Neurology #2 Precision and Pearls

Question 1

Encephalitis is infection of the brain parenchyma and causes include _____ (MCC), and others such as ______, ______, and ________

Answer 1

HSV-1 MCC

EBV, HIV, Rubella, Varicella

Question 2

What are symptoms of encephalitis?

Answer 2

-Meningitis symptoms (nuchal rigidity, Brudzinski, Kernig), neck stiffness, fever, headache
-PLUS AMS, changes in speech, personality, and movement
-Focal neurologic deficits (palsies, sensory deficits)

Question 3

Diagnostics done for encephalitis:
-What is done to rule out lesions
-What is preferred for encephalitis?
-What is the most accurate test for herpes?

Answer 3

-CT of the head to rule out lesions
-MRI preferred for encephalitis
-PCR most sensitives for herpes

Question 4

If HSV is the cause of encephalitis, what is seen on MRI?

Answer 4

Temporal lobe involvement

Question 5

Treatment for encephalitis (think about what the cause is)

Answer 5

IV Acyclovir

Question 6

Normal pressure hydrocephalus is dilation of the ventricles with normal opening pressure on LP. What are some symptoms of this?

What is seen on MRI?

Answer 6

Dementia + Gait Disturbance + urinary incontinence
–Wet, wacky, wobbly
—wide based shuffling gait, urinary urgency

MRI: enlarged ventricles in absence of sulcal dilation

Question 7

What is the treatment for normal pressure hydrocephalus?

Answer 7

Ventriculoperitoneal shunt

Question 8

Although a cerebral abscess is rare, it has symptoms such as insidious onset of headache, fever, focal neuro findings and a history of what?

Answer 8

Recent sinus infection or ear infection: direct spread to the brain

Question 9

An intracerebral hemorrhage, which is bleeding within the brain parenchyma that may compress the brain, ventricles, and sulci, has risk factors such as…..

Answer 9

Hypertension (MCC of ICH)

Cerebral amyloid angiopathy (MCC in old)

AVM (MCC in kids)

Question 10

Symptoms of ICH

Answer 10

-Neuro symptoms increase in minutes to hours: headache, n/v, syncope, AMS, focal neurologic symptoms (hemiplegia, seizures, hemiparesis)

Question 11

What diagnostic is done for ICH

Answer 11

CT scan!

Question 12

How do you treat ICH?

How should you prevent ICP?

Answer 12

Supportive, gradually reduce BP

ICP: Raise head of the bed, no IVF, reduce BP

Question 13

If the patient DOES have increased ICP, what should you give them?

Answer 13

IV Labetolol, Nicardipine, Hydralazine, Nitroprusside

Question 14

An essential tremor is an autosomal dominant movement disorder that (explain what an essential tremor is)

Answer 14

-Intentional tremor: postural, bilateral action tremor that is worse with movement.
-MC affects upper extremities
-Worse with stress, anxiety, caffeine

Question 15

What makes an essential tremor better?

Answer 15

Alcohol

Question 16

Treatment for an essential tremor

Answer 16

-None needed
-Propanolol if situational
-Primidone if no relief with Propanolol

Question 17

Explain the pathophysiology of Parkinson’s Disease

Answer 17

-Movement disorder due to loss of dopaminergic neurons in the substantia nigra –> failure of acetylcholine inhibition in the basal ganglia (acetylcholine is the excitatory neurotransmitter)

Question 18

Symptoms of Parkinson’s Disease

Answer 18

-Resting tremor, bradykinesia, muscle rigidity
-Tremor: pill-rolling tremor, worse with rest, better with activity
-Slowness of movement, no arm swinging when walking
-Masked facies
-Myerson’s Sign (tapping forehead)
-Postural instability: pull test
-Dementia in 50%
-Cogwheel rigidity

Question 19

What is the only way to make the definitive diagnosis for Parkinson’s Disease?

Answer 19

Post mortem histology: cytoplasmic inclusions (lewy bodies) and loss of pigment cells in the substantia nigra

Question 20

Most effective pharm treatment for Parkinson’s Disease?

Answer 20

Levodopa-Carbidopa

Question 21

What other drug class may be used in treating Parkinson’s?

Answer 21

Dopamine agonists (Bromocriptine, Pramipexole, Ropinorole)

Question 22

Levodopa is converted to dopamine when…..

What are some adverse effects of this?

Answer 22

When it crosses the Blood-brain-barrier

Dyskinesia, wean off trouble, hallucinations

Question 23

Dopamine agonists can be used in who?

