Neurology Flashcards
(143 cards)
1
Q
What is Lewy Body Dementia?
A
Dementia + >2 of the following: visual hallucinations, Parkinsonism, fluctuating cognition, and REM sleep behavior disorder; cognitive symptoms may precede or appear along with parkinsonian features; repeated falls and sleep disturbance are characteristic
Cognitive impairment would develop in this condition before or at the same time as Parkinsonism, not years later
Characterized by fluctuating cognition w/ pronounced variations in attention and alertness and bizarre visual hallucinations that are well formed and detailed
Cognitive decline, then Parkinsonism with severe sensitivity to potent dopamine antagonists
Micro: eosinophilic intracytoplasmic inclusion representing accumulation of alpha synuclein protein
Tx: carbidopa-levodopa for parkinsonism, cholinesterase inhibitors for cognitive impairment, 2nd generation antipyschotics if symptoms persist
2
Q
What is Frontotemporal dementia?
A
Characterized by early personality changes (e.g., euphoria, disinhibition, apathy), compulsive behaviors (e.g., peculiar eating habits, hyper-orality) and impaired memory; behavioral changes precede memory impairment
Presents around ag 60, autosomal dominant, progresses rapidly compared to AZ
Tau proteins, Pick bodies
Visual-spatial functions usually remain intact
Frontotemporal atrophy on neuroimaging
Manifests around age 60, demonstrably early than AD
3
Q
What is Myasthenia gravis?
A
Autoantibody-mediated degradation of Ach receptors at neuromuscular junction
Epidemiology: women - 2nd to 3rd decade, men - 6th to 8th decade
Involved site: Ach receptor in postsynaptic membrane
Features: fluctuating and fatigable muscle weakness that is worse later in the day - ocular (ptosis, diplopia), bulbar (dysphagia, dysarthria), facial, neck and limb muscles; respiratory muscles (myasthenic crisis)
Causes of exacerbation: medication (abx-fluoroquinolones, aminoglycosides; anesthetics-neuromuscular blocking agents; cardiac meds-beta blockers, procainamide; other-MgSulfate, penicillamine; tapering of immunosuppressive meds) pregnancy/childbirth; surgery (especially thymectomy); infection
Dx: bedside- edrophonium (tensilon) test, ice pack test (cold temp improves muscle strength by inhibiting breakdown of Ach at NMJ); Ach receptor antibodies (highly specific), CT scan of chest to evaluate for thymoma
Tx: AchE inhibitors (eg pyridostigmine), +/- immunotherapy (eg corticosteroids, azathioprine), thymectomy
Ptosis only. pupillary response is spared.
4
Q
What is Lambert-Eaton syndrome?
A
Approx. 50% of cases are assoc. w/ an underlying malignancy, mostly small cell lung cancer
Involved site: presynaptic membrane voltage-gated calcium channels
Features: proximal muscle weakness (eg standing from a chair, combing hair, putting dishes in overhead cabinets), autonomic dysfunction (eg dry mouth), cranial nerve involvement (eg ptosis), diminished or absent deep-tendon reflexes
Tx: guanidine or 3,4-diaminopyridine to increase presynaptic Ach levels; refractory - IV Ig or oral immunosuppressants (eg corticosteroids, azathioprine)
5
Q
What is dermatomyositis/polymyositis?
A
Involved site: muscle fiber injury
Features: symmetrical and more proximal muscle weakness; interstitial lung disease, esophageal dysmotility, Raynaud phenomenon; polyarthritis; skin findings (eg gottron papules, heliotrope rash) in dermatomyositis
Preserved reflexes, elevated muscle enzymes (eg creatine kinase)
6
Q
What is a CT with contrast?
A
Useful in identifying structural abnormality or mass lesions (eg primary or metastatic cancer, abscess, infarct)
Not helpful for identifying intracranial hemorrhage.
7
Q
What is a glucocorticoid-induced myopathy?
A
Complication of chronic corticosteroid use
Presentation: muscle atrophy and painless proximal muscle weakness, which is more prominent in the LE
No muscle inflammation or tenderness
Normal CK and ESR
Improves when offending med is discontinued
8
Q
What is polymyalgia rheumatica?
A
Muscle pain and stiffness in shoulder and pelvic girdle; normal muscle strength
Tenderness w/ decreased ROM at shoulder, neck and hip
Responds rapidly to glucocorticoids
Normal CK
Elevated ESR
9
Q
What is cerebral palsy?
A
Non-progressive motor dysfunction
RF: Prematurity*, low birth weight; premature infants are more likely to have periventricular leukomalacia (white matter necrosis from ischemia/infection) and intraventricular hemorrhage (germinal matrix bleeding due to fragile vasculature and unstable cerebral blood flow) assoc. w/ CP
Presentation: delayed motor milestones, hypertonia, hyperreflexia; comorbid seizures, intellectual disability; equinovarus deformity (feet point down and inward); commando crawl (commonly seen in CP due to contractures of the lower limbs)
Dx: MRI of brain, +/- EEG, +/- genetic/metabolic testing
Mgmt: physical, occupational, speech therapies; nutritional support, antispastic medications
10
Q
What is acute angle closure glaucoma?
A
Due to sudden narrowing or closure of the anterior angle chamber
Typically occurs as a response to pupillary dilation from meds (eg anticholinergics such as tolterodine, trihexyphenidyl; sympathomimetics, and decongestants) or other stimuli (eg dim light)
Anticholinergics cause mydriasis, which may precipitate acute ACG
More common in women (esp >40yo), Asian and Inuit populations, individuals with farsightedness
Presentation: rapid onset of severe eye pain, halos around lights; affected eye will appear injected, pupil will be dilated and poorly responsive to light; tearing and headache w/ subsequent nausea and vomiting as IOP increases
Untreated acute ACG can lead to severe and permanent vision loss w/in 2-5h of symptom onset
11
Q
What is Guillain-Barré syndrome?
A
Pathophys: immune-mediated demyelinating polyneuropathy of peripheral nerve fibers, preceding GI (campylobacter) or respiratory infection Presentation: paresthesia, neuropathic pain; symmetric, ascending weakness; decreased/absent deep-tendon reflexes; autonomic dysfunction (eg arrhythmia, ileus, orthostatic hypotension, urinary retention, lack of sweating); respiratory compromise Bulbar sxs (dysarthria) Dx: clinical; supportive findings (CSF fluid: albuminocytologic dissociation = increased protein, NORMAL WBCs; abnormal electromyography and nerve conduction) Mgmt: monitor autonomic and respiratory function; IV Ig or plasmapheresis
12
Q
What is CSF analysis normally?
