Neurology Flashcards
(76 cards)
1
Q
cerebrum
A
CORTEX:
fx in higher brain processes like thought/action, controls all voluntary activity (w/ help of the cerebellum)
-Frontal: reasoning, problem solve, parts of speech, mvmt, emo
-Parietal: perception/recognition of stimuli, orientation, mvmt
-Temporal: memory, perception/recognition of auditory stimuli and speech
-Occipital: visual processing
BASAL GANGLIA:
voluntary motor mvmt, coordination, cognition, emotion
LIMBIC SYSTEM:
thalamus, hypothalamus, amygdala and hippocampus
-Amygdala: located in temporal lobe, involved in memory, emo and fear
-Hippocampus: learning, memory; converts short-term into long-term memory
2
Q
diencephalon
A
THALAMUS:
- located deep in the forebrain
- processes nearly all sensor and motor info
- relays info to/from cortex
HYPOTHALAMUS:
- located below and ventral to thalamus
- controls homeostasis
3
Q
brainstem
A
MIDBRAIN:
controls eye mvmt, relays visual and auditory info
PONS:
REGULATES BREATHING, SERVES AS A RELAY STATION BTW CEREBRAL HEMISPHERE AND MEDULLA
-involved in motor control and sensory input
MEDULLA OBLONGATA:
extension of spinal cord
-regulates vital body fx such as heart rate, breathing, autonomic centers, swallowing and coughing
4
Q
cerebellum
A
posterior to medulla
maintains posture and balance, coordinates voluntary mvmt and controls certain head and eye mvmt
5
Q
basal ganglia disorders
A
EXTRAPYRAMIDAL SYMPTOMS:
- Dyskinesia
- Dystonia - sustained contraction, twisting abn position
- Myoclonus - invol jerk/twitch
- Tics - suppressible
- Chorea - rapid invol jerky, uncontrolled, purposeless
- Muscle spasms - tonic (sustained rigid) or clonic (repeat, rapid)
- Tremors
PARKINSONISM
- Parkinson Disease
- Dopamine antagonists (haloperidol, olanzapine, risperidone, promethazine, metoclopramide)
- Lewy body disease - loss of dopaminergic neurons, anticholinergic neurons
- Other: head trauma, HIV, carbon mo, mercury poisoning, cns dysfunction
6
Q
Huntington disease
A
huntington gene –> neurotoxicity as well as cerebral, putamen and caudate nucleus atrophy
- sx:
- Behavioral: personality, cognitive, intellectual and psych including irritability
- Chorea: rapid, invol or arrhythmic mvmt of face, neck, trunk and limbs initially; worse w/ vol mvmts and stress
- Dementia: most devo dementia before 50y (primarily exec fx)
- gait abnormalities/ataxia, incontinence, facial grimacing
- brisk DTR
-dx:
CT: CEREBRAL AND CAUDATE NUCLEUS ATROPHY
PET: dec glucose metabolism in caudate nucleus and putamen
- tx:
- usually fatal w/in 15-20y after presentation
- CHOREA MANAGEMENT: antidopinergics: typical/atypical antipsychotics, tetrabenazine, benzos
7
Q
essential familial tremor
A
-AUTO DOM, onset usually in 60s
- sx:
- INTENTIONAL TREMOR - POSTURAL, BILATERAL ACTION TREMOR OF HANDS, FOREARMS, HEAD, NECK OR VOICE
- mc in upper extremities and head
- WORSE W/ EMO STRESS AND INTENTIONAL MVMT
- SHORTLY RELIEVED W/ ETOH INGESTION
- normal neuro exam otherwise
- tx
- PROPANOLOL MAY HELP SEVERE OR SITUATIONAL
- Primidone (barbiturate) if no relief or instead of propanolol
- Alprazolam (benzo) 3rd line
8
Q
parkinson disease
A
IDIOPATHIC DOPAMINE DEPLETION –> failure to inhibit acethylcholine in basal ganglia (Ach is excitatory nt and dopamine is inhibitory)
- onset 45-65 mc
- LEWY BODIES (cytoplasmic inclusions), LOSS OF PIGMENT CELLS SEEN IN SUBSTANTIA NIGRA
- sx:
- RESTING TREMOR MC SIGN (PILL ROLLING) - worse w/ rest and emo stress; less w/ voluntary activity/intentional movement, usually starts w/ one limb for years until generalized
- BRADYKINESIA - slow vol mvmt, dec automatic mvmt
- RIGIDITY - inc resist to passive mvmt (COGWHEEL); festination = increasing speed while walking, norm DTR
- FACE INVOLVEMENT - FIXED FACIAL EXPRESSIONS, widened palpebral fissure; MYERSON’S SIGN: tapping bridge of nose repetitively causes a sustained blink
- POSTURAL INSTABILITY - usually late finding, “pull test”
- dementia in 50% (late finding)
- tx:
- drug tx not used initially if sx mild
- LEVODOPA/CARBIDOPA - MOST EFFECTIVE - levo converted into dopamine (carbidopa reduces amt of levo needed, reducing SE)
- DOPA AGONISTS: BROMOCRIPTINE, PRAMIPEXOLE, ROPINEROLE - stimulate dopamine receptors; sometimes used in young pt to delay use of levodopa
- ANTICHOLINERGICS: TRIHEXYPHENIDYL, BENZTROPINE - blocks excitatory cholinergic effects
- Amantadine - inc pre-synaptic dopa release
- MAO-B Inhibitors - inc dopa
9
Q
tourette syndrome
A
-onset usually childhood (2-5y), mc boys
+/- assoc w/ obsessions-compulsions
- sx:
- MOTOR TICS of face, head, neck
- VERBAL OR PHONETIC TICS: grunts, throat clearing, obscene words (coprolalia), repeating others (echolalia)
- self-mutliating tics: hair pull, nail bite, bite lips
- tx:
- HABIT REVERSAL THERAPY - 50% REVERSE BY 18
- Dapamine-blocking agents: HALOPERIDOL, RISPERIDONE
- Alpha-adrenergics: CLONIDINE, GUANFACINE, clonazepam as adjunct
10
Q
amyotrophic lateral sclerosis (ALS)
A
-necrosis of BOTH upper and lower motor neurons –> PROGRESSIVE MOTOR DEGENERATION
- sx:
- muscle weakness, LOSS OF ABILITY TO INITIATE AND CONTROL MOTOR MVMT
- MIXED UPPER AND LOWER MOTOR NEURON SIGNS
- Upper: spasticity, stiffness, hyperreflexia
- Lower: progressive bilateral fasciculations, muscle atrophy, hyporeflexia, muscle weakness
- bulbar sx: dysphagia, dysarthria, speech problems, eventual respiratory dysfunction
- SENSATION, URINARY SPHINCTER AND VOLUNTARY EYE MOVEMENTS ARE SPARED
- tx:
