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Flashcards in Neurology Falcon Review 2 Deck (118):
1

What are the types of parenchymal injuries

Concussion
contusion
diffuse axonal injury

2

Define concussion

Clinical syndrome of altered mental status secondary to head injury typically brought about by a change in momentum of the head

3

What are some of the symptoms of a concussion

Instantaneous onset of transient neurologic dysfunction, including loss of consciousness, temporary respiratory arrest, and loss of reflexes

4

Define contusion

Direct parenchymal injury to brain

5

What are the two types of contusions

Coup injury
Contracoup injury

6

What is a coup injury

Cerebral injury at point of direct contact

7

What is a Contracoup injury

damage to brain surface opposite to point of impact

8

What is a diffuse axonal injury

Injury to white matter due to acceleration and deceleration
– generally located in the corpus callosum, periventricular white matter, and hippocampus
– cerebral and cerebellar peduncle

typically associated with axonal swelling of white matter and is associated with a poor prognosis

9

What is the most common cause of an epidural hematoma

Trauma to skull causing an epidural artery tear (middle meningeal artery)
– patient may experience a lucid interval lasting upto a few hours

10

What are the deficits associated with an epidural hematoma

– Contralateral hemiparesis
– ipsilateral pupillary dilation

11

What is the most common cause of a Subdural hematoma

Tearing of bridging veins
– most common intracerebral lesions and dramatic brain injury

greatest risk is involved with:
– brain atrophy
– coagulopathy (alcoholics)

12

Do epidural hematomas require drainage

Always

– subdural hematomas to not always require drainage

13

What are the symptoms of a spinal cord transection

– Upper motor neuron signs below the level of the lesion
– complete sensory loss below the level
– bowel and bladder dysfunction
– may see lower motor neuron signs at the level of the lesion

14

What is a brown-Sequard syndrome

– Ipsilateral-weakness, joint positions sensory loss
– contralateral-pain and temperature loss
– bowel and bladder dysfunction is rare

15

What are the causes for central cord syndrome

Tumor
syringomyelia

16

What is syringomyelia

– Fluid filled cavity within the spinal cord
– most commonly occur in the cervical cord
– can occur after trauma
– can occur in conjunction with chiari malformation

17

What is the symptoms of a central cord syndrome

– Loss of pain and temperature in a cape like distribution
– lower motor neuron signs and arms
– upper motor neuron signs of lower extremities
– generally spares the dorsal columns

18

Discuss an anterior spinal artery syndrome

– Rear
– infarction of anterior two thirds of cord
–affects spinothalamic and corticospinal tracts, sparing dorsal columns
– results in spastic paralysis and loss of pain and temperature sensation with intact joint position since and vibration

19

what cranial nerves are associated with pain sensitive fibers

V
IX
X

20

Does the brain parenchyma have pain fibers

No

21

What is the most useful symptom regarding clinical approach to headaches

Time course is the most useful
– quality, severity and location have significant overlap between headache etiologies

22

What are the signs and symptoms of a subarachnoid hemorrhage

– Thunderclap headache - instantaneous onset, with maximal intensity within minutes
– worst headache of my life
– severe nausea and vomiting is common
– altered level of consciousness is frequent
– may have focal neurologic deficits

23

Discuss intraparenchymal hemorrhage

Acute onset
focal deficits commonly occur simultaneously
altered level of consciousness is related to the location and size of the bleed

24

how does a headache associated with meningitis typically present

Bacterial meningitis:
– headache is usually diffuse
– fever and meningismus are typical

viral meningitis
– diffuse headache usually has developed over several days
– associated symptoms of fatigue and myalgias are common

25

How is the headache associated with temporal arteritis

– headache is typically intermittent, unilateral, and temporal at first, then bilateral temporal, then continuous
– Pain is often throbbing in nature, but also described as aching or burning
– tenderness of the scalp

26

What is the typical patient presentation for a headache associated with temporal arteritis