A
OP: 100-180/200-300 mm H2O (8-15mm Hg)
WBC 0-5
Glucose 40-70
Protein <40
13
Q
What is CSF analysis in bacterial meningitis?
A
WBC >1000 (PMNs)
Glucose <40
Protein >250
14
Q
What is CSF analysis in tuberculous meningitis?
A
Similar to bacterial CSF findings:
WBC 100-500
Glucose <45
Protein 100-500
15
Q
What is CSF analysis in viral meningitis?
A
WBC 10-500
Glucose 40-70
Protein <150 (Normal to high)
16
Q
What is CSF analysis in GBS?
A
WBC 0-5
Glucose 40-70
Protein 45-1000
17
Q
What is Lesch-Nyhan syndrome?
A
Pathophys: X-linked recessive, deficiency of hypoxanthine-guanine phophoribosyltransferase, hypoxanthine and uric acid accumulation
Presentation: delayed milestones and hypotonia in infancy; early childhood - intellectual disability, extrapyramidal sxs (dystonia, chorea), pyramidal sxs (spasticity, hyperreflexia), self-mutilation; biting fingers and tongue, writhing movements, neprholithiasis; gouty arthritis in late, untreated disease
18
Q
What is subclavian steal syndrome?
A
Due to stenosis or occlusion of proximal subclavian artery, leading to reversal of blood flow in ipsilateral vertebral artery
Pts are often asymptomatic but may have sxs of upper extremity ischemia (eg pain, fatigue, paresthesias) or vertebrobasilar insufficiency (eg dizziness, ataxia, dysequilibrium) that are worsened by upper extremity exercise
Lower brachial SBP (>15mm Hg) in affected arm, systolic bruit in supraclavicular fossa on affected side
4th heart sound may be present due to LVH from systolic HTN
19
Q
What is cavernous sinus thrombosis?
A
B/c facial/ophthalmic venous system is valveless, uncontrolled infection of the skin, sinuses, and orbit can spread to the cavernous sinus
Headache = most common symptom; low grade fever and periorbital edema usually occur several days later secondary to impaired venous flow in the orbital veins
Vomiting = result of intracranial HTN and fundoscopy may reveal papilledema
Unilateral sxs of HA, binocular palsies, periorbital edema, hypoesthesia, or hyperesthesia can rapidly become bilateral b/c CN 3, 4, 5.1, 6 pass through cavernous sinus
20
Q
What is Sturge Weber syndrome?
A
Neurocutaneous disorder characterized by capillary malformation in CN 5.1, 2 distribution
Pathophys: mutation in GNAQ gene
Presentation: Port wine stain (CN 5.1, 2 distribution), leptomeningeal capillary-venous malformation, seizures +/- hemiparesis, intellectual disability, visual field defects, glaucoma (common)
Dx: MRI of brain w/ contrast
Mgmt: laser therapy to reduce appearance of port wine stain, antiepileptic drugs, IOP reduction
21
Q
What is infant botulism?
A
Pathogenesis: ingestion of c. botulinum spores from environmental dust
Highest in California, Utah, and Pennsylvania
Ingestion of raw honey is also a risk factor
Presentation: descending flaccid paralysis; bulbar palsies (ptosis, sluggish pupillary response to light, poor suck and gag reflexes), constipation and drooling
Treatment: human-derived botulism immune globulin
22
Q
What is foodborne botulism?
A
Pathogenesis: ingestion of preformed c. botulinum toxin
Presentation: descending flaccid paralysis
Treatment: equine-derived botulism antitoxin
23
Q
What is CNS lymphoma in an HIV patient?
A
Presence of EBV DNA in the CSF is specific for this condition
Dx: MRI reveals a weakly ring-enhancing mass that is usually solitary and periventricular
24
Q
What is psychogenic nonepileptic seizure?
A
A type of conversion disorder commonly misdiagnosed as a seizure disorder.
Presentation: forceful eye closure, side to side head or body movements, rapid alerting or reorienting, memory recall of the event, lack of post-ictal confusion
Not assoc. w/ abnormal cortical activity
Dx: video-EEG (gold standard) demonstrating lack of epileptiform activity
25
What is antiplatelet/antithrombotic therapy for ischemic stroke?
```
Presentation w/in 3-4.5h of symptom onset = IV alteplase (tPa)
Stroke w/ no prior antiplatelet therapy = aspirin
Stroke on aspirin therapy = aspirin + dipyramidole OR clopidogrel
Stroke w/ evidence of atrial fibrillation = long term anticoagulation (eg warfarin, dabigatran, rivaroxabn)
Stroke w/ larger anterior circulation artery occlusion w/in 24h of sxs onset = Mechanical thrombectomy (regardless if pt received alteplase), then aspirin
Pt w/ intracranial large-artery atherosclerosis = Aspirin + clopidrogrel for 90d, then aspirin
```
26
What is the criteria for thrombolytics in stroke?
Inclusion: ischemic stroke w/ measurable neurodeficits; sxs onset <3-4.5h before tx initiation
Strict exclusion criteria: hemorrhage or multilobar infarct involving >33% of cerebral hemisphere on CT scan, stroke/head trauma in past 3mo, hx of intracranial hemorrhage/neoplasm/vascular malformation, recent intracranial/spinal injury, active bleeding or arterial puncture in past 7d at non-compressible site, BP >185/100, platelets <100k or glucose <50, anticoagulant use with INR >1.7, PT >15s or increased active PTT
Relative exclusion: minor or rapidly improving neurodeficits, major surgery/trauma in past 14d, myocardial infarction in past 3mo, GU or GI bleeding in past 21d, seizure or stroke onset, pregnancy
27
What is duchenne muscular dystrophy?
X linked recessive deletion of dystrophin gene on chXp21
Presentation: onset at 2-3y; progressive weakness, Gower maneuver, calf pseudohypertrophy
Comorbidities: scoliosis, cardiomyopathy
Prognosis: wheelchair-dependent by adolescence, death by age 20-30 from respiratory or heart failure
28
What is Becker muscular dystrophy?
X linked recessive deletion of dystrophin gene on chXp21
Presentation: onset age 5-15y; milder weakness compared to duchenne's
Comorbidities: cardiomyopathy
Prognosis: death by age 40-50 from heart failure
29
What is myotonic muscular dystrophy?
