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Neurology Flashcards

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1
Q

HA red flags that prompt further eval

A 
dramatic increase in HA severity
HA that awakens CH from sleep
change in est. HA pattern
gradually increasing frequency & severity
   suggests increasing ICP
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2
Q

PE finding for intracranial HTN

A

papilledema

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3
Q

PE for HA

A

growth, HC, BP
intracranial HTN (papilledema)
focal neurologic signs
general- rhinitis, dental abscess, bruit, head trauma, hematoma, skull step-off

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4
Q

red flags in hx/PE for HA may entail further investigation with what

A

head imaging (CT for hemorrhage, MRI for tumor & cerebellar imaging)
electroencephalography (EEG)
+/- sleep deprivation

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5
Q

tension HA

A

diffuse
symmetric
often related to fatigue

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6
Q

cluster HA

A

extreme deep pain in & around one eye

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7
Q

migraine

A

triggered by stess
vomiting
FH

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8
Q

migraine classification

A

migraine w/ aura (visual or otherwise)
“ “ w/o aura
complicated migraine (transient focal abnormality)
migraine equivelent

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9
Q

paroxysmal torticollis

A

attacks of head tilt, +/- vertigo, vomiting

requires r/o posterior fossa pathology

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10
Q

benign paroxysmal vertigo

A

attacks of unsteadiness w/ nystagmus & vomiting followed by sleep
may precede development of typical migraine
requires r/o epilepsy & CNS tumor

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11
Q

cyclic vomiting

A

protracted attacks of vomiting, 1-4x/hr, up to 5 days

requires r/o epilepsy, GI d/o, urea cycle d/o

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12
Q

abdominal migraine

A

attacks of migraine lasting 1-72 hrs, untreatable by other means
midline, dull, mod-severe pain
assoc. w/ anorexia, n/v, pallor
dx often by response to anti-migraine therapy
requires r/o other GI d/o

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13
Q

confusional migraine

A

episodic disorientation/ combativeness, sometimes followed by HA
requires r/o drug abuse, epilepsy, CNS ischemia

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14
Q

Therapy for migraine acute episode

A

sleep
acute tx- acetaminophen, ibuprofen, sumatriptan, other triptans
rescue tx- NSAIDs, promethazine, metoclopramide

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15
Q

migraine prophylaxis

A

create mgnt plant to prevent stressors
biofeedback (stress reduction)
physical modalities (massage, PT, exercise)
meds (usu. involves a neurologist)
cyproheptadine
antihypertensives (propranolol, verapamil)
TCAs- amitriptyline, nortriptyline
anticonvulsants- valproate, topiramate, gabapentin

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16
Q

HA summary

A 
r/o underlying pathology
address exacerbating factors
mgnt plan
   meds (start w/ acetaminophen, ibuprofen)
   abortive agents
   daily prophylaxis (neurologist)
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17
Q

pseudotumor cerebri

A

increased ICP in absence of identifiable intracranial mass/ hydrocephalus
postulated to be d/t impaired CSF reabsorption

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18
Q

Risk factors of pseudotumor cerebri

A 
obesity
female
sinus thrombosis
head injury
chronic CO2 retention
SLE
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19
Q

Acute S&S of intracranial HTN in pseudotumor cerebri

A 
HA
pulse synchronous tinnitus
pain behind the eye
pain w/ eye movements
transient visual obscurations
blurred vision/double vision
CN VI paresis
vomiting
macrocphaly
altered behavior
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20
Q

Chronic S&S of intracranial HTN in pseudotumor cerebri

A

growth impairment
optic atrophy
visual field loss
total blindness

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21
Q

Diagnosing pseudotumor cerebri (one of exclusion)

A

CT- r/o hydrocephalus
MRI- r/o intracranial mass, hydrocephalus
Ophthalmologic- papilledema, optic n. changes
LP- measurement of opening pressure, normal CSF pnl & cx

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22
Q

Tx of pseudotumor cerebri

A

tx underlying causes- wt loss is mainstay of therapy, tx anemia
medical tx-
diuretics
acetazolamide (Diamox) causes peripheral paresthesias &
metabolic taste to carbonated soft drinks
furosemide (Lasix)
glucocorticoids
lumbar puncture
surgical tx- optic n. sheath decompression, lumboperitoneal shunt

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23
Q

Seizures

A

a sudden, transient disturbance of brain function, manifested by involuntary, motor, sensory, autonomic, or psychic phenomena, alone or in a any combo often accompanied by alteration of LOC