Usually women over the age of 60
firm and tender superficial temporal artery
elevated ESR

27

What is the treatment for temporal arteritis

Steroids until biopsy is negative
– may be continued for years to prevent recurrence

28

how will a patient with a headache due to hypertensive urgency present

Dull, bilateral ache and pain
no focal deficits
usually seen with BP >170/110

29

What is RPLS

Reversible posterior leukoencephalopathy
– high blood pressure leading to posterior demyelination in the brain

30

Discuss cluster headaches

Typically abrupt and onset, peeking over 5 to 10 minutes.
Persist for 45 minutes to 2 hours
clusters over days two weeks
consistently unilateral, orbital location

Nausea and vomiting are atypical

31

Who is generally affected by cluster headaches

Typically young adult men onsets in the third decade
male-female ratio 5:1

32

What is a treatment for cluster headache

Abortive therapy is often ineffective but can use:
– sumatriptan
– DHE
– oxygen
– intranasal lidocaine

Prophylactic therapy
– lithium
– valproic acid
– amitriptyline

33

Describe the headache that is associated with a venous sinus thrombosis

An abrupt onset headache that lingers
often diffuse, may localize near the vertex

34

What is the diagnosis and management of venous sinus thrombus

MRI to define
IV heparin followed by oral anticoagulation

35

What is the major difference between a classic migraine in common migraine

A classic migraine has a preceding neurologic symptom (aura)

common migraines or more likely to be bilateral

36

What is the treatment for migraine

Abortive therapy
– triptans
– IV ergotamine (status migrainnosis)
– caffeine
– NSAIDs

Preventive therapy
– avoid triggers
– treat attacks early
– tricyclic antidepressants

37

What is the mechanism of triptan's

Serotonin 5 HT-1D antagonists
– may cause chest pain and facial flushing

38

What is the pseudotumor cerebi

A.k.a. idiopathic intracranial hypertension
– headache is described as a diffuse, dull, ache or pressure sensation
– onset is gradual but often progressive
– worsened by laying down in my physical activity
– horizontal diplopia is occasionally seen

39

Discuss the epidemiology of pseudotumor cerebri

75% of patients are female
20 to 40 years of age
majority are obese
can be associated with drugs (steroid, vitamin A toxicity, tetracycline)

40

How's a diagnosis pseudotumor cerebri made

Imaging to rule out mass lesion
LP to document opening pressure (elevated)

41

What is the treatment for pseudotumor cerebri

Lumbar puncture
weight loss
carbonic anhydrase inhibitor
shunts

42

How do carbonic anhydrase inhibitors (acetazolamide) benefit pseudotumor cerebri

Decreased CSF production

43

how are headaches associated with brain tumors

No classic headache syndrome defines a tumor
usually insidious onset
worse in the morning or wakens patient at night due to raised ICP

44

Discuss tension headaches

Most common variant of headaches
– May limits, but not prohibit activities
– usually bilateral, within a occipital-temporal-frontal "band like" distribution
– tenderness in the cervical paraspinals and temporalis muscles
– typically respond to OTC analgesics

45

Was the prophylactic treatment for tension headaches

Tricyclic antidepressants arefirst line

46

What is chronic daily headaches

Typically involves out of tension type headaches associated with analgesic abuse
– cessation of analgesic use as first line treatment followed by tricyclic antidepressants

47

What is trigeminal neuralgia

Tic doulaureaux
– electric, shooting pain lasting seconds
– neuralgia of cranial nerve V
– triggered by non-noxious sensory stimuli to the affected face

48

What headaches are associated with an increased risk of suicide

Cluster headaches
trigeminal neuralgia

49

What is the treatment for trigeminal neuralgia

Carbamazepine or oxcarbamazepine
– may be combined with baclofen
surgical intervention
– decompression of trigeminal nerve

50

What are the AHS guidelines for imaging for headaches

– New onset headache inpatient over 40
– headache with abnormal neurologic exam
– reassure and anxious patient

