Neurology Flashcards
This deck covers Chapters 91-99 in Rosens, compromising all of neurology.
What are the NINDS-recommended stroke evaluation time targets in potential tPA candidates?
- Door to MD = 10 minutes
- Door to CT = 25 minutes
- Door to CT read = 50 minutes
- Door to tPA = 60 minutes
- Access to NSx = 120 minutes
List 6 indications for CT scan of first time seizure
- Focal deficit
- Persistently altered LOC
- Fever
- Trauma
- Persistent H/A
- Cancer history
- OAC
- HIV
- Age >40
- Partial complex seizure
I scan all first-time seizures…
Differentiate dementia and pseudodementia
Pseudodementia
- Usually rapid onset
- Previous psychiatric history
- Social skills intact
- Attention preserved
What does the CSF look like in GBS?
- High protein
- Mild pleocytosis
- Normal CSF does NOT rule out GBS
Describe the clinical syndrome of PCA stroke
- Homonymous hemianopsia
- Memory impairment (hippocampus)
- Visual agnosia
Define a myasthenic crisis.
List 5 drugs that may exacerbate MG. List 4 other triggers.
- Respiratory failure
Drugs
- Prednisone
- BB
- CCB
- Lidocaine
- Procainamide
- Clindamycin
- Phenytoin
Other
- Medication changes
- Infection
- Aspiration
- Surgery
- Pregnancy
List 8 contraindications for tPA in STROKE
Brain
- Hemorrhagic transformation
- Previous ICH
- AVM
- Brain cancer
- Stroke within 3 mo
- Closed head injury within 3 mo
- CNS surgery within 3 mo
Hematologic
- OAC
- Plt <100
- INR >1.7
- Heparin use
Other
- Arterial puncture non-compressible
- Severe uncontrollable HTN
- Glucose <2.8
- Active bleeding
- Bleeding diathesis
Differentiate the following diseases based one (a) strength, (b) DTRs, (c) sensation, and (d) wasting:
- Myelopathy
- Motor neuron disease (ALS)
- Neuropathy
- Neuromuscular junction disease
- Myopathy
- Myelopathy
- Strength - / DTR + / Sens N / No wasting
- Motor neuron disease (ALS)
- Strength - / DTR + / Sens N / Wasting
- Neuropathy
- Strength - / DTR - / Sens - / Wasting
- Neuromuscular junction disease
- Strength fatigued / DTR N / Sens N / No wasting
- Myopathy
- Strength - / DTR N / Sens N / Wasting
Name and describe a scale to grade the severity of Bell’s palsy
House Brackman Scale
- Normal
- Mild. Eye closes. Symmetrical at rest.
- Moderate. Eye closes. Asymmetrical at rest.
- Mod-Severe. Eye can’t close. Asymmetrical at rest.
- Severe. Eye can’t close. Only twitches.
- Complete paralysis
List 6 signs/symptoms associated with Bell’s palsy
- Dry eye
- Overflow of tears on the cheek
- Taste change
- Ear pain
- Hyperacusis
- Perception of ipsilateral sensory change
Define status epilepticus
Seizure activity >5 min
2 seizures without recovery between
What is the triad of carotid dissection? How do you treat it?
- Unilateral headache
- Horner’s
- Contralateral hemispheric signs
Treatment
- tPA if associated with stroke
- Heparin if thrombus with dissection
- Anti-platelets otherwise
List 6 risk factors for SAH
- PCKD
- FHx
- Cocaine
- HTN
- Smoking
- Connective tissue disorder
- Alcoholism
- Coarctation
List the 4 diagnostic criteria for dementia (major neurocognitive disorder)
From DSM-5:
- Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains:
* Learning and memory
* Language
* Executive function
* Complex attention
* Perceptual-motor
* Social cognition - Cognitive deficits interfere with independence in ADLs/IADLs
- Do not occur exclusively in the context of delirium
- Not better explained by another mental disorder (eg, major depressive disorder, schizophrenia).
What is the ABC/2 technique in ICH?
Take measurements widest area of bleed (A x B)
Count the number of slices (10 mm) that blood is present (C)
(A * B * C) / 2 = volume of blood
What is your BP target is SAH?
