Neurology Flashcards Preview

GI > Neurology > Flashcards

Flashcards in Neurology Deck (198):
0

Migraine Headaches
*female > males
*severity: moderate to severe
*freq: every few weeks
*duration: 1-2 days

*location: unilateral -temporal or frontal
*assoc: N/V,photophobia, aura, phonophobia
*tx: analgesics, isomethepten, ergotamine, sumatriptan
*prophylaxis:ASA, BB, TCA,CCB, divalproex sodium

1

Cluster headaches
*male>female
*freq: 1-2/day during cluster period
*duration: 30-120 minutes
*location: unilateral-orbital

*non-pulsating
*assoc: unilateral lacrimation, rhinorrhea or blockage, ipsilateral horners
*tx: 100% O2, sumatriptan, intra-nasal lidocaine
*prophylaxis: prednisone 60mg/d x 1 wk, ergotamine

2

Tension headaches
*female>male
*freq: variable
*duration:30"-7days
*location: bilateral, diffuse

*type: non pulsating
*assoc: none
*tx: analgesics
*prophylaxis: TCA, B blockers

3

Aura of migraine HA
*transient focal neuro dysfunction that deveops over few minutes and lasts no more than 60". may preceed or accompany HA

*visual-unformed flashes of light or zig zag lines in vision -#1
*aphasia or speech disorder, or visual field defects
*unilateral paresthesia or numbness
*unilateral weakness
*homonymous visual field defect

4

Rare manifestations of migraine headaches:
*prolonged sensory or motor deficit, diploplia
*altered consciousness

*ischemic stroke
-incr risk in migraine w aura
-incr risk in smokers, or on OCP
-incr risk of CV dz and MI

5

acute tx of migraines

*ASA, acetaminophen
*excedrin- above plus caffeine
*midrin

*triptan-drug of choice for moderate to severe migraine
-contraindicated: uncontrolled HTN, severe hepatic/renal fxn, basilar or hemiplegic migraine, CAD or multiple risks for CAD

6

Prophylaxis of migraine headaches
*indicated if >2 migraines/wk or severe disabling migraines
*B blockers-only FDA approved: propranolol, timolol
*TCA: amitriptyline best

*verapamil
*antiepileptics: valproate, topiramate
*botulinum toxin

7

thunderclap headache

*severe HA that reaches maximum intensity in 60 seconds

8

Causes of thunderclap headache
-subarachnoid hemorrhage
-sentinal bleed from unruptured aneurysm
-cerebral arterial, venous, or sinus thrombosis
-dissection carotid or vertebral arteries

-reversible cerebral vasoconstriction syndrome:
*recurrent thunderclap HAs
*acute infarct can occur
*transient segmental can be seen on MRA, resolve by 12 weeks
*may see in pregnancy or postpartum

9

treatment of thunderclap HA

*CCB-verapamil or nimodipine
*short term high dose steroids
*IV Mg if induced by eclampia/preeclampsia in pregnancy

10

Dx thunderclap HA

CT head without contrast, if negative, do lumbar puncture
*presence of xanthochromia on LP-ver suggestive of subarachnoid hemorrhage
*MRA or CT angiogram if above tests negative

11

clinical features of subarachnoid hemorrhage

*severe diffuse HA of sudden onset without aura
"thunderclap" HA
*may have brief LOC

*vomiting
*retinal hemorrhage
*ptosis + dilated pupil on one side =>posterior communicating aneurysm

12

DX of subarachnoid hemorrhage

CT head without contrast- if negative-do LP
*if CT & LP are negative-MRA or CT angio (catheter angiograpy preferred)

13

Tx subarachnoid hemorrhage

*endovascular coiling or craniotomy + clip ligation
*oral nimodipine X 21 days
*pt in coma=> place ventricular drain

14

Complications of subarachnoid hemorrhage

*rebleeding
*hydrocephalus

*vasospasm-focal ischemia and possible stroke
*hyponatremia-cerebral salt wasting
*ST depression and T wave inversion on EKG
*reversible cardiomyopathy

15

clinical features Pseudotumor cerebri

*most are young, female, obese

*headache, pulsatile tinnitus
*transient visual abscurations
*papilledema, blurred vision, diploplia, visual field loss

16

secondary causes pseudotumor cerebri
*cerebral venous sinus thrombosis
-focal neur findings, mental status change, seizures
-increased risk w congenital or acquired thrombophilias, pregnancy and OCP's

*obesity, sleep apnea
*renal failure
*hypervit. A, tetracycline, glucocorticoids
*OCP, amiodarone, retinoid
*growth hormone

17

diagnosis of pseudotumor cerebri

*MRI - if negative=> spinal tap=>CSF pressure >250mm
*visual field testing

18

Tx pseudotumor cerebri

*acetazolamide, topiramate
*repeated LPs, lumboperitoneal shunt,optic nerve sheath fenestration
*weight loss