CT useful only in ER situations suspected of SAH

MRI brain is the study of choice to rule out tumor

51

What is epilepsy

Tendency to experience recurrent unprovoked seizures
– 10% of the population will have a seizure in their lifetime. 30% chance of a future second seizure
– 1% have epilepsy

52

What are generalized seizures

A seizure which affects the entire brain at once
– primary generalization
– secondary generalization (begins locally then spreads to entire brain)

53

What is a partial seizures

A seizure which originates in one area of the brain. May secondarily generalized

54

What differentiates a simple partial seizure from a complex partial seizure

Simple partial seizures have no loss of consciousness. Associated with positive neurologic symptoms

Complex partial seizures has impaired consciousness. Associated with automatism's

55

What is a generalized tonic clonic seizure

Grand mal seizure
– tonic extension of all four extremities followed by chronic jerking
– Todd's paralysis is common

56

What is an absence seizure

Generalized seizure characterized by unresponsive staring lasting several seconds followed by immediate recovery
– typically seen in childhood

57

Discuss febrile seizures

Most common cause of new onset seizures in children
– six months to five years of age
– occur in the setting of a febrile illness without evidence of intracranial infection
– typically generalized at onset
– generally are benign

58

What is done in the workup for a first non-febrile seizure

History and physical
EEG
lab work
neuroimaging

59

What is benign Rolandic epilepsy

– childhood onset

– Simple partial seizure involving mouth and face, maybe generalized tonic clinic

– Nocturnal preponderance of seizures

– EEG findings: Centrotemporal spikes

– Treatment: generally no treatment needed, carbamazepine if necessary

60

What is Lennox-Gastaut syndrome

– childhood to early adolescence

– All types of seizures

– Associated with mental retardation

– EEG findings: slow (1 to 2 Hz spike and wave), proximal fast activity, multifocal spikes

– All anti-epileptic drugs

61

What is Absence Epilepsy

– childhood and adolescence

– Absence, may generalized tonic clonic

– Hyperventilation's often a trigger. May outgrow seizures

– EEG findings: 3 Hz spike-and-wave

– Treatment ethosuximide; valproate if it generalizes

62

What is juvenile myoclonic epilepsy (JME)

– adolescents and young adults

– Myoclonic, absence, generalized tonic clonic seizures

– Early-morning predominance of seizures. Triggers include sleep deprivation and alcohol use

– EEG findings: 4 to 6 Hz spike-and-wave. Frequent photo paroxysmal response (strobe light activation of seizures)

63

Was the most common cause of adult epilepsy

Adults
– idiopathic is most common
– medial temporal lobe sclerosis
– tumors are more common cause in adults than in children

Elderly
– stroke is the most common
– metabolic disturbances (calcium, sodium, magnesium)
– UTI
– medication related (benzodiazepine withdrawal)

64

When this treatment indicated for seizures

After the second unprovoked seizure

65

Were the common anti-epileptic drugs

Phenytoin
carbamazepine
valproic acid
phenobarbital
ethosuximide
gabapentin
lamotrigine
tiagabine
topiramate
zonisamide
felbamate
levetiracetam

66

Discuss phenytoin

– Na channel blocker

– Used for partial, generalized seizures

– Side effects: gingival hyperplasia, coarsening of facial features

67

Discuss carbamazepine

– Na channel blocker

– used for Partial, generalized seizures. May worsen myoclonus and absence seizures

