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STEP > Neurology > Flashcards

Neurology Flashcards

1
Q

What are the effects of B12 deficiency?

A

Subacute combined degeneration of the:

  1. dorsal columns
  2. lateral corticospinal tracts
  3. spinocerebellar tracts.
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2
Q

Damage to the dorsal column causes?

A

Sensory Ataxia

  • Loss of position and vibration sensation
  • Patient will have a positive rhomberg
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3
Q

Damage to the lateral corticospinal tract causes?

A

Spastic paresis

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4
Q

Damage to the Spinocerebellar tract causes?

A

Contributes to ataxia

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5
Q

What is atrophic glossitis?

A

Smooth shiny, erythematous tongue

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6
Q

Which two diseases cause destruction of the lower motor neurons in the anterior horn and what is the result?

A
  1. Poliomyelitis
  2. Werdnig-Hoffman
    - Flaccid paralysis, muscle atrophy and fasciculations
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7
Q

Migraine Headaches

  • Localization
  • Duration
  • Description
  • Treatment
A
  • Unilateral
  • Last 4-72 hours
  • Pulsating pain with nausea, photophobia or phonophobia. May have aura. Due to irritation of CN V, meninges, blood vessels (release of substance P, calcitonin gene related peptide, vasoactive peptides)
  • Treatment
    1. Acute: NSAIDs, triptans or dihydroergotamine
    2. Prophylaxis: Lifestyle (sleep, excercise, diet), beta-blockers, calcium channel blockers, amitriptyline, topiramate or valproate
    POUND
    Pulsatile
    One day
    Unilateral
    Nausea
    Debilitating
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8
Q

Pathophysiology of migraine headaches

A
  • Pain is due to trigeminal afferents that innervate the meninges
  • Release of vasoactive neuropeptides, substance P and calcitonin gene related peptide results in inflammation due to vasodilation and plasma protein extravasation
  • Neuronal sensitization also occurs causing central nociceptive pathways to become more sensitive to painful and non painful stimulation.
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9
Q

What medication is used to abort migraines?

A

Triptans

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10
Q

What is the mechanism of action of triptans?

A

Serotonin 5-HT1b/5-HT1d agonists
- Directly counter by inhibiting release of vasoactive peptides, prompting vasoconstriction and blocking pain pathways in the brainstem

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11
Q

Side effects of triptans?

A
  • Significant elevations in blood pressure and cardiac events
  • Avoid in those with cardiac or cerebrovascular disease
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12
Q

What medications are used for migraine prophylaxis?

A
  1. Beta blockers
  2. Calcium channel blockers
  3. Antidepressants
    - Amitrptaline and Venlafaxine
  4. Anticonvulsants
    - Valproate and Topiramate
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13
Q

Where does cranial nerve VII exit the skull?

A

Via the stylomastoid foramen

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14
Q

What are the 5 branches of the facial nerve?

A
  • Temporal
  • Zygomatic
  • Buccal
  • Mandibular
  • Cervical
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15
Q

What are the complication of a parotid gland tumor?

A
  • Compress and disrupt the ipsilateral facial nerve and its branches
  • Causes facial droop
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16
Q

In the setting of a UTI, what is pathognomonic for pyelonephritis?

A
  • WBC casts

- Formed by Tamm-Horsfall protein secreted by tubular epithelial cells

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17
Q

Where else can you find WBC casts?

A
  • With interstitial nephritis but urinary symptoms are usually not present.
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18
Q

What is axonal reaction?

A
  • The changes observed in the body of a neuron after the axon has been severed.
  • Becomes visible 24-48 hours after injury.
  • There is increased protein synthesis facilitating axon repair.
  • Cytoplasms has enlarged round cells, with peripherally located nuclei and dispersed finely granular Nissl substance
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19
Q

What is miosis and what causes it?

A
  • Pinpoint pupils
  • Caused by pupillary sphincter muscle contraction
  • Caused when light reaches the retina, the pupillary light reflex
  • Also caused when the eye is accommodating to a near object
  • Innervated by parasympathetic ciliary nerves that synapse in the ciliary ganglion
  • Atropine like eye drops results in blockage of this mechanism leading to mydriasis
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20
Q

Causes of miosis?

