo

1. MS
2. Cerebrovascular (VBI, TIA, Wallenberg’s)
3. migraine-associated vertigo


JME EEG findings

generalized 4- to 6-Hz spike or polyspike and slow wave discharges lasting between 1-20 seconds.When absence seizures are also present, 3-Hz spike and wave activity may be seen in addition to the polyspike and wave pattern. The ictal EEG associated with myoclonic jerks typically reveals 10- to 16-Hz polyspike discharges. These may be preceded by spike and wave activity and often are followed by 1- to 3-Hz slow waves


JME tx

Treat with valproic acid for life


early findings of uncal herniation

➢ Dilation of pupil of ipsilateral eye
➢ Contralateral hemiplegia
➢ May be ipsilateral hemiplegia due to compression of contralateral cerebral peduncle against tentorial notch…Ipsilateral weakness is false localizing sign (due to Kernohan’s notch)


Late findings of uncal herniation

➢ Loss of reflex movements in contralateral eye
➢ Bilateral decerebrate posturing
➢ Central neurogenic hyperventilation


What is the definition of a coma?

Coma = GCS ≤ 8 (4 weeks)


Definition of vegetative state.

It is called a vegetative state when a coma persists past 4 weeks – it is a permanent vegetative state when this state can be confidently established as irreversible. If the state lasts more than 12 months after a head injury or 6 months after another type of insult it is pretty much certain that it is irreversible.


What are the 7 criteria for brain death?

1. No pupillary response
2. No corneal response
3. No vestibulo-ocular response (COWS = cold → opposite; warm → same)
4. No motor response in cranial nerve distribution (painful stimulus to glabella)
5. No gag response
6. No respiratory reaction to hypercapnea
7. 2 exams by 2 doctors must be performed to confirm brainstem death


What must be ruled out before declaring brain death?

➢ A metabolic or drug-induced state must be excluded
➢ A neuromuscular blocking agent must be excluded as the cause of loss of motor function
➢ Retesting of brainstem reflexes should be repeated after 24 hours
➢ Hypothermia must be controlled so that the patient’s temperature is >35 C when testing
➢ A specific cause for the coma should be ID’d
➢ Certain spinal reflexes may still be present even in the absence of brainstem function – DTRs, plantar responses, flexion of limbs triggered by neck flexion


Cardinal features of narcolepsy

cataplexy, sleep paralysis, hypnagogic hallucinations, and sleep onset REM


Narcolepsy EEG findings

EEG shows REM within 10 minutes of sleep onset


Narcolepsy tx

methylphenidate or dexamphetamine, modafinil (Provigil)


MG dx

➢ Edrophonium (short-acting cholinesterase inhibitor)/Tensilon
➢ Give atropine beforehand/have crash cart nearby in case of bradycardia
➢ Acetylcholine receptor antibodies (90%)
➢ Negative AchR antibodies? Get MuSK antibodies
➢ Electrophysiology
➢ CT reveals all thymomas


MG tx

➢ Anticholinesterases (pyridostigmine, neostigmine)
➢ Corticosteroids
➢ Other immunosuppresants (e.g., azathioprine)
➢ Plasmapheresis
➢ IVIg
➢ Thymectomy (even if no thymoma)


Parkinson’s Disease S/Sx

bradykinesia, resting tremor (fine; 3-4 Hz), cogwheel rigidity, and the impairment of postural reflexes
➢ Micrographia, hypophonia, festinating gait with reduced arm-swing, masked facies


Parkinson's disease tx

➢ Selegiline (MAO-B inhibitor), entocapone (COMT inhibitor)
➢ Anticholinergics (benztropine)
➢ Amantadine (releases DA); can → livedo reticularis
➢ Bromocriptine, ropinirole, pramipexole (DA agonist)
➢ Levodopa/Carbidopa (Sinemet); can → hallucinations early, dyskinesia later


Herpes encephalitis tx

acyclovir, dexamethasone


Where does herpes encephalitis primarily affect?

➢ Basal frontal and temporal lobes are principally affected


Most common CN damaged in head trauma



fracture of the petrous temporal bone is associated with...

8th nerve damage
facial paralysis


What are the 3 types of skull fractures? Compare and contrast

Simple- linear fracture of the vault
Depressed- when the bone fragments are depressed beneath the vault
Compound- when there is direct communication with the external environment


What are the 3 portions of the neuro exam that should be emphasized in evaluating a pt with head trauma?