- RILUZOLE reduces progression for up to 6 mo
- usually fatal w/in 3-5 years of onset
11
Q
cerebral palsy
A
-CNS disorder assoc w/ muscle tone and postural abnormalities due to brain injury during perinatal or prenatal period
- sx:
- SPASTICITY HALLMARK - varying degrees of motor deficits, often assoc w/ intellectual/learning disabilities and devo abnormalities
- HYPERREFLEXIA, limb-length discrepancies, congenital defects
- tx:
- multidisciplinary approach
- spasticity –> Baclofen, Diazepam, antiepileptics for seizures
12
Q
restless legs syndrome (Willis-Eckbom disease)
A
-sleep-related mvmt disorder; usually primary but may occur secondary to cns Fe deficiency, pregnancy, peripheral neuropathy
- dx:
- uncomfortable or unpleasant sensation (itching, burning, paresthesias, etc) in the leg that creates an urge to move the legs
- worse at night, tends to occur w/ prolonged periods of rest or inactivity
- improves w/ movement
- tx:
- DOPAMINE AGONIST TX OF CHOICE: PRAMIPEXOLE, ROPINIROLE
- Alpha-2-Delta Calcium channel ligands: GABA, PREGAB
- Benzos
- Opioids in disease resistant to above
- FE SUPPLEMENT REC IN PT W/ SERUM FERRITIN LOWER THAN 75mcg/L bc of assoc w/ Fe deficiency in cns
13
Q
guillain barre syndrome
A
- acute/subacute acquired inflammatory DEMYELINATING POLYRADICULOPATHY of PERIPHERAL NERVES
- INC INCIDENCE W/ CAMPYLOBACKER JEJUNI MC or other antecedents RESPIRATORY OR GI INFX (CMV, EBV, HIV, mycoplasma, immunizations, postsurgical)
-Patho: immune-med demyelination and axonal degeneration slows nerve impulses –> symmetric weakness and paresthesias; post infx immune response cross-reacts w/ peripheral nerve components
- sx:
- ASCENDING WEAKNESS AND PARESTHESIAS (usually symmetric)
- DEC DTR (lower motor neuron), may involve muscles of respiration or bulbar muscles (swallowing), CNVII palsy
- AUTONOMIC DYSFUNCTION: tachy, hypoTN/hyperTN, BREATHING DIFFICULTIES
- dx:
- CSF: HIGH PROTEIN W/ NORMAL WBC (high protein after 1-3 wks of sx)
- Electrophysicoligc studies: dec motor nerve conduction
- tx:
- PLASMAPHERESIS best if done early - removes harmful auto-ab, equally effective as IVIG
- IVIG: suppress harmful inflam/auto-ab and induces remyelination; most recover w/in months
- mech vent if respiratory failure
- PREDNISONE CONTRAINDICATED
- PROGNOSIS: 60% FULL RECOVERY IN 1 YR, 10-20% left w/ permanent disability
14
Q
myasthenia gravis
A
AUTOIMMUNE peripheral nerve disorder; HLA-DR3
MC YOUNG WOMEN
75% have THYMIC ABNORMALITY (HYPERPLASIA OR THYMOMA) or other immune disorders
-Patho: inefficient skeletal muscle neuromusclar transmission d/t AUTOAIMMUNE AB AGAINST ACETYLCHOLINE (NICOTINIC) POSTSYNAPTIC RECPTOR at neuromuscular jx (dec ACh receptors)
-sx:
OCULAR: usually 1st presenting
-extraocular involvement –> DIPLOPIA, PTOSIS/eyelid weakness (more prominent w/ upward gaze) weakness worse w/ repeated use, pupils spared
GENERALIZED: WORSE MUSCLE WEAKNESS W/ REPEATED USE THROUGHOUT DAY (relieved w/ rest)
-normal sensation and DTR
-BULBAR WEAKNESS (oropharyngeal) w/ prolonged chewing, dysphagia
-RESPIRATORY MUSCLE WEAKNESS may lead to RESPIRATORY FAILURE = MYASTHENIC CRISIS**
-dx:
+ ACETYLCHOLINE RECEPTOR ANTIBODIES
+ MuSK (muscle-specific tyrosine kinase) AB
-EDROPHONIUM (TENSILON) TEST: rapid response to short-acting IV Edrophonium
-CT scan or MRI of chest may show THYMOMA or THYMUS GLAND ABNORMAL
-ICE PACK TEST –> eyelid 10 min –> improve ptosis
- tx:
- ACETYLCHOLINESTERASE INHIBITORS: PYRIDOSTIGMINE OR NEOSTIGMINE 1ST LINE –> inc ACh (dec breakdown), SE: CHOLINERGIC CRISIS (weak, n/v, sweat, salivation, diarrhea, miosis, brady, resp failure)
- IMMUNOSUPPRESSION: PLASMAPHERESIS OR IVIG for myasthenic crisis
- Chronic: CORTICO
- THYMECTOMY if thymoma
- AVOID FLUOROQUINOLONES AND AMINOGLYCOSIDES
CRISIS:
- IF FLACCID PARALYSIS IMPROVES W/ TENSILON –> MYASTHENIC CRISIS
- IF FLACCID PARALYSIS WORSENS W/ TENSILON –> CHOLINERGIC CRISIS
- ddx:
- MYASTHENIC SYNDROME (LAMBERT-EATON) MC ASSOC W/ SMALL CELL LUNG CA –> WEAKNESS IMPROVES W/ USE
15
Q
multiple sclerosis
A
AUTOIMMUNE, INFLAMMATORY DEMYELINATING DISEASE of IDIOPATHIC ORIGIN
-MC WOMEN AND YOUNG ADULTS 20-40Y
- RELAPSE-REMITTING MC episodic exacerbations
- Progressive: decline w/out acute exacerbations
- Secondary progressive: relapse-remitting that becomes progressive
- sx:
- Sensory Deficits: pain, fatigue, numbness, paresthesias in limbs, TRIGEMINAL NEURALGIA, UHTHOFF’S PHENOMENON (worsening of sx w/ heat), LHERMITTE’S SIGN
- OPTIC NEURITIS (RETROBULBAR) unilateral eye pain worse w/ movement, diplopia, central scotomas, VL
- MARCUS-GUNN PUPIL: swinging flashlight from unaffected to affected –> pupils appear to dilate
- MOTOR: UPPER –> SPASTICITY AND + BABINSKI
- spinal cord sx: bladder, bowel or sexual dysfunction
- CHARCOT’S NEUROLOGIC TRIAD: nystagmus, staccato speech, intentional tremor
-dx:
-mainly clinical - at least 2 discrete episodes of exacer
-MRI W/ GADOLINIUM - TEST OF CHOICE TO CONFIRM
WHITE MATTER PLAQUES (hyperdensities) hallmark
-LUMBAR PUNCTURE: INC IgG (OLIGOCLONAL)
- tx:
- ACUTE: IV CORTICO 1ST LINE, plasmapheresis
- RELAPSE/REMIT/PROGRESSIVE: B-INTERFERON or GLATIRAMER ACETATE decrease #/severity of relapse
- amantadine is helpful for fatigue, baclofen and diazepam for spasticity
16
Q
bell palsy
A
IDIOPATHIC, UNILATERAL CN 7/FACIAL NERVE PALSY d/t inflammation or compression
- lower motor neuron lesion, MC RIGHT SIDE
- STRONG ASSOC W/ HSV REACTIVATION
-RF: Dm, pregnancy (esp 3rd tri), post URI, dental nerve block