AHA says sBP <160 mmHg or MAP <110 mmHg
Describe the clinical syndrome of MCA stroke
- Contralateral weakness: Face/Arm > Leg
- Contralateral sensory loss: Face/Arm > Leg
- Contralateral hemianopsia
- Gaze preference toward the lesion
- Aphasia
- Neglect
What are the CSF findings in a patient with MS?
- Pleocytosis
- Elevated gamma globulin levels
- Oligoclonal bands of IgG
What are the three major ‘columns’ of the spinal column and what is their function?
- Spinothalamic - pain/temp
- Corticospinal - motor
- Posterior column - proprioception/vibration/touch
List 4 seizures that require ‘specialized therapy’ (not just benzos)
- Hyponatremia
- Hypoglycemia
- Hypocalcemia
- Eclamptic
- Isoniazid
What are your BP targets in ICH? What trial provided evidence on this?
ICH
- BP should be lowered to 140-160 mmHg
Interact-2: 2013
- 2800 patients –> Drop BP to 140 in first 6 hours
- Negative outcome but at p= 0.06 (mortality)
- Positive for a reduction in disability
ATACH 2
- Stopped early because of futility
- Supposed to be 180 vs 140, but was ~140-120
What is an abnormal CSF lactate?
What is an abnormal CSF glucose:serum glucose?
- CSF lactate >3.5
- Glucose CSF:Serum <0.33
Provide the Hunt and Hess classification scale for SAH
- 0 = Intact
- 1 = Mild H/A
- 2 = Severe H/A, nuchal rigidity
- 3 = Confused
- 4 = Hemiparesis
- 5 = Posturing
List 8 causes of delirium
I WATCH DEATH
- Infection
- Withdrawal
- Acute metabolic (acidosis, lytes, organ failure)
- Trauma
- CNS disease (bleed, tumour, seizure, CVA)
- Hypoxia
- Deficiencies (B12, Thiamine)
- Environmental (hypo/hyperthermia)
- Acute vascular (HTN, MI, CVA)
- Toxins
- Heavy metals
What nerve roots does the sciatic nerve arise from?
What are the 2 main branches?
What are the symptoms of sciatic mononeuropathy?
- L4-S3
- Tibial/Common peroneal
- Flail foot, can’t flex knee, can’t feel below knee
List 3 treatments for a myasthenic crisis
- Prednisone
- IVIG
- PLEX
- Airway management
* FVC <20
* MIP <30
* MEP <40
What is the most common cause of bilateral CN7 paralysis?
Lyme
Borrelia burgdorferi
Ixodes tick
Differentiate Tick paralysis from GBS and Botulism
Tick Paralysis
- Toxin injected by tick decreases ACh release
- Ascending paralysis
- Ocular findings
Botulism
- C. botulinum toxin prevents ACh release
- Descending paralysis
GBS
- Demyelinating
- Ascending paralysis
- Ocular muscles spared
What are the diagnostic criteria for migraine with aura?
2+ attacks with 3+ of:
- 1+ reversible aura symptom
- 1+ aura symptom over 4 minutes
- No aura >60 min
- Headache during or after aura
What is the agent involved in botulism?
What is the mechanism? List 3 causes. Treatment?
Clostridium botulinum
- Presynaptic inhibition of ACh release
Causes
- Food
- Wound
- Infantile
- Iatrogenic
Treatment
- Airway management
- Equine antitoxin
- BabyBIg if infantile
- PenG 3M units IV q4h if wound
List 8 causes of toxin-induced seizure
OTIS CAMPBELL
- Oral hypoglycemics, Oleander, Organophosphates
- Theophylline, TCAs
- Insulin, Isoniazid
- Sympathomimetics
- Camphor, CN, CO, Cocaine
- ASA, Anticholinergics
- Methanol
- PCP, Pesticides
- Barbiturate/Benzo W/D, Bupropion, Botanicals
- Ethanol W/D
- Lead, Lithium
- Lidocaine
What is the ABCD2 score?