A 
Clonidine
Barbiturates
Opiates
Cholinergic's
Pontine stroke
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21
Q

What is mydriasis and what causes it?

A
  • Dilation of the pupils
  • Caused by dilator papillae muscle contraction
  • Under sympathetic control from fibers that synapse in the superior cervical ganglion.
  • The nerve fibers follow the internal carotid artery and the ophthalmic arteries to reach the eye
  • Damage anywhere along the tract results in Horner syndrome (pinpoint pupil with slight drooping of eyelid)
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22
Q

Which class of medications cause dry skin?

A
  • Anticholinergics
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23
Q

Which class of medications cause wet skin?

A
  • Cholinergics

- Sympathomimetics

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24
Q

Gabapentin

  • MOA
  • Uses
  • Side effects
A

MOA: Inhibits presynaptic high voltage gated calcium channels. Prevents influx of calcium which prevents fusion and release of neurotransmitter vesicles into the synaptic cleft; also a GABA analogue
Uses: partial (focal) seizures, peripheral neuropathy and postherpetic neuralgia
Side effects: Sedation and ataxia

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25
Q

Levetiracetam

  • MOA
  • Uses
  • Side effects
A

MOA: Reacts downstream by disrupting vesicle fusion of GABA and glutamate release
Uses: Partial (focal) and Tonic-clonic seizures
Side effects: Fatigue, drowsiness, headache, neuropsychiatric symptoms such as personality change

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26
Q

Topiramate

  • MOA
  • Uses
  • Side effects
A

MOA: Blocks sodium channels and increases GABA action
Uses: Partial (focal) seizures and tonic-clonic seizures; also used for migraine prevention
Side effects

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27
Q

Lamotrigine

  • MOA
  • Uses
  • Side effects
A

MOA: Blocks voltage gated Na+ channels, inhibiting release of glutamate
Uses: Partial (focal), tonic-clonic and absence seizures
Side effects: Stevens-johnson syndrome (must titrate medication slowly)

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28
Q

Valproic acid

  • MOA
  • Uses
  • Side effects
A

MOA: Increases Na+ channel inactivation, increases GABA concentration by inhibiting GABA transaminase
Uses: Partial (focal), tonic-clonic (first line), absence and myoclonic seizures; also used for bipolar disorder and migraine prophylaxis.
Side effects: GI distress, rare but fatal hepatotoxicity (LFTs), pancreatitis, tremor, weight gain and contraindicated in pregnancy due to neural tube defects

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29
Q

Carbamazepine

  • MOA
  • Uses
  • Side effects
A

MOA: Blocks Na+ channels
Uses: First line for partial (focal) seizures and trigeminal neuralgia; also for tonic-clonic seizures
Side effects: Diplopia, ataxia, blood dyscrasias (agranulocytosis, aplastic anemia), liver toxicity, teratogenesis, induction of cytochrome p-450, SIADH and Stevens-Johnson Syndrome

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30
Q

Phenytoin

  • MOA
  • Uses
  • Side effects
A

MOA: Blocks Na+ sodium channels; has zero order kinetics; disrupts the generation and propagation of action potentials in the axon hillock and proper
Uses: First line prophylaxis for Status epilepticus, first line for tonic-clonic seizures and may be used for partial (focal) seizures.
Side effects: The most of all.
- Neurologic: Nystagmus, diplopia, ataxia, sedation, peripheral neuropathy.
- Dermatologic: hirsutism, Stevens-Johnson syndrome, gingival hyperplasia, DRESS syndrome
- Musculoskeletal: osteopenia, SLE-like syndrome
-Hematologic: Megaloblastic anemia
- Reproductive: Teratogenesis (fetal hydantoin syndrome)
- Other: cytochrome P-450 induction

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31
Q

Barbiturates

  • Phenobarbital, pentobarbital, thiopental, secobarbital
  • MOA
  • Uses
  • Side effects
A