- sx:
- sudden onset of IPSILATERAL HYPERACUSIS (EAR PAIN) 24-48h –> UNILATERAL FACIAL PARALYSIS, UNABLE TO LIFT AFFECTED EYEBROW
- TASTE DISTURBANCE ANTERIOR 2/3
- ONLY AFFECTS FACE
-dx: of exclusion
-tx:
-most resolve w/in 1 month w/out tx
-PREDNISONE (ESP W/IN 72H)
-ARTIFICIAL TEARS
+/- Acyclovir
- DDx:
- upper motor lesions (cva)
- IF UPPER FACE OK (wrinkle forehead) – NOT BELLS PALSY
17
Q
headaches - general
A
PRIMARY (90%): MIGRAINE, TENSION, CLUSTER OR REBOUND - IDIOPATHIC
SECONDARY (4%): meningitis, subarachnoid hemorrhage, intracranial htn, acute glaucoma (suspect if abrupt or progression of severity)
18
Q
tension headache
A
mc overall type
-ave age onset 30y, thought to be d/t mental stress
- sx:
- BILATERAL, TIGHT, BAND-LIKE, constant daily
- worse w/ stress, fatigue, noise or glare
- not usually pulsatile
- NO N/V, FOCAL NEURO SX (no photophobia)
- tx:
- treat like migraines; 1st line: NSAIDs, asa, tylenol, anti-migraine meds
- TCAs (amitriptyline) in severe/recurrent, prophylaxis, BB
19
Q
migraine headache
A
- mc women, mc cause of morning ha, family hx 80%
- 2 TYPES: W/OUT AURA (COMMON) AND W/ AURA
- thought to be caused by vasodilation of blood vessels innervated by the trigeminal nerve
- sx:
- LATERALIZED, PULSATILE/THROBBING HA, ASSOC W/ N/V, PHOTOPHOBIA usually 4-72h duration, +/-bilat
- WORSE W/ PHYSICAL ACTIVITY, stress, lack/excessive sleep, etoh, foods (choc, red wine), OCPs, menstruation
- AURAS: VISUAL CHANGE MC - light flashes (photopsia), zig-zag light (teichopsia), scotomas, aphasia, weak, numb
-tx:
Symptomatic:
-TRIPTANS OR ERGOTAMINES (serotonin 5HT-1 agonists –> vasoconstrict) c/i CAD, PVD, uncontrolled HTN, hepatic, renal dz, pregnancy
-DOPAMINE BLOCKERS (metoclopramide, promethazine, prochlorperazine) as ANTIEMETICS, GIVE W/ BENADRYL TO PREVENT EPS
-iv fluids, dark room
-mild: NSAIDs/tylenol 1st line
Prophylactic:
-ANTI-HTN (BB, CCB), tca, anticonvulsants (valproate, topiramate)
20
Q
trigeminal neuralgia
A
compression of trigeminal nerve root (by superior cerebellar artery or vein) 90%, idiopathic 10%
-mc middle-aged women
- sx:
- BRIEF, EPISODIC, STAB/LANCINATING PAIN in 2nd/3rd division of TRIGEMINAL NERVE (cn 5) lasts sec-min
- WORSE W/ TOUCH, EATING, DRAFTS OF WIND, MOVEMENTS (OFTEN UNILATERAL)
- starts near mouth and shoots to eye, ear and nostril on ipsilateral side
- tx:
- CARBAMAZEPINE (TEGRETOL) 1ST LINE, oxcarbazepine
- GABAPENTIN
- sx decompression in severe cases
*suspect MS in younger pt w/ TGN
21
Q
cluster headache
A
-young/middle-aged males mc
- sx:
- SEVERE, UNILATERAL PERIORBITAL/TEMPORAL PAIN (SHARP, LANCINATING)
- LASTS <2 HR w/ spontaneous remission
- several times/day over 6-8 wks
- WORSE AT NIGHT, ETOH, STRESS OR FOODS
- IPSILATERAL HORNER’S SYNDROME (ptosis, miosis, anhydrosis), HASAL CONGESTION/RHINORRHEA, CONJUNCTIVITIS AND LACRIMATION
- tx:
- 100% O2 FIRST LINE
- ANTI MIGRAINE MEDS - SQ SUMATRIPTAN or ergotamines
- Prophylaxis: VERAPAMIL 1ST LINE, cortico, ergotamines, valproic acid, lithium
22
Q
idiopathic intracranial htn (pseudotumor cerebri)
A
IDIOPATHIC INC INTRACRANIAL (CSF) PRESSURE and no other cause of intracranial htn evident on ct/mri
-mc in obese women of childbearing age, cortico w/drawal, growth hormone, thyroid replacement, ocp
- sx:
- HEADACHE (worse w/ strain), retrobulbar pain, n/v, tinnitus, VISUAL CHANGE (can lead to blindness)
-dx:
-PAPILLEDEMA
+/- CN6 (abducens) palsy = lateral rectus muscle weakness –> limits of abduction
-CT SCAN: 1ST TO R/O MASS –> LP = INC CSF PRESSURE
- tx:
- ACETAZOLAMIDE (reduces csf pressure/production) +/- furosemide, +/- short course steroids
- optic nerve sheath fenestration of CSF shunting allows evacuation of csf
23
Q
CSF Findings
A
MS = high IgG (oligoclonal bands)
GB = high protein, normal WBC
Bacterial = high protein w/ inc WBC (PMNs), dec glucose
Viral = normal glucose, increased WBCs (lymph)
Fungal / TB = decreased glucose, increased WBC (lymph)
Idiopathic Intracranial HTN = increased CSF pressure
Subarachnoid Hemorrhage = xanthochromia, blood in CSF
*IF GLUCOSE NORMAL, VIRAL MENINGITIS MOST LIKELY, IF PMNS PREDOMINANT, BACTERIAL MOST LIKELY
24
Q
normal pressure hydrocephalus
A
- dilation of cerebral ventricles w/ normal opening pressures on lumbar puncture
- unknown, thought to be d/t impaired CSF absorption after injury (SAH, tumors, infx, inflam, trauma)
-sx:
TRIAD:
-GAIT DISTURBANCES - wide base, shuffling gait
-DEMENTIA - impaired exec fx, psychomotor depression
-URINARY INCONTINENCE - urgency early in dz
-other: weakness, lethargy, malaise, rigidity, hyperreflexia and spasticity
- dx:
- MRI/CT: ENLARGED VENTRICLES in absence or out or proportion to sulcal dilation (MRI pref)
- LP: CSF usuall normal; lumbar tap test = remove up to 50 cc leads to improvement 30-60 min after
- tx:
- VENTRICULOPERITONEAL SHUNT TX OF CHOICE
25
concussion
-mild traumatic brain injury --> alteration of mental status w/ or w/out loss of consciousness
- sx:
- CONFUSION, blank expression, blunted affect
- AMNESIA: pre-traumatic (retrograde) or post-traumatic (antegrade)
- headache, dizzy, visual disturbances: blurry/double
- delated responses and emo changes
- signs of inc intracranial pressure: persistent vomiting, worsening headache, inc disorientation, changing levels of consciousness
- dx:
- CT TEST OF CHOICE
- MRI if prolonged sx >7-14d or w/ worsening of sx not explained by concussion
- tx:
- COGNITIVE AND PHYSICAL REST
