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12 yo boy has decreased visual acuity, peripheral visual field defects, papilledema B/L, and L CN6 palsy. No other neuro deficits. PE is normal. MRI of head is normal. What is it? Most appropriate next step?

Pseudotumor cerebri
- Elevated ICP (HA, visual deficits, papilledema)
- Only neuro deficits --> papilledema, CN6 palsy, vision loss

Next step --> LP (determine opening pressure)


What is progression of treatment in status epilepticus?

1) Benzo (lorazepam)
2) Phenytoin/Fosphenytoin
3) Phenobarbital

*Status epilepticus = continuous seizure activity for >30 minutes OR 2+ seizures w/o interval recovery


Treatment of myasthenia gravis?

Anticholinesterase --> pyridostigmine or neostigmine


If on high doses and stopped abruptly, what medication can trigger seizures as withdrawal symptom?

Benzos (alprazolam)


What is an essential tremor?

What is treatment?

Seen in upper extremities (hands) when the arms are outstretched --> increase in severity at the very end of goal-directed activities (finger-to-nose test)

Tx: propranolol


Best initial test for suspected stroke?

Suspicious s/s?

NON-contrast head CT

New-onset focal neuro deficits, vascular PMH, diabetes


What are 2 meds given for essential tremor?

Which one has side effects of abdominal pain, confusion, headaches, hallucinations, and dizziness? Why?

Propranolol, Primidone

Primidone --> anticonvulsant that may precipitate ACUTE INTERMITTENT PORPHYRIA causing these s/s


What type of brain herniation occurs with epidural hematoma?

Central herniation of thalamus/hypothalamus through notch in tantrum cerebelli


Describe Parinaud syndrome?

Pressure on midbrain near CN III from pinealoma

*Limitation of upward gaze
*Prefer downward gaze
*B/L eyelid retraction
*Pupils minimally reactive to light, but normal accommodation


Signs with posterior communicating artery rupture/aneurysm?

Retro-orbital headaches
*CN III palsy (+/- I/L mydriasis)

Second most common site for aneurysm


Signs with anterior communicating artery rupture/aneurysm?

Paralysis/weakness of LE
B/L Babinski (+)
Akinetic mutism/abulia
Personality changes

*Most common site for aneurysm


Signs with MCA rupture/aneurysm?

*C/L hemiparesis & hemisensory loss
Aphasia (if dominant hemisphere)
Apraxia, neglect


Signs with posterior inferior cerebellar artery rupture/aneurysm?

Wallenberg syndrome --> decreased pain/temp of I/L face and C/L body, dysphagia, slurred speech, vertigo, nystagmus
**CN 9, 10

Supplies cerebellum


Treatment of SAH?

Endovascular coiling


Man taking warfarin with no hx of intracranial hemorrhage or recent surgery. Has signs of MCA stroke. Hx of AFib. INR is 1.4. CT of brain shows no intracranial hemorrhage or other abnormalities. Current BP is 201/182. What is next best step in mgmt?

1) Need to lower BP systolic


Treatment for restless leg syndrome?

Dopamine agonists --> pramipexole


Gentleman who has recently been forgetting his wife's name and talking to people who are not present. PMH shows several UTIs and trouble walking requiring a walker. He has also had several episodes of urinary incontinence. What is it? What's best way to definitively diagnose his condition?

Normal pressure hydrocephalus

*Wet, wacky, wobbly*
- Urinary incontinence
- Dementia/memory concerns
- Gait/walking issues

Lumbar puncture


What type of antibiotics should NOT be given to someone with Myasthenia Gravis?

Aminoglycosides & Clindamycin


Woman with several different focal neurological deficits that occur at different periods of time?

If LP done, what is found in CSF?

Multiple sclerosis

Oligoclonal bands (IgG usually)


Most common organisms responsible for bacterial brain abscess from spread of bacteria from head/neck infection (sinusitis)?

