Neurology Flashcards
(72 cards)
What are the triad associated with pseudotumor cerebri?
Papilledema<div>Chronic headache</div><div>Blindness</div>
Triad suggestive central vertigo
Vertical or rotators nystagmus
<div>Diplopia</div><div>Dysmetria</div>
Triad of Normal pressure hydrocephalus
Wet, Wobbly, Wacky<div>Urinary incontinence</div><div>Ataxia</div><div>Altered mental status</div>
“Triad of Wernicke’s encephalopathy”
Altered mental status<div>Ophthalmoplegia</div><div>Ataxia</div>
What features of nystagmus suggest central cause?
Vertical, rotatory, or horizontal nystagmus that changes directions is a sign of central vertigo
Pt with HA, what are the important elements in Hx to ask?
Onset (sudden, severe)<br></br>Duration<br></br>Location of pain (unilateral vs bilateral)<br></br>Character of pain (throbbing vs tension)<br></br>Associated symptoms (n/v, photo/phonophobia)<br></br>Focal Neurologic signs/symptoms<br></br>Fever or other systemic symptoms<br></br>Comorbidities (esp. hx of malignancy)<br></br>History of trauma<br></br>IV drug use, immunocompromised<br></br>Age of patient<br></br>Prior headache history<br></br>Sleep disturbance<br></br>FMHx of intracranial lesions, masses<br></br>Medication history
How much opening pressure to suspect IIH
> 250 mm of H2O/CSF
Describe the LP procedure:
Obtain informed consent<br></br>Position patient (lateral NOT sitting, given need to measure opening pressures)<br></br>Landmark L3-4 interspace with posterior superior iliac spines<br></br>Sterile prep<br></br>Sterile technique<br></br>Local anesthetic infiltration<br></br>Spinal needle (20-25 G) advanced through anesthetized area through dura<br></br>Collect CSF<br></br>Replace stylet<br></br>Remove spinal needle<br></br>Apply bandage
“<span>What one abnormality would be most consistent with Guillain-Barre Syndrome LP diagnosis?</span>”
Elevated protein
Treatment of Guillain-Barre syndrome
Intubation<div>IVIG</div><div>Plasmapheresis</div><div>Supportive care</div>
Wallenberg’s syndrome
The history of diplopia and dysphagia are concerning for abnormalities of posterior circulation and central vertigo. Wallenberg’s syndrome is also known as lateral medullary infarction, and is associated with <b>acute onset of disequilibrium and vertigo</b>.<div>The classic findings are:</div><div> <i>ipsilateral (to the infarct) horner syndrome (anhydrosis, miosis, and ptosis),</i></div><div><i> ipsilateral limb ataxia, and</i></div><div><i> loss of pain and temperature sensation on the contralateral limb.</i></div><div>Wallenberg’s syndrome typically occurs as a result of either traumatic vertebral artery dissection, or from long-standing atherosclerosis. (PICA)</div>
Bacterial Meningitis causes by age
“<img></img>”
Causes of isolated bilateral facial n. palsy
“Lyme disease<div>Guillain-Barre synd</div><div>Atypical Bell’s palsy</div><div>Sarcoidosis</div><div>Meningitis</div><div>Encephalitis</div><div>Leukemia</div><div>DM</div><div>HIV</div><div>Syphilis</div><div>EBV</div>”
Best imaging for IIH
MR brain with venography to exclude venous sinus thrombosis
<div><div>Which of the following physical exam findings is an indication for CT scan prior to lumbar puncture in a patient with suspected meningitis?</div></div>
<div><div><br></br></div><div><div><br></br></div></div></div>
Papilledema
Miller Fisher Syndrome (MFS)
“a variant of Guillain-Barre syndrome: <div> ophthalmoplegia,<div> ataxia, and</div><div> areflexia.</div><div>The clinical context of a recent diarrheal illness points to the most common precipitant of this <b>immune-mediated acute neuropathy: Campylobacter jejuni<span>.</span></b></div></div><div><b><span><br></br></span></b></div>”
Ddx for ophthalmoplegia/bulbar abnormalities
MS<div>Botulism</div><div>M.gravis</div><div>Miller Fisher syndrome</div><div>IC SOL (hge, infarct, tumor, aneurysm)</div>
Stroke by areas of the brain
” <strong>Area of the brain</strong> <strong>Artery</strong> <strong>Features</strong> Internal capsule (Lacunar stroke syndrome) Penetrating branchs of MCA or Basilar 5 subtypes Lateral frontoparietal, superior temporal MCA <ul> <li>contralateral hemianesthesia, hemiparesis, hemianopia with gaze preference;</li> <li>If dominant hemisphere: aphasia and apraxia; if nondominant hemisphere: aprosodia, hemineglect</li> </ul> Lateral medulla (Wallenberg syndrome) PICA <ul> <li>ipsilateral facial sensory loss, Horner’s syndrome, palatal weakness, dysphagia and ataxia,</li> <li>contralateral body pain and temperature loss</li> </ul> Medial frontoparietal lobes ACA <ul> <li>contralateral anesthesia, leg > arm hemiparesis, abulia</li> <li>If dominant hemisphere: mutism; if nondominant hemi- sphere: acute confusional state</li> </ul> “
