Neurology Flashcards
1
Q
Vertigo diagnosis
A
most important is the history. “When you have dizzy spells, do you feel light headed or do you see the world spin around you?” True vertigo is the room spinning. Also need: neuro exam, head and neck exam, cardiac exam
2
Q
Chronic dizziness is associated with these conditions
A
Falls, functional disability, orthostatic hypotension, syncope, strokes, fear of falling, depression, decreased social activities
3
Q
What you need to dx neuro disorders
A
good hx, focal exam, a good differential dx to present to neurologists
4
Q
Dizziness, acute v chronic
A
Dizziness is a term used to describe various abnormal sensations arising from perceptions of the body’s relationship to space or unsteadiness. Acute is 2 months.
5
Q
Vertigo definition
A
Sensation of spinning in which the individual perceives movements of the environment in relation to the body (objective vertigo) or vice verson (subjective vertigo)
6
Q
Dizziness patho
A
Sensation of postural instability or imbalance, vestibular system maintains spacial orientation at rest and during acceleration. Infection or congestion could alter this.
7
Q
Diseases that could alter vestibular system
A
Menieres disease Benign Paroxysmal Positional Vertigo Recurrent Vestibulopathy Labyrinthitis/Vestibular Neuronitis Acoustic Neuroma Drug Toxicity Age related changes related to hair cells
8
Q
Disorders of the proprioceptive system
A
Peripheral neuropathy - b12 deficiency and DM, cervical degenerative disorders. Proprioceptive system consists of mechanoreceptors in the joints, peripheral nerves, and posterior columns and multiple CNS connections. ANY CNS disorder can lead to an imbalance causing dizziness. Bells palsy can have prodromal symptoms of dizziness.
9
Q
Ocular system and dizziness
A
Vision provides information about spacial orientation. Disorders of the ocular system: cataracts, macular degen, glaucoma, age related changes - decrease in acuity, dark adaption, contrast sensitivity, and accomodation
10
Q
CN 1
A
Olfactory, smell.
11
Q
CN 2
A
Optic, vision. Opthalmoscope, visual acuity
12
Q
CN 3
A
Oculomotor, raise eyebrows, pupil constriction
13
Q
CN 4
A
Trochlear
14
Q
CN 5
A
Trigeminal, facial sensation
15
Q
CN 6
A
Abducens
16
Q
CN 7
A
Facial, smile, puff cheeks, raise eyebrows
17
Q
CN 8
A
Acoustic, test hearing, test vertigo
18
Q
CN 9
A
Glossopharyngeal, palate elevation and gag reflex
19
Q
CN 10
A
Vagus, test articulation
20
Q
CN 11
A
Spinal accessory, shrug shoulders,
21
Q
CN 12
A
Hypoglossal, stick out tongue
22
Q
The most common type of dizziness reported by older people
A
Mixed dizziness - different circumstances of being dizzy
23
Q
Vertigo results from
A
disorders of the vestibular system and its connecting pathways
24
Q
Disequilibrium
A
Feeling of unsteadiness or imbalance primarily involving lower extremities or trunk rather than the head. Patient usually expressese the feeling that he or she is about to fall. Results from disorders of proprioceptive system, musculoskeletal weakness or cerebellar disease
25
Pre-syncope
Results from hypoperfusion of the brain, is a feeling of lightheaddedness or impending faintness or the sensation that one is about to pass out. ***cardiovascular causes including vasovagal disorders are common causes in older persons
26
Multifactoral dizziness
"whirling" "tilting" "floating" and other nonspecific sensations
27
Menieres Disease
(Endolymphatic hydrops) 2-8 percent of older patients with dizziness. Etiology unknown. Pathology: excess endolymph within the cochlea and labyrinth. Involvement of the inner ear, "fullness". Unilateral in majority of patients. May have nausea/vomiting/ha during episodes. Classic triad: episodic vertigo, tinnintus, and fluctuating sensory-neural hearing loss. True vertigo can last from 1-24 hours.