Anaerobes --> Strep viridans!


Hemi-sensory loss with severe dysesthesia of the affected side is typical for what area for a stroke?



In EtOH abuse, cerebellar dysfunction is common. What are s/s seen with this?

Progressive gait dysfunction
Truncal ataxia
Intention tremor
Impaired rapid alternating movements


Person has worsening insomnia, confusion and memory loss over 3 months. Also has muscle twitching and gait problems. No fever, HA, or urinary problem. No EtOH use. Vitals are stable. Misses 3/3 delayed recall items and has prominent agnosia. Has nystagmus, hypokinesia, and (+) Babinski b/l. EEG shows periodic sharp waves. What is it?

Creutzfeldt-Jakob disease

*Rapidly progressive dementia + myoclonus (twitching)*

*Sharp wave complexes on EEG*


Person has altered mental status, gait instability. He also has prominent horizontal nystagmus and conjugate gaze palsy. What is the cause of these s/s?

Wernicke's encephalopathy (thiamine deficiency)

**Encephalopathy, oculomotor nerve dysfunciton, gait ataxia**


Young obese female with headache and papilledema but normal MRI - what do you think?

Best initial tx?

Pseudotumor cerebrii

Impaired absorption of CSF by arachnoid villi

Suggestive of brain tumor but NO imaging findings!

*Tx: acetazolamide
(-) choroid plexus carbonic anhydrase --> decreases CSF production and intracranial hypertension


What area of the brain is affected when hemi-neglect is present?

OPPOSITES side of PARIETAL brain from symptoms

L side s/s = R parietal brain


Describe the tremor of Parkinson's?


WORSE with rest/emotional stress and BETTER with activity (opposite for essential tremor)

Tx: Trihexyphenidyl (anti-ACh)


Treatment for restless leg syndrome?

Dopamine agonists - pramipexole
Gabapentin (delta Ca channels)


What is treatment of Guillian Barre syndrome?
What is cause of death?

Resp paralysis of diaphragm


Patient develops sharp pains and loss of sensation over R side of face. The L trunk and extremities have loss of sensation and no pain as well. The gag reflex is diminished. There is partial ptosis of the R eye. Horizontal and rotational nystagmus are present. When sitting without support, he topples to the R side. Where is the stroke located?

Lateral medulla (Wallenburg)

Loss of pain/temp over I/L face & C/L body
I/L (dysphagia/dysarthria)
Vertigo/nystagmus (vestibulocerebellar)
Horner syndrome


Treatment of choice for absence seizures?

Ethosuximide OR valproic acid


Child develops HA most severe in the mornings, vomiting, and visual disturbances. He also has unbalanced gait, trunk dyslexia, and papilledema. If it was a medulloblastoma, where would it be located?

Cerebellar vermis --> vermis responsible for truncal balance

Posterior vermis syndrome


What type of seizure is described by staring spells, failure to respond to stimuli during the episode, post-ictal confusion, and automatisms (lip-smacking)?
What do you see on EEG?

Complex partial seizures

*EEG --> NO changes


How do you differentiate between absence and complex partial seizures?


CP seizures = NO changes on EEG
Absence = spike-and-wave activity brought on by HYPERVENTILATION


What are characteristics of Parkinsonism?

*Shuffling gait (hypokinetic), stooped posture, immobile arm swing, immobile facial expressions, bradykinesia, resting tremor, rigidity

Overactivity of cholinergic neurons and under activity of dopaminergic neurons in substantia nigra


What is characterized by hypoglycemia, hyponatremia, low libido, erectile dysfunction, cold intolerance and constipation?


*Glucocorticoid def (hypoglycemia, hyponatremia)
*Testosterone def (low libido, ED)
*Hypothyroidism (cold intolerance, constipation)


Difference b/w generalized and partial seizures?

Difference b/w complex and simple?

What is secondary generalization?