19

high grade or malignant astrocytoma brain tumors

most common

20

meningioma

dural based brain tumor
dense and uniform contrast enhancement

21

vestibular schwannoma

brain tumor
unilateral hearing loss
uniform enhancing lesion at cerebellopontine angle

22

metastatic brain tumor

breast
lung
melanoma
*solitary metastatic lesion=>surgical resection

23

CNS lymphoma

*most occur in immunosuppressed, single or multiple mass lesions
*non hodgkin B cell lymphoma
*related to EB viral infection

24

clinical presentation of brain tumors

*headache-worse w laying down, cough, valsalva
*seizure, papilledema, focal neuro deficits
*impaired lateral gaze, dementia, personality changes
*gait disorder

25

treatment of symptomatic brain tumor

dexamethasone

26

Upper motor neuron lesion

weakness, spasticity
hyperactive tendon reflexes
Babinski sign-extensor planter reflex

27

Lower motor neuron (anterior horn cells, motor roots, peripheral nerves)

weakness, hypotonia, atrophy
loss of tendon reflexes
fasciculations
sensory symptoms if mixed nerve is involved

28

Muscle diseases

weakness- proximal >distal
no sensory changes
reflexes preserved, atrophy
no fasciculations, eye and bulbar muscles spared

29

neuromuscular junction

weakness increases with activity
no sensory symptoms
eye and bulbar muscles involved
reflexes normal
no atrophy or fasciculations

30

Argyll Robertson pupil

no reaction to light
reacts to accommodation

**syphilis

31

Relative afferent pupillary defect (RAPD)

no response to direct light but constricts when light shown in the other eye

**MS

32

3rd nerve palsy

ptosis = dilated pupil

33

Horners syndrome

ptosis + constricted pupil

34

pin point pupils

narcotic overdose
pontine damage
thalamic hemorrhage

35

unilateral enlarged pupil in comatose

midbrain lesion or compression of 3rd CN

36

bilateral dilated unreactive pupil in comatose pt

severe bilateral midbrain damage
anticholinergic overdose

37

paralysis of 6th CN

inability to move the eye outward
eye turns toward the nose when looking straight

38

paralysis of 3rd CN

eye displaced downward and outward
ptosis
eye can only move laterally and downward +/- dilated nonreactive pupil

39

diplopia

Monocular: does not correct by covering one eye

Binocular: corrects by covering one eye

40

3rd CN paralysis

*acute isolated 3rd nerve paralysis w pupillary involvement=>posterior communicating artery aneurysm

*acute isolated 3rd nerve paralysis without pupillary involvement
-age 50: vascular, most common is diabetes-microinfarction of 3rd nerve

41

Trigeminal neuralgia

vascular compression of the trigeminal root

42

clinical features of trigeminal neuralgia

*episodes knife like pain lips,gums,cheeks, or chin, lasts seconds to 2 minutes

43

triggers for trigeminal neuralgia

*touching specific points on face
*talking, chewing
*exposure to breeze, bright light or loud noise

44

trigeminal neuralgia do MRI in all cases to r/o

structural compression of nerve

45

treatment of trigeminal neuralgia

*carbamazepine or oxcarbazepine
*others: baclofen, gabapentin, lamotrigine
*heat or gamma knife radiosurgery or surgical microvasc. decompression

46

Infranuclear facial nerve paralysis

Bell's palsy
Ramsay Hunt Syndr
Acoustic neuroma
Pontine tumor or infarction
Guillain Barre, sarcoid, lyme

47

Bell's palsy

*assoc Herpes simplex virus type 1

*weakness evolves over 12-48hrs and may be preceded by retroaural pain +/- hyperacusis
Tx: prednisone 60-80mg/d x 7 days +/- valcyclovir 1gm TID x 7days

48

Ramsay Hunt syndrome

*herpes zoster involving geniculate ganglion
*vesicular lesions in pharynx or external auditory canal & freq involves the 8th CN

49

peripheral vertigo (vestibular nerve or inner ear)

*severity: +++
*N/V: ++
*tinnitus/hearing loss: some cases

*nystagmus: unidirectional, horizontal (never vertical)
*visual fixation: inhibits nystagmus and vertigo
*assoc central abnl: none

50

causes of peripheral vertigo

vestibular neuritis
labyrinthitis
Menieres dz
acoustic neuroma
benign positional

51

Central vertigo (brain stem or cerebellum)

*severity: +
*N/V: +/-
*tinnitus/hearing loss: none

*nystagmus: multidirectional, vertical
*visual fixation: no inhibition of nystagmus or vertigo
*assoc central abnl: dysarthria, diplopia, ataxia, weakness

