Neurology Flashcards by David Felipe Ortiz Paredes

Patient comes to the ER with a focal neurological deficit in the right leg/foot. Which artery is blocked?

Left anterior cerebral atery

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Patient comes to the ER with a focal neurological deficit in the left face, left arm and afasia. Which artery is blocked?

Right middle cerebral atery

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Patient comes to the ER with stroke a focal neurological deficit (right blindness). Which artery is blocked?

Left posterior cerebral atery

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Patient who had a stroke and has locked-in syndrome. Which arteries is blocked?

Basilar and pons

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Patient has a syncope comes to the ER with stroke a focal neurological deficit (ataxia). Which artery is blocked?

Vertebral artery

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Young woman, pain in the neck after trauma and focal neurological deficit. Etiology of stroke?

Carotid dissection

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Patient with Thunderclap headache “worst headache of my life”. On physical has bradycardia, HTN, apnea. Dx?

Hemorrhagic stroke

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DM patient comes to the ER with a focal neurological deficit in the left face, left arm and aphasia. Sx started < 3 hrs. Non-hemorrhagic stroke on CT. Next steps?

o Imaging: ECG, Echocardiogram, carotid U/S
o Meds: tPA, ASA 325, high-potency statin
o Vitals: permissive HTN
o Labs: HgA1C, TSH, lipid panel, comprehensive metabolic panel (CMP), CBC
o Ancillary: speech therapy, occupational therapy, physical therapy

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Non-DM patient comes to the ER with a focal neurological deficit in the left face, left arm and aphasia. Sx started < 4.5 hrs. Non-hemorrhagic stroke on CT. Next steps?

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Patient comes to the ER with a focal neurological deficit in the left face, left arm and aphasia. The patient was ASx last night and was like that this morning. Non-hemorrhagic stroke on CT. Next steps?

o Imaging: ECG, Echocardiogram, carotid U/S
o Meds: ASA 325, high-potency statin (no tPA)
o Vitals: permissive HTN
o Labs: HgA1C, TSH, lipid panel, comprehensive metabolic panel (CMP), CBC
o Ancillary: speech therapy, occupational therapy, physical therapy

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Indications of tPA in stroke?

Ischemic stroke < 3 hrs + DM
Ischemic stroke < 4.5 hrs + not DM

Contraindicated with ICH, Bleeding, recent surgery or trauma

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Patient who had a stroke, allergic to ASA. How to prevent future stroke?

Copidogrel

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Patient with Hx of stroke on ASA 81 mg who has a second stroke. How to prevent future stokes?

ASA 81 mg + Dipyridamole

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Chronic management of stroke?

ASA 81 mg
Warfarin/NOAC if Afib with CHADS2 score 2+
High-potency statins
HTN control and DM management if needed

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Patient wih Hx of epilepsy who comes to the ER with Lost of consciousness, Limb jerking, Bowel/bladder incontinence, tongue biting.

Next step?

Check level of antiepilpectic medications
Increase Drug dose
Add a Drug
Change Drug .

….VITAMINS?

Vascular
Infxn
Trauma
Autoimmune
Metabolic
Idiopathic/withdrawal
Neoplasm
Sychiatric

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Patient wihout Hx of epilepsy who comes to the ER with Lost of consciousness, Limb jerking, Bowel/bladder incontinence, tongue biting. He is currently in seizure, which lasts more than 5 minutes.

Dx, tx?

Status (medical emergency!)

Tx:

IV Benzo
Phenytoin
Midazolam + Propofol
Phenobarbital

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Patient wihout Hx of epilepsy who comes to the ER with Lost of consciousness, Limb jerking, Bowel/bladder incontinence, tongue biting. He is not currently in seizure. The seizure lasted less than 5 minutes.

Next step?

CT
EEG 
Look for cause (VITAMINS)
- Vascular
- Infxn
- Trauma
- Autoimmune
- Metabolic
- Idiopathic/withdrawal
- Neoplasm
- Sychiatric

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Secondary causes of seizure

VITAMINS

Vascular: stroke
Infxn: encephalitis, meningitis
Trauma: brain bleeds
Autoimmune: cerebritis (lupus), vasculitis
Metabolic: glucose, perfusion, oxygenation, Na, Ca
Idiopathic/withdrawal: BDZ, alcohol
Neoplasm
Sychiatric

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Definition of seizure status

seizure > 5 min; > 20 mins of post-ictal

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First-line tx to prevent seizures

valproate, lamotrigine, levetiracetam

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Child with recurrent episodes of loss of tone without LOC. Dx and tx?

Atonic epilepsy

Tx: Valproate

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Boy with LOC without loss of tone. Dx and tx?

Absence

Tx: Ethosuximide

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Tx of Myoclonic epilepsy?

Valproate

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Patient with recurrent episodes of lancinating pain in face. Dx and tx?