Answer 23

< 65 years old to delay use of Levodopa

Question 24

Huntington’s Disease is an autosomal dominant neurodegenerative disorder. Explain the patho of this.

What are some symptoms?

Answer 24

Inheritance of CAG/glutamine repeats on Huntingtin gene (chromosome 4)

-Symptoms appear in 30-50 year olds
-Mood, Movement, Memory
–Behavior/mood changes
–Chorea
–Dementia
–Gait abnormalities, ataxia, incontinence

Question 25

What is seen on CT/MRI for Huntington's Disease?

Answer 25

Cerebral and striatal (caudate nucleus and putamen) atrophy

Question 26

Although Huntington's is fatal in 15-20 years, what can be given for dyskinesia/chorea?

Answer 26

Tetrabenazine NO MEDS STOP DISEASE PROGRESSION

Question 27

Explain what delirium is

Answer 27

-Abrupt, acute, transient confused state due to an identifiable cause -usually associated with fully recovery in 1 week

Question 28

What is the MC type of dementia

Answer 28

-Alzheimer Dementia

Question 29

What are the three hypothesized patho explanations for Alzheimer's?

Answer 29

1) Amyloid-beta protein plaques in brain 2) neurofibrillary tau protein tangles 3) Acetylcholine deficiency

Question 30

Symptoms of Alzheimer's Dementia

Answer 30

-1st symptom: short term memory loss -Progresses to long-term and cognitive deficits

Question 31

Although Alzeheimer's is a clinical diagnosis, what is seen on MRI and histology?

Answer 31

MRI: medial temporal lobe atrophy Histology: plaques and tangles

Question 32

Treatment for Alzheimer's

Answer 32

-Acetylcholine inhibition: Donepezil, Tacrine, Rivastigmine, Galantamine -NMDA Antagonist (Memantine): reduce glutamate cell death

Question 33

Vascular dementia, which is due to chronic ischemia and lacunar infarcts, has a risk factor of __________. Explain the symptoms of this condition.

Answer 33

Hypertension Sudden decline in functions with stepwise progression of symptoms: infarct --> stable --> infarct --> stable

Question 34

How to prevent vascular dementia

Answer 34

BP control

Question 35

Frontotemporal Dementia (Pick's Disease) is degeneration of the frontotemporal lobes. Therefore, the symptoms include...

Answer 35

-Changes in social behavior, personality, and language (aphasia) -Behavioral changes: socially inappropriate behaviors, hyperorality (changes in food likes), loss of sympathy/empathy

Question 36

On histology, what is seen in Pick's Disease?

Answer 36

Pick bodies: round aggregates of Tau Proteins on silver-staining

Question 37

Diffuse Lewy Body Disease is progressive dementia characterized by presence of diffuse Lewy Bodies, which are.... How does this differ from Parkinson's?

Answer 37

Abnormal neuronal protein deposits In Parkinson's, they are localized. In diffuse, they are everywhere!

Question 38

Symptoms in Diffuse Lewy Body Disease

Answer 38

-Visual hallucinations, episodic delirium, rapid eye movement sleep disorder, autonomic dysfunction (ortho hypotension), and Parkinsonism.

Question 39

Multiple Sclerosis is an autoimmune demyelinating disease of the CNS. What is happening here? What is the MC type?

Answer 39

Axon degeneration of the white matter (brain and spinal cord) Relapsing-Remitting (episodic)

Question 40

Symptoms of Multiple Sclerosis

Answer 40

-Sensory disturbances followed by weakness and visual disturbances --Diplopia, optic neuritis, trigeminal neuralgia, weakness, gait problems

Question 41

What is Uhthoff's Phenomenon (associated with MS)

Answer 41

Worsening of symptoms with heat

Question 42

What are some other exam findings associated with MS (be specific)

Answer 42

-Upper motor neuron signs: spasticity, upward Babinski, hyperreflexia, rigidity -Lhermitte's Sign: neck flexion leads to lightning pain down the leg -Marcus Gunn Pupil: pupils dilate with light -Bowel, bladder, and sexual dysfunction

Question 43

What is seen on MRI in Multiple Sclerosis?

Answer 43

MRI with gadolinium is the best test: hyper intense white matter plaques

Question 44

How about LP in MS?

Answer 44

-Increased IgG and oligoclonal bands

Question 45

For acute exacerbation of MS, what is the treatment

Answer 45

IV Glucocorticoids

Question 46

For a prevention of a relapse, what is the treatment for MS?

Answer 46

Beta-interferon or Glatiramer