Conscious state
pupillary size and reaction
focal neurological signs in the limbs


how do frontal and pontine gaze center direct lesions present?

either lesion causes tonic overreaction of the opposite gaze center. This causes ipsilateral deviation with a frontal gaze center lesion and contralateral deviation with pontine gaze center lesion.


Occular bobbing is seen in

pontine lesions


how can ventilation help treat ICP

Maintain PaCO2 at 30-35 mm Hg to cause constriction of the BVs in the brain


What is the cerebral perfusion pressure?

Mean arterial Bp - mean intracranial pressure; should be maintained at 70 mm Hg in severely brain injured pts


Management of compound fracture

closure of head laceration and prophylactic Abx


Prophylactic management following dura penetration

prophylactic anticonvulsant therapy for 1 yr


Presentation of anterior fossa fractures

usually radiologically occult but can be diagnosed clinically; subconjunctival hemorrhages, anosmia, nasal tip paraesthesia due to anterior ethmoidal nerve injury


Presentation of middle fossa fractures

CSF otorrhea or rhinorrhea, deafness, hemotypanum, brushing over the mastoid bone (Battle's sign), 7th nerve palsy (often delayed)


When should surgical repair of a dural CSF leak be done?

if CSF leak continues for more than 5 days
there is an intracranial aerocele
there has been an episode of meningitis in a pt with a fracture of the anterior cranial fossa

Surgery should be delayed by 2 weeks to allow for reduced brain swelling


3 categories of of missile injury

Tangential- missile does not enter the cranium but causes a depressed skull fracture, lacerating the scalp with an underlying cortical contusion, laceration or hematoma

Penetrating- the missile enters the cranium resulting in the deposition of metal, bone fragments and debris within the brain

Through- and- through- the missile enters and exists the cranium frequently creating more than one tract due to fragmentation


Why are extradural hematomas more common in younger age groups?

The dura more easily separates off of the skull. Extradural hematomas account for 2/3rds of of all traumatic intracranial hemorrhages in pots under 20 yo


What are the most common sites for a extradural hematoma?

temporal region followed by the frontal region


T/F a fracture most often overlies a intracranial hematoma

T- 95% in adults and 75% in children


Extradural hematoma can occur with minor or trival brain injury meaning a pt can experience transient LOC or no LOC. What are some symptoms to monitor for?

deteriorating conscious state- can occur after a lucid period; drowsiness should be taken seriously
Focal neurological signs (dilating pupil, hemiparesis), change in vital signs (HTN, bradycardia)


How can a subdural hematoma be classified based on CT imaging?

Acute- hyperdense (white)
Subacute- isodense (same color as the brain)
Chronic- hypodense (black)


Subdural hematoma are BL __% of the time



__% of pts with acute subdural hematoma have a fracture of wither the cranial vault or the base of the skull



What is the earliest finding of chronic subdural hematoma in infants?

excessive cranial enlargement because the sutures are unfused


weakness of dorsiflexion of the foot and extension of the great toe are signs of ___ intervertebral disc herniation

L4/L5 with the involvement of the L5 nerve root


Pain along the posterior thigh with radiation to the heel
Weakness of plantar flexion
Sensory loss in the lateral foot
Absent ankle jerk

L5/S1 prolapsed intervertebral disk


Pain along the posterior or posterolateral tight with radiation to the dorsum of the foot and great toe
Weakness of dorsiflexion of the toe or foot
Paraesthesia and numbness of the dorsum of the foot and great toe
Reflex changes unlikely

L4/5 prolapsed intervertebral disc


pain in the anterior thigh
Wasting od the quads
weakness of the quad function and dorsiflexion of the foot
Diminished sensation over the anterior thigh, knee and medial aspect of the lower leg
Reduced knee jerk

L3/L4 prolapsed intervertebral disc


What are the indications for surgery for sciatica?

