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3rd Year Quick Review > Neurology > Flashcards

Flashcards in Neurology Deck (182):
1

pupil size in coma:

- one dilated, nonreactive or sluggish pupil

- cause
- examples

- cause: parasympathetic nerve problem

- oculomotor nerve compression from uncal herniation
- aneurysm of posterior-communicating artery

2

pupil size in coma:

- one pinpoint pupil (miosis)

- cause
- examples

- cause: sympathetic nerve problem (Horner)

- lateral medullary syndrome
- hypothalamus injury
- Pancoast tumor
- carotid dissection

3

pupil size in coma:

- two midpoint, nonreactive pupils

- cause
- examples

- cause: parasympathetic and sympathetic nerve destruction

- midbrain disruption (can affect one or both pupils)
- anoxia
- hypothermia
- anticholinergics
- severe barbituate overdose

4

pupil size in coma:

- two dilated, nonreactive pupils

- examples

- anoxia
- hypothermia
- anticholinergics
- severe barbituate overdose

5

pupil size in coma:

- two dilated, nonreactive pupils

- examples

- opiates
- pontine destruction

6

what is a seizure?

- paroxysmal electrical discharges of brain that cause LOC
- alteration of perception or impairment of psychic function
- convulsive movements
- disturbance of sensation
- or some combination thereof

7

what is epilepsy?

recurrent, unprovoked seizures

8

what is status epilepticus?

- prolonged or repetitive seizures
- life-threatening

9

what are triggers for seizures in susceptible individuals?

- alcohol
- cocaine
- intense emotions
- strobe lighting
- loud music
- stress
- menstruation
- lack of sleep

10

seizures are categorized into what 2 categories?

- GENERALIZED
- FOCAL

11

focal seizures involve how many sides of the brain, and motor activity is noted on how many sides?

- 1 hemisphere
- usually 1

12

generalized seizures involve how many sides of the brain, and motor activity is noted on how many sides?

- both hemispheres
- usually both, but not necessarily

13

focal (partial) seizures are further classified into what categories?

1. simple partial: no LOC
2. complex partial: LOC
3. partial w/ secondary generalization

14

generalized seizures are further classified into what categories?

1. nonconvulsive: absence seizure
2. convulsive:
2a. myoclonic
2b. clonic
2c. tonic-clonic
2d. atonic

15

focal seizures are commonly d/t what?

focal brain lesions

16

primary generalized seizures are more typically d/t what?

genetics

17

if PNES (psychogenic nonepileptic seizures) are suspected or when the events do not respond to tx and the dx is not clear, what should be ordered?

video EEG monitoring

18

what percentage of pts w/ PNES (psychogenic nonepileptic seizures) also have epilepsy?

20%

19

what is an aura?

perceptual disturbance that may precede a FOCAL seizure

20

auras may precede what type of seizure?

FOCAL seizures

21

auras do NOT occur w/?

PRIMARY generalized seizures

22

how can auras manifest?

- SENSES
- MOTOR

23

auras are thought to be produced by?

EARLY seizure activity

24

describe generalized tonic-clonic seizures

- involve both hemispheres
- BILATERAL motor involvement
- LOC
- pronounced postictal period

25

describe absence seizures

- nonconvulsive
- no aura
- no postictal symptoms
- sudden interruption of consciousness
- can be induced by HYPERVENTILATING
- 3-per-second spike and wave pattern on EEG

26

what number of children outgrow absence seizures?

2/3

27

describe focal (aka simple partial) seizures

- no LOC
- symptoms depend on affected region of cortex

28

describe focal seizures w/ diminished consciousness (aka complex partial): temporal lobe type

- aura may hallucination
- altered behavior/consciousness
- amnesic
- automatisms: lip-smacking, chewing or swallowing movements, salivation, fumbling of hands, shuffling of feet

29

definition of status epilepticus

- seizure lasting > 30 minutes
- 2 or more seizures WITHOUT regaining consciousness in between

30

when should you be aggressive when treating seizures and use abortive therapy?

when seizure lasts 5 minutes or more

31

what are possible causes of status epilepticus?

