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Flashcards in Neurology Deck (124):
1

TIAs

always due to emboli or thrombosis

2

best initial diagnostic test for either stroke or TIA

head CT w/o contrast

3

Lesions: anterior cerebral artery

LE weakness
UE weakness
personality changes
urinary incontinence

4

Lesion: middle cerebral artery

UE weakness
aphasia
apraxia/neglect
Eyes deviated TOWARD side of lesion
C/L homonymous hemianopsia

5

Lesions: Posterior cerebral artery

prosopagnosia - inability to recognize faces

6

Lesion: Vertebrobasilar artery

vertigo
NV
"drop attacks"
labile BP
sensory changes in face and scalp
dysarthria, dystonia
vertical nystagmus

7

Lesion: posterior inferior cerebellar artery (lateral medullary)

ispilateral face
contralateral body
Vertigo
Horner's syndrome

8

what test is needed to evaluate posterior circulation infarcts?

MRI
MRA - for brainstem

9

C/I: thrombolytics

hx of hemorrhagic stroke
presence of intracranial neoplasm/mass
active bleeding/surgery within 6 weeks
presence of bleeding disorder
CPR within 3 weeks
suspicion of aortic dissection
stroke in last year
cerebral trauma/surgery within 6 months

10

best initial therapy for person with stroke > 3 hours

aspirin

11

what do you give if a person has developed a stroke while on aspirin?

switch to clopidogrel OR add dipyridamole

12

when do you use ticlopidine in a stroke patient?

only pts who are intolerant of both ASA and clopidogrel

13

s/e ticlopidine

TTP
neutropenia

14

important management post-TPA

neuro checks every hour
keep BP < 180/100

15

F/U studies to do in all stroke patients

Echo
Carotid dopplers
EKG and Holter monitor if EKG is normal

16

additional tests to run in a young patient (<50) with a stroke

ESR
VDRL/RPR
ANA, dsDNA
Protein C/S, factor V leiden, antiphospholipid

17

Management of status epilepticus

1. Benzos - Ativan; repeat if still seizing after 1 min
2. If seizure persists after 10-20 minutes --> Fosphenytoin
3. Continues for 10-20 minutes --> Phenobarbital (Intubation/ventilation considered)
4. General anesthesia --> pentobarbital, thiopental, midazolam or propofol

18

Tests to order in seizure patient:

1. Na, Ca, glucose, creatinine and Mg levels
2. Head CT
3. urine tox screen
if these are negative then:
4. EEG

19

when should you get a neuro consult in a seizure patient?

all seizure patients, once the initial workup is done

20

what should you order if you suspect a pseudoseizure?

psych consult
PRL level - normally rises after a real seizure

21

which conditions mandate that you treat chronically after first seizure?

1. strong family hx
2. abnormal EEG
3. status epilepticus
4. noncorrectable precipitating cause - brain tumor

22

first line therapies for seizures:

valproic acid
carbamazepine
phenytoin
levitiracetam

23

lamotrigine - s/e

steven johnson/severe skin reactions

24

second line therapies for seizures

gabapentin
phenobarbital

25

which anti-epileptic drug is most dangerous in pregnancy

valproic acid

26

which side are most anti-eplipetic drugs assoc with

bone loss and osteoporosis

27

DX. Parkinsons

clinical

28

Tx. mild parkinsons symptoms

60: amantadine

29

s/e anticholinergics in PD

worsen memory

30

first line treatment for severe PD (interferes with daily living)

Dopamine agonists - pramipexole, ropinirole, cabergoline

31

what do you start if you have really severe disease or disease progression in PD

levodopa/carbidopa --> most effective treatment

32

Pt with PD being treated with levodopa develops psychosis - what do you give?

quetiapine

33

Pt with PD on levodopa develops on off phenomena

COMT inhibitors

34

Alternatives to Levodopa/carbidopa if not effective for PD

add COMT inhibitors
MAOI: selegeline, rasagiline
deep brain stimulation

35

Features of essential tremor (4)