AD expansion of a CTG trinucleotide repeat in DMPK gene on ch19q13.3
Presentation: onset age 12-30y; facial weakness, hand grip myotonia, dysphagia
Comorbidities: arrhythmias, cataracts, balding, testicular atrophy/infertility
Prognosis: death from respiratory failure or heart failure depending on age of onset
30
What is a lacunar stroke?
Etiology: small penetrating artery occlusion (via thrombus) due to hypertensive arteriolar sclerosis and lipohyalinosis
Infarcts are quite small
Affected areas: basal ganglia, subcortical white matter (eg internal capsule, corona radiata), pons, cerebellum
RF: HTN*, DM, advanced age, increased LDL, smoking
Presentation: absence of cortical signs (aphasia, agnosia, neglect, apraxia, hemianopia, urinary incontinence), seizure, or mental status changes; common syndromes - pure motor hemiparesis (most frequent; from stroke in posterior limb of internal capsule), pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand
The face, arm, and leg are all equally affected.
Imaging: due to small size, not appreciated well on noncon CT scans shortly after event
[small, dont cause rapidly worsening global neuro sxs (eg vomiting, stupor, bradycardia)]
31
What is Wernicke-Korsakoff Syndrome?
Assoc. conditions: chronic alcoholism (most common), malnutrition (anorexia nervosa, short gut syndrome - Crohn's), hyperemesis gravidarum
Pathophys: thiamine deficiency
Presentation: confusion, encephalopathy, oculomotor dysfunction (eg horizontal nystagmus, bilateral abducens palsy), postural and gait ataxia; malnourishment
Treatment: IV thiamine followed by or along with glucose infusion
32
What is exertional heat stroke?
Heat exhaustion: due to inadequate fluid and salt replacement and body is unable to maintain adequate CO. CNS dysfunction (AMS) is not present.
Due to thermoregulation failure
RF: strenuous activity during hot and humid weather, dehydration, poor acclimatization, lack of physical fitness, obesity, meds (anticholinergics, antihistamines, phenothiazines, tricyclis)
Presentation: core temp >40C (104F) immediately after collapse AND CNS dysfunction (altered mental status, confusion, irritability, seizure), additional organ or tissue damage (renal/hepatic failure, disseminated intravascular coagulation - persistent bleeding (nose bleed), acute respiratory distress syndrome)
Mgmt: rapid cooling (ice water immersion preferred; can consider high flow cool water dousing, ice/wet towel rotation, evaporative cooling; fluid resuscitation, electrolyte correction, mgmt of end-organ complications, no role for antipyretic therapy
33
What is alcoholic cerebellar degeneration?
Epi: >10 years of heavy alcohol use, degeneration of Purkinje cells (cerebellar vermis)
Presentation: usually develops over weeks to months, wide based gait, in-coordination in legs, cognition usually intact
Dx: Clinical - impaired tandem walking/heel knee shin, preserved finger-nose testing;
Imaging: CT/MRI - cerebellar atrophy
Treatment: alcohol cessation, nutritional supplements, ambulatory assistance devices (walker)
34
What is pain management for cancer?
Mild: nonopioids (acetaminophen, NSAIDs)
Moderate: weak opioids +/- nonopioids (codeine, hydrocodone, tramadol)
Severe: strong short-acting opioids (morphine, hydromorphone) --> calculate total daily dose and convert to long-acting formulation (fentanyl patch, oxycodone) PLUS short-acting opioids for breakthrough pain
35
What is fetal alcohol syndrome?
Face: smooth philtrum, thin vermillion border, small palpebral fissures, microcephaly
Growth is compromised with percentiles <10th for age and sex
Social withdrawal and delays in motor and language milestones
36
What is down syndrome?
Most common genetic cause of developmental delay
Meiotic nondisjunction of chromosome 21
Face: flat facial profile, slanted palpebral fissures, small low-set ears
Body: excessive skin at nape of neck, single transverse palmar crease, clinodactyly, large space between the first 2 toes
37
What is Fragile X syndrome?
Caused by trinucelotide (CGG) repeat expansion in fragile X mental retardation (FMR1) gene
Most common X-linked inherited cause of intellectual disability
Speech and motor delays, begin walking and talking around 20mo instead of at 12mo; ADHD and Autism spectrum disorder are also common
Face: long narrow face, prominent forehead and chin, large ears, macrocephaly
Body: macroorchidism (large testicles)
38
What is hypokalemia?
Causes: K-wasting diuretics, diarrhea, vomiting, anorexia, hyperaldosteronism
Presentation: weakness, fatigue, muscle cramps; flaccid paralysis, hyporeflexia, tetany, rhabdomyolysis, arrhythmias
Dx: ECG - broad flat T waves, U waves, ST depression, premature ventricular beats
39
What is Parkinson's disease dementia?
Characterized by executive and visuospatial dysfunction (impaired attention and planning, inability to recognize familiar people, getting lost in familiar locations)
Dx: when Parkinsonism predates cognitive impairment by >1 year; PD then dementia = PDD
40
What are the clinical features of Alzheimer disease?
Most common cause of dementia in the western world.
RF: old age, female sex, family history, head trauma, and Down syndrome
Typical first symptoms: memory loss for recent events, language difficulties, and apraxia, followed by impaired judgement and personality changes
Early findings: anterograde memory loss* (immediate recall affected, distant memories preserved), visuospatial deficits (eg lost in own neighborhood), language difficulties (eg difficulty finding words), cognitive impairment w/ progressive decline
Late findings: neuropsychiatric (hallucinations, wandering, delusions, paranoia), personality changes (apathy, agitation), dyspraxia (difficulty performing learned motor tasks), lack of insight regarding deficits, noncognitive neurologic deficits (pyramidal and extrapyramidal motor, myoclonus, seizures), urinary incontinence
Imaging: generalized cortical atrophy; reduced hippocampal volume or medial temporal lobe atrophy may be seen in temporal lobe*
41
What is phenytoin toxicity?
Normal serum levels: 10-20, increase by 10% at a time; zero-order elimination
Acute toxicity manifests with cerebellar dysfunction: horizontal nystagmus (nystagmus on lateral gaze), ataxia (wide based gait), dysmetria (on finger to nose testing), slurred speech, n/v, and hyperreflexia
Severe toxicity: altered mental status (lethargy, confusion), coma, paradoxical seizures, death
Bactrim, fluconzaole inhibit cyp450 system and can increase the drug's concentration
Valproic acid can displace phenytoin from plasma proteins and increase concentration of drug
42
What is brain death?