- stroke
- alcohol
- drugs
- stopping or changing AEM's
- hypoxia
- CNS infection
- metabolic causes
- tumor
- trauma

32

seizure management: history

- alcohol use
- drug use
- head injury
- sleep deprivation
- diabetes
- thyroid or parathyroid surgery

33

seizure management: laboratory tests

- glucose
- Na+
- Ca++
- Mg++
- transaminases
- BUN
- LP for VDRL if meningeal sxs

34

seizure management: best neuroimaging test

MRI (to r/o structual abnormality)

35

seizure management: can confirm dx of seizures and localize the origin

EEG

36

can a NORMAL EEG exclude the dx of epilepsy?

NEVER

37

after initial seizure, RISK OF RECURRENCE increases w/ the following:

- abnormal EEG
- h/o prior neurological injury
- family h/o seizures
- 1st seizure is a FOCAL seizure
- MRI shows abnormality

38

ACUTE TX OF SEIZURES

IV benzos

39

typical tx of status epilepticus in adults

1. thiamine, and 1 amp of D50 if blood glucose is low
2. LORAZEPAM x 2 doses
3. loading dose of PHENYTOIN/fosphenytoin

40

tx of status epilepticus if pt continues seizing after initial tx

1. 3rd dose of lorazepam
2. maximize phenytoin dose
3. proceed to barbiturate or propofol
4. +/- ET intubation and ICU care (generally needed if first 2 doses and dose of phenytoin don't work)

41

mainstay of chronic tx of seizures

AEDs, w/ monotherapy as the preferred goal

42

PRIMARY DRUG for: focal

carbamazepine

43

advantage of carbamazepine

toxicity is UNcommon

44

disadvantages (adverse effects) of carbamazepine

- hyponatremia
- leukopenia
- thrombocytopenia
- aplastic anemia
- hepatotoxicity
- teratogenic
- liver inducer; reduces OCP efficacy

45

PRIMARY DRUG for: generalized tonic-clonic

valproic acid

46

advantages of valproic acid

- wide spectrum
- good efficacy
- IV form available

47

disadvantages (adverse effects) of valproic acid

- GI side effects
- can rarely cause BM suppression and hepatotoxicity/liver failure
- teratogenic (neural tube defects)
- tremor
- weight gain
- hair loss

48

PRIMARY DRUG for: absence (only)

ethosuximide

49

disadvantage (adverse effects) of ethosuximide

BM suppression (rare)

50

tx for absence (short-term adjunctive use only)

clonazepam

51

disadvantages (adverse effects) of clonazepam

loses efficacy

52

advantages of levetiracetam

- well tolerated in elderly
- safe in Asian pts w/ HLA-B*1502 (increased risk of SJS)
- renally excreted so no interaction w/ levels of other AEDs

53

disadvantages (adverse effects) of levetiracetam

- depression
- fatigue
- irritability
- increased infections

54

advantages of gabapentin

- one AED w/ NO significant drug interactions
- renally excreted so useful in pts w/ liver disease

55

disadvantages (adverse effects) of gabapentin

- ataxia
- amnesia
- limited efficacy

56

advantages of lamotrigine

- wide spectrum
- good efficacy
- well tolerated in elderly

57

disadvantage (adverse effects) of lamotrigine

severe rash and SJS w/ rapid titration

58

last choice tx for focal siezures

phenobarbital

59

disadvantages (adverse effects) of phenobarbital

- sedation in adults
- hyperactivity in children
- teratogenic
- liver inducer; reduces OCP efficacy
- DECREASES levels of other AEDs

60

advantages of topiramate

- weight loss
- headache ppx if present

61

disadvantages (adverse effects) of topiramate

- kidney stones
- increased glaucoma
- weight loss
- paresthesias
- cognitive dysfunction
- teratogenic
- reduces OCP efficacy

62

which AEDs can be used to tx focal seizures?