52

causes of central vertigo

brain stem dysfunction due to demyelinating, vascular or neoplastic diseases

53

conductive hearing loss - external auditory canal or middle ear

*air conduction-abnormal
*bone conduction-normal

*Rinne test
-tuning fork in front of the ear (air conduction)-abnormal
-at mastoid process (bone)-normal
*weber test-tuning fork over center of forehead
-hear better on affected side

54

sensory-neural hearing loss (inner ear, 8th nerve, or central auditory pathway)
*air conduction-abnormal
*bone conduction- abnormal
*Rinne test- abnormal in both locations

*weber test- hears only on the normal side

55

Unilateral lesion of the spinal cord

*pain & temp sense lost below the lesion - OPPOSITE side
*spastic paralysi on SAME side as the lesion

*loss of vibration and position sense SAME side below the lesion
**TOUCH sense is not lost**

56

Syringomyelia

*progressive myelopathy characterized by cavitation of central spinal canal
*usually starts from mid cervical cord

*wasting of muscles of neck, shoulder, arms
*progressive spastic paraparesis
*loss of pain & temperature sensation

57

ALS-amyotrophic lateral sclerosis

*progressive loss of motor neurons in cerebral cortex & anterior horn of spinal cord
*asymmetric weakness of both upper & lower motor signs

*hyperreflexia,spasticity in a weak atrophic limb suggest ALS
*MRI cervical cord to r/o cord compression
*no pain, no sensory loss, normal bowel & bladder function
*Tx: riluzole (anti glutamate), BIPAP if FVC and symptoms of nocturnal hypoventilation

58

clinical features of transverse myelitis
*develop over hours to days
bilateral sensorimotor signs w a clear sensory level
*hyperreflexia & Babinski present

*urinary incontinence or retention
*bowel incontinence or constipation
*sexual dysfunction
*Lhermittes sign- paresthesias radiating down spine or limbs with neck flexion

59

Diagnosis of transverse myelitis

*MRI-do entire spine=>enhancing intramedullary cord lesion
*CSF pleocytosis or high IgG index
*MRI brain =>demyelination on brain MRI suggests MS

60

causes of transverse myelitis

*post infection or post vaccine
*acute infection
*systemic autoimmune:SLE,sarcoid, sjogrens

*paraneoplastic
*idiopathic
*multiple sclerosis
*neuromyelitis optica (myelitis + optic neuritis)

61

Tx transverse myelitis

*high dose steroids
*plasma exchange if no response to steroids

62

most common demyelinating dz of the nervous system

*multiple sclerosis.
*plaques are widely distr. in white matter of brain, sp cord and optic nerves.
*50 fold incr risk in child of a patient w MS

63

clinical presentation of MS
*sensory loss or paresthesias, optic neuritits, diplopia, weakness, ataxia, hyperreflexia spasticity, heat sensitivity

*intranuclear opthalmoplegia-unable to adduct involved eye, other eye fully abducts which shows horizontal nystagmus
*paroxymal symptoms: dysarthria, ataxia, tonic contractions
*Lhermittes: shock like sensation radiating to back on neck flexion

64

Patterns of MS

*relapsing remitting
*secondary progressive
*primary progressive-worst prognosis
*progressive relapsing

65

diagnosis of MS

*MRI brain & spinal cord:periventricular bright T2 lesions, contrast enhancement with active disease
*CSF: oligoclonal band, incr IGG index & synthesis rate, lymphocytic pleocytosis
*evoked response testing

66

treatment of acute relapses of MS- that produce functional impairment or initial attacks of optic neuritis

Methylprednisolone IV 1 gram/day for 3-5 days then oral prednisone for 2 weeks

67

disease modifying drugs for MS

*no effective tx for primary progressive MS**

*interferon beta-1a & interferon beta-1b:decreases relapse and slows progression
*glatiramer (copaxone)-reduces relapse by 1/3
*mitoxantrone-for worsening MS-cardiotoxic, AML possible s/e
*natalizumab-decr relapse and disabling progression

68

Parkinson's disease

unknown etiology
degeneration of dopamine contained in neurons in the basal ganglion

69

clinical presentation of Parkinsons dz

*tremor: asymmetrical, more pronounced at rest, handwriting is small and irregular (essential tremor its large & tremulous)

*bradykinesia: abnl finger & toe tapping, decreased arm swing,slow gait,drag of feet, shuffling gait,falls,fixed expressionless face
*rigidity, freezing gait,postural instability, incr falls, dementia
*normal motor, sensory and DTRs

70

secondary causes of Parkinsons dz
*drugs:phenothiazine, reserpine,metoclopramide, antipsychotics,lithium
*toxins: CO poisoning, MPTP-methylphenyl tetrahydro., mercury

*head trauma
*wilsons disease
*post encephalitis
*MRI brain to r/o hydrocephalus or vascular lesions