– Side effects: hyponatremia, agranulocytosis

68

discuss valproic acid

– Na channel blocker, GABA receptor agonist

– Used for partial, generalized, absence

– Side effects: weight gain, tremor, hair loss, hepatotoxicity, thrombocytopenia

69

Discuss phenobarbital

– GABA receptor agonist

– Used for partial, generalized seizures

– Side effects: sedation, mild addiction potential

70

Discussed ethosuximide

– T type Ca channel blocker

– Used for absence seizures

– Side effects: G.I. symptoms

71

Discuss gabapentin

– manipulates GABA pathway

– Used for partial seizures

– Side effects: sedation, ataxia, weight gain at high doses

72

Discuss lamotrigine

– Na channel blocker, glutamate receptor antagonist

– Use for partial, generalized seizures

– Side effects: Stevens-Johnson's syndrome with rapid titration

73

Discuss tiagabine

– GABA reuptake inhibitor

– Used for partial seizures

– Side effects: sedation

74

Discuss topiramate

– mechanism unknown

– Used for partial, generalized seizures

– Side effects: weight loss, cognitive difficulty, renal stones (skinny and stupid)

75

Discuss zonisamide

– T-type Ca channel blocker, inhibits glutamate release

– Used for partial, generalized seizures

– Side effects: weight loss, drowsiness, ataxia at high doses, renal stones

76

Discuss felbamate

– unknown mechanism

– Used for partial, generalized seizures

– Side effects: weight loss, insomnia, aplastic anemia, liver failure

77

Discuss levetiracetam

– Unknown mechanism

– Used for partial, generalized seizures

– Side effects: somnolence, asthenia, dizziness, akasthesia

78

What is the problem with epilepsy in pregnancy

Untreated women have a higher risk of birth defects

All AED's are potentially teratogenic. Risk can be minimized by taking 1 mg folate PO Q day

79

What is the treatment for status epilepticus

1. ABCs, ABG, IV access
2. Benzodiazepines
3. Phenytoin if status continues
4. Intubate, phenobarbital 20 MG/KG IV to induce a coma

80

What is meningitis

Inflammation of the leptomeninges and cerebrospinal fluid within subarachnoid space

81

What is meningoencephalitis

Inflammation of the meninges and the brain parenchyma

82

What are the causes of meningitis

1. Infectious
– bacterial, viral, mycobacterial, spirochete, fungal, parasitic
2. Chemical
3. Neoplastic

83

With the CSF findings for acute bacterial meningitis

Wbc's >1000
neutrophils >50
glucose 100

84

Where the CSF findings for acute fungal or viral meningitis

Wbc's 100-500
neutrophils <50
glucose normal (40)
protein 50-100

85

What a CSF findings for acute HSV encephalopathy

Wbc's 10-1000
neutrophils 30
protein >75

86

What are the common bacterial pathogens for meningitis in a patient less than one month

Group B strep
E. coli
Listeria
Klebsiella

87

What is the treatment for bacterial meningitis in a patient less than one month

Ampicillin + cefotaximine

88

Were the common bacterial pathogens for meningitis in a patient 1 month to 23 months of age

Strep pneumonia
N. meningitidis
group B strep
H influenza
E. coli

89

What is the treatment for bacterial meningitis in a patient's 1 month to 23 months of age

Vancomycin and a third-generation cephalosporin

90

Were the common bacterial pathogens for bacterial meningitis in a patient 2-50 years old

N. Meningitidis
strep pneumoniae

91

What is the treatment for bacterial meningitis in a patient's 2-50 years old

Vancomycin plus a third-generation cephalosporins

92

What are the common bacterial pathogens for meningitis in a patient >50 years old

Strep pneumoniae
N. Meningitidis
Listeria
aerobic gram-negative bacilli

93

What is the treatment for bacterial meningitis in a patient's >50 years old

Vancomycin plus third-generation cephalosporin plus ampicillin

94

What are the etiologies associated with acute viral meningitis

Non-polio enteroviruses (85%)
– Echovirus
– coxsackievirus

Arboviruses (5%)
– Eastern equine encephalitis
– Western equine encephalitis
– St. Louis encephalitis

Herpes family viruses (4%)