ALMOST ALL AEDs, EXCEPT ethosuximide

63

tx for generalized seizures (tonic-clonic)

- TOPIRAMATE
- LAMOTRIGINE
- VALPROATE
- levetiracetam
- felbamate
- funinamide
- zonisamide

64

tx for generalized seizures (absence)

- lamotrigine
- ethosuximide
- valproic acid

65

when can you STOP AEDs?

individualized for each pt

66

tx options for INTRACTABLE EPILEPSY

- resective surgery
- vagus nerve stimulation
- ketogenic diet (works well in children)

67

which AEDs reduce OCP efficacy? (6)

- phenytoin
- phenobarbital
- carbamazepine
- lamotrigine
- oxcarbazepine
- topiramate (higher doses)

68

uncontrolled seizures during pregnancy can cause

- placental abruption
- early labor
- premature delivery

69

AEDs are still used in pregnancy bc the risk of complications from uncontrolled seizures is even GREATER than

risk of teratogenicity

70

tx strategy for seizures during pregnancy

- control seizures as much as possible
- MONOTHERAPY
- LOWEST DOSE possible

71

MOST LIKELY AED to cause NEURAL TUBE defects

valproic acid

72

teratogenic risk of AEDs is DECREASED by

FOLIC ACID

73

should prophylactic VITAMIN K be given during the last MONTH of pregnancy in pts on AEDs bc of reports of increased bleeding?

no, currently not enough evidence

74

what is the definition of dementia?


what is the definition of mild cognitive impairment?
what is the clinical triad in NPH?
how is AD diagnosed?
1st line tx for AD

- chronic cognitive decline w/ or w/o behavioral impairment
- PROGRESSIVE
- INTERFERES w/ normal daily functioning
- NOT d/t DELIRIUM or PSYCHIATRIC D/O

75

dementia is diagnosed ONLY after completion of the following 3 tasks

1. thorough H&P
2. neuropsychiatric testing
3. objective cognitive assessment (MMSE or MOCA)

76

how many abnormalities needed to diagnose dementia?

2 OR MORE out of 5 DOMAINS

77

which 5 domains may be impaired in pts w/ dementia?

1. memory
2. executive function
3. perception
4. language
5. behavior

78

typical feature of advanced dementia

PSYCHOSIS refractory to treatment

79

what is the dx?

- when only ONE OR MORE of the DOMAINS is in decline
- impairment does NOT significantly impact daily functioning

mild cognitive impairment (MCI)

80

what are the 2 types of mild cognitive impairment (MCI), and which is more common?

- amnestic and nonamnestic

- AMNESTIC

81

at what rate does mild cognitive impairment (MCI) progress to dementia?

5-10% per year

82

what are reversible causes of dementia that need to be r/o when evaluating dementia?

- medications
- vitamin B12
- hypothyroidism
- chronic subdural hematomas
- normal pressure hydrocephalus
- tumors
- infection/inflammation (AIDS, neurosyphilis, neurosarcoidosis, chronic meningitis, lupus cerebritis, vasculitis, autoimmune encephalopathy (such as Hashimoto encephalopathy))
- heavy metal poisoning (arsenic, mercury, lead)

83

- enlargement of ventricles w/o obstruction of aqueduct (ie "COMMUNICATING HYDROCEPHALUS)
- NO cerebral atrophy

normal pressure hydrocephalus (NPH)

84

NPH often occurs after...

- head TRAUMA
- MENINGITITS
- SUBARACHNOID HEMORRHAGE

85

- NORMAL intracranial pressure
- NO papilledema
- NO headache

normal pressure hydrocephalus (NPH)

86

classic triad of normal pressure hydrocephalus (NPH)

1. gradually worsening dementia
2. gait apraxia; "magnetic gait"
3. urinary incontinence

87

- must differentiate this from NPH
- more common in pts w/ HTN or DM
- can present w/ the SAME clinical TRIAD as NPH

diffuse white matter disease

88

treatment for NPH

VENTRICULOPERITONEAL or VENTRICULOATRIAL SHUNT

89

MC of dementia AFTER 60 YEARS OF AGE

Alzheimer disease (AD)

90

diagnosis for Alzheimer disease (AD)

- INSIDIOUS
- PROGRESSIVE
- 2 or more impaired domains (memory, executive functioning, perception, language, behavior) causing SIGNIFICANT IMPAIRMENT in normal daily functioning

91

do NOT use these for definitive dx of Alzheimer disease (AD)

- MRI
- PET scan
- CSF tau measurements

92

why should MRI, PET scan, and CSF tau measurements NOT be used for dx of Alzheimer disease (AD)?