71

First line tx of Parkinsons

levodopa & carbidopa
levodopa & carbidopa & entacapone
dopamine agonist: ergot-bromocriptine, pramipexole,, ropinirole, rotigotine patch

72

second line tx of Parkinsons

*MAO-B inhibitor-selegiline
*anticholinergics
*NMDA antagonists: amantadine (Symmetrel)

73

surgical tx Parkinsons

deep brain stimulation w implanted electrodes

74

Complicaions of levodopa therapy

*wearing-off phenomenon: incr dose and freq of levodopa, add dopamine agonist +/- COMT inhibitor

*N/V: increase carbidopa dose
*dyskinesias (choreiform & dystonic movements): add dopamine agonist +/- amantadine
*psychosis: add atypical antipsychotic drug Quetiapine

75

Myasthenia Gravis

autoimmune neuromuscular disorder due to antibodies against acetylcholine receptors
symptoms are provoked by exertion

76

clinical features of myasthenia gravis

*ocular: blur vision, binocular diplopia, ptosis
*generalized: limb weakness, slurred speech, dysphagia, dyspnea

77

diagnosis of myasthenia gravis

*acetycholine antibodies, muscle specific kinase antibodies, TSH
*EMG w repetitive nerve stimulation
*edrophonium test=> rapid & transient impovement of strength
*once dx confirmed: CT chest to exclude thymoma

78

tx of myasthenia gravis

**acetylcholinesterase inhibitor: pryridostigmine
*immunosuppress: steroids, azathioprine, mycophenolate, cyclosporin, rituximab
*thymectomy if thymoma and if

79

Myasthenia crisis

*worsening of disease w weakness, difficulty swallowing and respiratory insufficiency
*best initial tx: plasmapheresis or IVIG
if no improvement immunosuppressive therapy. mechanical vent if VC <20ml/kg

80

Lambert-Eaton syndrome

paraneoplastic syndrome

*most common malignancy: small cell lung cancer

81

clinical features of Lambert-Eaton

*muscle weakness, strength improvs with activity
*dry eyes and mouth
*erectile dysfunction
*constipation

82

diagnosis of Lambert-Eaton

*EMG with repetitive nerve stimulatioon
*calcium channel antibodies in serum
CXR-if negative, do CT chest, abdomen , pelvis
**TX: pyridostigmine

83

CVA types

thrombotic
embolic
hemorrhagic

84

TIA

transient episode of neurological dysfunction d/t focal brain, spinal cord, or retinal ischemia, without acute infarction

85

Carotid TIA

*contralaterial hemiparesis or sensory loss
*aphasia if dominant site
*ipsilateral visual loss-lasts few minutes, and loss evolves in less than one minute

86

vertebrobasilar TIA

*episodes of dizziness, diplopia, dysarthria, facial or circumoral numbness +/- bilateral weakness +/- drop attacks due to sudden weakness of legs

87

Intracerebral hemorrhage - clinical features-rapidly evolve:

*headache
*vomiting
*seizures
*impaired consciousness
*neurological deficit

88

causes of intracerebral hemorrhage

#1: HTN
*amyloid angiopathy-lobar hemorrhage in elderly
* vascular malformations
*anticoagulation/thrombolytics
*cocaine, alcohol

89

diagnosis of intracranial hemorrhage

CT head WITHOUT contrast
cerebral angiography if

90

TX of intracerebral hemorrhage

*SBP 140-160, mean pressure 70-130
*surgery: cerebellar hemorrhage
*mannitol, barbiturate coma, hyperventilation to decrease intracranial pressure
**NO role for steroids

91

ischemic stroke

defined by presence of cerebral infarct on imaging
several types

92

cardioembolic stroke

*suspect when multiple infarcts seen on imaging
*most common cause ATRIAL FIB

93

Large artery atherosclerosis as cause of ischemic stroke

*may involve extracranial ICA or intracranial arteries
*stroke occurs due to artery-to-artery emboli or decreased cerebral flow
*greatest risk is stenosis >70%
*no benefit of stenting intracranial blood vessels

94

cryptogenic stroke as cause of ischemic stroke

***most common cause of ischemic stroke
*imaging suggest embolic stroke
*on evaluation, no cardioembolic or large vessel source is found
*25% may have paroxysmal A Fib so prolonged cardiac monitoring is advised

95

Management of TIA

*admit recommended for all seen within 72 hours of initial symptoms whose ABCD score is 3 or greater
*risk of stroke is highest in first few days so eval. immediately

96

Evaluation of TIA

ASA 81-325mg/d
clopidogrel, or asa + dipridamole
warfarin if due to A fib (add heparin until INR at target)
urgent endarterectomy if ICA stenosis 70-99%

97

Risk factor management for TIA

BP< 120% of ideal body weight

98

ABCD scoring system in TIA

AGE 60 or greater 1
BP 140/90 or greater 1

CLINICAL symptoms:
*focal weakness w TIA 2
*speech impair w/o weakness 1
DURATION: 10-59" (1), 60" or longer (2)
DIABETES 1