95

For the spirochetes that can cause meningitis

Treponema
Borrelia
Leptospira

96

What is the Argyle-Robertson pupil

No direct or consensual light response, but pupils constrict with accommodation

97

What diagnostic testing is done for neurosyphilis

Non-Treponema antigen test
– R PR or VDRL

Treponema antigen test
– FTA-ABS

98

What diseases caused by the spirochete Borrelia burgdorferi

Lyme disease

99

What is the treatment for Lyme disease

Amoxicillin or doxycycline

100

Were the common fungal organisms associated with meningoencephalitis

Cryptococcus neoformans
coccidoides immitis
Candida albicans
Mucor
Aspergillus fumigatus
Histoplasma capsulatum
Blastomyces dermatiitidis

101

What is the most common fungal infection of the CNS

Cryptococcus meningoencephalitis

102

Discuss Cryptococcus meningoencephalitis

– typically in the immuno compromised
– inhalation of spores from soil and pigeon excrement
– increased intracranial pressure leading to a protean headache
– CSF: very low glucose, elevated protein

103

What is the treatment for Cryptococcus meningoencephalitis

Amphotericin B, flucytosine, fluconazole

104

Were the common parasitic organisms that lead to meningoencephalitis

Toxoplasmosis
Cysticercosis and echinococcosis
malaria
amebiasis
trypanosomiasis

105

What was CT and MRI demonstrate for a patient with cerebral toxoplasmosis

Multiple ring enhancing lesions
– similar findings with CNS lymphoma, tuberculosis, or fungal infections

Toxois the most common calls for a cerebral mass lesion in a patient with AIDS

106

What is the treatment for toxoplasmosis

Pyrimethamine, sulfadiazine and folinic acid

107

What is the most common parasitic infection of the CNS worldwide

Neuro-cysticercosis
– caused by the pork tapeworm Taenia solum
– brain involvement in 50 to 70% of cases

108

What will imaging demonstrated for Neuro cysticercosis

Ring enhancing cystic lesions (active cyst)

Parenchymal calcifications (old cyst)

Vasogenic edema

109

What is the treatment for Neuro cysticercosis

Albendazole to kill the parasite

110

What is leptomeningeal carcinomatosis

Diffuse seating of leptomeninges with metastatic tumor cells

Occurs in breast cancer, small cell lung cancer, melanoma, medulloblastoma, PNET tumors (primary Neuro ectodermal tumors)

111

What is encephalitis

Infection of the brain parenchyma
– leads to confusion, delirium, focal neurologic deficits, seizures and coma

112

What are the common etiologies to encephalitis

Arboviruses
Enteroviruses
herpes simplex virus
CMV, EBV, VZV

113

Discuss HSV encephalitis

Most common in children and young adults
– presents with alteration in mood, memory, and behavior
– involves inferior and medial regions of temporal lobes and orbital gyri of frontal lobes
– often hemorrhagic
– Cowdrey intra-nuclear viral inclusion bodies

114

What is the most accurate diagnostic procedure for HSV encephalitis

CSF HSV PCR

115

What is progressive multifocal leukoencephalopathy

A viral encephalitis caused by polyomavirus (JC virus)
– virus preferentially infects oligodendrocytes which leads to demyelination
– PML does not enhance on MRI

116

What are the transmissible spongiform encephalopathies

Creuzfeldt-Jakob disease
– new variant CJD (mad cow)
Gerstmann-Straussler-Scheinker syndrome
fatal familial insomnia
Kuru

All associated with abnormal forms of a specific protein (prion protein) which is infectious and transmissible

117

Discuss the pathogenesis of prion diseases

– Prion protein is usually a normal protein in neurons.
– The prion protein undergoes conformational change from Alpha helix to beta pleated sheet
– prion protein acquires relative resistance to digestion with proteases
– infectious nature comes from ability to corrupt the integrity of normal cellular components
– leads to a buildup in neurons

118

What are the clinical features of Creufeldt-Jakob disease

– Rapidly progressive dementia
– peak incidence in seventh decade
– iatrogenic transmission possible with transplants
– subtle changes in memory and behavior followed by rapidly progressive dementia with involuntary jerking muscle contractions (myoclonus)