Neurology Flashcards

Question

Most common mutations associated with PD

Answer 1

Glucocerebrosidase

Answer 2

prevents peripheral metabolism to dopamine and the development of nausea/vomiting Levodopa remains the most effective symptomatic tx for PD

Answer 3

weaing off effect

Answer 4

Subthalamic nucleus or Globus pallidus interna

Answer 5

Head trauma Immunocompromised Malignancies Focal neurologic findings In contrast, if bacterial meningitis is suspected, give antibiotics PRIOR to neuroimaging and LP

Answer 6

S. pneumoniae

Answer 7

S. aureus CONS

Answer 8

Fever Headache Nuchal rigidity

Answer 9

Cefotaxime/ Ceftriaxone/Cefepime + Vanco

Answer 10

Ampicillin + cefotaxime/Ceftri/Cefepime + Vancomycin

Answer 11

Ampicillin + ceftazidime/meropenem + vanco so dapat may coverage for P. aeuruginosa

Answer 12

Ampi + Genta

Answer 13

Meningococcus - 7 days Pneumococcus - 14 days Gram neg - 21 days L. monocytogenes -21 days

Answer 14

Pneumococcal- most striking benefit May also be given in Hib and N. meningitidis Should be given 20 mins prior to abx No benefit if given >6 hrs after Dexa may decrease penetration of VAN in the CSF. As a result, to assure reliable penetration of vancomycin into the CSF, children and adults are treated with vancomycin in a dose of 45–60 mg/kg per day. Alternatively, vancomycin can be administered by the intraventricular route.

Answer 15

Rifampin 600 mg q12 - not for pregnant women Alternative: Azithromycin x1 dose or IM ceftriaxone (250 mg) x 1 dose

Answer 16

CSF PCR Highest sensitivity if taken within 48 hrs of symptom onset More sensi that CSF viral culture which in general has poor sensitivity

Answer 17

IV acyclovir followed by an oral drug for 7-14d

Answer 18

Enteroviruses

Answer 19

Ganciclovi/ Foscarnet Cidofovir

Answer 20

Headache Fever Focal neurologic deficit

Answer 21

Third or 4th gen + Metronidazole

Answer 22

Acetylcholine receptors however levels do NOT correlate with severity

Answer 23

Thymus Thymus is abnormal in 75% of px (65% hyperplasia, 10% thymoma) Chest CT/MRI may be used

Answer 24

presynaptic calcium channels

Answer 25

Muscle specific kinase

Answer 26

Anticholinesterase drug pyridostigmine (Mestinon)

Answer 27

Atropine/ Diphenoxylate/ Loperamide

Answer 28

Glucocorticoids

Answer 29

Charcot Marie Tooth disease

Answer 30

GBS and CIDP

Answer 31

Lidoderm TCA (amitriptyline, nortriptyline) Gabapentin, Pregabalin Duloxetine

Answer 32

Fisher syndrome Assoc with antibody to GQ1b

Answer 33

Ulnar/Median nerve in the arm Peroneal/Fibular in the leg

Answer 34

Radial nerve Presents with wrist drop

Answer 35

Glucocorticoids may slow progression of dse for up to 3 yrs

Answer 36

Fascioscapularhumeral dystrophy

Answer 37

May be extended up to 4.5 hours

Answer 38

Epidural l-E-mon shaped = Epidural

Answer 39

middle meningeal arteries

Answer 40

bridging veins Water under the bridge Under= sub Bridge = bridging veins

Answer 41

Ophthalmoplegia, ataxia and confusion

Answer 42

generalized symmetric 3hz spike and slow wave pattern

Answer 43

Topiramate since it is a weak carbonic anhydrase inhibitor Also assoc with glaucoma

Answer 44

Indomethacin

Answer 45

Verapamil, Topiramate, Melatonin, Lithium

Answer 46

Lamotrigine Topiramate Gabapentin Lamotrigine --> most effective

Answer 47

TCA eg. amitriptyline

Answer 48

distal symmetric polyneuropathy

Answer 49

Trauma If outside trauma, ruptured saccular aneurysm

Answer 50

Cerebrovascular dse

Answer 51

medial medulla Medial medullary syndrome (Dejerine Syndrome): clinical triad of ipsilateral hypoglossal palsy, contralateral hemiparesis, and contralateral lemniscal sensory loss (loss of vibration and proprioception) Lateral medullary syndrome (Wallenberg syndrome): ipsilateral loss of facial pain and temp sensation, contralateral hemisensory loss of pain and temp sensation, ipsilateral losses (ataxia of arm/leg, gait, nystagmus, hoarseness, dysphagia, horner syndrome)

Answer 52

Alzheimers - AB/Tau FTD -Tau Lewy body- alpha synuclein Huntington dse - polyglutamine repeats CJD - prions

Answer 53

Predominates in the morning and improves during the day

Answer 54

6 Should be given 20 mins prior to abx

Answer 55

cardioembolic

Answer 56

Meningioma

Answer 57

Hematogenous

Answer 58

SRS It can sterilze visible lesins and produce local disease control in 80-90% of px Can tx up to 10 lesions gowever confined to lesions <= 3 cm and is most effective in <= 1 cm previously whole brain RT

Answer 59

<40mg/dL >3g/L

Answer 60

Aqueous Penicillin G 3-4 million units IV every 4 h for 10-14 days

Answer 61

5-HT2a receptor antagonist mirtazapine

Answer 62

Early capsule formation If capsule + gliosis --> Late capsule formation; inc risk of seizure

Answer 63

Late cerebritis stage

Answer 64

tension type

Answer 65

Calcitonin gene related protein

Answer 66

Cluster headache

Answer 67

vestibular/ acoustic neuroma NF2 have high incidence of vestibular schwanomma

Answer 68

Lung CA but greatest propensity to cause hemorrhage: melanoma, thyroid, kidney CA (these are just not as common as lung CA)

Answer 69

10 minutes

Answer 70

Nonrheumatic atrial fibrillation

Answer 71

Diffusion-weighted imaging (DWI)

Answer 72

Tenecteplase T for transfer

Answer 73

Age- >= 60 BP (SBP >140 OR DBP >90) Clinical symptoms (Unilateral weakness -2, Speech disturbance without weakness -1) Duration (>60 m -2, 10-59m -1) Diabetes -1

Answer 74

Generalized Tonic clonic

Answer 75

Characteristic rhomboid pattern

Answer 76

Mesial Temporal Lobe Epilepsy Syndrome Characteristic hippocampal sclerosis on MRI

Answer 77

Refractory to treatment with anticonvulsants but responds well to surgical intervention

Answer 78

Unilateral or bilateral anterior temporal spikes

Answer 79

Lamotrigine

Answer 80

Benzodiazepine (Midazolam, Lorazepam, Diazepam)

Answer 81

medial temporal lobes

Answer 82

age and family hx

Answer 83

Chorea, behavioral disturbance, and executive impairment

Answer 84

clinical triad includes an abnormal gait (ataxic or apractic), dementia and urinary urgency or incontinence

Answer 85

Progressive supranuclear palsy

Answer 86

Pimavanserin Patients with Lewy Body Dementia should not be exposed to typical neuroleptics that can lead to a neuroleptic malignant syndrome and death, or anticholinergics or dopamine agonists that can exacerbate their symptoms.

Answer 87

Apomorphine

Answer 88

Parkinson's dse

Answer 89

Amantadine

Answer 90

Facial weakness, Arm weakness, Speech abnormality, Time

Answer 91

Cocaine and amphetamine

Answer 92

periodic, stereotyped, sharp-and-slow complexes

Answer 93

Hypertension Bradycardia irregular breathing

Answer 94

Note gluc <40; protein >45

Answer 95

AmB (0-7-1.0 mg/kg/day) for 4-12 weeks (total of 30mg/kg is recommended)

Answer 96

cysticercosis

Answer 97

No definitive therapy for SSPE is available. Treatment with isoprinosine (Inosiplex, 100 mg/kg per day), alone or in combination with intrathecal or intraventricular interferon-α, has been reported to prolong survival and produce clinical improvement in some patients but has never been subjected to a controlled clinical trial.

Answer 98

Early cerebritis

Answer 99

Late capsule formation Associated with gliosis which inc risk for seizure

Answer 100

10–15 3 2

Answer 101

3 Cerebellar hemorrhages should be urgently referred to neurosurgery service for evaluation

Answer 102

>Lower the SBP to below 160 mmHg using nicardipine, labetalol, or esmolol. Cerebral perfusion pressure targeted to 60–70 mmHg. > Treatment with the calcium channel antagonist nimodipine (60 mg PO every 4 h) improves outcome. prevents ischemia > vasospasm >Euvolemia is targeted. Free-water restriction is contraindicated >Pneumatic compression stockings applied to prevent PE. >Unfractionated heparin administered subcutaneously for DVT prophylaxis can be initiated within 1–2 days following endovascular treatment or craniotomy

Answer 103

CGRP antagonists

Answer 104

when aura is completed and headache has begun

Answer 105

flunarizine

Answer 106

Oligodendrogliomas

Answer 107

codeletion of 1p/19q

Answer 108

prostate CA, breast CA also the 2 most common cause of epidural mets Most common site: THORACIC

Answer 109

EEG shows a generalized, slow spike- and-slow-wave pattern with a frequency of ≤2.5 per second

Answer 110

Brief, generalized spike-and-wave discharges → immediately by diffuse slow waves

Answer 111

b. Aphasia with preserved verbal repetition. a. Pinpoint (1mm) pupils that are reactive to light. --> unreactive to light c. Heteronymous visual field defects due to interruption of the visual pathway.--> homonymous d. Contralateral Horner’s syndrome and retraction nystagmus.--> ipsilateral Thalamic hemorrhages also produce a contralateral hemiplegia or hemiparesis from pressure on, or dissection into, the adjacent internal capsule. A prominent sensory deficit involving all modalities is usually present. Thalamic hemorrhages cause several typical ocular disturbances by extension inferiorly into the upper midbrain. These include deviation of the eyes downward and inward so that they appear to be looking at the nose, unequal pupils with absence of light reaction, skew deviation with the eye opposite the hemorrhage displaced downward and medially, ipsilateral Horner’s syndrome, absence of convergence, paralysis of vertical gaze, and retraction nystagmus. Patients may later develop a chronic, contralateral pain syndrome (Déjérine-Roussy syndrome).