1. both at rest and intention
2. Normal life expectancy, no other neuro sx
3. AD inheritance
4. Tx. Propranolol

36

good prognostic factors for MS

1. optic neuritis
2. female
3. early age onset
4. relapsing form of disease

37

best initial and most accurate diagnostic test for MS

MRI
- repeat 3 months after initiating therapy

38

when would you do a LP in a pt with MS

only if MRI is non-diagnostic
youll see: oligoclonal bands, T lymphocytes, elevated IgG index

39

best initial therapy for acute MS exacerbation

steroids

40

disease modifying therapy in MS

beta interferon and glatiramer
- both are teratogenic
mitoxantrone
natalizumab - may cause PML

41

additional meds in MS for fatigue (1) and spasticity (2)

1. amantadine
2. baclofen or tizanidine

42

for all patients with memory loss - what do you order?

1. head CT
2. B12 level
3. RPR/VDRL
4. Thyroid function testing

43

Tx. alzheimers disease

donepezil, rivastigmine, galantamine

44

CF: Frontotemporal dementia (Picks disease)

Personality changes (disinhibition, impaired executive function, irritability), Hyperoral behavior --> memory loss is the last part to go
Head CT: focal atrophy of frontal/temporal lobes

45

CF: Creutzfeld Jakob disease

young patient with rapidly progressive dementia and myoclonus

46

Dx. tests for CJD

EEG
MRI
CSF --> 14-3-3 protein
Brain biopsy = most accurate

47

Lewy body dementia

PD symptoms + dementia (visual hallucinations)

48

Dx. testing for normal pressure hydrocephalus

1. Head CT
2. LP
3. Miller Fisher test - assess gait before and after removal of CSF

49

phenytoin toxicity

nystagmus on far lateral gaze
blurred vision, diplopia
ataxia, slurred speech
dizziness, drowsiness, lethargy

50

what do you do if pt presents with phenytoin toxicity?

decrease dose or treatment schedule to minimize drug peak levels

51

once a stroke pt is admitted to the hospital and treated with ASA etc. - what should be evaluated next?

bedside swallow evaluation with speech therapy before giving any meds or food PO

52

is heparin used in treatment of acute stroke patients?

yes! low dose subcu heparin is used for DVT prophylaxis, esp. in patients with dense hemiparesis
- full dose heparin is not used

53

BP management in stroke patients

1. no tpa? permissive HTN up to 220/120. If greater, IV BB
2. tpa? want to keep BP < 180/100
3. hemorrhagic stroke? CCB, nicardipine

54

what should you do if PD patient presents with symptoms that make you consider depression?

difficult to ascertain bc many symptoms overlap, but may do trial of SSRIs before altering PD meds

55

senile gait (due to aging)

"walking on ice" - feed wide apart with knees/hips flexed, legs straight and arms flexed/extending as if expecting to fall

56

spastic paraparesis gait

pt drags legs forward with every step (circular leg movements)

57

cerebellar ataxic gait

drunken sailor gait - jerky pt, walks in zigzag pattern

58

First step in Wernicker's encephalopathy

THIAMINE 200 mg IV/24 hours
glucose after

59

Parinaud's syndrome

loss of pupillary reaction
vertical gaze paralysis
loss of optokinetic nystagmus
ataxia
headache --> obstructive hydrocephalus

60

CF: craniopharyngioma

headache
diabetes insipidus
deficiency of one or more pit. hormones

61

Foster Kennedy syndrome

frontal lobe tumor - optic atrophy on side of tumor and papilledema on contralateral side

62

antihypertensives used in controlling BP in acute stroke

IV labetalol, nicardipine or sodium nitroprusside

63

what tests must be done to rule out reversible causes of dementia?

thyroid function tests
vitamin B12 deficiency
vitamin B1 deficiency in alcoholics

64

Preventative therapy for cluster headaches with a duration of > 2 months

Verapamil
alt: prednisone, lithium but both are much less studied

65

acute (abortive) management of cluster headaches

100% O2 inhalation
- can also give triptans (easier for at home)