99

significance of ABCD scoring **2 day risk of stroke**

SCORE:
0-1 0%
2-3 1.3%

4-5 4.1%
6-7 8.1%

100

anterior cerebral artery cva

*medial cerebral hemisphere
*contralateral weakness and sensory loss in leg>arm
*behavioral changes

101

Internal carotid artery cva

*ipsilateral vision loss
*contralateral hemiparesis & sensory loss
*homonymous heminopis
*aphasia

102

Middle cerebral artery cva

*lateral cerebral hemisphere
*contralateral hemiplegia & sensory loss
*homonymous hemianopis
*aphasia

103

Branch of middle cerebral artery cva

*contralateral hemiplegia without sensory loss or can have sensory loss without hemiplegia

104

Posterior cerebral artery

*ipsilateral 3rd nerve and contralateral hemiplegia or ataxia
*homonymous hemianopia
*cortical blindness if bilateral

105

basilar artery cva

*brainstem, pontomedullary junction
*bilateral sensory & motor signs, CN 5-6-7, cerebellar signs
*diminished pain & thermal sense over half of body
*horners syndrome

106

vertebral artery

*brainstem, lateral medulla
*vertigo, ataxia, nystagmus
*Horners syndrome
*diminished pain & thermal sense half of body

107

Posterior inferior cerebellar artery

*lateral medulla
*ipsilateral facial sensory loss
*contralateral body sensory loss
*vertigo, ataxia, dysarthria

108

Prevention of stroke
*Tx HTN
*stop smoking
*regular exercise
*diet high fruit, veg, fiber, low in saturated fat

*anticoag if a fib
*tx carotid disease if indicated
*statin tx goal LDL< 100
*antiplatelet
*glucose control w diabetes

109

Tx ischemic stroke
*Tx HTN only if >220/120
*if eligible for thrombolytics, BP must be lowered & stabilized below 185/110 before thrombolytis started and maintained

*antiplatelet tx: ASA 160-325mg=>after 2 wk change to asa 81mg + dipyridamole, plavix if asa contraindication
*sq heparin 5000u BID for DVT prophy in immobile pt
*tx of cerebral edema
*IV thrombolytic tx

110

Tx ischemic stroke continued:
*possible intra-arterial thrombolytic tx in those w contraind. for IV thrombolysis
*neurosurg eval for cerebellar infarct or bleed

*cardioembolic stroke (AF + stroke , or other causes)
-thrombolytics if present in 4.5 hours of onset of symptoms
-do not use heparin (increase risk of intracranial hemorrhage)
-start warfarin when neuro stable with small infarcts
-delay warfarin for 2 weeks with large infarct

111

no benefit of stenting a blocked intracranial vessel or extracranial-intracranial bypass of

of a completely occluded ICA compared to medical therapy

112

Thrombolytic therapy in CVA
*indicated for:
-patients 18 or older presenting within 3 hours of onset of ischemic stroke that has measurable neurological deficit and CT shows no evid of bleed nor multilobar infarction

-select cases up to 4.5 hours onset of symptoms
*begin antiplatelet therapy w aspirin or plavix after 24 hours

113

Contraindications to thrombolytic therapy in CVA
*previous stroke/serious head trauma within 3 months
*BP>185/110 despite treatment
*recent invasive surg inpast 2 weeks
*INR>1.7 on warfarin,Incr PTT if heparin in past 48 hours

*evidence active bleed, GI/GU bleeding in past 21 days
*platelet

114

for thrombolitic exceptions of 3-4.5 hours after onset of symptoms, additional contraindications for this later tx include:

*age >80
*combination of prior stroke + diabetes
*NIH stroke scale >25
*oral anticoagulant use regardless of INR

115

Aphasia
*disturbance in comprehension (sensory) or production (motor) of spoken or written language
*several types:
-global

-wernickes
-conduction
-pure word deafness
-pure word blindness
-isolation of speech area

116

Global aphasia

*both sensory & motor
*due to large infarct involving DH, artery involved: MCA or ICA
*Brocas-motor or nonfluent
*difficulty in speech, involvement of dominant frontal lobe-MCA branch

117

Wernicke's aphasia

*speech is fluent but does not make sense
*parietal lobe involvement
*MCA branch involvement

118

aphasia-conductive

*repetition is severely affected
*parietal or frontal lobe
*MCA branch

119

aphasia-pure word deafness

no auditory comprehension

120

aphasia-pure word blindness

inability to read, name colors
dominant occipital lobe
PCA involvement

121

aphasia-isolation of speech area

*caused by extensive brain damage from shock
*parrot like repetition of spoken words