Answer 112

b. Flunarizine: drowsiness a. Propranolol: hair loss--> not typical side effect c. Topiramate: weight gain --> weight loss d. Valproic acid: weight loss --> weight gain

Answer 113

c. Uncontrolled hypertension ICH due to metastatic brain tumors, cerebral amyloid angiopathy and capillary telangiectasia are seen in the cortical areas of the brain.

Answer 114

a. Identification and control of modifiable risk factors, and especially hypertension and diabetes

Answer 115

b. Hypotension should be corrected slowly to avoid reperfusion injury. In the management of coma, hypotension is a medical emergency that must be corrected rapidly, as prolonged hypotension can lead to inadequate cerebral perfusion, worsening ischemic brain injury, and multi-organ failure.

Answer 116

b. Delirium

Answer 117

a. 43 a level of >65 mmol/L (0.3 g/dL) is associated with stupor. The development of tolerance may allow some chronic alcoholics to remain awake at levels >87 mmol/L (0.4 g/dL).

Answer 118

b. Cranial MRI In patients with subacute hemorrhage, MRI is the imaging of choice because the MR sequences may detect micro- hemorrhages, and determine the etiology of the bleed (eg. Cavernous malformations, amyloid, hemorrhagic metastaseds) CT scan is recommended for ACUTE Intracerebral hemorrhage as it can be done faster than MRI, and is reliable in detecting acute blood. 4 vessel angiogram is indicated for patients suspected to have vascular malformations and aneurysms. Transcranial doppler is used to monitor vasospasm and cerebral bloodflow

Answer 119

d. Initiate osmotic agents as soon as possible This patient who has a 1cm midline shift on CT scan and is starting to have decreased sensorium should be started on osmotic agents such as Mannitol or hypertonic saline. Maintaining a MAP of 110-130 to facilitate permissive hypertension is done in the management of cerebral INFARCTION. Recent trials in BP management for hypertensive ICH (INTERACT 2 AND ATTACH 2) showed that lowering the SBP to 140-180mmHg is likely safe and possibly beneficial. Patients with ICH are placed in moderate to high back rest to improve venous return to the heart. In lowering BP, Nonvasodilating IV meds such as Nicardipine, Labetalol and Esmolol should be used instead of Hydralazine.

Answer 120

b. 2 2= CN 3= motor 4= stu4 5= lima =coma

Answer 121

d. Posterior Communicating Artery An aneurysm of the posterior communicating artery will compress the third cranial nerve due to its proximity to the latter. This would result to an ipsilateral third cranial nerve is palsy, and present with pupillary dilation, and loss of ipsilateral (but retained contralateral) light reflex. Focal pain above or behind the eye, may occur with an expanding aneurysm at the junction of the posterior communicating artery and the internal carotid artery. Aneurysms of the Anterior circulation (ACA or Acomm) would present with leg weakness. Aneurysms involving the posterior inferior cerebellar artery or anterior inferior cerebellar artery often present with occipital and posterior cervical pain. MCA aneurysms may present with pain in or behind the eye and in the low temple but this would not present with third nerve palsies.

Answer 122

b. 3 thalamus is supratentorial

Answer 123

a. Arteritis This is a typical case of TB meningitis, with a subacute onset of symptoms and sudden focal deficit or stroke due to arteritis. The focal deficits due to empyema, brain abscesses and metastasis usually present gradually.

Answer 124

d. Streptococcus pnuemoniae The patient initially presented with community acquired pneumonia which is the most important risk factor in developing pneumococcal meningitis. The organisms most often responsible for community-acquired bacterial meningitis are Streptococcus pneumoniae (~50%), Neisseria meningitidis (~25%), group B streptococci (~15%), and Listeria monocytogenes (~10%). Haemophilus influenzae type b accounts for <10% of cases of bacterial meningitis in most series. There are a number of predisposing conditions that Additional risk factors include coexisting acute or chronic pneumococcal sinusitis or otitis media, alcoholism, diabetes, splenectomy, hypogammaglobulinemia, complement deficiency, and head trauma with basilar skull fracture and CSF rhinorrhea

Answer 125

b. Hydrocephalus Lower extremity weakness with headache and decreased sensorium are signs most compatible with increased intracranial pressure. In fungal meningitis, the most common complication is also **hydrocephalus**. Patients who develop hydrocephalus should receive a CSF diversion device. A ventriculostomy can be used until CSF fungal cultures are sterile, at which time the ventriculostomy is replaced by a ventriculoperitoneal shunt. Arteritis will present with focal neurologic deficits, while spinal meningitis will present with multiple radiculopathies. Status epilepticus would present with seizures

Answer 126

c. Syncope The patient’s premonitory symptom of tunneling of vision, gradual transition to unconsciousness and tonic movements lasting 10 seconds are features seen in syncope. Seizures usually present with immediate loss of consciousness lasting minutes, with tonic / clonic moevements lasting 30-60 seconds. Disorientation in seizures would last many minutes to hours while in syncope, it would last for less than 5 minutes. Patients with pseudoseizures present with side-to- side turning of the head, asymmetric and large-amplitude shaking movements of the limbs, twitching of all four extremities without loss of consciousness, and pelvic thrusting. In transient ischemic attack, there is usually a focal weakness that resolves in 1 hour with no evidence of infarction in imaging.

Answer 127

b. In elderly nonhypertensive patients, cerebral amyloid angiopathy should be considered --> most common cause of lobar hemorrhage in elderly Why other choices are wrong a. Hypertensive hemorrhages usually result from spontaneous rupture of superficial arteries in the brain --> deep seated arteries c. Medium sized arteries in the basal ganglia are most prone to hypertension induced vascular injury --> small penetrating arteries d. Most intracerebral hemorrhages would have significant hematoma expansion after 48 hours --> 24h

Answer 128

d. Long tract signs The gray matter is composed predominantly of neuronal cell bodies. Hence disorders in the grey matter would often present with seizures, early cognitive decline and movement disorders. On the other hand, the white matter is composed of axons, their myelin and glial cells which transmit signals to the other cells in the central nervous system. In white matter disorders, these signals are interrupted hence long track signs involving motor, sensory and cerebellar pathways are seen in these patients.

Answer 129

a. Immediate referral to a neurosurgeon or endovascular surgeon is recommended for all patients The definitive management to prevent rerupture of aneurysm is through “clipping” by a neurosurgeon or “coiled” by an endovascular surgeon. These patients should be referred immediately since early aneurysm repair prevents rerupture and allows the safe application of techniques to improve blood flow in the brain. Treatment with the calcium channel antagonist nimodipine (60 mg or 2 tabs of 30mg q4) improves outcome, perhaps by preventing ischemic injury rather than reducing the risk of vasospasm. Glucocorticoids may help reduce the head and neck ache caused by the irritative effect of the subarachnoid blood. However, there is no good evidence that they reduce cerebral edema, are neuroprotective, or reduce vascular injury, and their routine use therefore is not recommended. Free-water restriction is contraindicated in patients with SAH at risk for DCI because hypovolemia and hypotension may occur and precipitate cerebral ischemia.

Answer 130

d. Thrombocytopenia should be corrected with platelet transfusion Platelet transfusions should only be given in patients on antiplatelets if these patients present with thrombytopenia. In a recent trial, for ICH patients on antiplatelets but without thrombocytopenia, platelet transfusion suggested no benefit and was noted to have possible harm Administration of two doses of Idarizucimab reverses the anticoagulation effect of dabigatran quickly. A phase 3 trial of treatment with recombinant factor VIIa reduced hematoma expansion in ICH patients. However, clinical outcomes were not improved, so use of this drug is not recommended. When ICH is associated with thrombocytopenia (platelet count <50,000/μL), transfusion of fresh platelets is indicated

Answer 131

d. Seizure prophylaxis should be considered in severe cases of encephalitis In the treatment of HSV encephalitis, IV Acyclovir is given at **10mg/kg** q8 for 21 days in adults. Neonates are given 20mg/kg IV Acvclovir q8. Oral Valacyclovir has not been evaluated as a supplemental therapy after IV acyclovir is given in patients with HSV encephalitis. IV acyclovir should be diluted at a concentration <7mg/mL prior to infusion and slowly infused over **1 hour** to prevent renal dysfunction. Because of the high frequency of seizures in severe cases of encephalitis, seizure prophylaxis should be considered in severe cases of encephalitis

Answer 132

Fatigability of muscle power is a cardinal manifestation of some neuromuscular disorders such as myasthenia gravis and is distinguished from fatigue by finding clinically evident diminution of the amount of force that a muscle generates upon repeated contraction

Answer 133

On confrontational testing, full power may be generated for only a brief period before the patient suddenly gives way to the examiner. This type of weakness is often referred to as breakaway weakness and may or may not be associated with pain. This is contrasted with weakness due to lesions in the motor tracts or lower motor unit, in which the patient’s resistance can be overcome in a smooth and steady fashion and full power can never be generated.