66

Binswanger's disease

vascular dementia with white matter infarcts; presents with apathy, agitation and bilateral corticospinal/bulbar signs

67

drug approved for ALS

Riluzole - glutamate inhibitor; delays progression

68

Dx. of Cerebral palsy

diagnosed based on history and physical examination but MRI should be ordered to look for any abnormalities or possible etiology of symptoms

69

an area of decreased sensation over anterolateral thigh without any muscle weakness or DTR abnormalities

meralgia paresthetitica --> entrapment of lateral femoral cutaneous nerve

70

psychogenic coma

perform caloric testing - normal reaction to caloric testing of external auditory canal is suggestive (transient, conjugate, slow deviation of gaze to the side of the stimulus followed by saccadic correction to the midline)

71

classic triad of sx for spinal epidural abscess

fever
severe focal spinal pain
neurologic deficits --> radiculopathy, motor/sensory deficits, bowel or bladder dysfunction, paralysis

72

initial management of pt presenting with seizures

1. ventilation/circulation
2. IV lines - obtain blood for glucose, CBC and electrolytes
3. urine toxicology sent

73

management of patient presenting with unilateral Bell's palsy

no further workup
treat with corticosteroids and supportive eye care

74

MMSE score of < 20

dementia
- senility usually has > 25

75

sites that may be biopsied to diagnose sarcoidosis

1. any palpable LN
2. subcutaneous nodule except erythema nodosum
3. enlarged parotid gland
4. lacrimal gland

76

when should a head CT or MRI be done for a headache

1. sudden and/or very severe
2. onset after age 40
3. assoc. with focal neurological findings

77

best initial abortive therapy for a migraine

sumatriptan or ergotamine

78

prophylactic therapy for a migraine

if >4 headaches /month:
1. BB - propranolol
2. alternate prophylactic medications: CCBs, TCAs, SSRIs

79

CF: pseudotumor cerebri

obese young woman with headache plus:
- 6th nerve palsy
- visual field loss
- transiently obscure vision
- pulsutile tinnitus

80

most accurate diagnostic test for pseudotumor cerebri

LP with opening pressure measurement

81

Tx. pseudotumor cerebri

weight loss
acetazolamide
surgery if the above two fail

82

Management: BPV

1. canalith repositioning procedure
2. meclizine (modest response)

83

vertigo and dizziness that is not related to changes in position - dx? tx?

dx. vestibular neuritis
tx. meclizine

84

acute hearing loss, tinnitus and vertigo

labrynthitis - cochlear portion of inner ear
- self limited, may be treated with meclizine

85

vertigo, hearing loss and tinnitus that is chronic with remitting and relapsing episodes

Meniere's disease

86

Tx. Meniere's disease

salt restriction
diuretics i.e. furosemide
H1 antagonists - decrease amt of endolymph production

87

ataxia in addition to hearing loss, tinnitus and vertigo

acoustic neuroma

88

anyone with vertigo should get which test

MRI of internal auditory canal

89

normal CSF protein level can exclude...

bacterial meningitis

90

CSF glucose levels < 60% of serum levels are diagnostic of...

bacterial meningitis

91

empiric therapy for meningitis

ceftriaxone
vancomycin
steroids

92

meningitis in an HIV patient with CDC < 100: dx? tests?

dx. cryptococcal meningitis
best initial test: india ink stain
most accurate test: cryptococcal antigen

93

Tx. cryptococcal meningitis

IV amphotericin + flucytosine
Oral fluconazole prophylaxis until CDC >100

94

Tx. meningitis due to Lyme disease

IV ceftriaxone or penicillin

95

Tx. TB meningitis (Very high CSF protein level)

RIPE therapy + Steroids
- longer therapy (12 months)

96

who should receive prophylaxis with Neisseria meningitidis

Any close contacts (household members or those who shared cups/kisses etc); school and work contacts do not need prophylaxis

97

Neisseria prophylaxis

Rifampin
Ceftriaxone

98

patient presents with acute onset of fever and altered mental status - dx? best initial test? most accurate test?