Gen = both hemispheres
Partial = one hemisphere (Discrete part)

Complex = LOC, automatisms (biting, chewing, lip smacking)
Simple = no LOC

2ndary generalization --> tonic-clonic manifestations


Cafe-au-lait spots, multiple freckles on armpits and groin areas, large head for age, feeding problems and short with learning disabilities - what is this?

What eye finding can be seen?

Neurofibromatosis Type 1

*Optic gliomas (u/l progressive vision loss, decreased brightness sensation)


What are the 2 findings of Neurofibromatosis Type 2?

B/L acoustic (CN8) neuromas


Patient has been seizing for >5min without response to any meds. What area of the brain is he at most risk to damaging?

Cortical laminar necrosis

*Hallmark of prolonged seizures (status epilepticus > 5min)


4 yo boy has red flat lesion covering the L eye area and adjacent facial skin that does not blanch on pressure. He also had his first seizure just 2 hours ago. He also has hemianopia, hemiparesis, and hemisensory disturbances. He has tramline intra-cranial calcifications on X-ray. What is it?

Sturge-Weber syndrome

**Look for congenital cavernous hemangioma along trigeminal (CN5) nerve distribution

**Intra-cranial calcifications that look like tramline


In addition to NSAIDs and triptans, what are the best initial treatment for acute migraine headaches?

*Chlorpromazine, prochlorperazine, metoclopramide

Great for nausea and vomiting


6 yo boy has hemiplegia of acute onset and states she found the boy unconscious and he slowly gained consciousness, but he could not move his right arm and leg. Motor function restored spontaneously during 24hr observation in the hospital. Head CT is normal. What is the cause?

Todd's paralysis

**Sudden loss of consciousness with following disorientation and slow gain of consciousness afterwards with the motor deficit fully resolving 24hrs after onset**


Best initial treatment in fibromyalgia?

If the above fails, then what's first line med tx in fibromyalgia?

Aerobic exercise + good sleep hygiene

TCA's (amiptriptyline)


What are initial side effects of levodopa/carbidopa?

Hallucinations, confusion, dizziness, somnolence, nausea


Person has symptoms of SAH and has endovascular coiling. On the 5th day of hospitalization, he appears mildly confused and complains of tingling in his R hand. There is R-sided muscle weakness and mild facial droop. What is the cause of his s/s?

Cerebral vasospasm & infarction

*3-10 days after SAH --> vasospasm can occur and result in infarction


What is tx to prevent vasospasm and infarction after SAH?



Triad of findings in epidural abscess?

Best initial test?


FOCAL spinal tenderness/back pain
Neuro dysfunction

MRI of spine

Antibiotics with surgical decompression


If suspected Facial palsy, what test is vital to perform on physical exam?

**Eyebrow raising --> differentiates b/w peripheral and central lesion

Peripheral: have BOTH upper and lower facial weakness
Central: ONLY LOWER facial weakness (each side of the brain innervates both upper facial quadrants - if one side is knocked out, the other can compensate and still have normal upper facial fxn)


37 yo woman has severe vertigo, postural instabiliy, and vomiting. She also has a buzzing sound in her R ear that has occurred 2 times over the past year that lasted several hours but resolved spontaneously. She has horizontal nystagmus on exam. What is it? What could have prevented this from occurring?

Meniere's disease
- Distention of endolymph in cochlea/vestibular apparatus

1) Vertigo
2) Hearing loss (sensorineural)/ear fullness
3) Tinnitus

**Avoid high salt diet, caffeine, alcohol, nicotine**


Pulsatile headache, blurry or double vision, whooshing sound in the ears that gradually progresses to nausea, vomiting and visual disturbances?

What is best test and finding?

Pseudotumor cerebrii

LP --> elevated opening pressure


Drug causes of pseudo tumor cerebrii?

Growth hormone
Tetracyclines (minocycline, doxycycline)
Excessive Vit A (isotretinoin, all-trans-retinoid acid)


Eye finding in tuberous sclerosis?