Trigeminal neuralgia

Carbamazepine

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Patient < 70 y-o functional patient with Bradykinesia, mask-like facies, trouble gatting started, Cogwheel rigidity, Resting pill-rolling tremor, Gait/postral instability (no postural correction--> falls). Dx and tx?

Parkinson's Tx: - Levodopa + carbidopa - Dopamine agonists: ropinirole, pramipexole

Patient > 70 y-o non-functional patient with Bradykinesia, mask-like facies, trouble gatting started, Cogwheel rigidity, Resting pill-rolling tremor, Gait/postral instability (no postural correction--> falls). Dx and tx?

Parkinson's Tx: Levodopa + carbidopa • Carbidopa prevents conversion of levodopa in the periphery

Patient > 70 y-o non-functional patient with Parkinson's. Is currently treated with Levodopa + carbidopa. Sx keep worsening. Next step?

Add MAO-B-i: Selegeline, then COMT inhibitors: –capones

Young patient with mild Parkinson's. Tx?

Ach antagonist: Benztropine

Middle-aged man Tremor with movement. No tremor at rest. The treamor doesn't worsens when closer to the objective. Dx and Tx?

Essential tremor Tx: propranolol

Tremor with movement, no tremor at rest, worsens in amplitude the closer to the target. Dx and tx?

Intention tremor (Cereberal disfuntion caused by stroke or alcohol) No tx :(

Purposeless ballistic uncontrolled movements. What's the path of Core of Huntington’s?

- Autosomal dominant genetic disease - Caused by trinucleotide repeats (the more repeats, the younger the disease starts) - Anticipation: occurring earlier in subsequent generations