- pt may resume activity after resolution of sx and recovery of memory/cog fx
26
delirium
ACUTE, ABRUPT, TRANSIENT CONFUSED STATE d/t an IDENTIFIABLE CAUSE (MEDS, INFX)
- rapid onset assoc w/ fluctuating mental status changes and marked deficit in short-term memory
- recovery w/in 1 week most cases
27
dementia
PROGRESSIVE, CHRONIC INTELLECTUAL DETERIORATION
- MEMORY LOSS and loss of impulse control, motor and cognitive fx
- includes language dysfx, disorientation, inability to perform complex motor activity and inappropriate social interactions
- RF: age (esp >60) and vascular disease
- Includes: alzheimer's, vascular, frontotemporal, diffuse lewy body, creutzfeldt-jakob
28
Alzheimer disease
MC TYPE OF DEMENTIA
- AMYLOID DEPOSITION (SENILE PLAQUES)
- NEUROFIBRILLARY TANGLES (TAU PROTEIN)
- CHOLINGERGIC DEFICIENCY --> memory, language, visuospatial changes, normal reflexes
- sx:
- short-term memory loss (1st sx) progresses to long term, disorientation, behavioral and personality changes
- dx:
- CT SCAN - CEREBRAL CORTEX ATROPHY
- tx:
- AcH-ESTERASE INHIBITORS: DONEPEZIL, TACRINE, RIVASTIGMINE, GLANTAMINE (reverse cholinergic deficiency and sx relief - doesn't slow)
- NMDA ANTAGONIST: MEMANTINE (blocks nmda receptor, slow Ca influx and nerve damage) --> reduce glutamate excitotoxicity
29
vascular dementia
2nd MC TYPE
- BRAIN DZ D/T CHRONIC ISCHEMIA AND MULTIPLE INFARCTIONS (LACUNAR INFARCTS)
- HTN MOST IMPORTANT RISK FACTOR
- sx:
- Cortical: forgetfulness, confusion, amnesia, exec difficulties, speech abn
- Subcortical: motor deficits, gait abnormalities, urinary difficulties, personality changes
30
frontotemporal dementia (Pick's disease)
-rare type
-LOCALIZED BRAIN DEGENERATION OF FRONTOTEMPORAL LOBES
-MARKED PERSONALITY CHANGES (PRESERVED VISUOSPATIAL)
-apathy, disinhibition, +palmomental and palmar grasp reflexes, no amnesia
+PICK BODIES
31
diffuse lewy body disease
- lewy bodies: abn neuronal protein deposits (diffuse in comparison to parkinson's dz - local)
- VISUAL HALLUCINATIONS, DELUSIONS, episodic delirium, parkinsonism
- dementia later in dz course
32
upper motor neuron lesions
- UMN connects cortex to LMN (in spinal cord)
- nt glutamate transmits nerve impulses from upper motor to lower motor neurons
- etiologies:
- stroke
- MS
- cerebral palsy
- brain or spinal cord damage (tbi)
- SPASTIC PARALYSIS (HYPERTONIA)
- INCREASED DTR
- weakness
- no fasciculations
- UPWARD (POS/ABN) BABINSKI
- little/no muscle atrophy
33
lower motor neuron lesions
- LMN are located in spinal cord and links UMN to muscles
- LMN stim by glutamate release from UMN causing depolarization of LMN
- LMN terminates at effector (muscle); AcH RELEASE BY LMN STIMULATES MUSCLE CONTRACTION
- etiologies:
- guillain-barre
- botulism
- poliomyelitis
- cauda equina
- bell palsy
- FLACCID PARALYSIS (LOSS OF TONE / HYPOTONIA)
- DECREASED DTR
- weakness
- FASCICULATIONS
- DOWNWARD (NEG/NORM) BABINSKI
- MUSCLE ATROPHY
34
glasgow coma scale
eye-opening 1-4
verbal response 1-5
motor response 1-6
mild injury 13+
mod injury 9-12
severe injury = 8
35
astrocytoma
- derived from astrocytes (support endothelial cells ob BBB, provide nutrients for cells, maintain extra cellular ion balance)
- can appear in any part of brain
Types:
-PILOCYTIC ASTROCYTOMA (GRADE I) - juvenile, typically localized, MOST BENIGN, MC CHILDREN AND YOUNG ADULTS
- DIFFUSE ASTROCYTOMA (GRADE II) - tend to invade surrounding tissues but grow at slow pace
- ANAPLASTIC ASTROCYTOMA (GRADE III) - rare but aggressive
- GRADE IV ASTROCYTOMA = GLIOBLASTOMA MULIFORME - MC PRIMARY CNS TUMOR ADULTS
- sx:
- FOCAL DEFICITS MC - depends on location, mc in frontal and temporal areas
- general: ha, worse in morning, MAY WAKE PT UP AT NIGHT, cranial nerve deficits, ams, ataxia, vision change
- INCREASED INTRACRANIAL PRESSURE - MASS EFFECT
- dx:
- CT OR MRI W/ CONTRAST: grade I+II non-enhancing
- BX: pilocytic, diffuse, anaplastic, glioblastoma (may contain cystic material, calcium, bv)
- tx:
- Pilocytic: surgical excision +/-radiation
- Diffuse: sx if accessible +/- radiation
- Anaplastic: sx --> radiation +/-chemo after
- Glioblastoma: sx --> radiation + chemo
36
glioblastoma
MC AND MOST AGGRESSIVE PRIMARY TUMOR ADULTS
- GRADE IV ASTROCYTOMA
- PRIMARY MC (60%) SEEN IN ADULTS >50Y
- SECONDARY (40%) due to malignant progression from low-grade astrocytoma or anaplastic astrocytoma (grade III); may transform as early as 1 year or >10y
- RF: male, >50y, HHV-6, CMV, ionizing radiation
- sx:
- focal deficits mc, depends on location (mc frontal, temporal)
- ha, worse in morning, MAY WAKE PT UP AT NIGHT, cranial nerve deficits, ams, ataxia, vision change
- Frontal: dementia, personality change, gait, aphasia
- Temporal: partial complex and general seizures
- Parietal: contralateral sensory loss, hemianopia
- Occipital: contralateral homonymous hemianopia
- Thalamus: contralateral sensory loss
- Brainstem: papillary changes, nystagmus, hemiparesis
- INC INTRACRANIAL PRESSURE - MASS EFFECT: ha, n/v, papilledema, ataxia
- CUSHING'S REFLEX: IRREGULAR RESPIRATIONS, HTN, BRADYCARDIA
- dx:
- CT or MRI w/ contrast - mc seen in subcortical white matter of cerebral hemis --> nonhomogenous mass w/ hypodense center and VARIABLE RING OF ENHANCEMENT; MAY CROSS CORPUS CALLOSUM
- BX: small areas of NECROTIZING TISSUE surrounded by anaplastic cells and hyperplastic bv w/ areas of HEMORRHAGE
- tx:
- surgical excision, radiation and chemo w/ Temozolomide
- poor prognosis --> often <1 yr survival
