Neurology Notes Flashcards by Sarah Gillen

3 general etiologies of stroke and which one has the worst prognosis

Emboli

Thrombi

Hemorrhage (worst prognosis)

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Stroke affecting anterior circulation — possible area of deficits?

Leg/foot

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Stroke affecting middle cerebral artery — possible area of deficits?

Face/arm/speech

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Stroke affecting posterior circulation, which is composed vertebral arteries that come to form the basilar artery — possible deficits?

Cerebellar dysfunction, change in mental status (syncope), blindness

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Regardless of presentation, in the acute phase of a stroke (within 30 minutes of presentation and within 6 hours of symptoms) the goal is rapid identification and intervention if possible. What is the first step in workup?

CT scan without contrast — to rule out hemorrhage

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The first step in workup for stroke is CT without contrast to r/o hemorrhage. At that point, intervention can be considered. After initial presentation (day 2), additional testing is required to assess for cause. ______ can be done to assess cardiac valves, ________ for carotid stenosis, and ______ to assess for afib.

2D echo; carotid duplex; ECG

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If the workup for stroke is uncertain, _____ is the best radiographic test to confirm stroke but is not needed.

________ is a test that can replace the carotid ultrasound and can identify causes of ischemia such as vasculitis

MRI

CT angiogram

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Pt presents with focal neurologic deficit and you suspect stroke. CT scan confirms hemorrhagic stroke. What is the next step in management?

Neurosurgery — will decide to coil, clip, or craniotomy

ICU

BP control with goal systolic of <150

FFP if there is derangement in INR

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Pt presents with thrombotic stroke and you determine it was d/t carotid stenosis. U/S of carotids shows >70% stenosis. What is the next step in management?

Carotid endarterectomy (or stent)

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Terminology: the infarcted are is the area of brain affected by stroke that cannot be saved. The ______ is the surrounding area that can be saved with intervention

Penumbra

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Indications and contraindications for tPA following stroke

Indications:
Thrombotic/embolic stroke only
Symptom onset <3 hours

Contraindications:
History of brain bleed
History of head trauma
Surgery in the last 21 days

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Most strokes occur and it’s too late to do anything for them, so preventing another becomes crucial. _____ is the mainstay tx unless the pt has an allergy. If there is an allergy, use ________.

If there’s a stroke on the mainstay tx above, add a second agent, usually _______. Everyone gets an antiplatelet within 24 hours unless they get tPA.

ASA; clopidogrel

Dipyridamole

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What are some conditions that require medical management to prevent stroke?

Dyslipidemia — high potency statin

Diabetes — keep a1c <7%

HTN — goal BP <130/<80

Smoking — cessation counseling

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tPA’s use for strokes is greatly restricted but can actually rescue ischemic tissue and preserve the penumbra. The risk of transforming an ischemic stroke into a hemorrhagic one is high so caution must be used. What are 3 other physiologic parameters that you can control to allow the at-risk penumbra to recover?

Keep O2 sat >95%

Tight glucose control 60-100

Blood pressure - permissive hypertension (goal <220/120)

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If patients present within 4.5 hours of symptom onset, or 3 hours for pts with ________, they can be considered for tPA

Diabetes

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If stroke occurs due to carotid stenosis, a carotid endarterectomy can be performed. While carotid stenting can be performed, this should be reserved for pts who CANNOT undergo surgery. Stenting and endarterectomy should be performed in the acute setting, always within ________. A stuttering stroke (TIA) or an evolving stroke should prompt more emergent intervention

2 weeks

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If a pt has a stroke and they are determined to have afib, they need to be on anticoagulation. If warfarin is used, the goal INR is ______. It doesn’t matter whether you use warfarin or the non-vitamin K anticoagulants (NOAC), except that NOACs cannot be used in ______ afib.

2-3

Valvular

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If a pt has a stroke and they are determined to have afib, they need to be on anticoagulation. If warfarin is used, the goal INR is 2-3. It doesn’t matter whether you use warfarin or the non-vitamin K anticoagulants (NOAC), except that NOACs cannot be used in valvular afib. Which option for anticoagulant requires a bridge?

Neither!

Often, initiation of warfarin requires a heparin bridge. However, afib is one time where you definitely do NOT need to bridge (unless there is another indication like a mechanical valve)

NOTE that if a thrombus is found — you must bridge to warfarin!

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Warfarin or NOAC should be used when pt has chronic afib with CHADS2 score of 2+. What are the elements of the CHADS2 score for embolic stroke prevention?

CHF
HTN
Age >65
DM
Stroke (worth 2 pts)

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Hemorrhagic strokes due to subarachnoid hemorrhage or intracranial hemorrhage may present with cushing’s reflex, which is what?