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24
Q

epilepsy

A

repeated seizures w/o evident cause

recurrent, unprovoked seizures

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25
classification of seizures
symptomatic- cause is identified/ presumed | idiopathic- cause is unknown/ presumed to be genetic
26
Examples of symptomatic seizure
``` infxn (meningitis/encephalitis) trauma metabolic (hypoglycemia, hyponatremia) hypoxic tumor malformation (hydrocephalus) ```
27
nonepileptic paroxysmal events
``` benign nocturnal myoclonus shudder attacks tics & Tourette's syndrome sleep orders- night terrors, sleepwalking/talking, cataplexy, narcolepsy nightmares migraine- BPV, paroxysmal torticollis conversion rxn & pseudoseizure GERD masturbation hypoglycemia temper tantrums & breath-holding syncope & vasovagal events paroxysmal dystonia/ choreoathetosis ```
28
Seizure
``` hx- events prior, during, after exam lab- CBC, metabolic abnormalities CT scan/ MRI EEG- not sensitive or specific, may help classify seizure type to determine therapy, may reveal subclinical seizures ```
29
Seizure Tx
ABCs- protect against self-injury, airway clearance, monitor ABCs anticonvulsants- if seizures are prolonged/hindering ABCs education- seizure precautions, meds, daily life swimming, adequate sleep, driving, pregnancy
30
Seizure meds
``` abortive meds: benzodiazepines lorazepam parenterally diazepam orally/rectally midazolam nasally, PO, rectally phenobarbital & fosphenytoin LT anticonvulsants- different drug classes used for different types of epilepsy ```
31
febrile seizure is a convulsion assoc. w/ a temp > than
38.0 C
32
MC type of CH seizure
febrile seizure incidence 2-5% of CH under 5 yo peak occurrence 18-24 mo
33
When are febrile seizures most likely to occur (age)
6 mo-5yo seizure in younger infant should concern you some CH under 5 yo who develop febrile seizures may have persistant febrile seizures further on into CH
34
Febrile seizures are not d/t
CNS infxn/ inflammation no acute systemic metabolic abnormality that may produce convulsions no hx of previous febrile seizures
35
Criteria for simple febrile seizure (SFS) (65-90%)
duration under 15 min, total duration less than 30 min if in series no recurrence in 24 hrs no focal features
36
Complex febrile seizure (CFS)- meets 1+ criteria
duration > 15 mins recur in series for total duration > 30 min or more than 1 seizure in 24 hr period focal features
37
etiology of febrile seizure
infxn: HSV 6 (roseola), influenza, rotavirus immunization-related fever predisposing factors heredity, inhibitory NT production, maternal alcohol intake & smoking during pregnancy raises risk 2-fold
38
fever variability in febrile seizures
degree of fever is widely variable ht of fever does not seem to correlate w/ onset of seizure often the first sign of illness simple febrile seizures MC are generalized & tonic-clonic
39
DDx for febrile seizure
``` chills/rigors b/c of fever meningitis encephalitis intracranial tumor metabolic d/o meurologic d/o (developmental delay) ```
40
fevers in infants under 3 mo old
10% who appear well have a T > 38 C have a serious bacterial infxn or meningitis
41
fevers in CH 3-36 mo of age
2% who have a T above 39 C are found to have bacteremia
42
AAP recommends strong consideration of LP in febrile seizure if
infant <12 mo who have had 1st seizure w/ fever | febrile seizures occurring on/after 2nd day of illness
43
Diagnostic eval for febrile seizure
EEG no usually indicated for SFS if hx & PE benign neuroimaging electrolytes, glucose, Ca2+, BUN should be measured if hx & PE indicate (vomiting, diarrhea, edema, dehydration) or w/ CFS search for underlying cause of fever: CBC, blood cx, UA, urine cx
44
Febrile seizure Tx
ABCs anticonvulsants if seizure >10 min, watch for respiratory compromise, drugs in office/ED- midazolam, lorazepam, fospheytoin, rectal diazepam
45
Antipyresis in preventing febrile sizures
around the clock use not shown to be of benefit wo all CH w/ febrile seizures unknown if some subset benefits intermittent use warranted
46
Anticonvulsant therapy for febrile seizures
not recommended in CH w/ 1+ SFS
47
Continuous phenobarbital/ valproate reduce the risk of
recureent febrile seizures but have significant side effects
48
SE of phenobarbital
transient sleep disturbances decreased memory reduced concentration
49
SE of valproate
suppressed hematopoiesis renal toxicity pancreatitis hepatotoxicity