37
meningiomas
USUALLY BENIGN, 2nd MC CNS PRIMARY NEOPLASM
- mc women (estrogen receptors on tumor cells)
- ASSOC W/ NEUROFIBROMATOSIS (ESP 2)
- MC ARISE FROM DURA OR SITES OF DURAL REFLECTION
- sx:
- most asymptomatic, found incidentally
- focal deficits: seizures, progressive spasticity, weakness or other motor/sensory sx
- dx:
- CT or MRI w/ contrast: INTENSELY ENHANCING, WELL-DEFINED LESION OFTEN ATTACHED TO DURS
- mc parasagittal region, convexities of hemis, sphenoid and olfactory groove, calcification
- BX: SPINDLE-CELLS concentrically arranged in WHORLED PATTERN; PSAMMOMA BODIES: concentric round calcifications
- tx:
- observe if asymptomatic/small
- surgical removal or radiation if not candidate
38
cns lymphoma
- Primary: seen w/out evidence of systemic dz; VARIANT OF EXTRANODAL NHL
- Secondary: mc, mets from another site (ex NHL in neck, chest, groin, abdomen) ESP DIFFUSE LARGE B CELL LYMPHOMA (90%), BURKITT'S LYMPHOMA (10%)
- RF: immunosuppression, EBV+ in 90%
- sx:
- focal deficits mc; depends on location
- ocular sx: visual change, steroid-refractory posterior uveitis
- dx:
- CT/MRI w/ contrast: hypointense RING-ENHANCING LESION in deep white matter on CT
- BX
- workup: CT of abd/pelvis, PET scan, BM bx, slit lamp
- tx:
- CHEMO: METHOTREXATE MOST EFFECTIVE
- RADIATION, CORTICO
- surgical resection usually ineffective
39
oligodendoglioma
oligodendrocyte - supportive (glial) tissue of brain
- sx:
- may be asymptomatic, incidental finding (slow growth)
- focal deficits: seizures, ha, personality change (depends on location)
- dx:
- CT/MRI w/ contrast
- BX: soft, gray-ish, pink CALCIFIED tumors, areas of hemorrhage and or cystic; CHICKEN-WIRE CAPILLARY PATTERN W/ FRIED EGG SHAPED tumor cells
-tx:
-surgical resection tx of choice
+/- radiation and/or chemo
40
ependyoma
- ependymal cells line ventricles and parts of spinal column
- MC IN CHILDREN, MC IN 4TH VENTRICLE, +/- medulla, spinal cord
- sx:
- Infants: inc head size, irritability, sleeplessness, vomiting
- Older children: n/v, headache
- dx:
- CT/MRI w/ contrast: hypointense T1, hyperintense T2, enhances w/ gadolinium
- BX: PERIVASCULAR PSEUDOROSETTES (tumor cells surrounding a blood vessel)
- tx:
- surgical resection --> radiation tx
41
hemangiomas
- abnormal buildup of bv in skin or internal organs
- 10% have Hippel-Lindau syndrome (+ tumors of liver, pancreas and kidney)
- HEMANGIOBLASTOMA: arises from blood vessel lining; benign, slow-growing well-definited tumors
- mc found in BRAINSTEM AND CEREBELLUM
- RETINAL HEMANGIOMAS ASSOC W/ VON HIPPEL-LINDAU SYDROME
- sx:
- Hemangioblastoma: ha, n/v, gait, poor coordination, may produce epo
- Hemaiopericytoma: depends on location
- dx:
- CT/MRI w/ contrast
- BX: well-defined borders, FOAM CELLS W/ HIGH VASCULARITY
- tx:
- surgical resection, radiation may be used in tumors attached to brainstem
42
atlas C1 burst fracture (Jefferson)
BILATERAL FRX OF ANTERIOR AND POSTERIOR ARCHES OF C1
+/- C1/C2 dislocation
MOI: vertical compression force through occipital condyles to the lateral masses of the atlas
- dx:
- lateral xray --> inc predental space btw C1 and odontoid (dens)
- open-mouth (odontoid) view: may show step-off
- tx:
- nonoperative: hard cervical orthosis vs halo immobilization 6-12 wks
- operative: posterior C1-C2 fusion vs occipitocervical fusion if unstable
43
hangman's (C2/axis pedicle) fracture
TRAUMATIC BILAT FRX (SPONDYLOLYSIS) OF PEDICLES OR PARS INTERARTICULARIS OF THE AXIS VERTEBRA (C2) --> may lead to spondylolisthesis btw C2 and C3
-UNSTABLE FRX
- MOI: extreme hyperextension injuries of skull, atlas and axis (esp in already extended neck) and secondary flexion w/ subsequent subluxation
- sx: neck pain, neuro exam intact (cervical canal wide)
- dx:
- Cervical XRAY: subluxation (slipping of C2 forward compared to C3)
- CT - STUDY OF CHOICE (mri if artery injury suspected)
- tx:
- nonoperative: type I (<3mm displace) rigid collar 4-6wk, type II (3-5mm) closed reduction followed by halo immobilization 8-12wk
- operative: type II (>5mm w/ severe angulation)
44
odontoid fractures
-fracture of dens (odontoid process) of axis (c2)
MOI: head placed in forced flexion or extension in ant-pos orientation) - ex forward fall onto forehead
- Type II: MC - fracture at base of dontoid process (dens) where it attaches to C2; UNSTABLE
- dx: best seen on AP odontoid (open mouth) view
- tx:
- Os odontoideum (aplasia or hypoplasia of odontoid) --> observe
- Type II in young --> halo, sx if RF for nonunion
- Type II in elderly --> sx preferred; orthosis if not candidate
- Type III --> cervical orthosis
45
atlas fracture and transverse ligamental instability
MOI:
- hyperextension and compression injuries
- low risk of neuro complications; may be assoc w/ axis frx
46
atlanto-occipital dislocation
-extreme flexion injury involving atlas (C1) and axis (C2)
| +/- assoc w/ odontoid frx
47
atlanto-axial joint instability
instability btw atlas (C1) and axis (C2)
MOI:
- Trauma: d/t extreme flexion-rotation injury
- Non-trauma: degnerative change - down syndrome, RA, os odontiodium
- sx:
- neck pain, neuro sx/deficits
- myelopathic sx: muscle weakness, hyperreflexia, wide gait, bladder dysfx
- dx:
- XRAY: ODOINTOID VIEW - may see inc in atlanto-dens interval
-tx: depends on cause
48
clay shoveler's fracture
SPINOUS PROCESS AVULSION FRX MC AT LOWER CERVICAL (C6 OR C7) or upper thoracic vertebrae