ABCD2
- Age >60
- BP (HTN hx)
- Clinical (Sens/Speech/Motor)
- Duration (<10m/10m-60m/>60m)
- Diabetes
Used to predict CVA at 48h following TIA
List the 4 types of GBS
- Acute inflammatory demyelinating polyradiculopathy
- Acute motor axonal neuropathy
- Acute motor and sensory axonal neuropathy
- Miller Fisher syndrome
List 5 ischemic changes on CT following stroke
- Hyperdense artery sign
- Loss of grey-white differentiate
- Effacement of sulci
- Loss of insular ribbon
- Mass effect
- Hypodensity
Subtle findings as early as 3h post
Usually, 6h before more obvious
List 7 reversible causes of dementia
- Hydrocephalus
- CNS lesion
- Heavy metal poisoning
- Depression
- Hypothyroidism
- B12 deficiency
- Medication-induced
Describe 7 steps in the management of a SAH
- HOB
- ICP management
- BP <140-160
- NSx
- CCB prophylaxis (Nimodipine)
- Seizure prophylaxis
- Normothermia
- Antiemetics
- Neuroprotective intubation, if necessary
What is the clinical triad of Wernicke’s encephalopathy?
- Encephalopathy
- Eye findings (nystagmus, ophthalmoplegia)
- Ataxia
What are BP targets in stroke if you want to give tPA and if you don’t want to give tPA?
Name 3 agents that can be used to lower BP in this setting.
- No tPA = <220/120
- tPA = <185/110
- During tPA = <180/105
Drugs
- Labetolol
- Hydralazine
- Enaliprilat
- Nicardipine
- Nitroglycerin
Draw the Circle of Willis

What nerve roots does the median nerve arise from?
- C5-T1
- AIN (Galeazzi injury)
- Just proximal to wrist, palmar sensory branch comes off
Explain the DAWN Trial:
- Study Design
- Population (4)
- Intervention
- Outcome Measure (2)
- Results
- Study Design
- Multicenter, prospective RCT
- Population
- Seen well 6-24h previous
- Age ≥18
- Ischemic stroke
- Failed tPA therapy
- NIHSS ≥10
- Pre-stroke mRS <2
- Anticipated life expectancy ≥6 months
- Intervention
- Randomized 1:1 to EVT or not
- Outcome Measure
- Modified Rankin Score
- Functional independence
- Results
- EVT group did better
List 5 medications and doses used to stop a seizure
First-Line
- Lorazepam 0.1 mg IV
- Diazepam 0.2 mg IV
- Midazolam 0.2 mg IV
Second-Line (note all 20 mg/kg)
- Phenytoin 20 mg/kg
- Posphenytoin 20 mg/kg
- Phenobarbital 20 mg/kg
- Valproate 20 mg/kg
Third-Line
- Propofol 1-2 mg/kg
- Midazolam infusion 0.05-2 mg/kg/hr
List 2 treatments for GBS
- IVIG
- PLEX
Name 10 non-infectious causes of meningitis.
- Vaccine
- NSAID
- TMP-SMX
- INH
- IVIG
- SLE
- Radiation
- Cancer
- Autoimmune
- Sarcoid
List 6 causes of dementia
- Alzheimer’s
- Parkinson’s
- Huntington’s
- CVA
- Infectious
- Repeated head trauma
- Prions
- Hydrocephalus
- Mass effect (tumour, blood, pus)
List 8 host factors that predispose someone to meningitis
- Age <5y
- Age >60y
- Male
- Low SES
- Military
- Dorms
- Splenectomy
- Diabetes
- IVDU
- Alcohol
Describe a typical cluster headache. List 4 treatments.
Symptoms
- Unilateral flushing/sweating
- Red, tearing eye
- Rhinorrhea/Nasal congestion
- Clusters of brief severe pain, often retroorbital
- Worse in men
Treatment
- High-flow oxygen
- Triptans
- Maxeran
- Octreotide
Explain why a patient with DM has ptosis and a normal pupillary response.
Parasympathetic fibers on the outside of CN3
- If compression (by P.comm aneurysm), only this down
Motor fibers on the inside of CN3
- If vascular disease, ischemia happens at the central part of the nerve.
What are the diagnostic criteria for migraine?
