Neurological Flashcards

Question

Phases of seizures

Answer 1

Stabilization phase (0-5min) Initial therapy phase (5-20min) Second therapy phase (20-40min) Third therapy phase (40-60min)

Answer 2

-Stabilize patient (ABCs) -Time seizure from onset -FSBS: <60 treat with 100mg thiamine and amp of D50

Answer 3

Choose one: -IM versed (10mg >40kg; 5mg<40kg) OR -IV ativan (.1mg/kg; max 4mg may repeat once) OR -IV diazepam (0.15-0.2mg/kg; max 10mg may repeat once) If none are available then choose one of these: -IV phenobarbital (15mg/kg) OR -Rectal diazepam (.2-.5mg/kg, max 20mg) OR -Intranasal midazolam, buccal midazolam

Answer 4

Choose one of the following as a single dose: -IV fosphenytoin (20PE/kg; max 1500PR) OR -IV valporic acid (40mg/kg; max 3000mg) OR -IV keppra ( 60mg/kg; max 4500mg) If none are vailable: -IV phenobarbital (15mg/kg), last ditch effort *NOTE: there is no evidence based prefered choice*

Answer 5

Repeat second line therapy OR Anesthetic dose (with continuous EEG monitoring): -Thiopental -Versed -Pentobarbital -Propofol *NOTE: there is no evicence based preferred choice*

Answer 6

Periods of acute cerebral insufficiency lasting <1hour without any residual deficits. Ischemic strokes are more common (80%) than hemorrhagic strokes. Causes/geneal concepts: -Ischemia due to atherosclerosis, thrombus, arterial occlusion, embolus, intracerebral hemorrhage OR -Cardio-embolic events such as A-fib, MI, endocarditis, valve disease -TIA is indicative of impending stroke -Approx 1/3 of pts with TIA experience cerebral infarction within 5 years. S/S: -**Altered vision:** ipsilateral monocular blindness (known as amaurosis fugax); homonymous hemianopia (half vision). -Altered speech: Transient aphasia ****-Motor impairment:**** Paresthesia of contralateral arm, leg, or face. -Sensory deficits -Cognitive and behavioral abnormalities -Dysphagia -Vertigo -Nystagmus

Answer 7

Vertebrobasilar: Occurs as a result of inadequate blood flow from vertebral arteries (brainstem, cranial nerve impairment) -Vertigo, ataxia, dizziness, visual field deficits, weakness, confusion. Carotid: Occurs from carotid stenosis -Aphasia, dysarthria, altered LOC, weakness, numbness.

Answer 8

* CT scan (priority) is best in distinguishing between ischemic, hemorrhage and tumor. * MRI is better than CT in detecting ischemic infarcts (may be done later) * Electrocardiogram (workup) * Echocardiogram (workup) * Carotid doppler and ultrasonography * Cerebral angiography (may be done later in ischemic infarcts)

Answer 9

* First few days in hospital pt is on aspirin and clopidogrel and DC'd on only one. * Assess for HTN (#1 cause of HF) * Carotid Endarterectomy decreases the risk of stroke and death in pts with recent TIAs, pts that need them: -Symptomatic low-risk surgical pts with 50-90% stenosis AND -Asymptomatic pts with >70-99% stenosis.

Answer 10

The rapid onset of neurological deficits lasting longer than 24 hours, the 5th leading cause of death in the U.S. Caused by: -Atherosclerotic changes -Chronic hypertension -Trauma -Aneurysm -Arteriovenous malformation -Tumor

Answer 11

CVA infarct can produce subtle, progressive or sudden neurologic deficits: -Changes in LOC, motor weakness or paralysis, visual alterations, changes in vital signs. Hemorrhagic CVA usually present with acute onset of focal neurologic deficits. -Signs of sudden increase ICP including altered mentation, headache and vomiting are present when the hemorrhage is extensive. **-With left dominant hemisphere involvement, you'll see right hemiparesis, aphasia, dysarthria, difficulty reading/writing. -With right (non dominant) hemisphere involvement, you'll see left hemiparesis, right visual field changes, spatial disorientation.**

Answer 12

Large vessel stroke workup with: -Telemetry -TEE with bubble study -Carotid imaging (US, CTA, MRA, angio) -Intracranial imaging (CTA, MRA, angio) Lumbar puncture may be performed if the pt has a grade 1 or 2 aneurysm to detect blood in CSF -LP contraindicated with large bleeds as brain stem herniation can be induced with rapid decompression of the subarachnoid space.

Answer 13

Assess time of onset/time last seen normal -Up to 4.5 hrs can do fibrinolytic therapy with tPA -Up to 6 hours can do mechanical embolectomy for all Up to 24 hours can do mechanical embolectomy for some

Answer 14

3 H's of ICP: -Hypotension -Hypoxemia -Hypercapnia Nimodipine, a calcium channel antaognis, helps to counter vasospasms by preventing calcium from entering smooth muscle cells and causing contraction. Want <20

Answer 15

Seizure assessment includes the following: -Presence of aura, spread, type of movement, body parts involved, pupil changes and reactivity, duration, loss/level of consciousness, incontinence, behavioral and neurological changes after cessation of seizure activity. EEG is the most important test in determining seizure classification. CT of the head is indicated for all new onset seizures.