Irreversible cessation of brain activities
Absence of cortical and brain stem functions/reflexes (pupillary light reflex, oculovestibular reflex)
Heart rate fails to accelerate after atropine injection b/c vagal control of heart is lost
Apnea test: no spontaneous respiration at PCo2 of >50
Clinical diagnosis; spinal cord may still be functioning, therefore deep tendon reflexes (DTRs) may be present
43
What is status epilepticus?
Seizure lasting >/= 5 minutes or >/= 2 seizure events in which patient does not completely regain consciousness in between episodes
Increased risk of developing permanent injury due to excitatory cytotoxicity
Cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures
Tx: IV benzodiazepine (lorazepam, diazepam), + non-benzodiazepine (fosphenytoin, phenytoin, levetiracetam, or valproic acid) to prevent seizure recurrence
44
What is Bell's Palsy?
Etiology: reactivation of neurotrophic virus (most commonly HSV), infection causes inflammation and edema of facial nerve resulting in nerve compression and degeneration of myelin sheath
Peripheral neuropathy involving CN7; sxs onset is acute (over the course of hours) and progressive
May be preceded by prodrome of auricular pain or dysacusis (distortion of sound)
Unilateral facial paralysis: mouth drooping, disappearance of nasolabial fold, involvement of upper face, decreased ipsilateral eye lacrimation, hyperacusis, decreased sensation of taste over anterior 2/3 of ipsilateral tongue
Tx: oral glucocorticosteroids; valacyclovir or acyclovir may speed time to complete recovery of facial function and b/c of assoc. with HSV
Partial or complete recovery occurs w/in 3-4 months
45
What is a focal seizure?
Etiology: structural abnormality (eg tumor), genetic epilepsy, unknown
Presentation: origin - one cerebral hemisphere, intact (simple) or impaired (complex) awareness, +/- secondary generalization which can cause impaired consciousness; can involve motor (head turning, arm twitching), sensory (paresthesias), and autonomic (eg sweating)
Following episode, postictal confusion and lethargy are common, and transient postictal paresis or paralysis (Todd paralysis) may also occur
Not provoked by hyperventilation
Dx: MRI of the brain, EEG
46
What is tick paralysis?
Characterized by rapidly progressive ascending paralysis (over hours to days) which may be asymmetrical, paresthesias in the LEs
Absence of fever and sensory abnormalities, normal CSF examination, no autonomic dysfunction
Etiology of paralysis: neurotoxin; tick needs to feed for 4-7d for release of neurotoxin
Tx: meticulous search for tick; removal results in improvement w/in 1h and complete recovery after several days
47
What is cervical artery dissection?
Mechanism: penetrating trauma/neck strain/manipulation, fall with object in mouth (toothbrush, pencil), neck manipulation (eg yoga, sports)
Internal carotid artery is located directly behind lateral and posterior to the tonsillar pillars; injury leads to dissection or thrombus formation
Presentation: gradual-onset hemiplegia, aphasia, neck pain, "thunderclap" headache, facial droop
Dx: CT or MR angiography
48
What is lead poisoning?
RF: occupational exposure (eg lead paint, batteries, ammunition, construction)
Presentation: GI (abdominal pain, constipation, anorexia), neurologic (cognitive defects, peripheral sensorimotor neuropathy, short term memory loss), hematologic (anemia), HTN and possible nephrotoxicity (elevated Cr)
Labs: anemia, elevated venous lead level, elevated serum zinc protoprophyrin level, hyperuricemia (due to impaired purine metabolism)
Imaging: basophilic stippling on peripheral smear
Tx: chelation therapy with calcium disodium EDTA
49
What is the ddx for upper motor neuron disease?
Leukodystrophies, vasculitis, brain mass, B12 deficiency
50
What is the ddx for anterior horn cell disease?
Spinal muscular atrophy (flaccid paralysis in infancy), ALS, paraneoplastic syndromes, poliomyelitis
51
What is the ddx for peripheral nerve disease?
Hereditary primary motor sensory neuropathy, GBS, diabetic neuropathy, amyloid neuropathy (myeloma), lead poisoning
52
What is the ddx for NMJ disease?
Myasthenia gravis, Lambert Eaton syndrome, organophosphate poisoning, botulism
53
What is the ddx for muscle fiber disease?
Muscular dystrophies, polymositis/dermatomyostitis, hypothyroidism, corticosteroids, HIV myopathy
54
What is RA cervical myelopathy?
Spinal cord compression due to atlantoaxial joint instability
Sxs: neck pain radiating to occipital region, slowly progressive spastic quadriparesis (numbness and tingling), painless sensory deficits in hands or feet, respiratory dysfunction (eg from vertebral artery compression)
Signs: protruding anterior arch of atlas, scoliosis w/ loss of cervical lordosis, UMN signs (eg spastic paresis, hyperreflexia, Babinski sign), Hoffman sign
55
What is a brain abscess?
Micro: s. aureus, v. streptococci, anaerobes
Pathogenesis: direct spread (eg sinusitis, otitis media), hematogenous spread (eg endocarditis)
Findings: headache, vomiting, fever, focal neurological deficits, seizure, ring-enhancing lesion w/ central necrosis on neuroimaging (CT, MRI)
Tx: CT-guided aspiration/surgical drainage, surgical biopsy, prolonged antibiotic therapy (eg metronidazole, ceftriaxone, vancomycin)
56
What is multiple system atrophy (Shy-Drager syndrome)?
Degenerative disease characterized by Parkinsonism, autonomic dysfunction (postural hypotension, abnormal sweating, disturbance of bowel or bladder control, abnormal salivation or lacrimation, impotence, gastroparesis), widespread neurological signs (cerebellar, pyramidal, or LMN)
Accompanying bulbar dysfunction and laryngeal stridor may be fatal
Tx: anti-Parkinsonism drugs are generally ineffective, treatment aimed at intravascular volume expansion w/ fludrocortisone, salt supplementation, alpha-adrenergic agonists, and application of constrictive garment to the lower body
57
How does a lesion in the posterior limb of the internal capsule (lacunar infarct) present?
Unilateral motor impairment, no sensory or cortical defects, no visual field abnormalities
58
How does a lesion of MCA present?
Contralateral somatosensory and motor deficit (face, arm, and leg)
Conjugate eye deviation toward side of infarct
Homonymous hemianopia
Aphasia (dominant hemisphere)
Hemineglect (nondominant hemisphere)
59
How does a lesion of the ACA present?
Contralateral somatosensory and motor deficit predominantly in the LE than the UE
Abulia (lack of will or initiative)
Gait dyspraxia, emotional disturbances, urinary incontinence (from damage to the cortical micturition centers of the mesial frontal lobe), primitive reflexes (eg grasp, sucking)
60
How does a lesion of vertebrobasilar system (supplying the brain stem) present?