122

Alzheimers Disease

*most freq cause of dementia
*increased production and accumulation of beta-amyloid peptide which results in cell dysfunction =>deficiency of acetylcholine

123

Risk factors for alzheimers

*age
*family history
*Downs syndrome

*rare mutatin in amyloid precursor protein:presenilin 1 & 2 mutation
-early onset age 30-50
-autosomal dominant

124

clinical features of alzheimers

*predominant loss of short term memory
*progressive impairment of ADL's
*variety neuropsychiatric symptoms & behavior disturbance

125

Tx of alzheimers

*best initial tx: donepezil, rivastigmine, galantamine (central acting cholinesterace inhibitors)

*N-methyl-D-aspartate receptor antagonist-memantine
*vit E & C, ginkgo biloba
*SSRI for depression, antipsychotic for agitatin, delusions and hallucinations

126

other causes of dementia:
*multi-infarct :CT hypodense areas white&gray matter w no enhancement
*B1 or B12 deficiency
*hypothyroidism

*normal pressure hydrocephalus
*CNS infections
*creutzfeld-jakob disease
*frontotemporal dementia

127

Normal-pressure hydrocephalus

*dementia, gait disturbance, urinary incontinence
*CT shows dilated ventricles
*Tx: ventriculoperitoneal shunt

128

CNS infectious causes of dementia

HIV
syphilis
cryptococcus

129

Creutzfeld-Jakob disease

*cause:infectious prions
*transmission: corneal transplant, contaminated growth hormone

*rapidly progressive:dementia, myoclonus, focal cortical signs & rigidity
*EEG: markedly abnormal periodic discharges
*MRI (diffusion weighted): cortical & basal ganglion abnormality

130

Frontotemporal dementia

*dementia, prominent personality & behavior changes, parkinsonism
*MRI: prominent asymmetric frontal lobe atrophy

131

Guillain Barre syndrome

*rapidly progressive polyneuropathy

132

clinical features of Guillain Barre syndrome
*numbness, paresthesia
*symmetrical muscle weakness and absent tendon reflexes
*weakness progresses over 12hours to 28 days
*2/3 cases preceeded by URI or diarrhea

*weakness varies: mild difficulty walking to nearly complete paralysis of all extremities, facial, respiratory and bulbar muscles

133

Infectious agents assoc w Guillain Barre

*#1: campylobacter jejuni
*#2: CMV

*EBV
*varicella zoster
*mycoplasma pneumoniae

134

diagnosis of Guillain Barre

*nerve conduction study
*CSF: increased protein, normal WBC (albuminocytologic dissociation)
*anti-ganglioside antibodies

135

subtypes and variants of Guillain Barre

*acute inflammatory demyelinating polyneuropathy-most common here

*Miller Fisher syndrome-ophalmoplegia w ataxia & areflexia-IgG antibodies to GQ1b
*axonal forms: axonal neuropathy (japan & china), motor & sensory axonal neuropathy

136

Treatment of Gullain Barre

*IVIG 2G/kg over 5 days
*plasma exchanges
*combo of 2 above is not better than either one alone

*NO role for steroids
*DVT prophylaxis if pt cant walk
*mechanical ventilation: if PCO2 >48, or PO2<15

137

Neurological complications of diabetes:
*polyneuropathy
*mononeuropathy
*radiculopathy

*autonomic neuropathy
*diabetic amyotrophy

138

Polyneuropathy of diabetes

*numb, tingling, burinig pain of feet & hands
*then develop muscular atrophy, decreased reflexes and weakness

139

Mononeuropathy of diabetes

*wrist drop
*foot drop
*involvement of CN's 3-4-or 6th

140

diabetic radiculopathy

pain over distribution of one or more spinal nerves

141

diabetic autonomic neuropathy

diarrhea
erectile dysfunction
orthostatic hypotension

142

diabeetic amyotrophy

weakness of thigh muscles
anorexia
weight loss
normal CPK

143

treatment of neurologic complications of diabetes

pregabalin or duloxetine or elavil or venlafaxine
ultram for pain relief

144

Partial (focal) seizures:

*simple
*complex
*secondarily generalized tonic-clonic seizures

145

Simple seizure disorder

*focal sz that does not impair consciousness
*s/s may be localized to one area or spread to contiguous ipsilateral body parts (Jacksonian March)

*symptoms can be:
-sensory
-motor
-olfactory
-visual or gustatory

146

Complex seizure disorder

*alteration of consciousness lasting 1-2 minutes but may remain confused for 5-10 minutes after sz ends

* patient has blank stare and has automatisms (lip smacking, chewing, aimless walking, repetitive swallowing)

147

Secondarily generalized tonic-clonic seizures

*begins as partial sz then get tonic clonic sz and resolves in 1-2 minutes
* often urinary incontinence or tongue biting

148

Generalized seizures

*occur without warning

*tonic-clonic
*absence seizure (petit mal)
-sudden brief impairment of consciousness without loss of postural control and lasts 5-10 seconds

149

Treatment of seizures
*no rx if just a single unprovoked seizure with normal EEG & MRI
*Tx after first seizure if high risk group (age>65, focal findings on EEG or MRI, hx of head trauma or focal seizure, postictal Todd paralysis

*seizure meds usually started after a second seizure
*inpatient video EEG monitoring indicated in pt w seizures not responding to multiple medications

150

AED: anti epileptic drugs
*ALL seizure types:
-lamotrigine, valproate, topiramate, levetiracetam, felbamate,..