-MOI: forced neck flexion w/ muscle pulling off piece of spinous process, esp after sudden deceleration injuries (mva); usually stable injury
- tx:
- NONOPERATIVE: nsaids, rest, immobilization in hard collar for comfort
- surgical excision only used if non-union or persistent pain
49
flexion teardrop fractures
ANTERIOR DISPLACEMENT OF A WEDGE-SHAPED FRACTURE FRAGMENT (teardrop shape of ANTERIO-INFERIOR PORTION of superior vertebra)
MOI: severe flexion and compression causes the vertebral body to collide w/ an inferior vertebral body
- mc in lower cervical spine; loss of vertebral height
- HIGHLY UNSTABLE (bc disrupts posterior longitudinal ligament) MAY CAUSE ANTERIOR CERVICAL CORD SYNDROME
-tx: SURGERY
50
extension teardop fractures
-triangular-shaped avulsion fracture of the antero-inferior corner of the vertebral body as a result of the rupture of the anterior longitudianl ligament
MOI: ABRUPT NECK EXTENSION
-MC SEEN AT C2, may be seen at C5-C7 and assoc w/ central cord syndrome, no loss of vertebral height
-tx: CERVICAL COLLAR
51
burst fractures
-d/t nucleus pulposus of intervertebral disc being forced into vertebral body, causing it to burst outwards
MOI: axial loading injury causing vertebral compression injures of the cervical and lumbar spine
Stable: all ligaments intact, no posterior displacement
Unstable: >50% copression of spinal cord, 50% loss of vertebral height, >20 degrees of spinal angulation or assoc neuro deficits
XRAY: comminuted vertebral body and loss of height
-tx: UNSTABLE NEEDS SURGICAL CORRECTION
52
subclavian steal syndrome
signs/sx from reversed blood flow down ipsilateral vertebral artery to supply affected arm d/t occlusion or stenosis of subclavian artery; L ARM MC AFFECTED
Etiologies: ATHEROSCLEROSIS MC, thoracic outlet synd
- sx:
- most asymptomatic
- SX OF ARM ARTERIAL INSUFFICIENCY: claudication, paresthesias, BLOOD PRESSURE DIFFERENCE BTW ARMS (reduction in affected arm >15 mmHg)
- SX OF VERTEBROBASILAR INSUFFICIENCY: presyncope/syncope, dizzy, neuro deficits, vertigo, diplopia, nystagmus, weak, drop attacks, gait
- dx:
- continuous-wave doppler, duplex US, transcranial doppler, ct angio
- tx:
- revascularization or percutaneous transluminal angio in severe
53
anterior cord syndrome
MOI:
- MC after blowout vertebral body burst fracture (flexion)
- anterior spinal artery injury or occlusion
- direct anterior cord compression
- aortic dissection, sle, aids
Deficits:
MOTOR: LOWER EXTREMITY > UPPER (corticospinal)
SENSORY: pain, temp (spinothalamic), light touch, may devo BLADDER DYSFUNCTION (incontinence, retention)
Preserved:
-proprioception, vibration, pressure (dorsal column spared)
54
central cord syndrome
MOI:
- hyperextension injures (50% w/ mva), falls in elderly, gsw, tumors, cervical spinal stenosis, syringomyelia
- MC incomplete cord syndrome
- it affects primarily the central gray matter
Deficits:
MOTOR: UPPER EXTREMITY > LOWER (distal portion more severe involvement from corticospinal involvement)
SENSORY: pain, temp (spinothalamic) deficit greater in upper extremity --> SHAWL DISTRIBUTION
Preserved:
-proprioception, vibration, pressure (dorsal column spared)
55
posterior cord syndrome
MOI: rare
-damage to posterior cord or posterior spinal stenosis
Deficits:
-LOSS OF PROPRIOCEPTION AND VIBRATORY ONLY
Preserved:
-pain, light touch; no motor deficits
56
brown sequard
MOI:
- unilateral hemisection of the spinal cord
- MC after PENETRATING TRAUMA, tumors
- rare
Deficits:
IPSILATERAL DEFICITS
-MOTOR: lateral corticospinal tract, VIBRATION AND PROPRIOCEPTION (dorsal column)
CONTRALATERAL DEFICITS
-PAIN AND TEMP (lateral spinothalamic tract) usually 2 levels below injury
57
anterior circulation ischemic stroke lesions
Right-sided Lesions
- bx, learning process, short-term memory
- left hemiparesis, sensory loss, neglect, ANOSOGNOSIA
- left homonymous hemianopsia, APRAXIA
- dysarthria, SPATIAL/TIME DEFICITS
- FLAT AFFECT, IMPAIRED JUDGEMENT, IMPULSIVITY
Left-sided Lesions:
- speech language
- right hemiparesis, sensory loss, homonymous hemianopsia, dysarthria
- APHASIA, AGRAPHIA, DEC MATH COMPREHENSION
58
terms
hemiparesis = weakness
hemiplegia = paralysis
dysarthria = inability to articulate words
apraxia = loss of ability to execute purposeful mvmts
ataxia = loss of coordinated mvmts
aphasia = difficulty remembering words, speaking, write
broca's aphasia = frontal lobe nonfluency, sparse output (comprehension relatively preserved)
wernicke's aphasia = fluent aphasia (volume, meaningless) w/ marked impaired comprehension
59
transient ischemic attack
- caused by focal brain, spinal cord or retinal ischemia WITHOUT ACUTE INFARCTION
- OFTEN LASTS <24 H (most resolve 30-60 m)
- MC DUE TO EMBOLUS or transient hypoTN
- 50% of pt will have CVA w/in 24-48 h after (esp DM, HTN) 10-20% will experience CVA w/in 90 days
-sx:
INTERNAL CAROTID:
-AMAUROSIS FUGAX (MONOCULAR VL - LAMP SHADE DOWN ONE EYE), WEAKNESS CONTRALATERAL HAND
-sudden ha, speech, changes, confusion
VERTEBROBASILAR
-BRAINSTEM/CEREBELLAR SYMPTOMS (gait, proprioception, dizzy, vertigo)
-dx:
-CT HEAD - INITIAL TEST OF CHOICE to r/o hemorrhage
-CAROTID DOPPLER - endarterectomy rec if internal or carotid stenosis 70+%
-CT ANGIO, MRI AGIO
-blood sugar to r/o hypoglycemia, r/o electrolyte issue, coag studies, cbc
-TTE or TEE to look for cardioembolic sources
-ECG to look for a-fib
ABCD2 score to assess CVA risk: Age, Bp, Clinical features, Duration of sx, Diabetes
- tx:
- ASA +/- CLOPIDOGREL OR DIPYRIDAMOLE
- THROMBOLYTICS CONTRAINDICATED!!!