Alternate syndromes with contralateral hemiplegia and ipsilateral cranial nerve involvement
Possible ataxia
61
What are therapies for migraine?
Preventives (more frequent): topiramate, divalproex sodium, TCAs (amitriptyline), beta blockers (eg propranolol)
Abortives (less frequent): triptans (eg sumatriptan), ergotamines (eg dihydroergotamine), NSAIDs (eg naproxen), acetaminophen, anti-emetics (eg metoclopramide, prochlorperazine)
Subq triptan or IV antiemetic for severe migraine headache refractory to simple analgesics
Triptans and ergots are generally avoided in patients with significant coronary artery disease due to risk of coronary vasospasm
62
What is myasthenic crisis?
Severe respiratory muscle weakness leading to respiratory failure
Precipitating factors: infection or surgery, pregnancy or childbirth, tapering of immunosuppressive drugs, medications (eg aminoglycosides, beta blockers)
Signs/symptoms: generalized and oropharyngeal weakness, respiratory insufficiency/dyspnea; bulbar muscle weakness (eg difficulty coughing up sputum) prior to onset of crisis
Tx: intubation for deteriorating respiratory status, plasmapheresis or IVIG as well as corticosteroids
63
What is tabes dorsalis?
Late neurosyphilis, a form of tertiary syphilis
Epi: increased incidence of syphilis in MSM and HIV-infect patients, HIV+ pts develop neurosyphilis more rapidly
Pathogenesis: T. pallidum spirochetes directly damage the dorsal sensory roots, secondary degeneration of the dorsal columns
Clinical findings: sensory ataxia, dorsal root -lancinating pains (brief shooting pain in the face, back, or extremities) and hypo/areflexia, neurogenic urinary incontinence, assoc. w/ argyll robertson pupils (normal pupillary constriction w/ accommodation but not w/ light)
Tx: IV penicillin for 10-14d
64
What is the treatment for resting tremor of Parkinson's?
Occurs during rest, improves w/ activity, 4-5hz; often first manifestation of Parkison's
Often involves one hand before the other or presents asymmetrically
Trihexyphenidyl, an anticholinergic - used in younger pts when tremor is the predominant symptom
Propranolol is first line for treatment of essential tremor
65
What is metastatic brain cancer?
Incidence: Lung>breast>unknown primary>melanoma>colon
Primarily solitary brain metastases: breast, colon, renal cell carcinoma
Multiple brain metastases: lung, melanoma
Rare brain metastases: prostate, esophageal, oropharyngeal, hepatocellular, non-melanoma
66
What is dystonia?
Sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures.
Meds commonly responsible for torticollis, a focal dystonia, include typical antipsychotics, metoclopramide, and prochlorperazine
67
What is essential tremor?
Action tremor that worsens at the end of goal-oriented actions (eg drinking from a cup, or buttoning t-shirt)
Epi: fhx often present, up to 5% of population affected
Features: action tremor (eg hands outstretched), usually bilateral, hands>arms>head>legs
Tx: beta blockers - propranolol*, anticonvulsants: primidone, small amounts of alcohol, benzodiazepines: clonazepam
68
Neurologic findings based on site of hemorrhage.
Basal ganglia: contralateral hemiparesis and hemisensory loss, homonymous hemianopsia, gaze palsy
Cerebellum: usually no hemiparesis; facial weakness, ataxia and nystagmus, occipital headache and neck stiffness
Thalamus: pure sensory deficits; contralateral hemiparesis and hemisensory loss, nonreactive miotic pupils, upgaze palsy, eyes deviate TOWARD hemiparesis; can get thalamic pain sydrome (severe paroxysmal burning pain over the affected area that is exacerbated by light touch (allodynia))
Cerebral lobe: contralateral hemiparesis (frontal lobe), contralateral hemisensory loss (parietal lobe) homonymous hemianopsia (occipital lobe), eyes deviate away from hemiparesis, high incidence of seizures
Pons: deep coma and total paralysis w/in minutes, PINPOINT reactive pupils
69
What is an intracerebral hemorrhage?
Hx of uncontrolled HTN, coagulopathy, illicit drug use (eg amphetamines, cocaine)
Sxs progress over minutes to hours
Focal neurologoical sxs appear early, followed by features of increased intracranial pressure (eg vomiting, HA, bradycardia, reduced alertness)
70
What is vascular dementia?
Stepwise decline: some improvement but then another set back
Early executive dysfunction: early mild forgetfulness compared to more profound memory problems in AZ
Neuroimaging: Cerebral infarction and/or deep white matter changes from chronic ischemia (i.e., cortical and subcortical infarcts)
Large artery infarction produces cortical type: ie contralateral weakness and sensory impairment, typically follows the classic stepwise worsening course
Infarcts and ischemia in small arterial distributions lead to a subcortical type, which is characterized by focal motor deficits (eg reflex asymmetry), abnormal gait, urinary symptoms, and psychiatric sxs (eg depressive syndromes); has a gradual declining course
71
What is cerebral amyloid angiopathy?
The most common cause of spontaneous lobar (eg parietal, occipital) hemorrhage, particularly in the elderly.
Consequence of beta amyloid deposition in walls of small to medium sized cerebral arteries resulting in vessel wall weakening and predisposition to rupture
Presentation: contralateral hemisensory loss (due to primary somatosensory cortex injury) and contralateral hemineglect if parietal assoc. cortex (in nondominant hemisphere) is affected
72
What is cervical radiculopathy?
Degenerative condition of spine marked by osteophyte formation
Most cases arise in older adults due to acute cervical disc herniation or underlying cervical spondylosis
Presentation: nerve root compression (radiculopathy) with neck/shoulder pain and upper extremity sensory, motor, and/or reflex abnormalities in dermatomal distribution
Imaging: sclerotic facet joints w/ osteophytes
73
What is time frame of pain from acute herpetic neuralgia?
Rash, then pain
Persists = 30d from rash onset
Tx: NSAIDs, analgesics
74
What is time frame of pain from subacute herpetic neuraglia?
Rash, then pain
Persists >30d but resolves w/in 4 mo of rash onset
Tx: NSAIDs, analgesics
75
What is time frame of pain from postherpetic neuralgia?
Rash, then pain
Persist >4mo from rash onset
Tx: TCAs, gabapentin, pregabalin
76
What is optic neuritis?