Incapacitating pain despite 7-10 days of bed rest
Continuing episodes of recurrent pain when mobilizing despite adequate relief with bed rest
Significant weakness or increasing amount of weakness
bilateral sciatica or other features indicating a central disc prolapse (such as a sphincter disturbance or diminished perineal sensation
If the clinical features indicate a tumor maybe the cause


pain (ache or burning) radiating diffusely into the legs particularly with standing or walking; relieved with sitting
subjective feeling of weakness and diffuse numbness and tingling radiating down the legs

lumbar canal stenosis


Most frequently affected areas by lumbar stenosis



Management of spinal stenosis

do not respond well to conservative management and surgery is almost invariably successful


What is the most common demonstrable cause of low back pain?

lumbar spondylosis


What is spondlolisthesis?

subluxation of one vertebra on another


What is spondylosis?

defect in the pars interarticularis; often a precondition to spondylolisthesis


What is degenerative spondylolisthesisi

AKA psuedospondylolisthesi; results from severe arthritis of the facets of the slipped vertebrae


back pain and leg pain; back pain radiates into the buttocks; pt complains of tight feeling in the upper thighs ; "tight hamstring syndrome" is a gait disturbance in children and adolescents; can produce symptoms similar to sciatica and lumbar canal stenosis



tx of spondylolithesis in children and adolescents

most respond to conservative management


What are the guidelines for lumbar fusion in a pt with spondylolithesis?

pain unrelieved by conservative measures
progression of subluxation on serial radiological studies
Subluxation of greater than 30%
Tight hamstring gait


What are the indications for laminectomy in an adult with spondylolithesis?

symptomatic spinal canal stensosis
clinical features of nerve root compression unrelieved by conservative therapy


When should spinal fusion w/o laminectomy be considered in an adult with spondylolithesis?

incapacitating back pain unrelieved by conservative tx where the radiological findings show a relative absence of degenerative disease as a cause for pain
Documented progressive subluxation (uncommon in adults)


T/F: prolapse of an intervertebral disc is more common in the cervical region than the lumbar region

F- lumbar more common


How is nerve compression due to disk herniation in the cervical region different than the lumbar region?

In the cervical region the nerve exits directly laterally so herniation causes compression of the nerve at that level. Whereas lumbar disk herniation compresses a nerve below the level.


Neck and arm pain; pain begins in the cervical region it radiates into the sub scapular ares and shoulder and down the arm; neck pain commonly regresses while the radiating arm pain becomes more severe; pain described as a deep boring or aching pain ; sensory disturbance (numbness or tingling) in the dermatome affected

acute cervical disc herniation


The location of sensory disturbance is more helpful in locating the root level of cervical disc herniation; thumb involved-->



The location of sensory disturbance is more helpful in locating the root level of cervical disc herniation; middle finger involved-->



The location of sensory disturbance is more helpful in locating the root level of cervical disc herniation; little and ring finger-->



Compression of C6 causes

mild weakness of elbow flexion


Compression of C8 causes

weakness of long flexor muscles, triceps, finger extensors and intrinsic muscles


nerve root resopnsible for brachioradialis reflex



S/Sx of C6/C7 prolapsed intervertebral disc

Weakness of elbow extension
Absent triceps jerk
Numbness or tingling in the middle or index fingers


S/Sx of C5/C6 prolapsed intervertebral disc

depressed supinator reflex
numbness or tingling in the thumb or index finger
Occasionally mild weakness of elbow flexion


S/Sx of C7/T1 prolapsed intervertebral disc

Weakness may involve long flexor muscles, triceps, finger extensors and intrinsic muscles
diminished sensation in ring and little finger and on the medial border of the hand and forearm
Triceps jerk may be depressed


Management of acute cervical disc herniation

good pain relieve with conservative management- bed reset, a cervical collar, simple analgesic medication, NSAIDs, and muscle relaxants; manipulation of the neck is contraindicated


What are the indications for further investigation and surgery for cervical disc herniation?

continuing severe arm pain for more than 10 days without benefit from conservative therapy
chronic or relapsing arm pain
Significant weakness in the upper limb that does not resolve with conservative management
evidence of a central disc prolapse causing cord compression (urgent)


Imaging of choice for cervical disc herniation



What surgical procedure is mandatory for a central disc protrusion

anterior approach with disc excision


neck pain
radiating arm pain
cervical myelopathy

cervical spondylosis


Radiologic findings of cervical spondylosis

narrowing of the disc space
osteophyte formation
reduced mobility at positions of fusion and increased mobility at adjacent levels


Most common cause of neck pain

minor muscular or ligamentous strain usually following minor trauma


What are the S/Sx of Vit B12 deficiency

leads to loss of position/vibratory sense in lower extremities, ataxia, and upper motor neuron signs (increased DTRs, spasticity, babinksi, weakness); “subacute combined degeneration”
➢ Can lead to urinary/fecal incontinence, impotence
➢ Can lead to dementia


If a pt has severe head injury with GCS less than 8, the pt needs

an ICP monitor


How should ICP be managed?