Lacunar stroke:
” <strong>Type</strong> <strong>Area</strong> <strong>Features</strong> <p>Pure motor hemiparesis</p> Post limb of internal capsule <ul> <li>contralateral hemiparesis of face, arm, and leg</li> <li>Absence of sensory sympt</li> <li>Mild form of dysarthria</li> <li>Cortical signs like aphasia, cognitive deficit, or visual symptoms are always absent</li> </ul> <p>Pure sensory stroke:</p> Thalamus <ul> <li>absent or abnormal sensation of contralateral of face, arm, and leg</li> <li>The sensations affected are pain, temperature, touch, pressure, vision, hearing, and taste</li> <li>e.g:Dejerine Roussy syndrome</li> </ul> <p>Ataxic hemiparesis:</p> <p>internal capsule, pons, or corona radiata</p> <ul> <li>hemiparesis of the contralateral face and leg and ataxia of the contralateral limb.</li> <li>Ataxia is the prominent feature of this stroke.</li> </ul> <p>Dysarthria-clumsy hand syndrome</p> <p>pons or internal capsule</p> <ul> <li>dysarthria</li> <li>Contralateral clumsiness of the upper extremity with preserved motor strength</li> <li>difficulty with subtle fine movements such as writing or tying a shoelace may be present.</li> </ul> <p>A sensory-motor stroke</p> <p>thalamus, internal capsule, or putamen-capsule-caudate</p> <ul> <li>combination of ipsilateral sensory and motor loss</li> </ul> “
ECG Changes in raised ICP
Widespread giant T-wave inversion (cerebral T-wave)<div>OT prolongation</div><div>Bradycardia</div>
Rx of cluster HA
1st line:<div> High flow O2</div><div><br></br></div><div>2nd lines:</div><div> DHE</div><div> Sumitriptan</div><div> Intranasal lidocaine</div>
Important historical features for cauda equina syndrome:
<ul> <li>Onset/ progression of weakness/ falls</li> <li>Changes to voiding (urinary retention)</li> <li>Fecal incontinence</li> <li>Sensory symptoms (perineal or LE)</li> <li>Any known metastatic lesions</li> <li>Fever, night sweats, weight loss</li> <li>Erectile dysfunction</li> </ul>
<p>–Hx of malignancy, LE weakness, back pain <em>not accepted </em>– given in the stem and asked for “other features”</p>
Finings in examination in cauda equina synd
Midline tenderness<div>Motor weakness</div><div>Perianal anesthesia</div><div>Altered reflexes (early==>hypo, late==>hyper + babinski)</div><div>Ataxia</div><div>Decreased rectal tone</div><div>Plapable bladder</div>
<p>What is one bedside test you can order that will help you confirm your suspected diagnosis of Cauda equina synd?</p>
<p>–Post-void residual bladder scan/ POCUS</p>
<p>–>100-200mL – urinary retention</p>
Name 3 other (non-malignant) causes of cauda equina/SCC
–Spinal epidural abscess
–Post operative hematoma/ iatrogenic
–Lumbar disk herniation
–Fracture/trauma
–Spinal stenosis
Ankylosing spondylitis
–Think: ABCD2 Score – (still in Key Features)
- Age: >60
- Initial BP: >140/90
- *Clinical: speech disturbance +/- unilateral weakness*
- Duration: >10min vs >60 mins
- Diabetic
–Very high risk:
- *Speech disturbance +/- unilateral weakness*
- Recurrent/ fluctuating symptoms
- Early presentation (within 48hrs)
- Previous CVA
ABSOLUTE:
History
a. Ever
i. ICH
ii. Brain neoplasm, AVM, aneurysm
b. Recent
i. Head trauma / prior stroke in last 3 months
ii. Intracranial or intraspinal surgery
c. Today
i. Use of warfarin, DOAC AND evidence of its bleeding diathesis effect
Exam
a. Symptoms suggest SAH
b. BP > 185/110
c. Active internal bleeding
d. Bleeding diathesis
Investigations
a. Blood glucose < 2.7 mmol/L
b. Plt count <100,000
c. Elevated aPTT
d. INR > 1.7 or PT > 15 sec
e. CT showing multilobar infarction
Relative (for the 3 and 3-4.5 hr window)
History
a. Any oral anticoagulant
b. Older > 80
c. Hx of DB and prior ischemic stroke
d. Major surgery or serious trauma within 14 days
e. GI or GU hemorrhage in the past 21 days
f. MI in the last 3 months
Exam
a. Severe stroke (NIHSS > 25)
b. Minor or rapidly improving stroke symptoms
Labs
"What physical features are more suggestive of a large vessel occlusion that may be amenable to intravascular thrombectomy?