NOT SPECIFIC ENOUGH

93

when should a dx of Alzheimer disease (AD) NOT be made?

- h/o cerebrovascular disease
- clinical features of frontotemporal dementia
- clinical features of dementia w/ Lewy bodies
- evidence of another psych or neuro illness
- takes meds that cause cognitive impairment

94

what are the main diagnoses to consider in elderly pt w/ dementia w/o movement d/o?

- Alzheimer dz
- VASCULAR dementia
- MIXED dementia (w/ both neurodegenerative and vascular components)

95

1st line tx for Alzheimer dz

- CHOLINESTERASE INHIBITORS (CIs)

- donepezil (Aricept)
- rivastigmine (Exelon)
- galantamine (Razadyne)

96

what ADDITIVE drug tx can be used for Alzheimer dz?

memantine (Namenda)

(N-methyl-D-aspartate receptor antagonist)

97

what is better for tx of Alzheimer dz, especially advanced AD?

COMBINATION of CI and memantine

98

can you use cholinesterase inhibitors and memantine for MCI?

NO

99

what are the cholinergic sxs d/t adverse effects of cholinesterase inhibitors?

- anorexia
- nausea
- diarrhea
- bradycardia

100

which atypical antipsychotics can used to tx agitation, insomnia, delusions, aggression, and wandering, but can INCREASE MORTALITY?

- olanzapine
- quetiapine
- risperidone
- clozapine

101

what are the 2 general categories for dementia caused by cerebrovascular dz?

1. MULTI-INFARCT dementia
2. DIFFUSE WHITE MATTER disease (Binswanger dz)

102

characteristics of multi-infarct dementia

- d/t several strokes (large or small) in different brain regions
- have prominent motor, reflex, visual, and gait abnormalities
- do NOT have difficulty NAMING objects
- ABRUPT onset
- STEPWISE deterioration of mental function
- different from ALZHEIMER'S which is SLOW and steady

103

MCC of diffuse white matter dz

chronic HTN

104

similar in presentation and course to Alzheimer dz

frontotemporal dementia (previously Pick dz)

105

difference between frontotemporal dementia and Alzheimer dz

- MORE RAPID
- DISINHIBITION
- LANGUAGE DEFICITS
- onset in 5th to 6th decade of life
- males > females

106

CT or MRI scan results of ALzheimer pt

diffuse brain atrophy

107

CT or MRI scan results of frontotemporal dementia pt

MORE FOCAL ATROPHY of frontal and temporal lobes

108

only sure way to differentiate between Alzheimer and frontotemporal dementia pts

histologically at autopsy

109

one of the very rare PRION dzs

Creutzfeldt-Jakob disease (CJD)

110

how is Creutzfeldt-Jakob disease (CJD) subdivided?

- SPORADIC (most typical, 95%)
- FAMILIAL (about 5%)
- IATROGENIC
- VARIANT

111

when does sCJD (sporadic Creutzfeldt-Jakob disease) usually present, and what causes it?

- 55-65 yoa
- we have no idea!

112

when you see CJD in younger pts, think of

iCJD or vCJD

113

what is believed to be the cause of vCJD?

prion causing "MAD COW DISEASE" (bovine spongiform encephalopathy)

114

what causes iCJD?

- receipt of infected human tissues (dural grafts, corneal transplant, or liver transplant)
- receipt of infected hormones (eg GH, or gonadotropins)
- exposure to contaminated surgical instruments)

115

characteristics of Creutzfeldt-Jakob disease (CJD)

- RAPIDLY PROGRESSIVE dementia (weeks, not years)
- startle MYOCLONUS (startle to loud noises)

116

- changes in behavior
- changes in emotional response
- changes in intellectual function
- ataxia
- visual distortions
- confusion
- hallucinations
- delusions
- agitation
- dementia
- muteness

Creutzfeldt-Jakob disease (CJD)

117

younger pts w/ vCJD have dementia w/ what predominant features?