MOA: Facilitate GABA action by increased duration of Cl channel opening, decreasing neuron firing; contraindicated in porphyria
Uses: Sedatives for anxiety, seizures, insomnia and induction of anesthesia (thiopental)
Side effects: Respiratory and cardiovascular depression (can be fatal); CNS depression (can be exacerbated by alcohol use); dependence, drug interaction (induces cytochrome P-450
Overdose: Treatment is supportive by assisting respiration and maintaining BP

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32
Q

Phenobarbital

  • MOA
  • Uses
  • Side effects
A

MOA: Increases GABA action
Uses: For partial and tonic-clonic seizures, first line in neonates
Side effects: Sedatiom, tolerance, dependence, induction of cytochrome P-450, cardiorespiratory depression

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33
Q

Benzodiazepines

  • MOA
  • Uses
  • Side effects
A

MOA: Facilitate GABA action by increased frequency of Cl channel opening. Decrease REM sleep
Use: Anxiety, spasticity, status epilepticus, eclampsia, detoxification (alcohol withdrawal), night terrors, sleep walking, general anesthetic (amnesia, muscle relaxation), hypnotic (insomnia)
Side effects: Dependence, additive CNS depression effects with alcohol, less risk of respiratory depression and coma than with barbiturates
Overdose: Treatment is with flumazenil (competitive antagonist of GABA benzodiazepine receptor)
Withdrawal: can precipitate seizures with acute benzodiazepine withdrawal

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34
Q

Benzodiazepines are used for which sezures?

  • MOA
  • Side effects
A

First line for acute status epilepticus, can also be used for eclampsia seizures (MgSO4 is first line)
MOA: Increase GABA action
Side effects: Sedation, tolerance, dependence, respiratory depression

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35
Q

Ethosuximide

  • MOA
  • Uses
  • Side effects
A

MOA: Blocks thalamine T-type Ca2+ channels
Uses: Absence seizures
Side effects: EFGHIJ, Ethosuximide casues fatigue, GI distress, Headaches, Itching and Stevens-Johnson syndrome

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36
Q

Vigabatrin

  • MOA
  • Uses
  • Side effects
A

MOA: Increases GABA irreversibly inhibiting GABA transaminase
Uses: Partila (focal) seizures
Side effects: Black box warning for permanent vision loss

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37
Q

What are the nonbenzodiazepine hypnotics?

A

Zolpidem, Zaleplon and Eszopiclone

MOA: Act via BZ1 subtype of GABA receptor

38
Q

Phrenic nerve
Origin?
Motor and Sensory Function?

A
  • C3, C4 and C5
  • Motor function is that it innervates the diaphragm
  • Sensory function is that it innervates the central part of the diaphragm, the pericardium and the mediastinal part of the parietal pleura
39
Q

What is the interscalene nerve block?

A
  • Regional anesthetic technique used for procedures involving the shoulder and upper arm
  • Anesthetic is administered in the scalene triangle and affects the brachial plexus roots and trunks
  • May also cause ipsilateral diaphragmatic paralysis by anesthetizing the roots of the phrenic nerve (C3-5) as they pass through the interscalene sheath
  • Avoid in patients with chronic lung disease or contralateral phrenic nerve dysfunction
40
Q

What is asterixis?

A

The rhythmic flapping of dorsiflexed hands, a manifestation of hepatic encephalopathy.

41
Q

Hepatic Encephalopathy

A
  • Neurologic complication of cirrhosis
  • Liver can not metabolize ammonia (NH3) into urea ((NH2)2CO)
  • Excess ammonia crosses BBB and leads to altered mental status
  • Can lead to disorientation/asterixis, difficult arousal or coma
    -Triggers:
    1. Increased NH3 production/absorption (dietary protein, GI bleed, constipation, infection)
    2. Decreased NH3 removal (renal failure, diuretics, bypassed hepatic flow post-Transjugular Intrahepatic Portosystemic Shunt)
    Treatment
    A. Lactulose (Increases NH4+ generation)
    B. Rifaximin or Neomycin (Decrease NH3 producing gut bacteria)
42
Q

What is the function of the vermis in the cerebellum?