- place supine to inc cerebral perfusion, avoid lowering bp
- reduce modifiable rf: DM (gluc control), HTN, A-fib
60
ischemic stroke
-MC 80% d/t TROMBOTIC 49%, EMBOLI 31%, cerebrovascular occlusion
- LACUNAR STROKE:
- SMALL VESSEL DZ atheroembolic stroke, penetrating arteries providing blood to the brain’s deep structures is occluded
- PURE MOTOR MC, ATAXIC HEMIPARESIS, DYSARTHRIA, HX OF HTN 80%
- CT: SMALL PUNCHED OUT HYPODENSE AREAS
- tx: ASA, control risk factors
MIDDLE CEREBRAL ARTERY - MC 70%
- contralateral sensory/motor loss/hemiparesis: GREATER IN FACE, ARM > leg/foot
- GAZE PREFERENCE TOWARDS SIDE OF LESION
- LEFT SIDE --> APHASIA: BROCA, WERNICKE, MATH COMPREHENSION, AGRAPHIA
- RIGHT SIDE --> SPATIAL DEFECTS, DYSARTHRIA, LEF-SIDE NEGLECT, ANOSOGNOSIA, APRAXIA
ANTERIOR CEREBRAL ARTERY
- contralateral sensory/motor loss/hemiparesis: GREATER IN LEG/FOOT --> ABN GAIT
- FACE SPARED, speech preserved, slow response
- frontal lobe and mental status impairment: IMPAIRED JUDGMENT, CONFUSION, PERSONALITY CHANGES (FLAT AFFECT)
- URINARY INCONTINENCE, upper motor neuron weak
- gaze pref towards side of lesion
POSTERIOR CEREBRAL ARTERY
-VISUAL HALLUCINATIONS, CONTRALATERAL HOMONYMOUS HEMIANOPSIA, "CROSSED SX" (ipsilateral cranial nerve deficits, contralateral muscle weakness), coma, drop attacks
BASILAR ARTERY
-cerebral dysfx, CN palsies, dec vision, dec bilateral sensory
VERTEBRAL ARTERY
-VERTIGO, NYSTAGMUS, N/V, DIPLOPIA, ipsilateral ataxia
- dx:
- NON-CONTRAST CT: r/o hemorrhage (may be normal first 6-24h)
- tx:
- THROMBOLYTICS W/IN 3 HOURS of onset
- ALTEPLASE (tissue plasminogen activator TPA) given if no evidence of hemorrhage (c/i BP >185/110, recent bleed/trauma, bleeding disorder)
- antiplatelet: asa, clopidogrel, dipyridamole, +/- anticoag if cardioembolic
- only lower BP if >185/110 for thrombolytics or >220/120 if no thrombolytic use
- STROKES W/ FACIAL INVOLVEMENT INVOLVES LOWER HALF OF FACE (WILL STILL BE ABLE TO RAISE EYEBROW)
61
hemorrhagic stroke
- 20% of strokes
- HA, VOMITING FAVORS ICH OR SAH
- IMPAIRED CONSCIOUSNESS W/OUT FOCAL SX FAVORS SAH
SPONTANEOUS ICH
- COMMONLY CAUSED BY HTN, esp BASAL GANGLIA
- LOC, n/v, hemiplegia, hemiparalysis
- sx usually min-hrs gradually increasing
- NONCONTRAST CT -don't perform LP if ICH suspected!
- tx: supportive vs. hematoma evacuation; if inc intracranial pressure --> head elevation +/-mannitol, hyperventilation
SUBARACHNOID HEMORRHAGE
- SUDDEN, "WORST HA OF MY LIFE" --> BRIEF LOC, N/V, MENINGEAL IRRITATION, nuchal rigidity, seizures
- MC 2ry TO RUPTURE OF BERRY ANEURYSM or AVM
- no focal neurological sx
- CT SCAN --> if neg and high suspicion --> LP (XANTHOCHROMIA / RBC) esp if inc pressure
- tx: bedrest, no exertion/strain, anti-anxiety meds, stool softeners +/- lower BP
BERRY ANEURYSM
-MC CIRCLE OF WILLIS
-ANGIOGRAPHY GOLD STD
+/-ANEURYSM CLIP/COIL
62
epidural hematoma (hemorrhage)
Location:
ARTERIAL BLEED MC BTW SKULL AND DURA
Mechanism:
MC AFTER TEMPORAL BONE FRACTURE --> MIDDLE MENINGEAL ARTERY
- sx:
- varies, brief LOC --> lucid interval --> coma
- ha, n/v, focal neuro sx, rhinorrhea (csf)
- CN III palsy if tentorial herniation
- dx:
- CT: CONVEX (LENS-SHAPE) BLEED
- DOESNT CROSS SUTURE LINES
- tx:
- may herniate if not evacuated early, observe if small
- if INC ICP --> MANNITOL, hyperventilation, head elevation, shunt
63
subdural hematoma (hemorrhage)
Location:
VENOUS BLEED MC - btw dura and arachnoid d/t TEARING OF CORTICAL BRIDGING VEINS
-MC IN ELDERLY
Mechanism:
-MC BLUNT TRAUMA - often causes bleeding on other side of injury "CONTRE-COUP"
- sx:
- varies, may have focal neuro sx
- dx:
- CT: CONCAVE (CRESCENT-SHAPED) BLEED
- BLEEDING CAN CROSS SUTURE LINE
- tx:
- hematoma evac vs. supportive
- evac if massive or 5+mm midline shift
64
subarachnoid hemorrage (SAH)
Location:
ARTERIAL BLEED btw arachnoid and pia
Mechanism:
-MC BERRY ANEURYSM RUPTURE, AVM
-sx:
-THUNDERCLAP SUDDEN HA "WORSE HA OF LIFE", +/- unilateral, occipital area
+/-LOC, n/v, MENINGEAL SX: STIFF NECK, PHOTOPHOBIA, DELIRIUM
-NO FOCAL NEURO DEFICITS
-TERSON SYNDROME: retinal hemorrhages
- dx:
- CT SCAN
- if negative CT --> LP: XANTHOCHROMIA (RBC), INC CSF PRESSURE
- 4-VESSEL ANGIO after confirmed SAH
-tx:
-supportive: bed rest, stool softeners, lower icp
-surgical coil/clip
+/- lower BP gradually (NICARDIPINE, NIMODIPINE, labetalol)
65
intracerebral hemorrhage (ICH)
Location:
INTRAPARENCHYMAL
Mechanism:
-HTN, trauma, amyloid, ArterioVenous Malformation (AVM)
- sx:
- HEADACHE, N/V, +/- LOC, hemiplegia, hemiparesis
- not assoc w/ lucid intervals
- dx:
- CT: intraparenchymal bleed
- DON'T PERFORM LP IF SUSPECTED BC MAY CAUSE BRAIN HERNIATION
-tx:
-supportive: gradual bp reduction
+/-MANNITOL IF INC ICP