Answer 134

Fasciculations --> LMN

Answer 135

A “pure motor” hemiparesis of the face, arm, and leg often is due to a small, discrete lesion in the posterior limb of the internal capsule, cerebral peduncle in the midbrain, or upper pons.

Answer 136

cervical cord.

Answer 137

Myopathy often produces symmetric weakness of the pelvic or shoulder girdle muscles. Diseases of the neuromuscular junction, such as myasthenia gravis, may present with symmetric proximal weakness often associated with ptosis, diplopia, or bulbar weakness and fluctuate in severity during the day. In anterior horn cell disease, proximal weakness is usually asymmetric, but it may be symmetric especially in genetic forms. Numbness does not occur with any of these diseases. The evaluation usually begins with determination of the serum creatine kinase level and electrophysiologic studies.

Answer 138

The most useful bedside test of peripheral vestibular function is the head impulse test, in which the vestibulo-ocular reflex (VOR) is assessed with small-amplitude (~20 degrees) rapid head rotations. While the patient fixates on a target, the head is rotated quickly to the left or right. If the VOR is deficient, the rotation is followed by a catch-up saccade in the opposite direction after a rightward rotation). The head impulse test can identify both unilateral (catch-up saccades after rotations toward the weak side) and bilateral (catch-up saccades after rotations in both directions) vestibular hypofunction

Answer 139

Posterior canal BPPV can be diagnosed confidently if transient upbeating-torsional nystagmus is seen. For posterior canal BPPV, the Epley maneuver is the most commonly used procedure

Answer 140

Two forms of nystagmus that are characteristic of lesions of the cerebellar pathways are vertical nystagmus with downward fast phases (downbeat nystagmus) and horizontal nystagmus that changes direction with gaze (gazeevoked nystagmus)

Answer 141

Ménière’s disease is associated with excess endolymph fluid in the inner ear; hence the term endolymphatic hydrops. Patients suspected of having Ménière’s disease should be referred to an otolaryngologist for further evaluation. Diuretics and sodium restriction are typically the initial treatments. If attacks persist, injections of glucocorticoids or gentamicin into the middle ear may be considered. Nonablative surgical options include decompression and shunting of the endolymphatic sac. Full ablative procedures (vestibular nerve section, labyrinthectomy) are seldom required

Answer 142

In population-based studies, neurally mediated syncope is the most common cause of syncope. 2nd most common: cardiac

Answer 143

Typically, cerebral blood flow ranges from 50–60 mL/min per 100 g brain tissue and remains relatively constant over perfusion pressures ranging from 50–150 mmHg

Answer 144

Vasodepressor syncope describes syncope predominantly due to efferent, sympathetic, vasoconstrictor failure; cardioinhibitory syncope describes syncope predominantly associated with bradycardia or asystole due to increased vagal outflow;a

Answer 145

Reassurance, education, avoidance of provocative stimuli, and plasma volume expansion with fluid and salt are the cornerstones of the management of neurally mediated syncope. Isometric counterpressure maneuvers of the limbs (tensing of the abdominal and leg muscles, handgrip and arm tensing, and leg crossing) may raise blood pressure by increasing central blood volume and cardiac output. Of these, abdominal muscle tensing is the most effective

Answer 146

. Whereas tonic-clonic movements are the hallmark of a generalized seizure, myoclonic and other movements also may occur in up to 90% of syncopal episodes.

Answer 147

Loss of consciousness associated with a seizure usually lasts >5 min and is associated with prolonged postictal drowsiness and disorientation, whereas reorientation occurs almost immediately after a syncopal event.

Answer 148

Patients with cataplexy experience an abrupt partial or complete loss of muscular tone triggered by strong emotions, typically anger or laughter. Unlike syncope, consciousness is maintained throughout the attacks, which typically last between 30 s and 2 min. There are no premonitory symptoms. Cataplexy occurs in 60%–75% of patients with narcolepsy

Answer 149

Treadmill exercise testing with ECG and blood pressure monitoring should be performed in patients who have experienced syncope during or shortly after exercise. T

Answer 150

The sense of vibration is tested with an oscillating tuning fork that vibrates at 128 Hz. Vibration is tested over bony points, beginning distally; in the feet, it is tested over the dorsal surface of the distal phalanx of the big toes and at the malleoli of the ankles, and in the hands, it is tested dorsally at the distal phalanx of the fingers. If abnormalities are found, more proximal sites should be examined. Vibratory thresholds at the same site in the patient and the examiner may be compared for control purposes.

Answer 151

Inability to recognize numbers or letters is termed agraphesthesia Stereognosis refers to the ability to identify common objects by palpation, recognizing their shape, texture, and size.

Answer 152

Lateral hemisection of the spinal cord produces the Brown-Séquard syndrome, with absent pain and temperature sensation contralaterally and loss of proprioceptive sensation and power ipsilaterally below the lesion

Answer 153

Dysesthesias, when severe and persistent, may respond to anticonvulsants (carbamazepine, 100–1000 mg/d; gabapentin, 300–3600 mg/d; or pregabalin, 50–300 mg/d), antidepressants (amitriptyline, 25–150 mg/d; nortriptyline, 25–150 mg/d; desipramine, 100–300 mg/d; or venlafaxine, 75–225 mg/d).

Answer 154

vascular disease, particularly subcortical small-vessel disease in the deep frontal white matter and centrum ovale

Answer 155

With distal weakness (peripheral neuropathy), the step height is increased to compensate for foot drop, and the sole of the foot may slap on the floor during weight acceptance, termed the steppage gait.

Answer 156

The Timed Up and Go (“TUG”) test involves timing a patient as they stand up from a chair, walk 10 feet, turn, and then sit down. Patients with a history of falls or those requiring >12 s to complete the TUG test are at high risk for falls and should undergo further assessment

Answer 157

A Tai Chi exercise program has been demonstrated to reduce the risk of falls and injury in patients with Parkinson’s disease

Answer 158

The hallmark of delirium is a deficit of attention, although all cognitive domains—including memory, executive function, visuospatial tasks, and language—are variably involved. The attentional deficit that serves as the neuropsychological hallmark of delirium has a diffuse localization within the brainstem, thalamus, prefrontal cortex, and parietal lobes

Answer 159

The two most consistently identified risk factors are older age and baseline cognitive dysfunction.

Answer 160

Basic screening labs, including a complete blood count, electrolyte panel, and tests of liver and renal function, should be obtained in all patients with delirium. In elderly patients, screening for systemic infection, including chest radiography, urinalysis and culture, and possibly blood cultures, is important. In younger individuals, serum and urine drug and toxicology screening may be appropriate earlier in the workup Multiple studies have demonstrated that brain imaging in patients with delirium is often unhelpful.

Answer 161

global hypoperfusion in the setting of systemic hypotension from heart failure, septic shock, dehydration, or anemia Focal strokes in the right parietal lobe and medial dorsal thalamus rarely can lead to a delirious state.

Answer 162

Frontotemporal dementia

Answer 163

Brain imaging routine for dementia but not delirium

Answer 164

Dementia with Lewy bodies Visual --> lewy bodies

Answer 165

None Brief screening tools such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MOCA), the Tablet Based Cognitive Assessment Tool, and Cognistat can be used to capture dementia and follow progression. None of these tests is highly sensitive to early-stage dementia or reliably discriminates between dementia syndromes.

Answer 166

In AD, the early deficits involve episodic memory, category generation (“name as many animals as you can in 1 minute”), and visuoconstructive ability. Usually deficits in verbal or visual episodic memory are the first neuropsychological abnormalities detected, and tasks that require the patient to recall a long list of words or a series of pictures after a predetermined delay will demonstrate deficits in most patients. In FTD, the earliest deficits on cognitive testing involve executive control or language (speech or naming) functions, but some patients lack either finding despite profound social-emotional deficits.

Answer 167

Akinetic mutism refers to a partially or fully awake state in which the patient remains virtually immobile and mute but can form impressions and think, as demonstrated by later recounting of events. This condition results from damage in the regions of the medial thalamic nuclei or the frontal lobes (particularly lesions situated deeply or on the orbitofrontal surfaces) or from extreme hydrocephalus.

Answer 168

31°C (87.8°F)

Answer 169

The uncus can compress the third nerve as the nerve traverses the subarachnoid space, causing enlargement of the ipsilateral pupil as the first sign

Answer 170

metabolic encephalopathy or drug intoxication.

Answer 171

The most extreme pupillary sign, bilaterally dilated and unreactive pupils, indicates severe midbrain damage, usually from compression by a supratentorial mass.

Answer 172

Reactive and bilaterally small (1–2.5 mm) but not pinpoint pupils are seen in metabolic encephalopathies or in deep bilateral hemispheral lesions such as hydrocephalus or thalamic hemorrhage. Even smaller reactive pupils (<1 mm) characterize opioid overdoses but also occur with extensive pontine hemorrhage.