*Focal seizures: gabapentin, phenobarb, phenytoin, primidone, carbamazepine..
*absence seizures: ethosuximide

151

status epilepticus

*continuous seizure or repetitive discrete seizures w impaired consciousness in the interictal period

*if remains comatose after a seizure, do EEG to exclude ongoing status epilepticus
*generalized convulsive status epilepticus
*nonconvulsive status epil. - absence or partial seizures

152

treatment of status epilepticus

*IV lorazepam (Best initial tx) => repeat x 1 if no response in 5 minutes =>phenytoin or fosphenytoin =>more of the prior med given

=> phenobarbital => more phenobarb => anesthesia w midazolam or propofol

153

complications of status epilepticus

hyperpyrexia
metabolic acidosis
brain damage
rhabdomyolysis
CSF & peripheral leukocytosis

154

causes of death in epilepsy

*trauma, drowning
*status epilepticus
*SUDEP-sudden unexpected death in epilepsy

155

risk factors for sudden unexpected death in epilepsy
*gen tonic clonic sz
*prone position after nocturnal seizure
*frequent or recent sz
*long post ictal EEG suppression

*postictal breathing problem or cardiac arrhythmia
*inadequate therapy
*inadequate tx or rapid withdrawal of therapy

156

Mechanism of SUDEP

*resp arrest, laryngeal spasm, suffocation in prone position
*pulm edema is #1 autopsy finding
*hypercarbia & hypoxemia common after sz

157

Prevention of SUDEP

*sz control w appropriate medication
*avoid sleep deprivation
*avoid excess alcohol

*in pt w nocturnal tonic clonic sz, increase HS dose of medication
*after sz, reposition pt on side, stimulate pt for apnea or severe hypoventilation

158

CT findings in infarct

hypodense area, no enhancement

159

CT finding in multi infarct dementia

multiple hypodense areas
no enhancement

160

CT findings in tumor or lymphoma

diffuse enhancing lesion or ring enhancement w central necrosis

161

CT finding of brain abscess

ring enhancing lesion

162

CT findings of toxoplasmosis

multiple ring enhancing lesions

163

CT findings in cerebral atrophy

dilated ventricles & sulci

164

CT findings in alzheimers

atrophy +/- non enhancing periventricular white matter lesions

165

CT findings in AIDS dementia

atrophy +/- non enhancing white matter lesions

166

CT findings in multiple sclerosis

periventricular & sub cortical white matter lesions
lesions enhance with active disease

167

CT findings in NPH (normal pressure hydrocephalus)

dilated ventricles
normal sulci

168

CT findings in multi-focal leucoencephalopathy

large non enhancing white matter lesions

169

22 y/o male ER 2 hour hx severe diffuse HA. worst HA ever. had brief LOC prior to HA. +N/V, no vision chg.
hx HA in past but unilateral and throbbing and lasted 2 hours. neuro exam is normal, CT without contrast is negative. what is indicated next?

Lumbar puncture

170

70 y/o w 20 yr hx diabetes presents w 2 day hx of diplopia. exam-inability to move L eye outward and diplopia on looking toward the left side. diplopia disappears with covering either eye. fundus exam-mild diabetic retinopathy, no papilledema. no other neuro findings, most likely cause of diplopia?

L 6th nerve paralysis due to infarction of the nerve

171

76 y/o consults u w recurrent episodes L sided visual loss assoc w weakness of R arm and leg. about 4 episodes in 6 months, lasts approx 5-10". exam: VSS, no focal neuro deficit. carotid duplex 45% narrowing of carotids, now recommend?a

aspirin alone

172

60 y/o male w slow progressive weakness of arms, legs, and occ. difficulty swallowing. neuro : weakness, atrophy and fasciculations of upper extremities. lower extremities: weak, spasticity, hyperactive reflexes. no pain or paresthesia. CT head is negative.Most likely diagnosis?