–Motor weakness
–Visual defect
–Aphasia
–Neglect
(VAN or FAST-ED scores)
What are 4 means to prevent elevations in ICP prior to impending herniation?
–Elevate HOB
–Remove constriction around neck
–Treat anxiety/pain/nausea
–Normoglycemia (insulin)
–Prevent hyperthermia/ cooling
–Paralysis
What is a temporizing measure when there is concern for impending herniation?
–How does it work?
What negative effects could it have?
Hypotension leading to decrease CPP
"In a patient with a first presentation seizure, what high-risk activities must be addressed?
- Driving, including documentation to appropriate authorities
- Occupational: climbing, heavy equipment, factory equipment, etc
- Sports: swimming
What clues can prompt you to add seizure to your Ddx in an unwitnessed event?
–Confusion/ altered mental status (post-ictal)
–Incontinence
–Tongue biting
–Falls/accidents/other injury patterns
–Amnesia of event
- Cavernous sinus thrombosis
- Vasculitis/autoimmune
- Internal carotid or vert a dissection
- Angle closure glaucoma
- Iritis/scleritis/uveitis
- HZV inf
- CO poisoning
- Pre-eclampsia
- Age 6 months to 5 years,
- seizure must be generalized (non-focal),
- single seizure in 24 hours,
- seizure must last less than 15 minutes,
- normal neuro exam and with a return to baseline after a postictal state
Loop diuretics
Corticosteroids
Serial LPs to draine CSF
-Altered mental status
-Cachexia
-Focal neurological findings
-Papilledema
-Meningismus
-Rash
-Temporal artery tenderness
-Signs of trauma
-Vertical or torsional nystagmus
Provide a differential diagnosis for delerium
Infection (sepsis, meningitis, encephalitis, neurosyphilis)
Withdrawal (EtOH)
Acute metabolic (high Ca, Mg, Glu, Acidosis, hepatic or renal failure
Trauma (head injury, burn)
CNS pathology (abscess, hemorrhage, hydrocephalus, SDH, Infection, seizures, stroke, tumor, metastases, vasculitis)
Hypoxia (acute or chronic lung disease or Hypotension
Deficiencies (B12, Niacin, Thiamine)
Environmental (hypo or hyperthermia) or Endocrinopathies (DM, adrenal, thyroid)
Acute Vascular (CVA, HTN emerg, SAH)
Toxins (meds, EtOH, street drugs, pesticides, industrial poisons, CO, CN, solvents)
Heavy metals (Lead, mercury)
Describe Transverse Cord Syndrome
- Sensory: Below Lesion
- Motor : Below lesion
- Loss of Sphincter control
Describe Brown-Sequard Syndrome
- Sensory:
–Ipsilateral position & vibration
–Contralateral pain & temp
- Motor:
–Ipsilateral motor loss
- Sphincter:
Variable
"Describe Central Cord Syndrome
- Hyper extension of the C-spine (MVC, Diving)
- Sensory:
–Variable
- Motor:
–Upper Extremity > Lower
–Distal> Proximal
- Sphincter:
–Variable
- PEARL: (MUD)
–M otor > Sensory
–U pper > Lower
D istal > Proximal
"Describe Anterior Cord Syndrome
- Sensory:
–Loss of pain & temperature
–Vibration and position preserved
- Motor:
–Loss or weakness below level
- Sphincter:
Variable
"dDx of flaccid paralysis
- Ascending
Guillane Barre
Tick Paralysis
- Descending
Myasthenia Gravis
Botulism
Multiple Sclerosis
Vasospasm
Acute hydrocephalus
- Transient, fluctuating or persistent unilateral weakness (face, arm and/or leg);
- Transient, fluctuating or persistent language/speech disturbance;
- And/or fluctuating or persistent symptoms without motor weakness or language/speech disturbance (e.g. hemibody sensory symptoms, monocular vision loss, hemifield vision loss, +/- other symptoms suggestive of posterior circulation stroke such as binocular diplopia, dysarthria, dysphagia, ataxia).”
coarctation of the aorta,
polycystic kidney disease,
Marfan syndrome, and
Ehlers-Danlos syndrome