Answer 173

Ocular bobbing” describes brisk downward and slow upward movements of the eyes associated with loss of horizontal eye movements and is diagnostic of bilateral pontine damage, usually from thrombosis of the basilar artery. “Ocular dipping” is a slower, arrhythmic downward movement followed by a faster upward movement in patients with normal reflex horizontal gaze; it usually indicates diffuse cortical anoxic damage.

Answer 174

Alpha coma results from pontine or diffuse cortical damage and is associated with a poor prognosis.

Answer 175

A unique EEG pattern in adults of “extreme delta brush” is characteristic of a specific (anti–N-methyl-d-aspartate [NMDA] receptor) form of autoimmune encephalitis.

Answer 176

Established criteria contain two essential elements, after assuring that no confounding factors (e.g., hypothermia, drug intoxication) are present: (1) widespread cortical destruction that is reflected by deep coma and unresponsiveness to all forms of stimulation; and (2) global brainstem damage as demonstrated by absent pupillary light reaction, absent corneal reflexes, loss of oculovestibular reflexes, and destruction of the medulla, manifested by complete and irreversible apnea. Demonstration that apnea is due to medullary damage requires that the Pco2 be high enough to stimulate respiration during a test of spontaneous breathing. Apnea testing can be done by the use of preoxygenation with 100% oxygen prior to and following removal of the ventilator. CO2 tension increases ~0.3–0.4 kPa/min (2–3 mmHg/min) during apnea. Apnea is confirmed if no respiratory effort has been observed in the presence of a sufficiently elevated Pco2 . The apnea test is usually stopped if there is cardiovascular instability and alternative means of testing can be employed

Answer 177

For anoxic coma, clinical signs such as the pupillary and motor responses after 1 day, 3 days, and 1 week have predictive value 1,3,7

Answer 178

narcolepsy

Answer 179

Subjects awakened from REM sleep recall vivid dream imagery >80% of the time, especially later in the night. Less vivid imagery may also be reported after NREM sleep interruptions REM- REMember dreams

Answer 180

Blood pressure and heart rate decrease during NREM sleep, particularly during N3 sleep.

Answer 181

Certain human leukocyte antigens (HLAs) can increase the risk of autoimmune disorders, and narcolepsy has the strongest known HLA association. HLA DQB1*06:02 is found in >90% of people with type 1 narcolepsy, whereas it occurs in only 12–25% of the general population. Researchers now hypothesize that in people with DQB1*06:02, an immune response against influenza, Streptococcus, or other infections may also damage the orexin-producing neurons through a process of molecular mimicry.

Answer 182

Cataplexy is usually much improved with antidepressants that increase noradrenergic or serotonergic tone because these neurotransmitters strongly suppress REM sleep and cataplexy. Venlafaxine (37.5–150 mg each morning) and fluoxetine (10–40 mg each morning) are often quite effective. The tricyclic antidepressants, such as protriptyline (10–40 mg/d) or clomipramine (25–50 mg/d) are potent suppressors of cataplexy, but their anticholinergic effects, including sedation and dry mouth, make them less attractive Sodium oxybate, twice each night, is also very helpful in reducing cataplexy.

Answer 183

The treatment of narcolepsy is symptomatic. Most patients with narcolepsy feel more alert after sleep, and they should be encouraged to get adequate sleep each night and to take a 15- to 20-min nap in the afternoon. This nap may be sufficient for some patients with mild narcolepsy, but most also require treatment with wakepromoting medications. Modafinil is often used because it has fewer side effects than amphetamines and a relatively long halflife; for most patients, 200–400 mg each morning is very effective. Methylphenidate (10–20 mg bid) or dextroamphetamine (10 mg bid) are also effective, but sympathomimetic side effects, anxiety, and the potential for abuse can be concerns. Solriamfetol, a norepinephrine– dopamine reuptake inhibitor (75–150 mg daily), and pitolisant, a selective histamine 3 (H3 ) receptor antagonist (8.9–35.6 mg daily), also improve sleepiness and have relatively few side effects. Sodium oxybate (gamma hydroxybutyrate), given at bedtime and 3–4 h later, is often very valuable in improving alertness, but it can produce excessive sedation, nausea, and confusion

Answer 184

IDA iron replacement should be considered if the ferritin level is <75 ng/mL. RLS is treated by addressing the underlying cause such as iron deficiency if present. Otherwise, treatment is symptomatic, and dopamine agonists or alpha-2-delta calcium channel ligands are used most frequently. Agonists of dopamine D2/3 receptors such as pramipexole (0.25–0.5 mg q7PM) or ropinirole (0.5–4 mg q7PM) are usually quite effective, but about 25% of patients taking dopamine agonists develop augmentation, a worsening of RLS such that symptoms begin earlier in the day and can spread to other body regions

Answer 185

A deficit of naming (anomia) is the single most common finding in aphasic patients. Anomic aphasia is the single most common language disturbance seen in head trauma, metabolic encephalopathy, and Alzheimer’s disease.

Answer 186

The lesion site most commonly associated with Wernicke’s aphasia caused by CVAs is the posterior portion of the language network. An embolus to the inferior division of the middle cerebral artery (MCA), to the posterior temporal or angular branches in particular, is the most common etiology

Answer 187

The most common etiology of pure alexia is a vascular lesion in the territory of the posterior cerebral artery or an infiltrating neoplasm in the left occipital cortex that involves the optic radiations as well as the crossing fibers of the splenium. Because the posterior cerebral artery also supplies medial temporal components of the limbic system, a patient with pure alexia also may experience an amnesia, but this is usually transient because the limbic lesion is unilatera

Answer 188

The combination of acalculia (impairment of simple arithmetic), dysgraphia (impaired writing), finger anomia (an inability to name individual fingers such as the index and thumb), and right-left confusion (an inability to tell whether a hand, foot, or arm of the patient or examiner is on the right or left side of the body) is known as Gerstmann’s syndrome. MCA involvement

Answer 189

The individual fragments of information remain preserved despite the limbic lesions and can sustain what is known as implicit memory. For example, patients with amnestic states can acquire new motor or perceptual skills even though they may have no conscious knowledge of the experiences that led to the acquisition of these skills

Answer 190

Biceps, achilles, patellar

Answer 191

Cremasteric (L1-L2) Anal (S2-S4)

Answer 192

Postural headache due to leakage of CSF If persists >48h, place epidural blood patch

Answer 193

Stroke (embolism/thrombosis)

Answer 194

d. Raised intracranial pressure may present with palsy of the sixth cranial nerve. CSF is produced by the choroid plexus and absorbed by the arachnoid villi. In basal meningitis, inflammatory deposits in the brainstem result to multiple cranial nerve palsies, not hydrocephalus. Stimulation of the nociceptive fibers in the meninges (not in the brain parenchyma) result to headache. Raised intracranial pressure may present with palsy of the sixth cranial nerve. Obstruction of CSF pathways at the foramina or arachnoid villi may produce hydrocephalus and signs and symptoms of raised intracranial pressure (ICP), including headache, vomiting, apathy or drowsiness, gait instability, papilledema, visual loss, impaired upgaze, or palsy of the sixth cranial nerve.

Answer 195

c. Age >50 In general, the risk of death from bacterial meningitis increases with (1) decreased level of consciousness on admission, (2) onset of seizures within 24 h of admission, (3) signs of increased ICP, (4) young age (infancy) and age >50, (5) the presence of comorbid conditions including shock and/or the need for mechanical ventilation, and (6) delay in the initiation of treatment. Decreased CSF glucose concentration (<2.2 mmol/L [<40 mg/dL]) and markedly increased CSF protein concentration (>3 g/L [> 300 mg/dL]) have been predictive of increased mortality.

Answer 196

c. CSF pleocytosis The characteristic CSF findings in viral encephalitis are: normal glucose and mildly elevated protein concentration. A CSF pleocytosis (>5 cells/μL) occurs in >95% of immunocompetent patients with documented viral encephalitis. Only about 20% of patients with encephalitis will have a significant number of red blood cells (>500/μL) in the CSF in a nontraumatic tap. The pathologic correlate of this finding may be a hemorrhagic encephalitis of the type seen with HSV.

Answer 197

c. Bradycardia, Hypertension and irregular respirations

Answer 198

b. CSF/serum glucose <0.4

Answer 199

c. Prednisone 60 – 80 mg daily for the first 5 days A course of glucocorticoids, given as prednisone 60–80 mg daily during the first 5 days and then tapered over the next 5 days, modestly shortens the recovery period and improves the functional outcome in Bell’s palsy. Although large and well-controlled randomized trials found no added benefit of the antiviral agents valacyclovir (1000 mg daily for 5–7 days) or acyclovir (400 mg five times daily for 10 days) compared to glucocorticoids alone, some earlier data suggested that combination therapy with prednisone plus valacyclovir might be marginally better than prednisone alone, especially in patients with severe clinical presentations

Answer 200

c. Inferior division of the middle cerebral artery Proximal superior division – supplies large portions of the frontal and parietal cortices –> combination of sensory disturbance, motor weakness, and nonfluent aphasia Inferior division of the MCA - supplies posterior part (temporal cortex) of the dominant hemisphere –> fluent (Wernicke’s) aphasia without weakness Jargon speech and an inability to comprehend written and spoken language are prominent features, often accompanied by a contralateral, homonymous superior quadrantanopia. Inferior division of the MCA in the nondominant hemisphere –> hemineglect or spatial agnosia without weakness

Answer 201

Multiple seizure types EEG slowing <3 Hz Impaired cognitive function

Answer 202

a. Anterior choroidal artery Complete syndrome of anterior choroidal artery occlusion consists of: - contralateral hemiplegia - hemianesthesia (hypesthesia) - homonymous hemianopia. ** similar to complete MCA occlusion except for lack of dysarthria/aphasia However, because this territory is also supplied by penetrating vessels of the proximal MCA and the posterior communicating and posterior choroidal arteries, minimal deficits may occur, and patients frequently recover substantially.