28
Weber Rinne megahertz
512
29
Benign Paroxysmal Positional Vertigo
Etiology unknown in most cases, although some have a history of head injury or viral labyrinthitis. Pathology: Results from freely moving particulate matter within the posterior semicircular canal. This movement causes alteration in the endolymphatic pressure resulting in vertigo and nystagmus
30
BPPV s/s
Vertigo, nystagmus, sudden onset, n/v. Precipitated by changes in the position of the head. Classically accompanied by rotational nystagmus. Dx w Dix-hallpike test
31
Recurrent vestibulopathy
Idiopathic, vertigo lasts from 5minutes until 24 hours. Characterized by recurrent episodes of vertigo without auditory or neurological symptoms or signs. As opposed to Menieres disease, auditory symptoms are absent
32
Acoustic Neuroma
aka Cerebellopontine Angle Tumor. 1-3% of persons with dizziness. A benign tumor of the 8th CN. Clinical features: tinnitus and progressive UNILATERAL sensourineural hearing loss, particularly for the higher frequencies like phone ring or doorbell. Feel unsteady not true vertigo. Large tumors may have occipiral headache, diplopia, paresthesias in trigeminal or facial nerve distribution and or ataxic gait
33
CNS Disorders
cerebrovascular disease ranges from 4-70 percent among older people with dizziness. TIA/Stroke c/o dizziness, diplopia, dysarthria, numbness or weakness. Cerebellar infarct, posterior lateral medullary infarction Wallenberg Syndrome
34
Psych disorders and dizziness
Depressive symptoms are a/w dizziness and vice versa among older persons
35
Cervical disorders and dizziness
Usually present with vague lightheadedness or vertigo a/w turning the head, most common vascular mechanism of cervical dizziness is an obstruction of the vertebral arteries. degenerative changes in the cervical spine may cause dizziness because of impairment of the cervical proprioceptive mechanoreceptors. May present with radicular pain in the neck upon movement as well as dizziness.
36
Systemic causes of dizziness
hypothyroidism, anemia, electrolyte imbalance, HTN, CAD, CHF, DM. These can lead to decreased cerebral perfusion or oxygen delivery leading to a sensation of dizziness
37
Orthostatic hypotension
20/10 drop after standing from supine or sitting.
38
Postural dizziness
dizziness in standing from supine but no drop in pressure
39
Postprandial hypotension
A decrease in systolic blood pressure of 20 or more in sitting or standing within 1-2 hours of eating a meal
40
Meds causing dizziness
Antihypertensives, loop diuretics causing ototoxicity or volume depletion, antiarrhythmics, anticonvulsants, anxiolytics through effect on CNS, tricyclic antidepressents, anithistamines, and cold preparations through anticholinergic properties, antibiotics and nsaids and loops cause through ototoxicity especially with decreased renal function which decreases their clearance
41
Vestibular dizziness
BPPV, Menieres, Vestibular neuritis, labyrinthitis, cholesteatoma, superior semicircular canal dehiscence, perilymphatic fistula
42
Neurologic dizziness
Vestibular migraine, posterior fossa tumor, MS, cerebellar stroke, vertebrobasilar insufficiency, wallenberg syndrome, trauma, paraneoplastic cerebellar degeneration, benign intacranial HTN, mal de debarqument syndrome
43
Cardiovascular dizziness
syncope/presyncope, orthostatic hypotension, autonomic dysregulation
44
Psych dizziness
psychophysiologic dizziness, psychogenic dizziness
45
Metabolic dizziness
DM, hypothyroidism
46
Autoimmune dizziness
RA, SLE, Cogan syndrome, wegener granulomatosis, bahcet disease
47
Iatrogenic dizziness
post surgical
48
Infectious dizziness
Lyme, Syphillis, HIV, CMV, HSV1
49
Sense of rotation or being pushed
Vertigo
50
Relieved by sitting or lying down
Presyncope or impending faint
51
Imbalance
Sensation localized to the body relieved by support
52
Ill-defined lightheadedness
Cerebral sensation of being woozy, visual abnormalities
53
If dizziness cause is uncertain
Provocative testing to stimulate cephalic ischemia by producing orthostatic hypotension, including valsalva, hyperventilation
54
Stimulate vestibular dysfunction by
swiveling then rapidly stopping in a chair to induce vertigo that the pt can compare to their symptomatic dizziness
55
Dizziness/Vertigo tx
Tx underlying cause, educate to reduce anxiety, modify activities that lead to dizziness, avoid harm
56
Pharm tx of dizziness
Vestibular suppressants for acute episodes only. Antihistamines use with caution as they can cause dizziness. Anticholinergics. Benzos for long term treatment
57
Referral for dizziness
Consider referral to cardiology, neurology, endocrinology. PT for vestibular rehab consists of sets of exercises using movements of the eyes, head and body to stimulate the vestibbular system
58
Pharm mgmt of orthostatic hypotension