• Hyperventilation to PCO2 to 35
• Raise the head of the bed
• Mannitol
• Sedation- fighting raises ICP
• Ventricular drain
• Chemically paralysis
• 2nd line- craniotomy
• NEVER use steroids in head trauma


What is the definition of a severe concussion?

post-traumatic amnesia lasting more than 1 day


S2 sensation loss, bowel and bladder incontinence

Cauda equina


What is the difference between myelopathy and radiculopathy?

myelopathy is an UMN injury and radiculopathy is a LMN injury


What is Hoffman's sign?

An abnormal sign seen in UMN injury; tapping or flicking the nail of the middle or ring finger causes flexion of the distal phalanx of the thumb


Contrast positional influence on HAs of post dural puncture HA and pseudo tumor cerebri.

Post dural puncture HA worse when sitting up, better when lying down; vs HA of pseudo tumor cerebri- worse when lying down


Are cluster HA more common in men or women?

80% are men


Cerebral salt wasting/SIADH is a complication of what type of cerebral hemorrhage?



Fever, HA, depression of conscious state, focal seizures and neurological signs

viral encephalitis


What is the presentation of viral meningitis?

fever, HA, meningeal signs, UNCOMMON to have impaired consciousness ( vs viral encephalitis- depression of conscious state)


Management of suspected acute bacterial meningitis

➢ Blood cultures before antibiotics and CT before LP
➢ Start IV empiric antibiotics after LP, steroids if cerebral edema


When can a carotid endartectomy be done in a pt with stenosis of the carotid?

➢ Carotid endarterectomy if there is >70% stenosis in symptomatic patients.


What should be done for an asymptomatic pt with carotid stenosis?

in asymptomatic patients, reduction of atherosclerotic risk factors and use of aspirin


What is the difference between the presentation of thrombotic stroke and embolic stroke?

➢ Thrombotic stroke presentation: patient awakens with neuro deficits
➢ Embolic Stroke Presentation: onset rapid and deficits maximum initially


MCA occlusion findings

✦ contralateral hemiplegia and hemisensory loss
✦ aphasia (if dominant hemisphere)
✦ apraxia, contralateral body neglect, confusion (if nondominant hem)


Intracerebral hemorrhage presentation

➢ Abrupt onset of focal neurologic deficit that worsens steadily over 30-90 min
➢ Altered level of consciousness, stupor, coma
➢ HA/ vomiting
➢ Increased ICP signs


s/Sx of optic neuritis

monocular vision loss, pain on eye movement, central scotoma (black spot in center of vision), decreased pupillary light reflex

Can be part of MS presentation


hydrocephalus in the absence of papiledema and with normal CSF opening pressure

Normal Pressure Hydrocephalus


Normal Pressure Hydrocephalus tx

LP may clinically improve pt's symptoms; tx with surgical CSF shunting


Always give ____ before ____ in an alcoholic to prevent precipitating Wernicke’s encephalopathy

thiamine before glucose


Status Epilepticus tx

1st Lorazepam, then fosphenytoin, then phenobarbital, then midazolam/propofol


Why is there an increase in seizure in the elderly?

• Main cause: Cerebrovascular disease. (acute stroke)
• 2nd cause: Degenerative (Alzheimer’s)


Patients with mesial temporal lobe epilepsy, associated with hippocampal sclerosis, achieve a __% remission with mesial temporal resection



Automatisms (1-3min) – purposeless, involuntary, repetitive (lip smacking) Olfactory, and gustatory hallucinations are associated with what type of seizure

Complex partial


Eye scores

4 – spontaneous eye opening
3 – to speech
2 – to pain
1 – none


Verbal score

5 – oriented
4 – confused
3 – inappropriate
2 –incomprehensible
1 – none


Motor score

6 – obeying commands
5 – localizing
4 – withdrawing
3 – flexor (decorticate)
2 – extensor (decerebrate)
1 – none


At which grade on the GCS should someone be intubated?

GCS < 8


What are the different classifications of tremors?

➢ Rest – present when limb fully supported against gravity (Parkinson’s)
➢ Action – during any voluntary muscle contraction
➢ Postural – during maintenance of a particular posture (benign essential, physiologic)
➢ Kinetic – during any type of movement
➢ Intention – exacerbation of kinetic tremors the planned movement nears completion (cerebellar)
➢ Task-specific – during a particular skilled action (ex – writing)


Serum Na below ___ can cause neurologic impairment and decreased levels of consciousness

125 mmol/ L