What can results from lesions to this region?

A

Vermis

  • Modulates axial and truncal posture and coordination via connections with the medial descending motor systems (anterior corticospinal, reticulospinal, vestibulospinal and tectospinal tracts)
  • Lesion results in truncal ataxia (wide based or unsteady gait), vertigo and nystagmus due to disruption of the inferior vermis and the flocculonodular lobe (vestibulocerebelum)
43
Q

What is the function of the cerebellar hemispheres in the cerebellum?
What can result from lesions to this region?

A
  • Primarily responsible for motor planning and coordination of the ipsilateral extremities via connections with the lateral descending motor systems (lateral corticospinal tract, rubrospinal tract)
  • Lesions result in ipsilateral dysdiadochokinesia (impaired rapid alternating movements) limb dysmetria (overshoot/undershoot during targeted movement) and intention tremor (tremor during targeted movement)
44
Q

What is Horner Syndrome?

A

Ptosis, Miosis and Anhydrosis

-Due to lesions affecting the ipsilateral hypothalamus or sympathethic tracts in the brainstem (lateral medulla)

45
Q

What are the signs of occulomotor nerve palsy and when does it result?

A

Mydriasis, complete ptosis and down and out eye deviation

  • May occur with nerve compression in posterior communicating artery aneurysm or uncal herniation.
  • ay occur due to microvascular nerve ischemia due to DM
  • Can also result from ipsilateral lesion at the level of the anterior midbrain or midbrain tegmentum
46
Q

What lesions can cause contralateral homonymous hemianopia?

A

Any unilateral visual pathway lesion beyond the optic chiasm (optic tract, lateral geniculate body, optic radiations, primary visual cortex)

47
Q

What causes simian hand?

A
  • Lesion to ulnar and median nerve
48
Q

What causes wrist drop?

A
  • Lesion to radial nerve
49
Q

What causes ulnar claw?

A
  • If present when trying to extend the fingers or at rest, then it is due to distal ulnar nerve lesion
  • If present when trying to make a fist, then may be preachers hand which is proximal median nerve lesion
50
Q

What causes preachers/pope’s blessing hand?

A
  • If present when trying to make a fist, then it is due to proximal median nerve lesion
  • If present when trying to extend fingers or at rest then may be ulnar claw
51
Q

Radial Nerve

A

Largest branch of the brachial plexus (C5-T1)

  • Innervates all extensor muscles of upper limb below the shoulder
  • Provides sensory innervation to the skin of the posterior arm
  • Nerve travels through the radial groove on the humurus
  • Vulnerable to traumatic injury at the humeral midshaft
52
Q

What causes median claw?

A
  • If present at rest or when trying to extend fingers, then distal median nerve
  • If present when trying to make a fist, then proximal ulnar nerve lesion
53
Q

Median claw is present when at rest or trying to extend the fingers, where is the lesion?

A

Distal median nerve lesion

54
Q

Median claw is present when trying to make a fist, where is the lesion?

A

Proximal ulnar nerve lesion

55
Q

Ulnar claw present when at rest or trying to extend the fingers, where is the lesion?

A

Distal ulnar nerve lesion

56
Q

Ulnar claw present when trying to make a fist, where is the lesion?

A

Proximal median nerve lesion

57
Q

Erb palsy is a lesion to?

What causes it?

A
  • Upper (Erb-er) trunk, C5-C6 roots
  • Infants, lateral traction on the neck during delivery
  • Adults, trauma
58
Q

What is the muscle and functional deficit in Erb’s palsy?

A
  1. Deltoid and supraspinatus
    - Deficit in abduction of the arm (hangs by the side)
  2. Infraspinatus
    - Deficit in lateral rotation (arm is rotated medially)
  3. Biceps brachii
    - Deficit in flexion and supination (arm extended and pronated)
59
Q

Klumpke palsy is a lesion to?