Inflammatory demyelination of the optic nerve
Epi: primarily in young women, assoc. w/ MS, immune-mediated demyelination
Manifestations: acute, peaks at 2 weeks, monocular vision loss, central scotoma, eye pain with movement, "washed out" color vision, afferent pupillary defect
Fundoscopy is usually normal as inflammation occurs behind the optic nerve head so look for other areas of inflammation
Dx: MRI of the orbits and brain
Tx: IV corticosteroids, 35% of cases recur
77
What is cryptococcal meningitis?
Common in pts w/ advanced AIDS
Presentation: increased ICP, HA, n/v, CN6 palsy (lateral gaze palsy and diplopia), umbilicated skin lesions (due to hematogenous dissemination to skin)
Replicats in the CNS and clogs the arachnoid villi w/ yeast components and capsular polysaccharides leading to CSF outflow obstruction and increased ICP (ha/n/v, confusions)
Imaging (CT scan): enlarged ventricles
Dx: LP, CSF analysis, India ink stain, capsular polysaccharide antigen testing
78
What is an absence seizure?
Characterized by sudden impairment of consciousness w/o loss of postural tone
Episodes occur throughout the day, during all activities w/o warning; short in duration <20s, lack of response to vocal or tactile stimulation
Presence of automatisms (eg eyelid fluttering, lip smacking)
Can usually be provoked by hyperventilation
Dx: EEG classically revealing 3Hz spike wave discharge pattern
Tx: Ethosuximide
79
What is transverse myelitis?
Motor and sensory loss below the level of the lesion with bowel and bladder dysfunction.
Due to infection or inflammation of spinal cord
Pts initially have flaccid paralysis (LMN; spinal shock), followed by spastic paralysis w/ hyperreflexia (UMN)
Common initial sx in MS
80
What is mastoiditis?
Pathophys: complication of acute otitis media; most commonly due to s. pneumoniae
Presentation: fever and otalgia; inflammation of mastoid; deviation of ear
Imagin: opacification of mastoid air cell on CT scan or MRI
Mgmt: IV abx, drainage of purulent material
Complications: extracranial extension (subperiosteal abscess, facial nerve palsy, hearing loss, labryrinthitis); intracranial extension (brain abscess, meningitis)
81
What are the contraindications for an LP?
Elevated intracranial pressure due to risk of cerebral herniation and death; bleeding; low platelets; skin infection; intracranial mass w/ edema
82
What is a transient ischemic attack?
FNDs last for <24h
| Tx: aspirin and statin, improve BP control
83
What is homonymous hemianopia?
Any unilateral visual pathway lesion beyond the optic chiasm (eg optic tract, lateral geniculate body, optic radiation, primary visual cortex) can cause contralateral homonymous hemianopia.
This is frequently seen w/ intracerebral hemorrhage affecting the basal ganglia or occipital lobe.
84
What is Miller Fisher Syndrome?
A variant of GBS, a group of immune mediated polyneuropathies that are caused by molecular mimicry
Presentation: opthalmoplegia, ataxia, and areflexia; strenth is preserved
High assoc. w/ anti-GQ1b antibody
85
What is Angelman syndrome?
Intellectual disability, a happy disposition, jerky gait, hypermotoric behaviors, hand flapping.
86
What is Landau Kleffner syndrome?
Regression of language skills due to severe epileptic attacks.
Language skills typically deteriorate at age 3-6 as a result of severe epileptic attacks.
87
What is Lennox-Gastaut syndrome?
Characterized by severe seizures of multiple types and typically presents in children age 3-5. Assoc. w/ intellectual disability and a slow, generalized spike and wave pattern on EEG.
88
What is Krabbe disease?
AR, lysosomal storage disorder
GALACTOcerebrosidase deficiency
Presentation: developmental regression, hypotonia, areflexia, cherry red macula, blindness, deafness, paralysis, neuropathy, and seizures
89
What is Gaucher disease?
GLUCOerebrosidase deficiency
| Presentation: anemia, thrombocytopenia, hepatosplenomegaly
90
What is Hurler syndrome?
Lysosomal storage disorder, due to lysosomal hydrolase deficiency
Presentation: 6mo-2y, course facial features, inguinal or umbilical hernias, corneal clouding, hepatosplenomegaly
91
What is galactosemia?
Due to galactose 1 phosphate UDT deficiency
Elevated blood levels of galactose
Presentation: FFT, bilateral cataracts, jaundice, hypoglycemia
92
What is galactokinase deficiency?
Presents w/ cataracts only; otherwise asymptomatic
93
Solitary brain metastasis treatment.
Surgical resection is recommended in pts w/ good performance status and stable extracranial disease. Typically followed by stereotactic radiosurgery (SRS) or whole brain radiation therapy (WBRT) to tumor bed.
SRS: pts who are not surgical candidates, have a surgically inaccessible lesion, or smaller mets (<3cm)
WBRT: multiple brain mets or poor performance
In pts w/ multiple brain metastases, whole braine radiation therapy is typically used.
94
What is the Parkinson tremor?
A resting tremor w/ pill rolling quality
More pronouned w/ distractibility (eg performing mental tasks).
Decreases w/ voluntary movement.
95
What is tuberous sclerosis?
Neurocutaneous disorder
Presentation: seizures, intellectual disability, retinal hamartomas, hypopigmented ash-leaf spots, angiofibromas (malar erythematous papules), shagreen patches (flesh-colored plaque on the back)
CT: cortical tubers
96
Trihexyphenidyl.
An anticholinergic used in tx of parkinson's (eg resting tremor, cogwheel rigidity)
Causes mydriasis, which may precipitate acute angle closure glaucoma.
97
Levodopa + entacapone.
Common side effects: nausea, orthrostatic hypotension, dizziness.
98
Hypertensive hemorrhage
Generally involve same small penetrating arteries responsible for lacunar stroke
Most affected locations: basal ganglia, cerebellar nuclei, thalamus, pons
Putaminal hemorrhages always involve the adjacent internal capsule: contralateral hemiparesis and hemianesthesia (due to disruption of the corticospinal and somatosenosry fibers in the posterior limb) and conjugate gaze deviation TOWARD the side of the lesion due to damage of the FEF efferents in the anterior limb).
99
Onset of FND.
Sudden FND that gradually worsen over minutes to hours: intraparenchymal brain hemorrhage
Sx severity is maximal at onset: Subarachnoid hemorrhage, embolic stroke
Sx progress in stuttering fashion: ischemic stroke
100
Benzos and the elderly.
Benzos are often prescribd for insomnia and/or anxiety. But they should be used sparingly in the elderly due to increased risk of adverse side effects.