Answer 16

Maintenance doses of long acting anticonvulsants -Carbamazepine, ethosuximide, phenobarbital, phenytoin, primidone, valporic acid Dosages should be titrated D/C should be tapered and never abruptly withdrawn.

Answer 17

Autoimmune disorder resulting in the reduction of the number of acetylcholine receptor sites at the neuromuscluar junction. Weakness is typically worse after exercise and better after rest. Wariable clinical could with remissions and exacerbations. Most commonly occurs in women

Answer 18

* Ptosis (droopy eyelid) * Diplopia (double vision) * Dysarthria (difficulty speaking) * Dysphagia * Extreme weakness * Fatigue * Respiratory difficulty * Sensory modalities and DTRs are normal

Answer 19

Antibodies to acetylcholine receptors (AchR-ab) are found in the serum of ~85% of pts.

Answer 20

* Neurology referral * Anticholinesterase drugs block the hydrolysis of acetylcholine and are used to symptomatic improvement * -Pyridostigmine bromide * Immunosuppresants * Plasmapheresis * Ventilator support may be needed during a crisis.

Answer 21

Autoimmune disease marked by numbness, weakness, loss of muscle coordination and problems with vision, speech and bladder control. The bodys immune system attacks the myelin sheat, a key substance that serves as a nerve insulator and helps in the transmission of nerve signals. Variable clinical course with remissions and exacerbations. More common in persons of Western European descent, living in temperate zones.

Answer 22

* Weakness, numbness, tingling or unsteadiness in a limb--may progress to all limbs. * Spastic paraparesis * Diplopia * Disequilibrium * Urinary urgency or hesitancy * Optic atrophy * Nystagmus

Answer 23

* MRI of brain is most specific test * Definitive diagnosis can never be based solely on lab findings. * Mild lymphocytosis common * Slightly elevated protein in CSF * Elevated CSF IgG

Answer 24

No treatment to prevent progression of the disease--neurology consult. Recovery from acute relapses hastened by steroids Antispasmodics Interferon therapy Immunosuppressive therapy Plasmapheresis

Answer 25

An acute, usually rapidly progressive form of inflammatory polyneuropathy characterized by demyelination of peripheral nerves resulting in progressive symmetrical ascending paralysis. Cause is unknown but usually preceded by a suspected viral infection accompanied by fever 1-3 weeks before the onset of acute bilateral muscle weakness in lower extremities. Flaccid paralysis can result within 48-72 hours. Males more commonluy affected

Answer 26

Typical presentation is a rapidly progressive ascending paralysis Cranial nerve impairment, as evidence by difficulties in speech, swallowing and mastication can occur. Reflexes are usually hypoactive or absent Impairment of the muscles of respiration occur as paralysis ascends.

Answer 27

CSF protein is usually elevated, especially immunoglobulin G. CBC, leukocytosis with a shift is seen early. LP, MRI, CT are sometimes used in aiding diagnosis.

Answer 28

Treatment is supportive while myelin is regenerated Symptoms begin to recede within 2 weeks with recovery in 2 years Neurologist consult

Answer 29

Meningitis should be considered in any patient with fever and neurologic symptoms, especially if there is a history of other infections (pna) or head trauma) Acute bacterial meningitis is a medical emergency. Streptococcus pneumoniae most common pathogen Hemophilus influenzea or neisseria meningitidis

Answer 30

* Fever * Severe HA * N/V * Nuchal rigidity * Positive kernigs sign: Pain and spasms of hamstring muscles after flexing knee * Positive Brudzinski's sign: Legs flex at both the hips and knees in response to flexion of the head and neck to the chest. * Photophobia * Seizures

Answer 31

CT of the head is indicated first to rule out bleed or other problem. LP should be performed as soon as diagnosis is suspected * Bacterial CSF: -Cloudy or xanthochromic (yellow in color) -Elevated pressures -Elevated proteins -Decreased glucose -Presence of WBCs * Viral CSF -Clear -Normal pressures -Normal protein -Normal glucose -WBC present

Answer 32

Treatment based on age <50: Vancomycin plus ceftriaxone >50: Vancomycin plus amoxicillin plus ceftriaxone

Answer 33

An alteration in brain function, or other evidence of brain pathology that is caused by an external force.

Answer 34

When one of the contents of the skull (blood, brain, CSF) increases, another must decrease to compensate and maintain normal ICP.

Answer 35

Bleeding into the epidural space between the skull and the dura mater. Caused by rupture of the middle meningeal artery. CT scan shows lens shaped that does not cross suture line. Generally causes brief loss of consciousness with lucid intervals

Answer 36

Most commonly caused by tearing of bridgning veins, causing bleeding between dura mater and arachnoid mater. Develops over minutes to hours.