+/-hematoma evac if mass effect
66
acute bacterial meningitis
-may have hx of sinusitis or pneumonia prior to devo of meningitis
-sx:
-FEVER/CHILLS (95%), MENINGEAL SX: ha, nuchal rigidity, photosensitivity, n/v --> AMS, SEIZURES
+KERNIG'S SIGN: inability to straighten knee w/ hip flexion
+BRUDZINSKI'S SIGN: neck flexion produces knee/hip flexion
-dx:
-LUMBAR PUNCTURE: CSF EXAMINATION DEFINITIVE
100-1000 PMN, DEC GLUCOSE (<45), INC TOTAL PROTEIN, INC CSF PRESSURE
-HEAD CT: to r/o mass effect BEFORE LP if high risk (>60, immunocomp, h/o CNS dz, AMS, focal neuro findings, papilledema)
- tx:
- DON'T WAIT FOR LP RESULTS - START EMPIRIC
<1 mo --> GROUP B STREP (STREP AGALACTIAE) MC
-AMP (listeria) + CEFOTAXIME
1 mo - 18y --> N. MENINGITIDIS MC (ASSOC PETECHIAL RASH)
-CEFTRIAXONE (CEFOTAXIME) + VANC
18y - 50y --> S. PNEUMO MC, N. MENINGITIDIS
-CEFTRIAXONE (CEFOTAXIME) + VANC
>50y --> S. PNEUMO, LISTERIA
-AMP + CEFTRIAXONE (CEFOTAXIME) +/-VANC
*DEXAMETHASONE RECOMMENDED IF KNOWN/SUSPECTED S.PNEUMO
Prophylaxis/exposed: CIPRO 500mg x 1 dose, alternate Rifampin
67
viral (aseptic) meningitis
VIRAL INFX OF MENINGES
-ENTEROVIRUS FAMILY MC (echovirus, coxsackie), ARBOVIRUSES (transmitted by mosquitoes), mumps, HSV 1+2, HIV
-sx:
-ha, fever, mild confusion
+MENINGEAL SX: nuchal rigidity, +Brudzinski, +Kernig, photophobia, phonophobia, lethargy (sx not as intense as bacterial)
-ASSOC W/ NORMAL CEREBRAL FX - not asoc w/ neuro deficits or seizures
-dx:
-CT FIRST TO R/O MASS
-CSF ANALYSIS: MOST IMPORTANT TO DIFFERENTIATE
lymphocytosis, normal glucose, +/-inc protein
-MRI: diffuse enhancement of meninges; frontal/temporal seen w/ HSV-1
-serologies, viral cx
- tx:
- SUPPORTIVE: antipyretics, fluids, antiemetics
- good prognosis, usually self-limited (7-10d)
68
encephalitis
VIRAL INFX OF BRAIN PARENCHYMA
-HSV-1 MC CAUSE, Enteroviruses, Arboviruses, zoster, rubeola, toxoplasmosis, cmv, rabies
- sx:
- ha, fever, PROFOUND LETHARGY, AMS
- ASSOC W/ ABNORMAL CEREBRAL FX AND FOCAL NEURO DEFICITS (ex cranial nerve II, IV, VI, VII), sensory and motor deficits, personality, mvmt, speech and bx disorders, SEIZURES
- dx:
- CSF ANALYSIS: SAME AS VIRAL - LYMPHOCYTOSIS, NORMAL GLUCOSE, inc protein
- Brain Imaging: temporal lobe mc involved (+/- mass eff)
-tx:
-SUPPORTIVE: antipyretics, fluids, control cerebral edema, seizure prophylaxis if needed
-VALACYCLOVIR if HSV or no identifiable cause of meningitis (hsv assoc w/ poor prognosis)
+/-Immunoglobulin if immunocompromised
-assoc w/ higher M/M than viral; HSV assoc w/ 70% mortality if not treated
69
simple partial (focal) seizure
CONSCIOUSNESS FULLY MAINTAINED
EEG: focal discharge at onset of seizure
-may have focal sensory, autonomic, motor sx
-may be followed by transient neurologic deficit lasting up to 24 hrs
70
complex partial (focal - temporal lobe) seizure
CONSCIOUSNESS IMPAIRED, starts focally
EEG: interictal spikes w/ slow waves in temporal area
Aura (sec-min) --> impaired consciousness
- Auras: sensory/autonomic/motor sx of which the pt is aware; may precede/accompany or follow
- AUTOMATISMS: LIP SMACKING, MANUAL PICKING, PATTING, COORDINATED MOTOR MVMT
71
absence (petit mal) generalized seizure
BRIEF LAPSE OF CONSCIOUSNESS; pt usually unaware of attacks
BRIEF STARING EPISODES, EYELID TWITCHING
NO POST-ICTAL PHASE
-may be clonic (jerk), tonic (stiff) or atonic (loss of postural tone)
-MC IN CHILDHOOD --> USUALLY STOPS BY 20Y
EEG: bilateral symmetric 3Hz spike and wave action or normal
- tx:
- ETHOSUXIMIDE 1ST LINE (only works for absence), Valproic acid 2nd line
72
tonic-clonic (grand mal) generalized seizure
TONIC PHASE: LOSS OF CONSCIOUSNESS --> RIGID, sudden arrest of respiration (usually <60sec) --> clonic phase
CLONIC PHASE: REPETITIVE, RHYTHMIC JERKING (LASTS <2-3 MIN) --> postictal phase
POSTICTAL PHASE: FLACCID COMA / SLEEP (VARIABLE DURATION)
- may be accompanied by incontinence, tongue biting or aspiration w/ postictal confusion
- AURAS ARE PREWARNINGS TO SEIZURES
EEG: generalize high-amp rapid spiking, may be normal in between seizures
- tx:
- VALPROIC ACID, PHENYTOIN, CARBAMAZEPINE, LAMOTRIGINE, topiramate, primadone, levetiracetam, gabapentin, phenobarbital, midazolam
73
myoclonus (generalized)
SUDDEN, BRIEF, SPORADIC INVOLUNTARY TWITCHING, NO LOC
-maybe 1 muscle or group of muscles
- tx:
- Valproic Acid, Clonazapam
74
atonic (generalized)
"DROP ATTACKS" - SUDDEN LOSS OF POSTURAL TONE
75
status epilepticus (generalized)
repeated, generalized seizures w/out recovery >30 min
- tx:
- LORAZEPAM OR DIAZEPAM --> PEHNYTOIN --> PHENOBARBITAL
- thiamine + ampule of D50
- place left-lateral-decubitus position
76
differentiate btw pseudoseizures
prolactin levels increased in true seizures