Answer 203

d. Local thrombus formation rather than artery-to-artery embolism appears to be the dominant vascular mechanism causing large-vessel brain ischemia. Unlike the myocardial vessels, artery-to-artery embolism, rather than local thrombosis, appears to be the dominant vascular mechanism causing large-vessel brain ischemia.

Answer 204

a. Deficit that is maximal at onset, or remits Perform an emergency non-contrast head CT scan to differentiate between ischemic stroke and hemorrhagic stroke there are no reliable clinical findings that conclusively separate ischemia from hemorrhage, although a more depressed level of consciousness, higher initial blood pressure, or worsening of symptoms after onset favor hemorrhage, and a deficit that is maximal at onset, or remits, suggests ischemia.

Answer 205

a. Infuse through central line Peripheral line is sufficient

Answer 206

a. Cortical blindness but patient may deny it (Anton’s syndrome) C also correct??

Answer 207

c. Pentobarbital (PTB in picture) Given in late refractory SE

Answer 208

a. She will most likely have a complicated gestation and deliver a baby with at least mild physical or developmental defects. Most women with epilepsy who become pregnant will have an UNcomplicated gestation and deliver a normal baby Seizure frequency during pregnancy: unchanged in ~50% of women, increase in ~30%, and decrease in ~20% Enzyme-inducing drugs such as phenytoin cause a transient and reversible deficiency of vitamin K–dependent clotting factors in ~50% of newborn infants. Although neonatal hemorrhage is uncommon, the mother should be treated with oral vitamin K (20 mg/d, phylloquinone) in the last 2 weeks of pregnancy, and the infant should receive intramuscular vitamin K (1 mg) at birth.

Answer 209

d. 115-119 mmol/L Coma and seizures are common accompaniments of large shifts in sodium and water balance in the brain. Sodium levels <125 mmol/L induce confusion, and levels <119 mmol/L are typically associated with coma and convulsions, especially when these levels are achieved quickly.

Answer 210

b. Metabolic encephalopathy In a drowsy and confused patient, bilateral asterixis is a sign of metabolic encephalopathy or drug intoxication.

Answer 211

a. Lack of sleep Precipitant only not a cause The most common causes of GCSE are anticonvulsant withdrawal or noncompliance, metabolic disturbances, drug toxicity, CNS infection, CNS tumors, refractory epilepsy, and head trauma. Sleep deprivation can be a precipitant though, including psychological or physical stress and hormonal changes as well.

Answer 212

b. Stuporous patients can be transiently awakened by vigorous stimuli and avoid or withdraw from uncomfortable or aggravating stimuli. Catatonia is hypomobile and mute syndrome that occurs usually as part of a major psychosis, typically schizophrenia or major depression. Patients with make few voluntary or responsive movements, although they blink, swallow, and may not appear distressed. There are nonetheless signs that the patient is responsive. Akinetic mutism refers to a partially or fully awake state in which the patient is able to form impressions and think, as demonstrated by later recounting of events, but remains virtually immobile and mute. The condition results from damage in the regions of the medial thalamic nuclei or the frontal lobes (particularly lesions situated deeply or on the orbitofrontal surfaces) or from extreme hydrocephalus. In a small proportion of patients in the vegetative state from posttraumatic cases, meaningful cerebral activation in response to verbal and other stimuli have been demonstrated by functional MRI. The locked-in state describes an important type of pseudocoma in which an awake patient has no means of producing speech or volitional limb movement but retains voluntary vertical eye movements and lid elevation, thus allowing the patient to signal with a clear mind. The pupils are normally reactive.

Answer 213

d. ~120 seconds Cerebral neurons are dependent on cerebral blood flow (CBF) and the delivery of oxygen and glucose. Brain stores of glucose are able to provide energy for ~2 min after blood flow is interrupted, and oxygen stores last 8–10 s after the cessation of blood flow. Glucose = 2 mins/120m Oxygen= 8-10sec

Answer 214

BP > 220/120 OR BP >185/110 and thrombolytic tx is anticipated others Malignant hpn concomitantMI

Answer 215

Hypertension Target <130/80 Preferred drugs: thiazide, diuretics, ACE-I

Answer 216

b. Cheyne-Stokes respiration Shallow, slow, but regular breathing suggests metabolic or drug depression. Rapid, deep (Kussmaul) breathing usually implies metabolic acidosis but may also occur with pontomesencephalic lesions. Agonal gasps are the result of lower brainstem (medullary) damage and are recognized as the terminal respiratory pattern of severe brain damage.

Answer 217

c. Loss of deep tendon reflexes ** should be loss of oculovestibular reflexes, Occasionally other reflexes that originate from the spine may be present and should not preclude a diagnosis of brain death

Answer 218

d. Mesial temporal lobe epilepsy (MTLE)

Answer 219

d. Smaller diameter myelinated and unmyelinated fibers Nerves can be subdivided into three major classes: large myelinated, small myelinated, and small unmyelinated. Motor axons are usually large myelinated fibers that conduct rapidly (~50 m/s). Sensory fibers may be any of the three types. >Large-diameter sensory fibers conduct proprioception and vibratory sensation to the brain >Smaller-diameter myelinated and unmyelinated fibers transmit pain and temperature sensation >Autonomic nerves are also small in diameter. DCML (capital letters --> large only) TemP pAin --> (mixed small and large)

Answer 220

c. Diabetic radiculoplexus neuropathy Autonomic neuropathy is typically seen in combination with DSPN - abnormal sweating, dysfunctional thermoregulation, dry eyes and mouth, pupillary abnormalities, cardiac arrhythmias, postural hypotension, GI abnormalities (e.g., gastroparesis, postprandial bloating, chronic diarrhea, or constipation), and genitourinary dysfunction Diabetic Radiculoplexus Neuropathy (Diabetic Amyotrophy or Bruns-Garland Syndrome) - presenting manifestation of DM in ~1/3 of patients; typically, patients present with severe pain in the low back, hip, and thigh in one leg; rarely, diabetic polyradiculoneuropathy begins in both legs at the same time. Atrophy and weakness of proximal and distal muscles in the affected leg become apparent within a few days or weeks. The neuropathy is often accompanied or heralded by severe weight loss. Weakness usually progresses over several weeks or months, but can continue to progress for 18 months or more. Subsequently, there is slow recovery but many are left with residual weakness, sensory loss, and pain

Answer 221

d. Vasculitis

Answer 222

b. Glucocorticoids are highly effective at reducing perilesional edema and improving neurologic function, often within hours of administration. Definitive treatment is based on the specific tumor type and includes surgery, radiotherapy, and chemotherapy. Symptomatic treatments apply to brain tumors of any type. Most high-grade malignancies are accompanied by substantial surrounding edema, which contributes to neurologic disability and raised intracranial pressure. Glucocorticoids are highly effective at reducing perilesional edema and improving neurologic function, often within hours of administration. >Dexamethasone - glucocorticoid of choice because of its relatively low mineralocorticoid activity; initial doses are 8–16 mg/d. Patients with brain tumors who present with seizures require antiepileptic drug therapy. >Agents of choice are drugs that do not induce the hepatic microsomal enzyme system (levetiracetam, topiramate, lamotrigine, valproic acid, and lacosamide) There is NO role for prophylactic antiepileptic drugs in patients who have not had a seizure. Venous thromboembolic disease occurs in 20–30% of patients with high-grade gliomas or brain metastases. Prophylactic anticoagulants should be used during hospitalization and in nonambulatory patients. Those who have had either a deep vein thrombosis or pulmonary embolus can receive therapeutic doses of anticoagulation safely and without increasing the risk for hemorrhage into the tumor. Inferior vena cava filters are reserved for patients with absolute contraindications to anticoagulation such as recent craniotomy.

Answer 223

b. Muscle stretch reflexes are present. weakness developing in critically ill patients while in the ICU is usually caused by critical illness polyneuropathy (CIP) or critical illness myopathy (CIM) or, much less commonly, by prolonged neuromuscular blockade. Both CIM and CIP develop as a complication of sepsis and multiple organ failure and usually present as an inability to wean a patient from a ventilator. Muscle stretch reflexes are absent or reduced. Serum creatine kinase (CK) is usually normal; an elevated serum CK would point to CIM as opposed to CIP. NCS reveal absent or markedly reduced amplitudes of motor and sensory studies in CIP, whereas sensory studies are relatively preserved in CIM. Needle EMG usually reveals profuse positive sharp waves and fibrillation potentials, and it is not unusual in patients with severe weakness to be unable to recruit motor unit action potentials.

Answer 224

c. Fever and constitutional symptoms are often present at the onset. Guillain-Barre Syndrome >Acute, frequently severe, and fulminant polyradiculoneuropathy; autoimmune in nature >Manifests as a rapidly evolving areflexic motor paralysis with or without sensory disturbance >Usual pattern is an ascending paralysis that may be first noticed as rubbery legs. >Weakness typically evolves over hours to a few days and is frequently accompanied by tingling dysesthesias in the extremities. >The legs are usually more affected than the arms, and facial diparesis is present in 50% of affected individuals. >The lower cranial nerves are also frequently involved, causing bulbar weakness with difficulty handling secretions and maintaining an airway; the diagnosis in these patients may initially be mistaken for brainstem ischemia. >Pain in the neck shoulder, back, or diffusely over the spine is also common in the early `stages of GBS, occurring in ~50% of patients. >Most patients require hospitalization, and in different series, up to 30% require ventilatory assistance at some time during the illness.