Answer 37

Assess: -Time and place of injury, how the event occurred, onset of symptoms, LOC, occurence of lucid interval, seizure activity associated with event, whether amnesia occurred afterward (indicative of severity of blow) Decompensating pts may show cushings triade -Bradycardia -Decreased RR -Widening pulse pressure Battles sign: Brusing behind ear at mastoid process Racoon eyes: Basilar skull fracture Otorrhea or rhinorrhea

Answer 38

Results in absence of sensory and voluntary motor function below the level of injury.

Answer 39

Consists of: * Anterior cord syndrome * Posterior cord syndrome * Central cord syndrome * Brown sequard syndrome * Cauda equina syndrome

Answer 40

Anterior: Disruption of blood flow through the anterioir spinal artery. -Weakness or paralysis with loss of sense or pain and temp. -Propioception and vibration intact *They're opposite* Posterior: Disruption of blood flow through the posterior column. -Decrease in touch propioception and vibration below the level of injury. -Motor, pain and light touch sensation preserved.

Answer 41

Hyperextension injuries with stretching of the cord and subsequent hemorrhaging in the center of the cord. -Occurs almost exclusively in the cervical spine. -Greater motor loss and sensation in the upper extremities than in the lower extremities because the upper extremities are comtrolled by the central portion of the cord.

Answer 42

Not a true spinal cord injury but spinal fracture to the thoracic and lumbar levels can cause injury to nerves in the cauda equina. -Presentation highly variable depending on level of injury. -Asymmetric weakness or complete paralysis of lower extremities with atleast partial preservation of sensation. -Pain is often severe and asymmetrical -Patellar and achilles reflexes absent -Sphincter disturbances -Treatment is MRI, steroids and emergent surgery for decompression.

Answer 43

* C4 and above=respiratory dysfunction * C4-C5= able to shrug shoulders and flex elbows. * C5-C6=Diaphragm is intact although paralysis of intercostal and abdominal muscles. * C6-C7=Elbow extension * C7-T1=hand movement * T1-T2=Paraplegic, able to control upper but not lower. * T3-T8=some trunk control * T9-T10=Can move trunk and upper thigh * T11-L1=Ambulation possible

Answer 44

A degenerative disorder as a result of insufficient amounts of dopamine in the body. Dopamine deficieny Wont get any better, we just try to prevent it from getting worse. Unknown cause, more common in men 45-65 yrs

Answer 45

Trio of findings in all PD pts: * Tremor- slow, most conspicuous at rest, may be enhanced by stress. * Rigidity (cogwheel)- robot like movement * Bradykinesia- slow movement Other: Wooden facies, impaired swallowing, drooling, decreased blinking. Myerson's sign

Answer 46

A PD sign Repititive tapping over the bridge of the nose produces a sustained blink response (glabellar reflex)

Answer 47

None, it's a diagnosis of exclusion

Answer 48

* Carbidopa-levodopa- increases dopamine in the body. * Dopamine agonists (mimic dopamine): -Pramipexole -Ropinirole -Rotigotine * MAO-B inhibitors, prevent the breakdown of dopamine. -Selegiline -Rasagiline -Safinamide

Answer 49

Sudden, transiet onset of clouded sensorium associated with a physical stressor. Reversible. Can also be caused by: Toxins, alcohol/drugs, trauma, impactions in the elderly, poor nutrition, electrolyte imbalances, anesthesia.

Answer 50

Now called neurocognitive disorder Gradual memory loss with decreased intellectual functioning usually occurring over the age of 60yrs. Causes include: Atherosclerosis, neurotransmitter deficits, cortical atrophy, ventricular dilation, loss of brain cells, possible viral causes and alzheimers (most common form) *Make sure to rule out other diseases*

Answer 51

The development of multiple cognitive defects characterized by both memory impairment AND one or more of the following: -Aphasia (difficulty with speech) -Apraxia (inability to perform a previously learned task) -Agn*o*sia (Inability to recognize an *o*bject) -Inability to plan, organize, sequence and make abstract difference. Caused by an acetylcholine deficiency

Answer 52

Diagnosis of exclusion although want to rule out other possible causes of confusion such as CBC, CMP, VDRL, liver function etc.

Answer 53

Neuro consult * Cholinesterase inhibitors (increases availability of acetylcholine) -Donepezil (used in all stages of AD) -Galantamine (Used in mild-moderate) -Rivastigmine (Used in mild-moderate) * N-methyl D Aspartate (NMDA) antagonist: -Memantine (moderate to severe disease) * Combine preparations: -Memantine and donepezil (Namzaric) (moderate to severe disease)

Answer 54

If pt asks yeas to 2 or more of these then more questions should be asked. Screens alchol use disorder C- Have you ever fel you need to CUT down on your drinking? A- Have people ANNOYED you by criticizing your drinking? G- Have you ever felt GUILTY about your drinking? E- Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? EYE-OPENER

Answer 55

Affects the face and eye on one side of body due to disruption of nerve pathways. S/S: Ptosis, miosis and anhidrosis which is reduced sweat secretion on one side of body/face. Get an MRA of the neck/head to rule out carotid dissection.