Red flags headache?

``` o Fever o Focal neurological deficit o New onset headache in a > 50 patient o Thunderclap headache o Progressive nausea and vomiting ```

Patient with a headache that described bilateral vice-like pain that radiates from the front to the back/neck. Dx and tx?

Tension headache NSAIDs, acetaminophen

Patient who takes chronic analgesics (opiates, ergots, triptans, OTC, taken 2-3 times/week) who suffers from frequent headaches (10x/month). Dx and tx?

Analgesic rebound Withdraw offending medications despite initial worsening of sx

Patient with who was ASx for months but then has many headache 8-10 times/day, Unilateral eye pain and autonomic symptoms: rhinorrhea, lacrimation, conjunctival injection, Horner’s (facial anhidrosis, ptosis, myosis). Dx and tx?

Cluster headache Acute attack: • 1st: Oxygen • 2nd: SC Sumatriptan Ppx: CCB like verapamile F/U: Brain MRI

Patient with Unilateral pulsatile headache, Photophobia/phonophobia, Nausea/vomiting, Trigger (nitrites, caffeine, chocolate, menstrual cycle, stress, etc), Sleep may abort it, but hangover the next day. Dx and tx?

Migraine Tx: Acute • Mild: NSAIDs • Severe or refractory: triptans, ergot (careful if CAD) Ppx: propranolol, valproic acid, topiramate

Woman on oral contraceptive pill, consults with headache, Nausea/vomiting, and Focal neurological deficit. On physical she has Papilledema Negative CT Dx, next step and tx?

Idiopathic intracranial hypertension/pseudotumor cerebi (secondary headache) Next step: Lumbar puncture with pressure opening > 25 H2O cm Tx: Acetazolamide - If refractory: serial lumbar puncture or ventricularperitoneal shunt

Idiopathic intracranial hypertension/pseudotumor cerebi is associated with?

OCPs (oral contraceptive pill) Vitamin A Isotretinoin Glucocorticoid withdrawal.

lancinating pain of the face. Dx, tx and F/U?

Trigeminal neuralgia Tx: carbamazepine F/U: MRI to r/o compressions

Alarm sx in back pain, next steps and tx?

Alarm sx o Bladder/bowel incontinence o Saddle anesthesia: restricted to the area of the buttocks, perineum and inner surfaces of the thighs o New/rapidly progressive focal neurological deficit o History of cancer o Sexual dysfunction o Fever Next steps: 1. Dexamethasone 2. X Ray/MRI Tx: - Drain hematoma - Incision and drainage - Abx for abscess - Radiation for cancer - Surgery for facture

Male, young, heavy lifting with a belt-like back pain. Dx, tx?

Musculoskeletal pain Tx: Exercise and NSAIDs F/U: Reasses in 4-6 month. If tx fails--> X Ray, MRI

30-50-y-o male doing heavy lifting, back pain, lightning or shooting pain down the leg. On physical: (+) Straight leg raise test. Dx, next step and tx?

Disk herniation Next step: • X Ray • MRI Tx: NeuroSurgery vs conservative tx depending on severity and lifestyle of patient

Old male, back pain, no heavy lifting, lightning or shooting pain down the leg. On physical: (+) Straight leg raise test. Dx, next step and tx?

Osteophyte Next step: • X ray • MRI Tx: Surgery

Old woman, back pain, she had fell on coccyx. On physical: Vertebral step off and Point tenderness. Dx, next step and tx?

Compression fracture Next step: • X Ray • MRI Tx: Surgery F/U: Dexa scan and treat osteoporosis

Old patient, with leg and butt pain when upright and with exercise. No sx when hunched over. Dx, next step and tx?

Spinal stenosis Next step: • X Ray • MRI Tx: Laminectomy

Patient with Chronic, Insidious, and Permanent Cognitive impairment and Memory loss. Next step?

R/O reversible cause. Order: - TSH, T4 - BMP - Vit B12 - LFTs - RPR - Depression - CT - MRI(?)

Alzheimer associated with what genetic disease?

Down syndrome

Patient with Memory loss (first short term, then long term). Social graces are normal. CT: diffuse cortical atrophy Dx and tx?

Alzheimer’s disease Tx: Supportive care and family education • Mild AD = ACh-Esterase-i (Donepezil, Rivastigmine, Galantamine) • Severe AD = Memantine

Old patient, normal before, the family has noted progressively that he has no filter, is violent and hypersexual. No memory loss yet. • CT: frontotemporal degeneration Dx?

Pick’s disease

Patient with Bradykinesia: mask-like facies, trouble gatting started, Cogwheel rigidity, Resting pill-rolling tremor, who in addition has memory loss and visual hallucinations. MRI: loss of substantia nigra Dx?

Lewy-body’s dementia

Patient who has had a few strokes. The family has noted stepwise functional decline with each stroke. • CT: many brain infracts Dx?

Vascular dementia

Young with dementia, rapid funcitonal decline and myoclonus. Dx and next step?

Creutzfeldt-Jakob Disease (CJD) Next step: - MRI - Palliative care

Patient with Urinary incontinence, Gate ataxia, and Dementia. CT with hydrocephalous Dx and tx?

Normal Pressure Hydrocephalus Tx: - LP improves condition - VP shunt

Patient with dizziness, no tinnitus, no hearing loss. On physical exam cerebellar signs. Next step?

MRI (MS, stroke, tumor, abscess, migraines, seizures)

Patient with recurrent vertigo that lasts < 1 min and is reproducible with movement. Dx, next step and tx?

Benign paroxysmal positional vertigo Next step: Dix Hallpike Tx: Epley maneuver

Patient with vertigo that lasts 1-10 min, + hearing loss, Nausea/vomiting. 4 weeks ago the patient had an upper respiratory infection (URI). Dx and tx?

Labyrinthitis/vestibular neuritis Tx: • Steroids • Anti-vertigo meds like meclizine

Patient with episodes that last between 30-60 min of Hearing loss, Tinnitus and Vertigo without movement. Dx and tx?

Menière’s Disease Tx: • Salt restriction • Thiazides diuretics • Meclizine

Young woman with pain with eye movements and blurry vision who now has tingling of the arm. MRI: Periventricular plaques Dx and tx?

Multiple sclerosis ``` Tx: Flare: steroids and r/o infection Chronic o Interferon o Glatiramer o Fingolimod ```

Tx of Urinary retention in multiple sclerosis?

Bethanechol

Tx of Incontinence in multiple sclerosis?