POUND
- Pulsatile
- Onset 4-72h
- Unilateral
- Nausea and/or Vomiting or Photo- AND Phonophobia
- Disabling
Need 5 episodes lasting 4-72h with 2 of the above
List 5 causes of CN3 palsy
- DM
- Aneurysm
- Herniation
- Tumour
- CVST
- Trauma
- GBS (Miller Fisher)
Describe a typical tension headache.
- Band-like squeezing
- Temples/Neck
- 30min - 7hr
- Triggered by stress/poor sleep
What is the triad of Miller-Fisher GBS?
- Ophthalmoplegia
- Ataxia
- Areflexia
List 4 inclusion criteria for the Ottawa SAH rule
- Age >16
- Non-traumatic
- Peak intensity within 1 hour
- GCS 15
List 6 DDx for seizure
- Syncope
- Hypoglycemia
- Hyponatremia
- TIA
- Narcolepsy
- Motor Tics
- Hyperventilate/Breath holding
- GERD in babies
- Conversion D/O
Describe 2 ways to diagnose myasthenia gravis in the ED
-
Tensilon
* AChEi (max 10 mg) -
Ice pack
* 2 min on one eye
Positive if 2mm difference in lid opening
Which GBS patients need intubation?
Usual reasons to intubate, plus:
- FVC <20 cc/kg
- MIP <30 cmH2O
- MEP <40 cmH2O
Describe the epidemiology, pathophysiology, and symptoms of GCA
Epidemiology
- Older women
- PMR
Pathophysiology
- Large-vessel vasculitis
Symptoms
- Headache
- Jaw/Tongue claudication
- Constitutional symptoms
- Visual symptoms
Describe and differentiate cauda equina and conus medullaris
Conus Medullaris
- Sudden
- Bilateral
- UMN
- More back pain
- Less radicular symptoms
- More impotence
Cauda is opposite
Explain the components FAST-ED scale
Field Assessment Stroke Triage for Emergency Destination
- Facial Palsy (normal/noticable) - 0/1
- Arm weakness (normal/drift/paralysis) - 0/1/2
- Speech (normal/slurred/severe) - 0/1/2
- Eye deviation (normal/partial/forced) - 0/1/2
- Neglect (normal/1 sens mod/complete) - 0/1/2
If >=4 pts, likely to have IC/M1 clot
List 8 causes of status epilepticus
- Isoniazid
- Hyponatremia
- Hypoglycemia
- Hypocalcemia
- Eclampsia
- CNS infection
- CNS trauma
- Cancer
- AVM
- Stroke
- Hydrocephalus
- Epilepsy
- Toxic (OTIS CAMPBELL)
- Alcohol withdrawal
What is the cut-off time for tPA in ischemic stroke? What are the 2 other inclusion criteria?
- tPA < 4.5 hours
- NIHSS >3
- Age >18
What are the 5 diagnostic criteria for GCA
- Age >50
- New-onset localized headache
- Temporal artery pain
- ESR >50
- Positive biopsy
Diagnosed if 3+ (90%+ sensitive and specificity)
Treat with Prednisone 1 mg/kg (max 60 mg)
List 3 mechanisms by which NMJ can diminish strength on repeated stimulation. Give an example of each.
-
Decreased ACh release
* Botulism -
Blocked receptors
* Myasthenia gravis -
AChEi
* Organophosphates
How do you treat a hyponatremic seizure (dose)?
3% saline 2 cc/kg over 10-60 minutes
List 3 causes of meningitis in each of:
- Bacterial
- Viral
- Fungal
- Parasitic
- Non-infectious
Many…
- Bacterial
- S. pneumoniae
- N. meningitidis
- H. influenzae
- L. monocytogenes
- Viral
- HSV
- West Nile
- HIV
- Fungal
- Cryptococcus
- Histoplasma
- Blastomyces
- Candida
- Parasitic
- Toxoplasma
- Neurocysticercosis
- Bartonella
- Non-infectious
- NSAIDs
- Vaccine-related
- IVIG
- Cancer
- SLE
What nerve root does the ulnar nerve arise from?