Answer 225

a. The presence of anti-acetylcholine receptor antibodies is diagnostic but a negative test does not exclude the disease b. If a patient has ptosis, application of a pack of ice over a ptotic eye often results in worsening of the ptosis --> improves c. Repetitive nerve stimulation of weak muscles after anti-acetylcholinesterase medications are stopped 6–12 h prior may show evoked muscle action potentials that does not change by >10%. --> Rapid reduction of >10% in the amplitude of the evoked responses in MG d. Edrophonium chloride inhibits acetylcholinesterase that will cause immediate improvement and as a test should be done before subjecting the patient to nerve stimulation.--> done if other tests are neg

Answer 226

d. There is no evidence for the use of vitamin K antagonists over aspirin for secondary prevention of non-cardiogenic stroke

Answer 227

c. Ampicillin + ceftriaxone + vancomycin c. Ampicillin + ceftriaxone + vancomycin The patient's presentation is consistent with bacterial meningitis, and he is at increased risk for Listeria monocytogenes due to his age (≥60 years) and diabetes mellitus.

Answer 228

a. Hypermagnesemia

Answer 229

d. 5, yes, admission is necessary 65 - 1 30m -1 weakness -2 BP -1 >3, admit

Answer 230

b. Arteriovenous malformations consist of a tangle of abnormal vessels across the cortical surface or deep within the brain substance

Answer 231

b. Continue acyclovir and repeat the lumbar puncture Herpes simplex virus (HSV) encephalitis is a medical emergency, and early treatment with acyclovir is critical to prevent severe neurological sequelae and death. A negative initial CSF PCR does not definitively exclude HSV encephalitis, particularly if the test was performed early in the disease course

Answer 232

c. Normal CSF cell count within 12 months and decrease in VDRL titer by two dilutions or revert to nonreactive within 2 years of completion of therapy

Answer 233

d. Human T-cell lymphotropic virus-1 Tropical spastic paraparesis (TSP), also known as HTLV-1-associated myelopathy (HAM), is a progressive neurologic disorder caused by Human T-cell lymphotropic virus-1 (HTLV-1). It primarily affects the spinal cord, leading to chronic myelopathy and progressive spastic weakness of the lower extremities.

Answer 234

c. Skin biopsy The gold standard for diagnosing small-fiber neuropathy (SFN) is a skin biopsy. SFN primarily affects small unmyelinated (C fibers) and thinly myelinated (Aδ fibers) nerves, which are not well assessed by conventional nerve conduction studies (NCS) or electromyography (EMG).

Answer 235

choriocarcinoma, malignant melanoma, renal cell carcinoma, bronchogenic carcinoma

Answer 236

CN 3 palsy with pupillary dilatation Loss of ipsilateral reflex focal pain above or behind the eye

Answer 237

Delayed cerebral ischemia (DCI) Vasospasm is the narrowing of the arteries at the base of the brain following SAH. This may cause symptomatic ischemia and infarction in ~30% of patients and is the major cause of delayed morbidity and death. Signs of DCI appear 4–14 days after the hemorrhage, most often at 7 days. Nimodipine prevents ischemic injury

Answer 238

hyponatremia due to CSW Avoid free water restriction since will inc risk of stroke Supplemental oral salt with normal saline will mitigate hyponatremia BUT often requires hypertonic saline

Answer 239

Tolcapone Fatal hepatotoxicity thus requires periodic LFT monitoring

Answer 240

Symptomatic No tx to slow progression or improve ssx

Answer 241

Lasts for >= 8 days, >=15 total days per month

Answer 242

>=4 attacks per month

Answer 243

CSF cytology showing tumor cells positive in only 50% on 1st LP Most useful in hematologic malignancies Also definitive: (+) tumor markers or markers of clonal proliferation (flow cytometry)

Answer 244

May be reduced or absent in elderly, very young, immunocompromised False positive: cervical spine dse (older px)

Answer 245

Patients with S. pneumoniae meningitis should have a repeat LP performed 24–36 h after the initiation of antimicrobial therapy to document sterilization of the CSF. Failure to sterilize the CSF after 24–36 h of antibiotic therapy should be considered presumptive evidence of antibiotic resistance. Patients with penicillin- and cephalosporinresistant strains of S. pneumoniae who do not respond to intravenous vancomycin alone may benefit from the addition of intraventricular vancomycin. The **intraventricular** route of administration is preferred over the intrathecal route because adequate concentrations of vancomycin in the cerebral ventricles are not always achieved with intrathecal administration.

Answer 246

CSF culture if viral: PCR Additional note: Dexamethasone recommended in HIV neg px

Answer 247

NON HIV, NON transplant Induction Amp B + flucytositosine x 4 weeks after 2 weeks negative CSF culture; extend to 6w if with neuro complications Consolidation Fluconazole x 8 weeks -------------------------------------- Organ transplant px Induction Lip Amp B + Flucyosine at least 2 weeks or until CSF is sterile Consolidation Fluconazole 8-10w ------------------------------------- HIV + Amp B + lipo formulation + Flucytosine x 2 week followed by Fluco x 8 weeks May require indefinite maintenance tx with Fluconazole ------------------------------------- Most common complication: hydrocephalus

Answer 248

TB #2 is Cryptococcus

Answer 249

Rituximab, Efalizumab May have peripheral ring enhancement on MRI

Answer 250

JC virus HIV---> classically non enhancing

Answer 251

Streptococcus particularly viridans if frontal abscess : Strep milleri

Answer 252

False No value in empyema and brain abscess Also inc risk of herniation

Answer 253

Community acquired --> 3rd gen + Metronidazole Penetrating head trauma/ recent neurosurgical procedure --> cover for Pseudomonas (CAZ/MEM) + S. aureus (VAN) Tx duration: Min 6- 8 weeks Prophylactic anticonvulsant: min 3 months (12wks). Repeat EEG. If abnormal, continue; if normal may slowly withdraw

Answer 254

Serial MRI/CT scan monthly or 2x a month to document resolution

Answer 255

AIDP Additional Note: Fever and constitutional ssx not seen at onset of GBS GBS only has mild sensory deficits except for DTR and proprioception

Answer 256

Ophthalmoplegia Areflexia Ataxia 90% have anti GQ1b antibodies

Answer 257

AIDP: prolonged F wave latencies (earliest) , prolonged distal latencies, reduced CMAP AMAN and AMSAN: reduced amplitude of CMAP WITHOUT conduction slowing or prolongation of distal latencies

Answer 258

IVIG = plasmapheresis IVIG = 5 daily infusions for total of 2g/kg BW Plasmapheresis= 40-50 mk/kg plasma exchange daily for 4-5 days No role for glucocorticoids

Answer 259

Rapid reduction in amplitude of the evoked response by > 10-15% Acetylcholinesterases should be witheld 6-24 hrs prior to testing

Answer 260

Improvement after administering edrophonium (1st give 2 mg, if no improvement, give 8 mg)

Answer 261

Anti ACh R --> positive in 85-90% of px; virtually diagnostic of MG Anti MuSK --> 40% of ACh R neg px with generalized MG others: Anti LRP4 (small proportion), anti-agrin

Answer 262

SCLCA LEMS would have incremental response to repetitive nerve stimulatio

Answer 263

Allopurinol because the combination may result in myelosupression

Answer 264

d. Focal seizure with impaired awareness The patient's symptoms, including staring off into space, automatisms (chewing and picking movements), postictal confusion, and amnesia, are characteristic of a focal seizure with impaired awareness. This type of seizure originates in a specific region of the brain (commonly the temporal lobe) and affects consciousness.

Answer 265

a. Usually no immediate precipitating factors

Answer 266

d. Primavanserin Pimavanserin is frequently helpful to treat the psychosis and does not worsen parkinsonism Selective inverse agonist of the serotonin 5-HT2A receptor that does not block dopamine receptors Low-dose clozapine is also effective for treating hallucinations and delusions, but requires frequent blood draws due to the risk of agranulocytosis CLOZAPINE not clonazepam

Answer 267

c. Ropinorole The patient's symptoms of disorientation, visual hallucinations, short temper, and impulsive behaviors (e.g., gambling and shopping sprees) are suggestive of impulse control disorders (ICDs) and dopaminergic psychosis. These behaviors are strongly associated with dopamine agonists, such as ropinirole.

Answer 268

d. Meropenem + Vancomycin + Anti-convulsant + Dexamethasone If brain abscess with prior head trauma, may give CZA / MEM + VAN Steroids not routine unless with edema and inc ICP which are present in this case

Answer 269

d. Progressive Multifocal Leukoencephalopathy 90% of HIV PML - non ehnancing white matter

Answer 270

c. Maximal surgical resection followed by partial-deld external-beam RT with concomitant temozolomide, followed by 6–12 months of adjuvant temozolomide Glioblastomas are the most common malignant primary brain tumor. Patients usually present in the sixth and seventh decades of life with headache, seizures, or focal neurologic deficits. The tumors appear as ring-enhancing masses with central necrosis and surrounding edema. Treatment involves maximal surgical resection followed by partial-field external-beam RT (6000 cGy in thirty 200-cGy fractions) with concomitant temozolomide, followed by 6 months of adjuvant temozolomide. With this regimen, median survival is increased to 14.6–18 months compared to only 12 months with RT alone, and 5-year survival is ~10%.