50
recurrence risk of febrile seizures
``` young age at onset hx of FS in 1st degree relative low degree of fever while in ED brief duration bet onset of fever & initial seizure all 4 factors- 70% risk 0-4 factors- <1yr old ```
51
febrile seizures & risk of epilepsy
2% chance (twice as high as gen. pop) | FH of FS, ethnicity, gender not risk factors
52
infantile spasms
seizures that have characteristic clinical findings in age group 4-8 months sudden adduction & flexion of limbs, head & trunk usually occurs in clusters when pt is irritable/ fatigued
53
Cryptogenic infantile spasm (40%)
no etiology evident, normal development before seizures
54
Symptomatic infantile spasms (60%)
association w/ perinatal & prenatal event or other identifiable cause have poor responses to anticonvulsants & poor intellectual prognosis
55
EEG with infantile spasms
waking state EEG reveals chaotic high-voltage slow waves, random spikes & background disorganization
56
Tx of infantile spasms
anticonvulsant therapy ACTH may be helpful ketogenic diet
57
neurocutaneous d/o's
d/o's of tissue arising from neuroectoderm skin findings brain, spinal cord, eye manifestations hamartomas
58
hamartoma
nml tissue growing at abnormal sites/ abnormally rapidly
59
neurofibromatosis type 1
NF-1>NF-2 cafe´ au lait spots neurofibromatosis (small, rubbery, usu. on skin) plexiform neurofibroma (diffuse thickening of n. trunk) Lisch nodule (hamartoma located in iris)
60
Complications of neurofibromas
``` scoliosis learning disabilities HTN (renal artery stenosis) d/o's of the hypothalamus tumors- brain, eye ```
61
neurofibromatosis type 2
``` bilateral acoustic neuroma unilateral 8th nerve mass neurofibroma meningioma glioma Schwannoma juvenile posterior subcapsular lenticular opacities ```
62
Tuberous sclerosis
AD (autosomal dominant) d/o characterized by proliferation of tubers from abnormal production of protein hamartin & tuberin
63
Clinical manifestations of tuberous sclerosis
may present w/ seizures (infantile spasms) calcified tubers in periventricular areas mental retardation hypopigmented skin lesions ash leaf macules shagreen patch adenoma sebaceum subungual/ periungual fibroma: commonly appear during adolescence
64
ash leaf spot
hypopigmented macule/patch | Wood's lamp highlights appearance
65
shagreen patch
roughened, raised lesion w/ an orange peel, leathery texture | often located in lumbosacral region
66
sebaceous adenomas
tiny, red, hyperpigmented nodules over the nose & cheeks
67
Sturge-Weber dz
anomalous development of the vascular bed during early cerebral vascularization. overlying leptomeninges richly vascularized & the brain beneath becomes atrophic & calcified
68
Clinical manifestations of sturge-weber dz
``` facial nevus (port-wine stain) seizures mental retardation intracranial calcifications hemiparesis ```
69
CT scan findings of Sturge-Weber dz
cerebral atrophy | intracranial calcifications
70
Guillain-Barre Syndrome m>f all ages, but rarely < 2 yo
acute idiopathic acquired inflammatory demyelinating polyradiculoneuropathy d/o is thought to result from a post-infectious immune mediated process that predominantly affects motor nerves
71
Pathophys of Guillain-Barre syndrome
most likely grouping of d/o's w/ peripheral n. demyelination as a common mechanism mediated by humoral factors & cell mediated phenomenon
72
In 2/3s of cases Guillain-Barre syndrome occurs after infxn with...
``` Campylobacter sp CMV, EBV Haemophilus influenzae Mycoplasma pneumoniae viruses ```
73
Clinical manifestations of Guillain-Barre syndrome
``` fine paresthesias & tingling of toes & fingertips pain may be prominent feature ascending weakness/paralysis LE symmetric weakness ascends to arms & cranial nerves ```
74
Guillain-Barre syndrome exam
``` diminshed/absent DTR paralytic ileus poor respiratory effort bladder dysfunction autonomic dysregulation HTN, HoTN, tachycardia/bradycardia, abnormal sweating ```
75
Dx of Guillain-Barre Syndrome
electrophysiologic studies mildly elevated ESR CSF elevated protein
76
Tx of Guillain-Barre Syndrome
IVIG plasmapheresis physical therapy watch for complications: respiratory failure, nutrition, autonomic disturbance
77
transverse myelitis
``` inflammation of the spinal cord w/ perivascular cuffing by lymphocytes thought to have immunologic basis pathogenesis (proposed) cell mediated immune response direct invasion of the spinal cord autoimmune vasculitis ```