What causes it?

A
  • Lesion to lower trunk, C8-T1 root
  • Infants, upward force on arm during delivery
  • Adults, trauma such as grabbing tree branch to break a fall
60
Q

What are the muscle and functional deficits in Klumpke’s palsy?

A
  • Deficit in intrinsic hand muscles (lumbricals, interossei, thenar and hypothenar)
  • Causes total claw hand because lumbricals normally flex the MCP joints and extend the DIP and PIP joints
61
Q

Thoracic outlet syndrome is a lesion to?

What causes it?

A
  • Compression of the lower trunk and subclavian vessels

- Due to cervical rib (extra rib at C7) or pancoast tumor (apex of lung tumor, most are non-small cell)

62
Q

What are the muscle and functional deficits in thoracic outlet syndrome?

A
  • Same as Klumpke palsy, deficit in intrinsic hand muscles (lumbricals, interossei, thenar, hypothenar)
  • Causes atrophy of intrinsic hand muscles
  • Leads to ischemia, pain and edema due to vascular compresion
63
Q

Winged scapula is lesion to?

It is caused by?

A
  • Lesion of the long thoracic nerve (from T1 root)

- Axillary node dissection after mastectomy, stab wounds

64
Q

What are the muscle and functional deficits in winged scapula?

A
  • Serratus anterior deficit
  • Inability to anchor scapula to thoracic cage
  • Can not abduct the arm above the horizontal position
65
Q

What are partial focal seizures?

What are the two types?

A
  • Affect single area of the brain
  • Originate in the medial temporal lobe
  • Preceded by seizure aura, can become generalized seizure
    1. Simple partial
    2. Complex partial
66
Q

Simple partial seizures

A
  • Consciousness is intact, no loss or posticatal state
  • Motor, sensory, autonomic or psychic symptoms
  • Treated with narrow spectrum anticonvulsants
    1. Carbamazepine
    2. Gabapentin
    3. Phenobarbital
    4. Phenytoin
67
Q

Complex partial seizures

A
  • Impaired consciousness and postictal state
  • May have automatisms such as lip smacking
  • Treat with narrow spectrum antibiotics
    1. Carbamazepine
    2. Gabapentin
    3. Phenobarbital
    4. Phenytoin
68
Q

What are generalized seizures and what are the five types?

A 
They are diffuse (spread) types of seizures
1. Absence
2. Myoclonic
3. Tonic-clonic
4. Tonic
5 Atonic
69
Q

Absence seizures

A
  • AKA Petit mal
  • 3 Hz spike and wave discharges
  • No postictal (after seizure) confusion
  • Blank stare
    Treatment
  • Ethosuximide (first line)
  • MAO: blocks thalamic T-type Ca2+ channels
70
Q

Myoclonic seizures

A
  • Quick repetitive jerks
71
Q

Tonic-clonic seizures

A
  • AKA Grand mal seizure
  • Alternating stiffening and movement
    Treatment:
  • Phenytoin, fosphenytoin (first line)
  • Valproic acid (first line)
  • May also use phenobarbital, carbamazepine, topiramate, lamotrigine, levetiracitam
72
Q

Tonic seizures

A
  • Stiffening
73
Q

Atonic seizures

A
  • Drop seizures, pt falls to floor

- Commonly mistaken for fainting

74
Q

What is epilepsy?

A
  • Disorder of recurrent seizures

- Does not include febrile seizures

75
Q

What is status epilepticus?

A
  • Continous ( > 5-30 min) or recurring seizures that may result in brain injury
76
Q

Where is the amyloid prescursor protein located?
What does it encode?
What can its innapropriate processing lead to?
What pathways is it processed via?
Which pathway leads to disease?