Caffeine, Fludrocortisone, Midodrine, Desmopressin, Erythropoeiten
59
definition of dementia DSM-5
decline in cognition involving at least one or more cognitive domains:
learning and memory
language
executive function (make decisions, balance checkbook)
complex attention* added in dsm5
perceptual- motor (tripping over everything)
social cognition*added in dsm5
- must represent a significant decline from previous level of functioning
- deficits NOT explained by another mental disorder and no not occur exclusively in the context of delirium
60
number one job pertaining to alzheimer's
early recognition- history taking is key
61
new name for dementia according to DSM5
major neurocognitive disorder
62
criteria for dementia according to DSM 4
```
A1. Memory
impairment
A2. At least one of the following:
Aphasia
Apraxia
Agnosia
Disturbance
in executive
functioning
B. The cognitive deficits in A1 and A2 each cause
significant impairment in social or occupational
functioning and represent a significant decline
from a previous level of
functioning
C. The cognitive deficits do not occur exclusively
during the course of delirium
```
63
criteria for DSM 5
A. Evidence of significant cognitive decline
from a previous level of performance in one or
more cognitive domains:
Learning
and memory
Language
Executive
function
Complex attention*
Perceptual- motor
Social cognition*
B. The cognitive deficits interfere with
independence in everyday activities. At a
minimum, assistance should be required with
complex instrumental activities of daily living,
such as paying bills or managing medications.
C. The cognitive deficits do not occur
exclusively in the context of a
delirium
D. The cognitive deficits are not better
explained by another mental disorder (eg,
major depressive disorder, schizophrenia)
64
biggest problem with dementia
insidious nature of the problem, years typically pass before informants come forward (rarely self reported)
65
mild cognitive impairement (MCI)
generally defined by the presence of memory difficulty
| and objective memory impairment but preserved ability to function in daily life.
66
cause/ differentials for: Gradual onset of short- term memory loss and functional impairment in more than one domain:
I. Executive function (finances,
shopping, cooking, laundry, transportation)
II. Basic activities of daily living (feeding, dressing,
bathing, toileting, transfers)
cause- dementia
differentials: Alzheimer disease, Parkinson
dementia, Lewy body dementia,
Pick's disease, alcohol-related dementia, Creutzfeld-Jacobs disease
67
cause/ differentials for: Stepwise, sudden deterioration in
| cognition; episodes of confusion, aphasia, slurred speech, focal weakness
cause- Cerebrovascular disease
differentials- Vascular dementia, multi-infarct
dementia, Binswanger's dementia (subcortical dementia)
68
cause for: Acute cognitive impairment
with clouded sensorium; difficulty with attention; may have
hypersomnolence
cause- delirium
69
Complains of memory loss, decreased concentration, impaired judgment, feels worse in morning
and hopeless
cause- depression
| differentials- Minor depression, dysthymic disorder, major depression, pathologic grief reaction
70
examination for dementia patient should include
cognitive, mini mental exam, clinical dementia rating, mini cog, neuropsychological testing, premorbid ability (SEE up to date "Eval of cognitive impairment and dementia" these are explained- one will be on exam)
71
clinical dementia rating (CDR)
(0, 0.5, 1, 2, 3)
Score only as decline from previous usual level due to cognitive loss, not impaired due to other factors
•increasingly used in clinical decision making as well, such as driving
•In a semi- structured interview with the patient and caregiver
http: //www.biostat.wustl.edu/~adrc/cdrpgm/ind
ex. html (BECOME FAMILIAR WITH THIS)
72
delirium
Acute confusional state characterized by an alteration of consciousness with reduced ability to focus, sustain, or shift
attention
73
dx of delirium
**multi- layered- 5 key features (need all of them**)
1. abrupt disturbances
2. disturbances in attention
3. disturbance in cognition
4. no other explanation of the disturbance
5. disturbance is caused by a medical condition, substance
intoxication or withdrawal, or medication side effect
74
management of delirium
Avoiding factors known to cause or aggravate delirium, such as multiple medications, dehydration, immobilization, sensory impairment, and sleep disturbance
1. identifying and treating underlying problem
2. providing supportive/ restorative care to prevent further physical and cognitive decline
3. Where appropriate, controlling dangerous and severely
disruptive behaviors using low dose, short acting pharmacologic agents
75
syncope
is a symptom defined as a transient,
| self- limited loss of consciousness, usually leading to falling.
