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
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
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
➢ CSF: ↑ protein, PMN predominate, ↓ glucose, ↑ opening pressure
➢ CSF: ↑ lymphocytes, slight ↑ protein, normal glucose and opening pressure
Acute Bacterial Meningitis- neonates
tx-cefotaxime + ampicillin + vanc
Acute Bacterial Meningitis- children > 3 mo
tx- cefotaxime + vanc
Acute Bacterial Meningitis- adults
tx- cefotaxime + vanc
Acute Bacterial Meningitis- elderly
tx- cefotaxime + ampicillin + vanc
Acute Bacterial Meningitis- immunocompromised
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
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 LOC or temporary amnesia
ASA and antiplatelet medications
Transcortical motor Aphasia
Transcortical sensory aphasia
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
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
CSF – elevated protein, normal cell count ➢ Cytoalbuminologic dissociation: ↑ CSF protein, nl cell count; NCV-decreased motor nerve conduction velocity
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
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
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
Dix-Hall pike manuever
watchful waiting, vestibulosuppressant medication, vestibular rehabilitation, canalith repositioning, and surgery
vertigo, nystagmus, hearing loss; attacks last minutes-hours
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
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
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
methylphenidate or dexamphetamine, modafinil (Provigil)
➢ 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
➢ CT reveals all thymomas
➢ Anticholinesterases (pyridostigmine, neostigmine)
➢ Other immunosuppresants (e.g., azathioprine)
➢ 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
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
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?
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
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?
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
radiating arm pain
Radiologic findings of cervical spondylosis
narrowing of the disc space
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
• 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
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
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
4 – spontaneous eye opening
3 – to speech
2 – to pain
1 – none
5 – oriented
4 – confused
3 – inappropriate
1 – none
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)