ALS-amyotrophic lateral sclerosis

173

32 y/o female to ER sudden onset of severe headache and diplopia. exam: R ptosis, R pupil is dilated and fixed. there is paralysis to adduction and elevatin of R eye. most likely Dx?

leaking posterior communication aneurysm with compression of the 3rd nerve nucleus

174

56 y/o male w tingling hands and feet, poor memory and unsteady gait. exam: spasticity & weakness of legs, + ankle clonus, extensor plantar response, loss of vibratory sense in LE and + rhomberg sign. likely Dx?

vit B12 deficiency

175

44 y/o female to ER w weakness and inability to walk. started 6 days ago w numb/weak of both hands and feet. gradually extended proximally of all extremities.. exam: quadriparesis, unable to close both eyes or move facial muscles, no DTRs. LP shows protein 100, normal glucose, no cells best test to confirm?

EMG and nerve conduction studies ( Guillian barre)

176

36 y/o with hearing loss L ear. Rinnes test-best on L mastoid process, hears better L ear with tuning fork on center forehead. likely cause of disease affecting

external auditory canal or middle ear

177

42 y/o male w episodes of severe HA for 3 days. Ha wakes him at night, always behind L eye, excruciating, lasts 2 hours. with the HA he has tearing of L eye, stuffiness of L nose and drooping of L eyelid. now recommend?

start high dose oral prednisone for one week- he has cluster HA

178

60 y/o female w recurrent episodes intense pain lips, cheek and chin on L side several episodes a day and each lasts a few seconds . now recommend

cabamazepine

179

54 y/o male with sudden onset of L facial weak, drooping of the saliva and inability to close L eye. exam: droop angle of mouth , unfurrowed forehead, unable to close L eye, and on opening mouth the face is pulled to R side. rest neuro exam normal. now recommend?

patching of L eye, prednisone, valacyclovir
(Bells palsy)

180

26 y/o female w recur attacks of vertigo and tinnitus for 6 months. exam during episode: horizontal nystagmus that disappears on visual fixation on an object. audiogram: high freq hearing loss L ear. most likely dx?

*Menieres disease

181

22 y/o female w pain & progressive visual loss R eye. 20/100R, 20/20 Leye. right pupil does not change in size when light shone in front of R eye but in front of L eye both pupils constrict. eye movements and fundus exam is normal. now recommend?

IVmethylprednisolone then oral prednisone

182

28 y/o female w double vision. exam: unable to adduct L eye w nystagmus in the abducting R eye. exam otherwise normal. likely dx?

multiple sclerosis

183

24 y/o to ER w generalized rigidity and inability to move quickly for past few days. exam: marked rigidity of muscles and severe bradykinesia. Likely Dx?

MPTP intoxication-methyl-phenyl-tetrahydropyridine

184

55 y/o w long hx HTN presents w sudden onset weakness R arm & leg and aphasia. Hx of episodes of transcient vision loss of L eye in past 3 months, each lasting 5-10". exam: complete loss vision L eye, aphagia, weakness R arm and leg . likely occlusion of:

L internal carotid artery

185

72 y/o male w HTN, DM with progressive increasing memory loss. Hx of CVA 4 yr ago. exam: 170/100, poor memory, brisk tendon reflexes and extensor plantar response, CT would likely show:

multiple hypodense lesions in white & gray matter

186

25 y/o male to ER with generalized sz. no hx of prior sz. acute intoxicaion with what drug may be responsible for his seizure?

cocaine

187

50 y/o female w tremors both hands and difficulty writing due to tremors of hands. tremors disappear at rest and after drinking alcohol. now recommend?

propranolol- she has benign essential tremors

188

72 y/o presents w R sided vision loss. exam: dense R homonymous hemianopsia. no other neuro abnormalities. likely lesion affecting the

L occipital lobe

189

70 y/o female w poor memory, unsteady gait and urinary incontinence. exam: shuffling gait, broad based and unsteady. CT shows dilated ventricles and normal sulci. most likely dx?

normal pressure hydrocephalus

190

76 y/o male with headache and intermittent blurring of vision for last 2 weeks. neuro exam is normal . most impt initial test in eval of this patient?

sed rate

191

lesions that may be assoc with contrast enhancing CNS lesions in AIDS

toxoplasmosis
CNS lymphoma
brain abscess

192

alzheimers patients CT and PET scan show

CT: enlarged ventricles and sulci and non enhancing hypodense areas in white matter
PET: hypometabolism in the parietal lobes

193

True about MS

*MRI in active disease: contrast enhanced white matter lesions in periventriccular and subcortical areas

*identical twins of patient w MS have an increased risk of developing active disease
*chronic progressive disease has a poor prognosis
*intranuclear opthalmoplegia in young pt is highly suggestive of MS

194

Presence of acetylcholine receptor antibodies confirms the dx of

myasthenia gravis

195

major cause of death in pt with Duchenne muscular dystrophy is

respiratory failure

196

myotonic dystrophy may be complicated by

cardiac conduction defects

197

complications of status epilepticus include

*hyperpyrexia
*irreversible brain damage
*CSF & peripheral leukocytosis
*rhabdomyolysis
*metabolic acidosis