Answer 271

c. Topiramate can also cause renal stones

Answer 272

d. Valproic Acid The patient’s symptoms (sudden head drop, brief impairment of consciousness without postictal confusion) and EEG findings (generalized spike-and-wave discharges followed by slow waves) are consistent with myoclonic seizures or atonic seizures. These seizures are often part of generalized epilepsy syndromes, such as juvenile myoclonic epilepsy (JME) or Lennox-Gastaut syndrome (LGS). Valproic acid is a first-line treatment for generalized seizures, including: >Myoclonic seizures. >Atonic seizures. >Absence seizures. >Generalized tonic-clonic seizures

Answer 273

b. Topiramate Atypical absence --> Valproic, Lamotrigine, Topiramate Typical --> Valproic , Lamotrigine, Ethosuximide

Answer 274

d.62/M, Pontine infarct, BP=160/110mmHg, on his 3rd hospital day, initially admitted for NSTEMI Since with recent MI Contraindications BP > 185/110 GI bleed within 3 weeks Major GI surgery within 2 weeks

Answer 275

b. Putamen Key Features of Hypertensive Putaminal Hemorrhage: Hemiparesis: Contralateral to the lesion. Gaze Deviation: Eyes deviate away from the side of weakness. Altered Consciousness: Common with larger hemorrhages. Flaccidity: Early phase due to disruption of motor pathways.

Answer 276

d.Indomethacin Paroxysmal hemicrania THROBBING , >5x per day, 2-30mins No mention of periodicity hence not cluster. A core feature of cluster headache is periodicity. At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a cluster bout. The typical cluster headache patient has daily bouts of one to two attacks of relatively short-duration unilateral pain for 8–10 weeks a year; this is usually followed by a pain-free interval that averages a little less than 1 year

Answer 277

a. Cluster Headache A core feature of cluster headache is periodicity. At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a cluster bout. The typical cluster headache patient has daily bouts of one to two attacks of relatively short-duration unilateral pain for 8–10 weeks a year; this is usually followed by a pain-free interval that averages a little less than 1 year

Answer 278

c. Amantadine The only oral drug for dyskinesia that will not worsen parkinsonism

Answer 279

d. Normal-pressure hydrocephalus Wacky - Dementia Wobbly- Ataxic Wet - urinary incontinence Triad of NPH - WWW

Answer 280

a. B1 Wernicke Korsakoff syndrome

Answer 281

c. CSF PCR Utility in both viral and bacterial especially since with involvement of temporal lobes (common in HSV) Viral - low sensitivity viral culture

Answer 282

b.C. immitis M. tuberculosis --> Mononuclear, may have PMN in early course of the dse T. gondii --> Mononuclear

Answer 283

a. CSF Analysis CSF analysis no value in brain abscess. May inc risk of herniation

Answer 284

a. Aspirin and Clopidogrel

Answer 285

c. E4 allele of the ApoE gene

Answer 286

d. Alzheimer’s Disease Dementia The pattern of binding is largely consistent with Braak neuropathologic staging of NFTs, with early retention in medial temporal regions, followed by spread into temporoparietal and cingu- late cortices, dorsolateral prefrontal regions, and, ultimately, primary sensory and motor areas

Answer 287

a. Combined intrathecal chemotherapy and radiation therapy

Answer 288

a. Breast cancer

Answer 289

b. Periodic, stereotyped, sharp-and-slow complexes repeating at regular intervals 2-3 seconds. Distinctive EEG pattern consisting of periodic, stereotyped, sharp-and-slow complexes originating in one or both temporal lobes and repeating at regular intervals of 2–3 s. Typically noted between days 2 and 15 of the illness and are present in two-thirds of pathologically proven cases of HSV encephalitis. Acyclovir is of benefit in the treatment of HSV and should be started empirically in patients with suspected viral encephalitis, especially if focal features are present, while awaiting viral diagnostic studies. Treatment should be discontinued in patients found not to have HSV encephalitis, with the possible exception of patients with severe encephalitis due to VZV or EBV. HSV, VZV, and EBV all encode an enzyme deoxypyrimidine (thymidine) kinase that phosphorylates acyclovir to produce acyclovir-5′-monophosphate

Answer 290

a. Listeria monocytogenes Risk group: Pregnant women and their neonate, older adults and immunocompromised persons Source: Dairy products are an important source, especially soft cheese made with raw mily or produced from pasteurized milk in unsanitary facilities; ice cream and raw milk also have cause outbreaks

Answer 291

b. EBV Atypical lymphocytes in the CSF or peripheral blood is suggestive of EBV infection

Answer 292

d. Late capsule formation Since patient has seizures and fever for 2 weeks (14 days) most likely px has capsule formation + gliosis which is seen in late capsule formation The early cerebritis stage (days 1–3) is characterized by a perivascular infiltration of inflammatory cells, which surround a central core of coagulative necrosis. Marked edema surrounds the lesion at this stage. In the late cerebritis stage (days 4–9), pus formation leads to enlargement of the necrotic center, which is surrounded at its border by an inflammatory infiltrate of macrophages and fibroblasts. A thin capsule of fibroblasts and reticular fibers gradually develops, and the surrounding area of cerebral edema becomes more distinct than in the previous stage. The third stage, early capsule formation (days 10–13), is characterized by the formation of a capsule that is better developed on the cortical than on the ventricular side of the lesion. This stage correlates with the appearance of a ring-enhancing capsule on neuroimaging studies. The final stage, late capsule formation (day 14 and beyond), is defined by a well-formed necrotic center surrounded by a dense collagenous capsule. The surrounding area of cerebral edema has regressed, but marked gliosis with large numbers of reactive astrocytes has developed outside the capsule. This gliotic process may contribute to the development of seizures as a sequela of brain abscess

Answer 293

d. Vancomycin and Ceftriaxone

Answer 294

b. Nocardia spp

Answer 295

D. Dementia with Lewy Bodies REM and Visual problems = Lewy body

Answer 296

B. CBC, electrolytes, TSH, Vit B12, head CT scan

Answer 297

B. Frontotemporal Dementia

Answer 298

A. Acetylcholine Biochemically, AD is associated with a decrease in the cortical levels of several proteins and neurotransmitters, especially acetylcholine, its synthetic enzyme choline acetyltransferase, and nicotinic cholinergic receptors Dopamine is decreased in PD

Answer 299

A. Yawning Photophobia and Allodynia = headache phase (2nd phase) The first phase of a migraine attack for most patients is the premonitory (prodromal) phase consisting of some or all of the following: yawning, tiredness, cognitive dysfunction, mood change, neck discomfort, polyuria, and food cravings; this can last from a few hours to days. Typically, the headache phase follows with its associated features, such as nausea, photophobia, and phonophobia as well as allodynia. When questioned, these typical migraine symptoms also emerge in the premonitory phase, and typical premonitory symptoms also continue into the headache phase. As the headache lessens, many patients enter a postdrome, most commonly feeling tired/weary, having problems concentrating, and experiencing mild neck discomfort that can last for hours and sometimes up to a day

Answer 300

C. Acephalgic Migraine Patients with acephalgic migraine experience recurrent neurologic symptoms, often with nausea or vomiting, but with little or no headache. Vertigo can be prominent; it has been estimated that one-third of patients referred for vertigo or dizziness have a primary diagnosis of migraine.

Answer 301

C. Ceftazidime + Metronidazole + Vancomycin

Answer 302

B. Continue Ceftriaxone to complete total duration of 7 days Meningococcal - 7 days Pneumococcal -14 days G- and Listeria -21days

Answer 303

B. Cranial CT scan

Answer 304

D. Posterior Inferior Cerebellar Artery Wallenburg syndrome- PICA Ipsilateral Horner and face Contralateral limb

Answer 305

B. Intravenous Thrombolysis Within golden perior. no contraindications to rtpa

Answer 306

D. Increase the dose of the anti-seizure medication The patient is experiencing catamenial epilepsy, where seizures are more frequent during menstruation due to hormonal fluctuations. In such cases, seizure control may worsen during specific phases of the menstrual cycle, even when the patient is compliant with their anti-seizure medication. Catamenial epilepsy is often managed by adjusting the dose of the anti-seizure medication during the menstrual cycle when seizures are more likely to occur. Increasing the dose during this period can help control the increased seizure activity.

Answer 307

B. Entacapone The patient is experiencing "wearing-off" or motor fluctuations, which are common in Parkinson's disease after a few years of treatment with Levodopa and Carbidopa. This is characterized by periods of reduced efficacy of the medication, leading to the reappearance of symptoms like rigidity, tremors, and involuntary movements (dyskinesias). Entacapone is a COMT (catechol-O-methyltransferase) inhibitor that helps to prolong the effect of Levodopa by inhibiting its breakdown, thereby improving motor symptoms and reducing "wearing-off" episodes. A - is an option for managing dyskinesias but may not be the best initial approach for wearing-off fluctuations. C - is a dopamine agonist, which could be considered, but adding a COMT inhibitor like Entacapone is usually the preferred first step when motor fluctuations occur. D - is an MAO-B inhibitor that also helps to extend the effect of Levodopa, but Entacapone is generally more effective in managing wearing-off symptoms.