People metabolize benzos more slowly as they age and are more likely to experience CONFUSION and increased risk of FALLS.
Paradoxical agitation is another side effect: increased agitation, confusion, aggression, disinhibition typically w/in 1h of administration
Tx: taper and eventual discontinuation of medication
101
Parkinson's disease.
Caused by accumulatoin of alpha synuclein w/in neuron of substantia nigra pars compacts
Rest tremor, rigidity, bradykinesia, postural instability
Dx: clinical
102
Blepharospasm
A form of focal dystonia, forceful contraction of the eyelid muscles; most cases are idiopathic
+spasm of lower face = Meige syndrome
Bilateral and symmetric
Commonly affected by sensory input
Terminate by touching or brushing skin around the eye ("sensory trick")
Tx: trigger avoidance (wearing dark glasses to block bright lights), botulinum toxin injection needed for more significant symptoms
103
What are argyll robertson pupils?
Typically miotic and irregular
| Characterized by normal pupillary constriction w/ accommodation, but not with light.
104
What is neurogenic shock?
Due to traumatic spinal cord injury (in cervical spine)
Acute cord injury assoc. w/ several min of massive sympathetic stimulation (leading to HTN and tachycardia) due to release of NE from the adrenals
Quickly thereafter, sympathetic tone plummets due to injury to the descending spinal tracts that carry signals from brainstem to preganglionic sympathetic neurons in the lateral horn of spinal cord (at levels T1-L2)
This results in unopposed parasympathetic stimulation (carried by intact vagus nerve) leading to hypotension and hypothermia from peripheral vasodilation and bradycardia
Last 1-5w before improving; at increased risk for hypotension, bradycardia, and hypothermia due to long-standing reducing sympathetic tone
105
Cerebellar hemorrhage
Occipital headaches (may radiate to neck/shoulders), neck stiffness (due to extension of blood into the 4th ventricle), n/v, nystagmus
Ipsilateral hemiataxia of the trunk (cerebellar vermis) and/or limbs (cerebellar hemispheres)
Dx: noncontrast head CT scan
106
Peroneal nerve compression
Unilateral footdrop
Numbness/tingling over the dorsal foot and lateral shin
Impaired ankle dorsiflexion (walking on heels) and great toe extension
Preserved plantar flexion (walking on toes) and reflexes
Leads to foot drop
Dx: electromyography and nerve conduction studies
Tx: reducing pressure on nerve (avoid crossing the legs), an ankle foot orthosis splint, PT
107
What is generalized convulsive status epilecticus?
```
A seizure lasting >=5 min or >=2 seizure events in which the pt does not completely regain consciousness.
IV benzos (eg lorazepam,diazepam) should be administered for seizure terminatoin.
In addition, a nonbenzo antiepilectic medication should be administered to prevent seizure RECURRENCE - fosphenytoin, phenytoin, levetiracetam, or valproic acid
After initial stabilizatoin, neuroimaging shoudl be performed to evaluate for any underlying structural abnormality, hemorrhage, or area of ischemia. Any pts who does not return to a normal state of consciousness after medical therapy should undergo continuous EEG to r/o nonconvulsive status epilepticus.
```
108
What is rem behavior disorder?
More likely to occur in men >50yo
Characterized by dream enactment during REM sleep atonia.
Dream enactment occurs b/c the muscle atonia that usually accompanies REM sleep is absent or incomplete in RBD.
Most pts w/ idiopathic RBD eventually develop a disorder of alpha-synuclean neurodegeneration, most commonly Parkinson disease.
109
MS
Bilateral lesions of MLF classically seen.
110
Spinal cord injury
In pt w/ traumatic spinal cord injuries, urinary catheter placement can assess for primary retention and prevent acute bladder distention and damage.
Pt may present with abdominal discomfort.
111
Wafarin-assoc. intracerebral hemorrhage.
Due to supratherapeutic levels of warfarin.
Tx:
-Prothrombin complex concentrate (PCC) contains vit. K dependent clotting factors (2, 7, 9, 10) that offer rapid (minutes) and short term (hours) reversal of warfarin
-IV vitamin K (takes 12-24h) to be effective (promotes clotting factor synthesis in the liver)
FFP can be considered if PCC is not available, however it takes longer to administer/prepare and require more volume infusion compared to PCC
112
Hemorrhage stroke
Tx: nicardipine or labetalol lower BP to <140
113
Increased intracranial pressure
Headaches, vomiting, bulging fontanelle
VP shunt increases risk due to shunt malfunction (cathether obstruction, shunt migration, split tubing)
Dx: brain imaging w/ CT or fast MRI
[Fontanelle's close between 9-18mo.]
114
Non-pupil sparing CN3 palsie
| Motor/somatic: levator palpebrae muscle, IO, SR, IR, MR
Down and out pupil
Caused by mass effect
Likely due to intracranial aneurysm until proven otherwise
Pt should undergo immediate MR or CT angio
115
Pupil sparing CN3 palsie
| PNS: responsible for pupil constrictioni by controlling sphincter papillae muscle
Pupillary dilation
Typically caused by microvascular ischemia
Assoc. w/ DM, HTN, hyperlipidemia, and advance dage
Observation and supportive care for pts w/ vasculopathic risk factors (eg diabetes, HTN).
116
Hemorrhagic stroke transformation
Pts w/ large or embolic ischemic strokes and those treated w/ thrombolytics are at high risk for hemorrhagic transformation.
This condition usually occurs w/in 48h of the stroke and often manifests w/ deteriorating mental status.
Dx: emergent noncontrast CT head
117
What is ependymoma?
Glial cell tumors that arise from the ependymal cell lining of the ventricles and spinal cord.
In children, the most common site is the 4th ventricle in the posterior fossa, where tumor expansion leads to obstruction of the CSF and increased ICP.
Weakness and seizures are not common.
118
What is medlloblastoma?
2nd most comon tumor in the posterior fossa in children.
| Infratentorial tumor that typically arise from the cerebellar vermis and present w/ vomiting, headaches, and ataxia.
119
What is neuroblastoma?
Tumors that arise from the sympathetic ganglion cells and usually present w/ an abdominal mass.
Mets can occur to the bone and liver, although late-stage disease can spread to the brain.
However, primary CNS tumors are much more common in peds pts than are mets to the CNS.
120
Pilocytic astrocytoma
Most common type of brain tumor in children
Supratentorial: seizures, weakness, sensory changes, increased ICP
Classically occurs in the cerebellar hemispheres: fine motor planning and coordination deficits (eg dysmetria, intention tremor, dysdiadochokinesia) and obstructive hydrocephalus
121
Seizures in children
Tongue-biting, urinary incontinence, perioral cyanosis
| Post-ictal state of sleepiness and confusion for minutes to hours
122
What is a breath holding spell?