- C5-T1
- Mainly C7-T1
List 5 indications for endovascular therapy in stroke
- Age >18
- NIHSS >6
- ASPECTS >6
- IC/M1 clot
- mRS 0 or 1
- Groin puncture possible within 6h
List 4 causes of complete sciatic mononeuropathy
- Buttock hematoma
- Penetrating trauma
- Posterior hip dislocation
- Deep IM injection
Differentiate UMN vs LMN findings
UMN
- Spastic paralyis
- Increased tone
- Increased reflexes
- Babinski +
- Rigid
- Bulk preserved
LMN
- Flaccid paralysis
- Decreased tone
- Decreased reflexes
- Babinski -
- Fasculations
- Atrophy
List 5 reasons to do a CT scan before an LP in suspected bacterial meningitis
- Papilledema
- Altered
- Focal deficits
- Seizure
- Immunocompromised
List 5 causes of mononeuropathy multiplex (2+ named nerves in separate body parts)
- Vasculitis
- Diabetes
- Cancer
- HIV
- Lyme
- Sarcoid
- Lead
What is the dose of tPA in stroke? How is it given?
0.9 mg/kg (max 90 mg)
10% bolus, 90% over 1hr
How do you diagnose IIH (4)? List 3 treatment options.
Diagnosis
- Normal neuro exam +/- papilledema/field cut/CN6p
- CT to rule out mass/CVST
- LP with normal CSF
- LP with opening pressure:
- >20 cmH2O (normal weight)
- >25 cmH2O (obese)
Treatment
- Stop offending agent (OCP)
- Lower ICP (drain, lasix, acetazolamide)
- Steroids
- VP shunt if visual symptoms
List 6 conditions associated with carpal tunnel syndrome
- Pregnancy
- Diabetes
- Acromegaly
- Scleroderma
- RA
- Amyloidosis
- Obesity
- Hypothyroidism
List the 5 types of lacunar strokes
- Pure motor
- Pure sensory
- Sensorimotor
- Ataxic-Hemiparesis
- Dysarthria-Clumsy Hand
Who should receive chemoprophylaxis for meningitis? What medication(s) and dose?
- Household contacts
- Intimate contacts
- HCWs with mucosal contact with secretions
N. meningitidis
- Ciprofloxacin 500 mg PO x1
- Rifampin 600 mg PO q12h x4
H. influenzae
- Rifampin 600 mg PO daily x4
Should you give steroids in meningitis?
Yes!
- Lower mortality in S. pneumoniae
- Lower hearing loss in H. influenzae
Dex 0.6 mg/kg IV
List 6 DDx for a ring-enhancing lesion on CT head
-
Bacteria
* TB/Listeria/Syphilis -
Parasitic
* Toxo/Amoeba -
Fungi
* Crypto/Coccidiomycosis -
Malignancy
* Lymphoma/Primary/Met -
Inflammatory
* SLE/MS/Sarcoid
What are the 5 diagnostic criteria for delirium?
From DSM-5:
- Disturbance in attention and awareness
- Develops acutely, is a change from baseline, and fluctuates over the day
- Disturbance in cognition
- Not explained by another preexisting, established, or evolving neurocognitive disorder
- Due to medical condition, substance intoxication or withdrawal, or exposure to a toxin, or multiple etiologies
What are the 4 most common sites for ICH?
- Putamen (44%)
- Thalamus (13%)
- Cerebellum (9%)
- Pons (9%)
- Other cortical areas (25%)
List 6 causes of CVST
- AOM
- Sinusitis
- Orbital cellulitis
- Meningitis
- Trauma
- NSx procedures
What is the Ottawa SAH rule?
ANT LEaF
- Age >40
- Neck pain/stiff
- Thunderclap
- LOC
- Exertional
- Flexion limited
Investigate for SAH if any positive
List 10 stroke mimics
- Migraine
- Hypoglycemia
- Hyponatremia
- Bell’s palsy
- SDH/EDH/SAH/ICH
- CVST
- HTN encephalopathy
- CNS tumour
- CNS abscess
- Encephalitis/Meningitis
- Seizure (Todd’s paralysis)
- Conversion disorder
List 5 demyelinating polyneuropathies
- GBS
- AIDP
- CIDP
- Cancer
- HIV
- Hepatitis B
- Diphtheria
- Buckthorn
What is Ramsay Hunt Syndrome? How do you treat it?