76
Regardless of the etiology, the underlying mechanism
| responsible for syncope is ?
a drop in cerebral oxygen delivery below the threshold for consciousness also known as transient cerebral hypoperfusion
77
pathophys behind syncope- The “blunted baroreflex sensitivity” with aging is
manifested as
a reduction in the heart rate response to hypotensive stimuli
78
pathophys behind syncope- Older adults are prone to reduced blood volume:
a decline in plasma renin and aldosterone, which
causes excessive salt wasting by the kidney, a rise
in atrial natriuretic peptide, and concurrent diuretic therapy
79
orthostatic hypotension
Is arbitrarily defined as either a 20 mmHg fall in systolic blood pressure or a 10 mmHg fall in diastolic blood pressure on assuming an upright posture from a supine
position
80
possible causes of orthostatic hypotension
Aging, HTN, medications, myocarditis, atrial myxoma, aortic stenosis, constrictive pericarditis, hemorrhage, diarrhea, vomiting, ileostomy, burns, hemodialysis, salt losing nephropathy, diabetes insipidus, adrenal insufficiency, fever, extensive varicose veins, primary autonomic failure syndromes, secondary autonomic dysfunction and volume depletion
81
orthostatic hypotension- Precipitating factors
speed of positional change, prolonged recumbency, warm
| environment, raised intrathoracic pressure (coughing, defecation, micturition), physical exertion, and vasoactive drugs.
82
Carotid Sinus Syndrome & Carotid Sinus Hypersensitivity pathophys
–Characterized by episodic bradycardia and/or
hypotension resulting from exaggerated baroreceptor
mediated reflexes or carotid sinus hypersensitivity
–Is diagnosed in persons with otherwise unexplained
recurrent syncope who have carotid sinus
hypersensitivity
–Is considered present if carotid sinus massage
produces asystole exceeding 3 seconds
(cardioinhibitory), or a fall in systolic blood pressure
exceeding 50 mmHg in the absence of cardioinhibition (vasodepressor), or a combination of the two (mixed).
83
Carotid Sinus Syndrome: Presentation
The syncopal symptoms are usually precipitated by mechanical stimulation of the carotid sinus such as head turning, tight neckwear, neck pathology, and by vagal stimuli such as prolonged standing. In a significant number of patients no triggering event can be identified
84
carotid sinus syndrome- possible triggers
postprandial state, straining, looking or stretching
| upward, exertion, defecation, and micturition
85
normal response to orthostasis
an ↑ in heart rate, rise in peripheral vascular resistance (↑ in diastolic blood pressure), and minimal ↓ in systolic blood pressure, to maintain an adequate cardiac output
86
pathophys of vasovagal syncope
The possible mechanism involves a sudden fall in venous return to the heart, rapid fall in ventricular volume, and virtual collapse of the ventricle because of vigorous ventricular contraction → stimulation of ventricular mechano-receptors and activation of Bezold–
Jarisch reflex leading to peripheral vasodilatation (hypotension) and bradycardia.
87
more pathophys of vasovagal syncope
Possible central sympathetic inhibition due to several neurotransmitters: serotonin, endorphins, and arginine vasopressin
88
older persons susceptible to vasovagal syncope because?
Hypertension, atherosclerotic cerebrovascular disease, cardiovascular medications, and impaired baroreflex sensitivity can cause dysautonomic responses during prolonged orthostasis (in which blood pressure and
heart decline steadily over time) and render older persons susceptible to vasovagal syncope. also Diuretic use further increase the risk of vasovagal syncope bc they cause you to become hypovolemic.