Occurs in children age 6 months to 6 years
Presents with either cyanosis or pallor following an upsetting event or minor injury
Pt typically recover w/o any postictal period
123
MS treatment
Acute exacerbation: steroids
Refractory to steroids: plasmapheresis
Chronic maintenance therapy: interferon beta and glatiramer acetate - decrease frequency of exacerbation w/ relapsing-remitting or seconday, progressive forms of MS; no role in tx of acute exacerbations
124
What is central vertigo?
Central vertigo presents w/ nonfatigable nystagmus, which cannot be suppressed by visual fixation.
CT (then MRI) should be performed to evaluate for cerebellar stroke or hemorrhage in pts who have persistent, new onset central vertigo, headache, and vascular risk factors, neuro signs/sxs, or accompanying headache.
125
Benign paroxysmal positional vertigo
Brief <1m episodic vertigo triggered by head positioin changes (eg looking up, bending down) is consistent w/ BBPV - the most common cause of vertigo
DixHallpike- assesses the posterior semicircular canals: vertigo and nystagmus are triggered as the pt quickly lies back into a supine position w/ head roated 45 degrees
Tx: Otolith repositioning maneuvers (eg epley) are used to treat BPPV
BPPV does not cause headache but affects the semicircular canals and therefore has characteristics of peripheral vertigo
126
What is HIV related dementia?
More likely to present in poorly controlled HIV w/ CD <200 and in pts w/ long-standing HIV disease
Macrophage mediated signaling pathways and assoc. toxicity lead to neuronal dysfunction
Subcortical dysfunction (eg basal ganglia, nigrostriatal) = slowed movement, difficulty w/ smooth limb movement
Followed by cortical neuronal loss and memory decline
Resuming tx may improve sxs
127
What is Fabry disease?
Alpha galactosidase deficiency
Presentation: angiokeratomas, peripheral neuropathy, asymptomatic corneal dystrophy
Renal and HF, risk for thromboemoblic events
128
What is phenylketonuria?
An inborn error of metabolism resulting from deficiency of phenylalanine hydroxylase
Presentation: intellectual disability, fair complexion, eczema, musty body odor
129
What is Tay sachs disease?
Autosomal recessive gangliosidosis caused by a deficiency in Beta hexosaminidase A
Presentation: intellecutal disability, weakness, seizures, cherry red macula
130
What is medulloblastoma?
Second most common cerebellar tumor in children.
| High grade tumors that occur in the cerebellar vermis or midline, leading to truncal and gait ataxia.
131
Pineal tumor
Presents w/ Parinaud syndrome (limitation of upward gaze, light-near dissociation, and eyelid retraction) and obstructive hyrocephalus given proximity to pretectal region of midbrain.
132
What is an ependymoma?
Arises from ependymal lining of ventricles and spinal cord.
Most common site is 4th ventricle in posterior fossa, where tumor expansion leads to signs of increased ICP due to obstruction of CSF.
Tumors do not typically arise from cerebellum and are therefore unlikely to cause symptoms such as ataxia or dysmetria.
133
What is brainstem glioma?
Can present w/ ataxia due to obstructive hydrocephalus but also classically causes cranial nerve deficits such as diplopia and limited extraocular movements, facial nerve palsy, drooling, and difficulty swallowing.
134
Todd paralysis
Self-limited, focal weakness or paralysis that occurs after a focal or generalized seizure
Presents in the postictal period w/ hemiapresis or complete hemiplegia involving extremities on one side of the body
Pathophysiology is unknown
Dx: from hx, other causes of paralysis should be ruled out w/ CT or MrI
Tx: supportive, typically resovles w/in 36h
135
What is unilateral foot drop?
Characterized by "steppage" gait: exaggerated hip and knee flexion while walking
Common causes include L5 radiculopathy and compression peroneal neuropathy
L5 radiculopathy may also have weak foot inversion and plantar flexion, while these will be normal in peroneal neuropathy
136
Slap gait
Patients w/ loss of proprioception due to sensory neuronopathy may have postural or gait instability and a wide-based gait.
Pts may stop their feet against the floor (slap gait) to help them know where their lower limbs are relative to the ground.
137
Transient ischemic attack or cerebrovascular accident of the posterior circulation
Can present as vertigo in an elderly patient
However, it is a central cause of vetigo and would not cause recurrent discrete episodes of vertigo w/ changes in head position
Assoc. w/ tinnitus, blurred vision, and syncope
138
Epilepsy v seizure
Evidence of tongue biting is the most reliable finding to differentiate epilectic seizure and syncope. It has low sensivity but HIGH specificity for epilectic seizure, making it highly useful in confirming the dx when present.
Lateral tongue biting is likely even more specific for epileptic seizure as frontal tongue biting is occasionally seen w/ syncope.
139
Alzheimer disease
The most specific for dementia (major neurocognitive disoder) is impaired function in daily acitivites (getting lost in familiar surroundings)
Other areas of impaired functioning: difficultlies w/ dressing, maintaining personal hygiene, food acquisition and intake, self-administration of meds, social interactions, and operating common appliances.
Mini Mental state exam is less sensitive for mild dementia.
140
Hypertensive hemorrhage + basal ganglia
HTN hemorrhages most commonly occur in the basal ganglia and may result in uncal herniation.
Sxs: dilated, nonreactive ipsilateral pupil, contralateral extensor posturing, coma, and respiratory compromise.
141
Febrile seizures
Simple febrile seizures are typically generalized and occur in setting of fever >100.4
Less than 15minutes and do not recur w/in 24h.
Dx testing is unncessary.
Pts can be discharged home w/ reassurance and seizure precautions.
142
Pediatric migraines
Migraine headaches are the most common cause of acute and recurrent headaches in the pediatric population.
They typically present w/ unilateral or bifrontal pain, photophobia, phonophobia, nausea, vomiting, and a visual, auditory, or linguistic aura; short duration
Occipital headaches are extremely rare and should raise concern for structural lesion if present
First line treatment under 12yo: acetaminophen, NSAIDs, and supportive mgmt (lying a a dark, quiet room w/ cool cloth on forehead)
Triptans may be tried if these measures are not effective
143
Toxoplasmosis
MRI reveals multiple ring-enhancing spherical lesions in the basal ganglia.
Positive Toxo serology is quite common in normal subjects and thus not specific for toxo.