Herpes zoster re-activation causing:
Facial paralysis with ear pain and/or vesicular involvement
- Valacyclovir 1g TID x10d
- Prednisone 1 mg/kg x10d
- Artificial tears
What is the pathophysiology of myasthenia gravis?
Auto-Ab targeting nicotinic ACh receptors
List 8 complications of meningitis
- Seizure
- Coma
- Death
- Hearing loss
- Focal neuro deficits
- DIC
- Adrenal hemorrhage
- CVST
- Stroke
- SIADH
What are the two branches of the common peroneal nerve? What are the motor/sensory findings?
- Superficial nerve
- Everters
- Lateral foot
- Deep peroneal nerve
- Ankle dorsiflexion
- 1st dorsal webspace
List 6 risk factors for Alzheimer’s dementia
Classic cardiac risk factors
- HTN
- DLD
- DM
- Smoking
- FHx
- Age
- Gender
- Alcohol
- Obesity
- CVA
- Depression
- Sedentary
- Low education
- Traumatic brain injury
List 5 infectious organisms associated with GBS
- Campylobacter
- Mycoplasma
- EBV
- CMV
- Enterovirus
List 8 acute, emergent causes of weakness with possible airway compromise
- MG
- LES
- Tick paralysis
- GBS
- Botulism
- Tetanus
- Coral snake
- Heavy metal poisoning
- Polio
- HyperMg
- Hypophos
- ALS
- Organophosphate
- Pufferfish
Name 5 types of generalized seizure
- Tonic-Clonic
- Absence
- Myoclonic
- Clonic
- Tonic
- Atonic
Differentiate generalized and partial seizures
Generalized
- Both cerebral hemispheres
- Unconscious
Partial
- One cerebral hemisphere
- Simple vs Complex based on cognition
Differentiate Wernicke’s and Broca’s aphasia
- Broca’s = expressive (motor cortex)
- Wernicke’s = receptive (temporal lobe)
How would you treat meningitis in:
- Neonate (<1m)
- Infant (1-23m)
- Adult (2-50y)
- Older Adult (>50y)
- Neonate (<1 mo)
- Ampicillin + Cefotaxime
- Ampicillin + Gentamycin
- Infant (1-23 mo)
- Ceftriaxone + Vanco
- Adult (2-50 yr)
- Ceftriaxone + Vanco
- Older Adult (>50 yr)
- Ceftriaxone + Vanco + Ampicillin
*Consider dexamethasone and acyclovir
List 5 physical exam features of GBS
- Ascending paralysis
- Loss of DTRs
- Variable sensory findings
- Sparing of anal sphincter
- Urinary retention
- Autonomic dysfunction (50%)
- Sparing of ocular muscles (unless Miller Fisher)
Describe the clinical syndrome of ACA stroke
- Contralateral weakness: Leg > Arm
- Contralateral sensory loss: Leg > Arm
- Apraxia (poor motor planning)
- Bowel/Bladder incontinence
- Primitive reflexes (suckle, grasp)
- Impaired judgment
List 4 treatment options for post-LP headache
- Tylenol
- IVF
- Caffeine
- Blood patch
List 8 treatments for migraine
- Tylenol
- NSAIDs
- Prochlorperazine
- Metoclopramide
- Triptans
- Ergot
- Opiates
- Haldol
- Magnesium
- Propofol
What nerve root does the radial nerve arise from? How do you splint an acute radial nerve palsy?
- C5-T1 brachial plexus
- C5-C7 mainly
- The radial nerve innervates brachioradialis
- Then bifurcates to PIN and sensory at the elbow
- Volar splint in 60-degree extension
Provide a scoring system for predicting mortality with ICH
LAGII
- Location (Supra/Infratent)
- Age (>80/<80)
- GCS (3-4/5-12/13-15)
- ICH Volume (>30 mL/<30 mL)
- IVH (Yes/No)
- 2 pts = 26% mortality
- 3 pts = 72% mortality
- 4 pts = 97% mortality