Neurology Flashcards
1
Q
TIAs
A
always due to emboli or thrombosis
2
Q
best initial diagnostic test for either stroke or TIA
A
head CT w/o contrast
3
Q
Lesions: anterior cerebral artery
A
LE weakness
UE weakness
personality changes
urinary incontinence
4
Q
Lesion: middle cerebral artery
A
UE weakness aphasia apraxia/neglect Eyes deviated TOWARD side of lesion C/L homonymous hemianopsia
5
Q
Lesions: Posterior cerebral artery
A
prosopagnosia - inability to recognize faces
6
Q
Lesion: Vertebrobasilar artery
A
vertigo NV "drop attacks" labile BP sensory changes in face and scalp dysarthria, dystonia vertical nystagmus
7
Q
Lesion: posterior inferior cerebellar artery (lateral medullary)
A
ispilateral face
contralateral body
Vertigo
Horner’s syndrome
8
Q
what test is needed to evaluate posterior circulation infarcts?
A
MRI
MRA - for brainstem
9
Q
C/I: thrombolytics
A
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
Q
best initial therapy for person with stroke > 3 hours
A
aspirin
11
Q
what do you give if a person has developed a stroke while on aspirin?
A
switch to clopidogrel OR add dipyridamole
12
Q
when do you use ticlopidine in a stroke patient?
A
only pts who are intolerant of both ASA and clopidogrel
13
Q
s/e ticlopidine
A
TTP
neutropenia
14
Q
important management post-TPA
A
neuro checks every hour
keep BP < 180/100
15
Q
F/U studies to do in all stroke patients
A
Echo
Carotid dopplers
EKG and Holter monitor if EKG is normal
16
Q
additional tests to run in a young patient (<50) with a stroke
A
ESR
VDRL/RPR
ANA, dsDNA
Protein C/S, factor V leiden, antiphospholipid
17
Q
Management of status epilepticus
A
- Benzos - Ativan; repeat if still seizing after 1 min
- If seizure persists after 10-20 minutes –> Fosphenytoin
- Continues for 10-20 minutes –> Phenobarbital (Intubation/ventilation considered)
- General anesthesia –> pentobarbital, thiopental, midazolam or propofol
18
Q
Tests to order in seizure patient:
A
- Na, Ca, glucose, creatinine and Mg levels
- Head CT
- urine tox screen
if these are negative then: - EEG
19
Q
when should you get a neuro consult in a seizure patient?
A
all seizure patients, once the initial workup is done
20
Q
what should you order if you suspect a pseudoseizure?
A
psych consult
PRL level - normally rises after a real seizure
21
Q
which conditions mandate that you treat chronically after first seizure?
A
- strong family hx
- abnormal EEG
- status epilepticus
- noncorrectable precipitating cause - brain tumor
22
Q
first line therapies for seizures:
A
valproic acid
carbamazepine
phenytoin
levitiracetam
23
Q
lamotrigine - s/e
A
steven johnson/severe skin reactions
24
Q
second line therapies for seizures
A
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