PSYCHOTIC

118

gold standard for diagnosing Creutzfeldt-Jakob disease (CJD)

brain BIOPSY

119

other supportive studies for diagnosing Creutzfeldt-Jakob disease (CJD)

- MRI
- EEG
- 14-3-3 PROTEIN in CSF

120

mortality rate of Creutzfeldt-Jakob disease (CJD)

fatal in < 1 yr in > 90% of pts

121

treatment for Creutzfeldt-Jakob disease (CJD)

none

122

cause of Parkinson dz (PD)

loss of dopaminergic neurons in substantia nigra

123

what percentage of Parkinson dz (PD) develop dementia?

80%

124

dementia in Parkinson dz (PD) pts primarily affects what?

- EXECUTIVE FUNCTIONS
- ATTENTION

125

when dementia PRECEDES or develops w/i 1 year after onset of motor dysfunction, it is referred to as

DEMENTIA W/ LEWY BODIES (DLB)

126

clinical features of dementia w/ Lewy bodies (DLB), besides dementia

- spontaneous motor features of parkinsonism
- recurrent, vivid visual hallucinations
- prominent fluctuations of attention and cognition

127

which med spares D2 dopamine receptor and can be helpful in PDD and DLB?

CLOZAPINE

128

which meds are not good for dementia w/ Lewy bodies (DLB)?

older antipsychotic drugs; haloperidol and chlorpromazine

129

which meds are under FDA SAFETY ADVISORY bc they are associated w/ an INCREASED RISK OF DEATH in elderly pts w/ dementia, especially DLB?

antipsychotic drugs

130

- dementia
- usually occurs in 6th decade of life
- GAZE PALSY
- abrupt falls

progressive supranuclear palsy (PSP)

131

- DEMENTIA
- MOVEMENT DISORDER
- autosomal dominant w/ complete penetrance

Huntington disease

132

what gene is responsible for Huntington disease (HD)?

HTT gene on chromosome 4p

133

when does Huntington disease (HD) occur?

LATE 30s

134

what are sxs of Huntington disease (HD)?

- dementia
- CHOREA
- psychiatric disturbances (personality changes, depression, and PSYCHOSIS)

135

dx for Huntington disease (HD)

- positive family hx
- clinical features
- genetic testing for HTT gene

136

imaging finding in Huntington disease (HD)

caudate nuclei atrophy ("boxcar" ventricles)

137

cure for Huntington disease (HD)?

none, FATAL

138

tx for MILD CHOREA in Huntington disease (HD)

tetrabenazine

139

adverse effects of tetrabenzapine

- depression
- sedation
- bradykinesia

140

MCC of dementia in younger pts

AIDS

141

- cognitive impairment
- movement d/o
- depression
- HIV

HIV-associated dementia (HAD)

142

what is "pseudodementia?"

significant cognitive dysfunction in pts w/ MAJOR DEPRESSION

143

what is one differentiating feature seen in moderate or advanced dementia, but NOT pseudodementia?

FRONTAL LOBE release signs (grasp, suck, rooting, and palmomental reflexes)

144

is commonly poor in depression d/t attentional dysfunction, but good in dementia pts

immediate recall

145

what is delirium?

- acute, often transient, altered mental status
- typically occurs w/i hours to days

146

in whom and where is delirium most commonly seen?

- hospitalized elderly pts
- ICU pts

147

dx delirium

- clinical
- decreased attention span
- varying states of confusion

148

most crucial aspects in dx type and etiology of a headache

history and physical

149

what history must be determined when dx a headache?