Dx. encephalitis
Test initial: head CT
accurate test: PCR of CSF

99

Tx. herpes encephalitis

IV acyclovir 10 mg/kg q8

100

HIV positive patient presents with fever, headache and focal neurological deficits. Head CT shows ring enhancing lesion - next step?

Tx. with pyrimethamine and sulfadiazine for 2 weeks and then repeat head CT. If toxoplasma will go away - if cancer, will need a brain biopsy

101

Management of PML

Tx. HIV and raise the CD4 count; lesions will disappear as HIV improves

102

A patient who recently moved from Mexico comes in with seizures. Head CT shows multiple cystic lesions that are not yet calcified. Management?

Neurocysticercosis
COnfirm diagnosis with serology
Tx. Albendazole + Steroids

103

Steps in Management of Large Intracranial Hemorrhage with mass effect

1. Decreased ICP:
a) Intubation/Hyperventilation (pCO2 25-30)
b) Mannitol - takes 90 min to work
c) Barbiturate coma = last effort
2. Surgical Evacuation

104

Subarachnoid hemorrhage
Best initial test(1)
Most accurate test (2)

1. Head CT w/o contrast
- may be normal w/in first 24-72 hours of onset
2. Lumbar Puncture
- xanthochromia; supernatant will be yellow

105

normal WBC to RBC ratio

1:500
infection is present only if > 1:500

106

Treatment SAH

1. Angiography
2. Embolization of the vessel
3. Rx. nimodipine PO (CCB that decreases risk of stroke)

107

Pt presents with loss of sensation of pain and temperature in UE bilaterally in capelike distribution over neck, shoulders and down both arms - dx? test? tx/

Dx. syringomyelia
Test: MRI
Tx: surgery

108

what can present with tenderness over the spine? in either of these cases - what is the next best step?

cord compression
spinal epidural abscess
NEXT step -> MRI

109

most urgent next step in cases of cord compression

give steroids - to decrease swelling

110

You suspect a spinal epidural abscess - what should you treat with?

Antibiotics against Staph ex. oxacillin, nafcillin

111

anterior spinal artery infarction

all sensation is lost except position and vibratory sense (which travel down posterior column)

112

Brown Sequard syndrome

traumatic injury to the spine, i.e. knife wound
Pt loses ipsilateral position, vibratory sense and Contralateral pain and temp below the lesion

113

Tx. diabetic peripheral neuropathy

Gabapentin or pregabalin

114

Management of carpal tunnel syndrome

Initially = wrist splint
on CCS - move the clock forward, and if no improvement may try injecting steroids

115

Tx. Bell's palsy

steroids

116

Tx. reflex sympathetic dystrophy

1. NSAIDs
2. Gabapentin
3. Nerve block
4. Surgical sympathectomy

117

Tx. restless legs syndrome

pramipexole, ropinirole

118

Pt comes in with suspected Guillain Barre syndrome - next best step?

peak inspiratory pressures (predicts weakness of diaphragm and likelihood of respiratory failure) and determines who gets treatment

119

Tx. Guillain Barre syndrome

either IVIG or plasmaphoresis (not combination)

120

Myasthenia Gravis
- best initial test (1)
- most accurate test (2)
- what test do you order after DX? (2)

1. ACH-R antibodies
2. clinical presentation and ACH-R ab are most SN and SP than Tensilon test
3. CHEST CT - to r/o thymoma

121

best initial therapy for myasthenia

pyridostigmine or neostigmine

122

Tx. of myasthenia in pt unresponsive to neostigmine

if pt is < 60, thymectomy
Prednisone if thymectomy does not work

123

Man presents to you after his most recent gym outing c/o NV, dizziness, auditory changes, blurry vision, diplopia and interscapular pain - DX? test?

Dx. intracranial hypotension
Test: MRI

124

Tx. intracranial hypotension

best rest and IVF for 2 weeks