A
  • Located on chromosome 21
  • Encodes highly conserved transmembrane protein
  • Innapropriate processing leads to Alzheimers
  • APP is processed via alpha and gamma secretase pathways or the beta and gamma secretase pathways
  • The beta and gammma secretase pathway leads to production of beta amyloid
  • If beta amyloid is not sufficiently cleared by cellular processes, it forms insoluble fibrils that lead to amyloid plaques
  • These amyloid plaques are neurotoxic and lead to AD
  • Patients who have abnormal APP processing, impaired beta-amyloid clearance or production of higher levels of APP can develop AD
77
Q

Cluster headaches

  • Localization
  • Duration
  • Description
  • Treatment
A
  • Unilateral
  • Last 15 min - 3 hrs; are repetitive
  • Repetitive brief headaches. Excrutiating periorbital pain with lacrimation and rhinorrhea. May present with horner syndrome (Ptosis, Anhydrosis, Miosis)
  • Treatment:
    1. Acute: Sumatriptan, 100% O2
    2. Prophylaxis: Verapamil
78
Q

Tension Headaches

  • Localization
  • Duration
  • Description
  • Treatment
A
  • Bilateral
  • Last > 30 minutes (typically 4-6 hrs); constant
  • Steady pain. No Photophobia or phonophobia. No aura
  • Treatment: Analgesics, NSAIDs, acetaminophen or amitriptyline for chronic pain
79
Q

Trigeminal Neuralgia

A
  • Repetitive, unilateral, shooting pain in the distribution of CN V
  • Typically lasts <1 minute
  • First line therapy is carbamazepine (blocks Na+ channels)
80
Q

Which nerve is more likely to be damaged during excisional biopsy of enlarged lymph nodes in the posterior triangle of the neck?
What does it result in?

A
  • The spinal accessory nerve (CN XI)
  • Results in trapezius weakness with shoulder droop, impaired abduction of the arm above the horizontal plane and winging of the scapula.
  • If the proximal nerve is damaged, weakness of the sternocleidomastoid may be seen
81
Q

What nerve innervates the deltoid?

What does injury to nerve cause?

A
  • Axillary nerve (C5-C6)

- Causes inability to abduct arm below the horizontal plane

82
Q

What nerve innervates the latissimus dorsi?

What is its action?

A
  • Thoracodorsal nerve

- The most powerful adductor of the arm, assists with extension and medial rotation

83
Q

What nerve innervates the levator scapulae?

What is its action?

A
  • C3 and C4 cervical nerves and the dorsal scapular nerve (C5).
  • Elevates the scapula and raises the medial border to allow inferior rotation of the glenoid
84
Q

What nerve innervates the rhomboid major?

What is its action?

A
  • Dorsal scapular nerve (C5)

- Inserts on the medial border of the scapula and draws it upward and medially

85
Q

What nerve innervates serratus anterior?
What is its action?
What does injury to nerve result in?

A
  • Long thoracic nerve
  • Originates in first 8 ribs and inserts into medial border of scapula
  • It rotates the scapula upward, allows abduction of the arm over the head
  • Paralysis results in impaired arm abduction past the horizontal plane and winging of the scapula with no shoulder droop.
86
Q

If a patient is homozygous for apolipoprotein E-4 allele, what are they most likely to develop in the future?

A

Late onset Alzheimer’s disease (after age 60)

- May be involved in the formation of senile plaques

87
Q

What mutations are thought to cause early onset Alzheimer’s in 30% of patients with the disease?

A
  1. Amyloid precursor protein gene on chromosome 21
  2. Presenilin 1 gene on chromosome 14
  3. Presenilin 2 gene on chromosome 1
88
Q

What is kinesin?

A
  • A microtubule associated ATP powered motor protein

- Facilitates anterograde transport of neurotransmitter containing secretory vesicles down axons to synaptic terminals

89
Q

What is the first line treatment for absence seizures?

A

Ethosuximide

90
Q

What is the treatment if a patient has absence seizures that progress to tonic-clonic seizures?

A

Valproate, a broad spectrum anti-seizure drug

91
Q

What is a germinoma?

A

Most common pineal mass

Midline malignant tumor arising from embryonic germ cells

92
Q

Limitation of upward gaze with downward gaze preference
Bilateral eyelid retraction
Light near dissociation

A

Perinaud syndrome

STEP (28 decks)

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