Amitriptyline

Tx of Spasms in multiple sclerosis?

Baclofen

Tx of Neuropathic pain in multiple sclerosis?

gabapentin

Patient with Ascending paralysis and Hyporeflexia. A few days agos he had watery diarrhea caused by campylobacter or flu vaccine. Dx, next step and tx?

Guillaim-Barré Next step: Lumbar puncture: ↑proteins with few cells Tx: • Intubation? • IV Ig or plasmapheresis • DON’T give steroids

Patient of 55 years of age with Blurry vision, dysphagia, lack of hand coordination that are worse in the evening. Dx, next steps, and tx?

Myasthenia Gravis Next step: • Anti-Ach receptor • EMR • CT scan of chest looking for thymoma Tx: • Cholinesterase inhibitors: Pyridostigmine • Steroids • In crisis (trouble breathing or swalling): IV Ig or plasmapheresis • Thymectomy

Myasthenia Gravis is associated with what tumor?

Thymoma

Patient of 55 years of age with Trouble raising from a chair and Difficulty combing that improves over the day. Dx, next steps, and tx?

Lambert-Eaton Next steps: • Antibody • EMR • CT looking for small cell carcinoma Tx: Treat lung cancer

Patient with a combination of upper and lower motor neuro lesions • Upper: hyperreflexia, with weakness and hypertonicity • Lower: Areflexia, weakness, hypotonicity and fasciculation Dx, next step and tx?

Amyotrophic Lateral Sclerosis (ALS) Next steps: - CT/MRI to r/o spinal lesion - Confirm dx with EMR Tx: Riluzole and supportive

Patient with depressed EEG, positive corneal reflex, you irrigate cold water on ear canal and eyes towards the ipsilateral side, no nystagmus, you move their head and his eyes move. Normal ECG, normal motor reflexes. Dx, causes and management?

Coma Causes: Toxins (EtOH, Benzos, Opiates), Electrolytes, Hypothyroid, Thiamine, hypoxic/ischemic encephalopathy, trauma (diffuse axonal injury) or brainstem path (hemorrhage or infarction) ``` Management: CMP, CT scan, LP, EEG Coma cocktail (Thiamine, D50, Oxygen, Naloxone), ```

Cold water caloric reflex?

- Normal: Irrigate cold water--> eyes towards the ipsilateral side, then opposite nystagmus - Coma: Irrigate cold water--> eyes towards the ipsilateral side, no nystagmus - Brain dead: Irrigate cold water--> no eye movement

Patient with flat EEG, positive corneal reflex, you irrigate cold wateron ear cannal and eyes towards ipsilateral side, no nystagmus, you move their head and his eyes move. Normal ECG, normal motor reflexes. Dx?

Persistent vegetative state

Patient with flat EEG, negative corneal reflex, you irrigate cold water on ear cannal and there's no response from eyes, you move their head and his eyes don't move. Normal ECG, no motor reflexes. Dx and next step?

Brain dead Get a coleage to confirm the dx

Patient with arroused EEG, positive corneal reflex, you irrigate cold wateron ear cannal and eyes towards the ipsilateral side, then opposite nystagmus; you move their head and his eyes move. Normal ECG, but not motor. Dx?

Locked-in syndorme

Unilateral, severe periorbital headache with tearing and conjunctival erythema.

Cluster headache.

Prophylactic treatment for migraine.

Antihypertensives, antidepressants, anticonvulsants.

The most common pituitary tumor. Treatment?

Prolactinoma. Dopamine agonists (e.g., bromocriptine).

A 55-year-old patient presents with acute “broken speech.” What type of aphasia? What lobe and vascular distribution?

Broca’s aphasia. Frontal lobe, left MCA distribution.

The most common cause of subarachnoid hemorrhage (SAH).

Trauma; the second most common is berry aneurysm.

A crescent-shaped hyperdensity on CT that does not cross the midline.

Subdural hematoma—bridging veins torn.

A history significant for initial altered mental status with an intervening lucid interval. Diagnosis? Most likely source? Treatment?

Epidural hematoma. Middle meningeal artery. Neurosurgical evacuation.

CSF fi ndings with SAH.

Elevated ICP, RBCs, xanthochromia.

Albuminocytologic dissociation.

Guillain-Barré syndrome (↑ protein in CSF without a | signifi cant ↑ in cell count).

Cold water is flushed into a patient’s ear, and the fast phase of the nystagmus is toward the opposite side. Normal or pathologic?

Normal.

The most common 1° sources of metastases to the brain.

Lung, breast, skin (melanoma), kidney, GI tract.

May be seen in children who are accused of inattention in class and confused with ADHD.

Absence seizures.

The most frequent presentation of intracranial neoplasm.

Headache.

The most common cause of seizures in children (2–10 | years).

Infection, febrile seizures, trauma, idiopathic.

The most common cause of seizures in young adults (18–35 years).

Trauma, alcohol withdrawal, brain tumor.

First-line medication for status epilepticus.

IV benzodiazepine.

Confusion, confabulation, ophthalmoplegia, ataxia.

Wernicke’s encephalopathy due to a defi ciency of thiamine.

What % lesion is an indication for carotid endarterectomy?

Seventy percent if the stenosis is symptomatic.

The most common causes of dementia.

Alzheimer’s and multi-infarct.

Combined UMN and LMN disorder.

ALS.

Rigidity and stiffness with resting tremor and masked facies.

Parkinson’s disease.

The mainstay of Parkinson’s therapy.

Levodopa/carbidopa.

Treatment for Guillain-Barré syndrome.

IVIg or plasmapheresis.

Rigidity and stiffness that progress to choreiform movements, accompanied by moodiness and altered behavior.

Huntington’s disease.

A six-year-old girl presents with a port-wine stain in the V2 distribution as well as with mental retardation, seizures, and ipsilateral leptomeningeal angioma.

Sturge-Weber syndrome. Treat symptomatically. Possible focal cerebral resection of the affected lobe.

Café au lait spots on skin. Associated dx?

Neurofibromatosis type 1.

Hyperphagia, hypersexuality, hyperorality, and hyperdocility. Dx?

Klüver-Bucy syndrome (amygdala).

May be administered to a symptomatic patient to diagnose myasthenia gravis.

Edrophonium.