78
Clinical manifestations of transverse myelitis
BACK PAIN AT LEVEL OF LESION ABRUPT ONSET of progressive weakness; legs weak & flaccid areflexia sensory disturbances in LE's below level of spinal lesion hx of preceding viral infxn sphincter disturbances
79
Lab findings in transverse myelitis
``` lumbar puncture- non specific increased protein pleocytosis w/ lymphocytes MRI (often diagnostic) dwelling of area of spinal cord EMG normal early in dz may show denervation at level of lesion ```
80
Tx of transverse myelitis
``` meds (controversial benefit) corticosteroids IVIG plasmapheresis supportive care physical therapy ```
81
infant botulism
acute, flaccid paralytic illness caused by the neurotoxin produced by soil orgnaism Clostridium botulinum 95% of cases between 3 wks & 6 mo of age almost 1/2 of cases are from CA
82
Clostridium botulinum
gram + spore forming anaerobe found in fresh & cooked agricultural products botulinum toxin is heat labile
83
forms of botulism
wound food-borne infantile
84
botulism pathogenesis
toxin carried by blood to peripheral cholinergic synapses binds irreversibly, blocking Ach release & causing impaired neuromuscular & autonomic transmission loss of motor endplate function recovery requires re-growth of terminal unmyelinated motor neurons
85
Infantile botulism clinical signs
``` symmetric, descending paralysis cranial nerve palsies poor feeding weak suck feeble cry ptosis obstructive apnea ```
86
lab confirmation of infant botulism
detection in serum detection of C. botulinum in feces CSF normal EMG defect in neuromuscular transmission
87
tx of infant botulism
``` supportive care tube enteral feeding respiratory support positioning to avoid aspiration mechanical ventilation botulism immune globulin (BIG) reduces duration of illness if given early ```
88
tics
quick, repetitive, irregular, briefly suppressible movements -facial: blinking, grimaces, twitches -trunk & extremities: twisting, flinging usu. last 1 mo-1yr stress/anxiety tend to increase the amt of tics
89
Tx of tics
teach parents natural hx disregard monitor for co-morbidities: school problems, ADHD, OCD, sleep difficulties
90
Tourette's syndrome is not d/t
direct physiological effects or a substance or a general medical condition
91
Diagnostic Criteria for Tourette's syndrome
- tics occur many times a day (bouts) nearly q day/intermittently throughout a period of >1 yr (never a tic free period of >1 yr; never a tic free period of >3 consecutive mo) - multiple motor & 1+ vocal tics present at some time - onset before 18yo
92
Tx of Tourette's syndrome
non-pharm: counseling, adjustment of school & family members | -meds: haloperidol, fluoxetine, clonidine
93
spinal muscular atrophy (SMA) types I, II, III
group of d/o's characterized by degeneration of motor neurons w/ compensation from re-innervation of an adjacent motor unit upper motor neurons NOT involved
94
SMA type I | Werdnig-Hoffman dz clinical manifestations
``` severe hypotonia generalized weakness thin muscle mass involvement of the tongue (fasciculations) perservation of extraocular muscles ```
95
Labratory Dx of Werdnig-Hoffman dz (SMA type I)
serum CK may be mildly elevated (different from muscular dystorphy) muscle bx- areas of atrophy, adjacent areas of hypertrophy molecular genetic dx
96
Tx of Werdnig-Hoffman dz (SMA type I)
``` no tx to delay progression funtional aids in type II or type III supportive care feeding NG feeds respiratory support O2 pulmonary toilet ```
97
microcephaly
head circumference more than 2 std deviations below the mean for age
98
macrocephaly
HC > 2 std deviations above the mean for age
99
DDx for microcephaly
``` chromosomal d/o (trisomy 13, 18, 21) non-chromosomal genetic d/o congenital malformation placental insufficiency perinatal hypoxia/trauma metabolic degenerative dz (Krabbe, Tay-Sachs) toxins (fetal alcohol syndrome, meds, maternal PKU) infxns (TORCH, toxoplasmosis, rubella, CMV, herpes, HIV) radiation familial ```
100
DDx for macrocephaly
pseudomacrocephaly increased ICP (w/ dilated ventricles-hydrocephalus, with mass effect-tumor, arachnoid cyst, porencephalic cyst) benign familial macrocephaly megalencephaly (large brain)- neurocutaneous d/o, gigantism, metabolic d/o, lysosomal storage dz, leukodystrophy- progressive white matter degeneration thickened skull

Peds-Final (10 decks)

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