Answer 308

B. IVIg therapy Either IVIG or PLEX (Plasma exchange). Cannot be used in combination IVIG usually first choice due to ease of administration and good safety record compared to PLEX

Answer 309

D. Pyridostigmine Pyridostigmine is a cholinesterase inhibitor that increases the availability of acetylcholine at the neuromuscular junction, improving muscle strength. It is the first-line treatment for symptomatic management in Myasthenia Gravis.

Answer 310

C. Surgical Resection with subsequent Radiation therapy If with EPIDURAL mass --> surgery then RT RT remains mainstay of tx

Answer 311

b. Left anterior cerebral artery Leg > Arm weakness = ACA

Answer 312

c. Malignant middle cerebral artery infarction The patient's presentation of sudden hemiplegia, hemianesthesia, global aphasia, and gaze preference to the left is consistent with a large middle cerebral artery (MCA) infarction affecting the dominant hemisphere. The progression to coma and a dilated, non-reactive left pupil 2 days later suggests malignant MCA infarction with herniation due to massive cerebral edema.

Answer 313

b. Lumbar puncture

Answer 314

c.2.5-3.5 For patients with a bileaflet mechanical mitral valve receiving vitamin K antagonist (VKA) therapy (e.g., warfarin), the target international normalized ratio (INR) is 2.5–3.5. This higher range is required due to the increased thromboembolic risk associated with prosthetic mitral valves compared to aortic valves.

Answer 315

b. Prevents ischemic injury DCI remains the leading cause of morbidity and mortality following aneurysmal SAH. Treatment with the calcium channel antagonist nimodipine (60 mg PO every 4 h) improves outcome, perhaps by preventing ischemic injury rather than reducing the risk of vasospasm

Answer 316

b. Hemorrhagic transformation of the infarct . Cardioembolic strokes are often caused by emboli originating from the heart (e.g., atrial fibrillation, mechanical heart valves, or left ventricular thrombus) and tend to occlude large cerebral arteries. The characteristics of these strokes make them more prone to hemorrhagic transformation due to: >Reperfusion injury after spontaneous clot dissolution. >Fragile ischemic brain tissue subjected to high-pressure arterial blood flow.

Answer 317

c. Lamotrigine Lamotrigine levels are significantly reduced when administered with estrogen-containing oral contraceptives. This interaction occurs because estrogen induces the synthesis of hepatic glucuronyltransferase enzymes, which enhance the metabolism of lamotrigine through glucuronidation. As a result, lamotrigine clearance increases, leading to lower plasma levels and reduced therapeutic efficacy.

Answer 318

a. Bilaterally synchronous spike and slow wave discharges immediately prior to appearance of muscle artifacts. Myoclonic Seizure Myoclonus is a sudden and brief muscle contraction that may involve one part of the body or the entire body. Pathologic myoclonus is most commonly seen in association with metabolic disorders, degenerative CNS diseases, or anoxic brain injury. The EEG shows bilaterally synchronous spike-and-slow-wave discharges immediately prior to the movement and muscle artifact associated with the myoclonus. Myoclonic seizures usually coexist with other forms of generalized seizures but are the predominant feature of juvenile myoclonic epilepsy (JME)

Answer 319

d. Sodium The bursting activity in individual neurons (the “paroxysmal depolarization shift”) is caused by a relatively long-lasting depolarization of the neuronal membrane due to influx of extracellular calcium (Ca2+), which leads to the opening of voltage-dependent sodium (Na+) channels, influx of Na+, and generation of repetitive action potentials Influx of Calcium but it is the sodium channels which will open

Answer 320

d. Mesial Temporal Lobe Epilepsy Mesial temporal lobe epilepsy (MTLE) is the most common syndrome associated with focal seizures with impairment of consciousness and is an example of an epilepsy syndrome with distinctive clinical, EEG, and pathologic features High-resolution magnetic resonance imaging (MRI) can detect the characteristic hippocampal sclerosis that appears to be essential in the pathophysiology of MTLE for many patients

Answer 321

c. Maintain the dose of levetiracetam and add folic acid at 4 mg/day. Because the potential harm of uncontrolled convulsive seizures on the mother and fetus is considered greater than the teratogenic effects of antiseizure drugs, it is currently recommended that pregnant women be maintained on effective drug therapy. When possible, it seems prudent to have the patient on monotherapy at the lowest effective dose, especially during the first trimester. For some women, however, the type and frequency of their seizures may allow for them to safely wean off antiseizure drugs prior to conception. Patients should also take folate (1–4 mg/d), because the antifolate effects of anticonvulsants are thought to play a role in the development of neural tube defects, although the benefits of this treatment remain unproved in this setting.

Answer 322

b. Fluvoxamine Among the options, fluvoxamine is most likely to interact with ASMs because it is a potent inhibitor of CYP1A2, CYP2C19, and CYP3A4, enzymes involved in the metabolism of many ASMs

Answer 323

c. Brain Relatively few cranial structures are pain producing; these include the scalp, meningeal arteries, dural sinuses, falx cerebri, and proximal segments of the large pial arteries. The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are not pain producing

Answer 324

b. Shift to another anti-seizure medication Mood changes is an adverse effect of Levetiracetam

Answer 325

Predominant high-voltage slowing (δ or triphasic waves) in the frontal regions is typical of metabolic coma, as from hepatic failure, and widespread fast (β) activity implicates sedative drugs (e.g., benzo- diazepines).

Answer 326

A. MRI reveals a symmetric area of abnormal high signal intensity within the basis pontis

Answer 327

C. Topiramate

Answer 328

C. Lorazepam IV infusion Lorazepam IV is considered the first-line treatment for status epilepticus due to its rapid onset of action and prolonged duration of effect compared to other benzodiazepines like diazepam. Diazepam is also effective but is not preferred because it has a shorter duration of action and may require repeated doses or a continuous infusion to maintain seizure control.

Answer 329

C. Normal neurologic examination, excluding intelligence Discontinuation criteria: (1) Complete medical control of seizures for 1 to 5 years (2) Single seizure type, either partial or generalized (3) Normal neurologic examination, including intelligence ( 4) Normal EEG NOTE: all must be met for at least 2 years

Answer 330

B. Agnosia, constructional apraxia and hemineglect is seen when the dominant hemisphere is involved MCA Dominant: aphasia MCA Non-dominant: agnosia, constructional apraxia, hemineglect ICA: sudden onset transient monocular blindness ACA: LE>UE weakness, abulia, muteness, perseveration, disinhibition

Answer 331

C. Development depends on the proximity of a caseous lesion to the subarachnoid space Subacute meningitis/Chronic meningitis Common causative organisms: M tuberculosis, C neoformans, H capsulatum, C immitis, T pallidum SSx Days to weeks: unrelenting headache, sti-neck, low-grade fever, lethargy, night sweats, cranial nerve abnormalities

Answer 332

D. Language impairment initially with fluency then comprehension then naming Memory loss rst then progresses to language and visuospatial defects –> Language impairment--> naming comprehension --> fluency

Answer 333

A. Pramipexole

Answer 334

C. About 2 weeks after the first motor symptoms, it is not known whether immunotherapy is still effective

Answer 335

C. Bladder dysfunction is generally not seen, and when present should direct attention to other differentials Bladder dysfunction present in >90%

Answer 336

B. Vitamin D

Answer 337

What is the most common form of Multiple Sclerosis? A. Relapsing or Bout MS 3 clinical types of MS: 1. Relapsing or Bout MS (RMS): 90% of MS cases 2. Secondary progressive MS (SPMS): always begins as RMS 3. Primary progressive MS (PPMS): ∼10% of cases

Answer 338

B. Patients who are alcoholic are predisposed to having pneumococcal meningitis Risk factors for pneumococcal meningitis Most important: pneumococcal pneumonia § Others: coexisting acute/chronic pneumococcal sinusitis/otitis media, alcoholism, DM, splenectomy, hypogammaglobulinemia, complement deciency, head trauma with skull fracture and CSF rhinorrhea

Answer 339

B. Loss of balance in the dark without vertigo

Answer 340

D. Spinal MRI

Answer 341

B. CSF cytologic examination is often positive for tumor cells in only 50% of patients on the first lumbar puncture.

Answer 342

A. Ethambutol

Answer 343

A. Decrease the pyridostigmine daily dose. .

Answer 344

A. Chronic subdural hematoma

Answer 345

A. Daily symptoms of sadness, indifference and apathy for at least 2 weeks

Answer 346

B. Biceps, patellar and Achilles reflexes should be checked in all patients.

Answer 347

B. Idiopathic seizure The clinical presentation of a first-onset generalized seizure in an otherwise healthy 38-year-old man, with normal laboratory investigations, imaging, and CSF findings, strongly points to an idiopathic seizure. The EEG findings showing a posteriorly situated 9-Hz alpha rhythm that attenuates with eye opening indicate a normal background rhythm, which supports the diagnosis of idiopathic seizure

Answer 348

C. May be discontinued after 12 months as long as he has been completely seizure-free

Answer 349

D. Posterior cerebral artery Claude syndrome

Answer 350

D. Topiramate

Answer 351

A. Asymmetric motor abnormalities, rest tremors, and a good response to levodopa

Answer 352

C. Glucocorticoids

Answer 353

D. Sensory loss Sensory loss, optic neuritis and weakness

Answer 354

C. Treat as chronic inflammatory demyelinating polyneuropathy (CIDP)