89
presentation of vasovagal syncope
The hallmark is hypotension and/or bradycardia sufficiently
profound to produce cerebral ischemia and loss of neural
function
90
Usually there is a precipitating factor/situation to cause vasovagal syncope such as?
```
Emotional stress(fight/flight response), anxiety, mental anguish, trauma, physical pain or anticipation of physical pain (e.g., anticipation of
venesection), warm environment, air travel, and prolonged
standing
```
91
vasovagal syncope classified into 3 types:
Cardioinhibitory (bradycardia), vasodepressor (hypotension), and mixed (both)
92
vasovagal syncope- Manifestations occur in 3 phases:
```
A prodrome (aura- ie taste in your mouth, smell, vision change), loss of consciousness, and
postsyncopal phase
```
93
*The most common triggers of vasovagal syncope in older patients:
*prolonged standing and vasodilator medications
94
Prodromal symptoms include: (elderly patients may not remember prodromal sx)
Extreme fatigue, weakness, diaphoresis, nausea, visual defects, visual and auditory hallucinations, dizziness, vertigo, headache, abdominal discomfort, dysarthria, and paresthesias
95
vasovagal syncope may mimic what? why?
seizure since during syncopal period some patients develop involuntary movements usually myoclonic jerks, but tonic– clonic movements also occur
96
Recovery for vasovagal syncope
Usually rapid, but older patients can experience protracted symptoms such as confusion, disorientation, nausea, headache, dizziness, and a general sense of ill health.
97
postprandial hypotension**
**In healthy older patients, systolic blood pressure falls by
11 to 16 mmHg, and heart rate rises by 5 to 7 beats/min
60 minutes after meals of varying compositions and
energy content**
98
postprandial hypotension*
***In older persons with hypertension, orthostatic
hypotension, and autonomic failure, the postprandial
blood pressure fall is much greater and without the
corresponding rise in heart rate. (heart rate can't go up in older patients sometimes bc of meds)
99
postprandial hypotension: Postprandial Physiologic
| Changes
Increased splenic and superior mesenteric artery blood flow at the expense of peripheral circulation and a rise in plasma insulin levels without corresponding rises in
sympathetic nervous system activity.
–
Vasodilator effects of insulin and other gut peptides, including neurotensin and VIP contribute
to hypotension.
100
possible reasons for syncope dx- neuro
```
Neurally mediated
Orthostatic hypotension
Acute vertibrovascularstroke
Migraine
Seizure
```
101
possible reasons for syncope dx- endocrine
hypoglycemia, addison's disease
102
possible reasons for syncope dx- psych
psychogenic pseudosyncope
103
possible reasons for syncope dx- cardi
```
Acute coronary syndrome
Ventricular arrhythmias
A – V block
☼☼Wolff –Parkinson
White syndrome
Cardiac temponade
Aortic dissection
PE
Ruptured AAA
Acute A-Fib
Heart failure
Volume depletion
Sinus node dysfunction
Long QT syndrome
Aortic Stenosis
Hypertrophic cardiomyopathy
Mitral Stenosis
Atrial myxoma
Subclavian steal syndrome
```
104
syncope dx most important step
*most important tool is a careful history! It will suggest the correct cause and exclude other potential indicators. Hx should be focused on nature of events prior, during, and after syncope (i.e. supine position indicates probable cause of arrhythmia or seizure)
105
syncope dx- what should be ordered?
tests should be guided by h & p. Important to get SBP (supine and upright). Lab tests- serum electrolytes, glucose, hematocrit, blood and urine tox screening (to r/o drugs and etoh), cardiac enzymes (to r/o MI) and EKG should be done on all patients bc it could provide a clue to cause of syncope (e.g. prolongation or bundle branch block may indicate bradyarryhthmias)
106
if cardiac cause for syncope is suspected order?
step 1. echo, halter, stress test, lunh scan
step 2. EP study
step 3. carotid sinus message (CSM), upright tilt table test
step 4. Loop ECG
107
if neurally mediated is suspected for syncope order?
step1. CSM, tilt test
step2. echo, halter
step3. EP study (if heart disease)
108
if cerebrovascular or psychiatric cause is suspected for syncope order?
step1. psych eval
step2. EEG if seizures suspected
step3. doppler ultrasound of the carotid and vertebrobasilar systems
step4. MRI of cerebral vasculature