- QUALITY of pain (dull, sharp, throbbing, constant)
- LOCATION
- DURATION
- EXACERBATING factors
- ALLEVIATING factors
- associated sxs

150

how are headaches classified?

primary or secondary

151

what are the primary types of headache? (5)

1. migraine
2. tension-type headache
3. cluster headache
4. other trigeminal autonomic cephalgias
5. other headaches

152

what are the characteristics of primary headache?

- chronic
- recurrent
- w/o signs of neurologic dz

153

what are the secondary types of headache? (10)

1. d/t hemorrhage
2. head/neck trauma
3. benign intracranial HTN
4. brain tumors
5. cranial/cervical vascular d/o
6. substance abuse/withdrawal
7. infection
8. homeostasis d/o
9. facial pain
10. psychiatric d/o

154

what hemorrhage can cause severe headache?

subarachnoid

155

what are some examples of cranial/cervical vascular d/o that can cause headache?

- carotid dissection
- sinus venous thrombosis
- giant cell arteritis

156

what are some examples of substances or their withdrawal that can cause headache?

- nitrates
- EtOH
- caffeine

157

what are some examples of infection that can cause headache?

- meningitis
- encephalitis

158

what are some examples of homeostasis d/o that can cause headache?

- HTN
- hyperviscosity

159

what are some examples of facial pain that can cause headache?

- cranium
- neck
- eyes
- sinuses
- teeth
- trigeminal neuralgia
- herpes zoster

160

- typical
- largely familial d/o
- periodic
- often U/L
- pulsatile (throbbing) pain
- begin in childhood, adolescence, or early adulthood, and diminish in frequency w/ age

migraine headache

161

definition of EPISODIC migraine headache

< 15 headaches/month

162

definition of CHRONIC migraine headache

> 15 headaches/month x 3 months

163

triggers for migraine headaches

- emotional stress
- foods (eg chocolate, AGED CHEESE, foods rich in tyramine
- alcohol
- menstruation
- glare
- strong sensory stimuli (eg perfume)
- rapid changes in barometric pressure

164

what % of migraine headaches have an aura?

25%

165

most common visual sxs in migraine w/ AURA

- sparkling lights (scintillating scotomata)
- jagged zigzag lines (fortification spectra)

166

how long do migraine auras last?

5-60 minutes

167

what do longer than usual migraine auras represent?

complicated migraine or concern for stroke

168

how much more typical is a migraine withOUT aura than one w/?

5x

169

- visual phenomena that occupy BOTH visual fields (temporary cortical blindness)
- vertigo
- dysarthria
- INCOORDINATION of limbs
- diplopia
- tingling
- headache that affects BRAINSTEM

basilar migraine

170

- migraine w/o headache
- abnormal transient neurologic dysfunction

acephalic migraine

171

multiple or virtually continuous headaches w/ scalp tenderness, > 72 hours

status migrainosus

172

diagnosis for migraine headache

HISTORY

173

if pt presents w/ typical migraine sxs, next step?

FIRST give TREATMENT TRIAL

174

initial study for migraine w/ atypical sxs, HA pattern change, seizure, or focal neurologic sxs

CTH w/ and w/o contrast

175

what is ACUTE tx for migraine headache?

any tx given WITHIN FIRST HOUR of HA

176

what are some effective txs for acute migraine?

- acetaminophen
- aspirin
- NSAIDs

177

1st line treatment for migraine

TRIPTANS

(sumaTRIPTAN, zolmiTRIPTAN, rizaTRIPTAN, naraTRIPTAN, almoTRIPTAN, eleTRIPTAN, frovaTRIPTAN)

178

which triptan works the fastest?

rizaTRIPTAN

179

which triptan has 3 methods of delivery, injection, intranasal, and PO?

sumaTRIPTAN

180

which tx combination for migraine HA works synergistically and better than taking either as monotherapy?

sumaTRIPTAN and naproxen

181

when are triptans CI bc of r/o inducing ischemia?

- complicated or basilar migraines
- CHD or Prinzmetal angina
- h/o stroke
- uncontrolled BP
- pregnancy

182

which 2 medications are effective for termination of migraine in pts who present to the ER w/ VOMITING?

- PROCHLORPERAZINE
- METOCLOPRAMIDE