Retinal hamartoma


What finding may be present in brain death?


*Spinal cord may still be functioning


Sensorineural b/l hearing loss can be caused by what drugs?

Aminoglycosides ("-micin/mycin")
Loop diuretics (high doses)
Aspirin (tinnitus)


47 yo woman develops recent mood instability and mild forgetfulness. Her father had these same s/s at her age and died shortly afterwards. She also has writhing movements of her extremities. What is it?

Huntington disease


What other symptoms are seen with Lewy Body demential?

Parkison-like motor s/s
Visual hallucinations


Person in recent MVA now has weakness in UE more than LE. What is the cause?

Central cord syndrome
*Hyperextension injuries that cause damage to CST


What type of injury is characterized by B/L spastic motor paresis DISTAL to the lesion?

Anterior cord syndrome
*Occlusion of anterior spinal artery


I/L weakness, spasticity, and loss of vibration and positional sense with C/L loss of pain and temperature?

Brown-Sequard syndrome


Drug used to treat AML?



Weakness and hyperreflexia with a conjugate gaze deviation away from the hemiparesis is in what area?

Basal ganglia


What findings are seen with thalamic hemorrhage?

Hemiparesis and sensory loss + conjugate gaze palsy TOWARDS the side of hemiparesis

*Thalamic = Towards


Characteristic history and imaging findings in glioblastoma multiforme?

Personality changes, strange behaviors --> frontal lobe

CT/MRI --> "butterfly" appearance w/ central necrosis


Characteristic CT/MRI finding of high-grade astrocytoma?

Heterogenous, serpiginous contrast enhancement


Treatment for trigeminal neuralgia?



Intense one-sided headache located behind the eye that starts very suddenly - can wake one from sleep. Peaks rapidly and lasts for 2 hours. Can have redness of the eye, tearing, stuffy/runny nose, or one-sided Horner syndrome. What is it?

Cluster HA

*Acute, severe retro-orbital pain that wakes patient from sleep
*Can have eye redness, tearing, stuffy/runny nose, and Horner syndrome

Prophylatic tx = verapamil, lithium, ergotamine
*ACUTE tx = 100% O2


Effects of internal capsule infarct?

I/L motor weakness in face, arm, and leg (entire one side of the body)
NO higher cortical dysfunction
NO visual field abnormalities


Effects of vertebrobasilar system infarcts involving brainstem?

ALTERNATE syndromes --> C/L hemiplegia + I/L cranial nerve involvement


How do cerebellar tumors present?

I/L ataxia --> falls TOWARD side of lesion
Intention tremors
Loss of coordination


Gait seen in tabes dorsalis?

Wide-based gait
Feet lifted higher than usual
*Slapping sound when contacting floor


Gait in muscular dystrophy?

Waddling gait (weakness in gluteal muscles)


Best indicator distinguishing dementia (Alzheimer) from normal changes of aging?

Impairment of daily functioning


What occurs with lacunar infarct of posterior limb of internal capsule?

Pure motor hemiparesis --> U/L face, arm, leg
*NO sensory, visual, higher cortical dysfxn


What occurs with lacunar infarct of VPL nucleus of thalamus?

Pure sensory stroke --> U/L numbness, paresthesias, hemisensory loss in face, arm, trunk, leg


What occurs with lacunar infarct of anterior limb of internal capsule?

Ataxic-hemiparesis --> LE weakness, I/L arm + leg incoordination


What occurs with lacunar infarct of pons?

Dysarthria-clumsy hand syndrome --> hand weakness, mild motor aphasia
NO sensory abnormalities


Main cause of lacunar strokes?



Where is the lesion in a person with internuclear ophthalmoplegia?



What area of the brain presents with motor and sensory loss greater in the LE than UE?

Anterior cerebral artery stroke


Dizziness, nausea, sensation of ear fullness?

Meniere's disease