Bradycardia + HTN

[impending herniation]

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A grand mal seizure presents with tonic clonic convulsions, bowel/bladder incontinence, and tongue biting. There’s a loss of consciousness, but it is the __________ that separates a seizure from alternative causes of LOC

Post-ictal confusion

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A pt presenting with a seizure that is not actively seizing requires what 3 tests for workup?

VITAMINS mnemonic

EEG

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If a pt presents with a seizure, is post-ictal, or has entered status epilepticus, they need to be treated as a medical emergency. What steps must immediately be followed (i.e., one after another if the prior step does not work)?

IV/IM Benzos (lorazepam/diazepam)
Fosphenytoin
Midazolam
Propofol
Phenobarbital
Draw labs and reverse any underlying defects

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The VITAMINS mnemonic helps determine cause of a seizure — what does it stand for?

Vascular — stroke, AVM, hemorrhage

Infection — encephalitis, meningitis

Trauma — MVA, TBI

Autoimmune — lupus, vasculitis, arthritis

Metabolic — Na, Ca, Mg, O2, glucose

Idiopathic

Neoplasm

Sychiatric — faking it or iatrogenic

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3 antiseizure medications considered broad specturm and first line therapy

Valproate Lamotrigine Levetiracetam

What test is used to diagnose a seizure and the location of origination?

EEG Look for spike and waves indicative of organized neuronal firing (which is abnormal for an awake adult). Note that 24 hr video monitoring may be required to catch the seizure and its manifestations

Partial seizures involve a specific complaint while generalized indicate total brain involvement. What is the difference in treatment options?

Partial = Carbamazepine or Phenytoin Generalized = Valproate or Lamotrigine

Difference between complex vs. simple seizures

Complex = with LOC Simple = without LOC

Tx for atonic seizures

Valproate

Define atonic seizures

Loss of tone without loss of consciousness

Define absence seizures

Loss of consciousness without loss of tone

Tx for absence seizures

Ethosuximide

Jerky muscles indicates myoclonic seizures, what is the tx of choice?

Valproate

Tx of choice for trigeminal neuralgia

Carbamezepine

Parkinson’s is caused by a loss of ______ neurons within the _______. This essentially eliminates the “go” signal, preventing the initiation of movement.

Dopaminergic; substantia nigra

Classic symptoms of parkinsons

Bradykinesia (difficulty initiating movement) Cog-wheel rigidity Resting pill-rolling tremor Gait disturbances/postural instability Pt will have difficulty with get-up-and-go test, and will walk with shuffling steps. A board buzz word is a mask-like expressionless face

Tremor etiologies

``` Parkinsons Essential Huntingtons Delirium tremens Cerebellar dysfunction ```

T/F: MRI of the substantia nigra to show degeneration is needed to confirm dx of Parkinsons

False Parkinsons is a clinical dx. Imaging may be utilized to r/o something else (CT for bleeding, MRI for stroke), but these are not needed for diagnosis

Treatment of Parkinsons is about the “go” signal which is dopamine. The stop signal is acetylcholine. Dopamine agonists are the mainstay of therapy for young, functional people (<70, maintained function). Bromocriptine is an older dirtier dopamine agonist, so the 2 better options are ______ and _____

Ropinirole | Pramipexole

While dopamine agonists are the mainstay of therapy for Parkinsons in young, functional people (<70, maintained function), __________ is the mainstay of therapy for everyone else.

Levodopa-carbidopa

Why is levidopa combined with carbidopa for the tx of Parkinsons?

Levodopa CAN cross the BBB while carbidopa cannot. Carbidopa prevents the conversion of L-dopa into dopamine peripherally, meaning that more levodopa gets to the brain and more dopamine is created

Eventually, levodopa-carbidopa begins to wear off in the tx of Parkinsons. The _______ and _______ are brought in as L-C begins to fail. There’s no way to determine how to add them

COMT-inhibitors (capones); MAO-B inhibitors (Selegiline)

Acetylcholine-R antagonists like _______ could theoretically work to tx Parkinsons, but the acetylcholine side effects are not worth it for the elderly and the effect is weak. Use this on young people who have tremor only

Benztropine

Side effects of dopamine agonists used in Parkinsons

Hypotension | Psychosis — schizophrenic sxs with hallucinations

Anti-influenza drug sometimes used to tx Parkinsons in functional pts >60 y/o

Amantadine

Tremor that is absent at rest but worsens with movement. There’s typically a family history of tremor and it’s often a man.

Essential tremor (aka Familial tremor)

Tx option for essential tremor

Beta blockers

Tremor that’s absent at rest but worsens the closer to the target the finger gets. Usually due to physical lesion (stroke, atrophy, etc)

Intention tremor (indicates cerebellar dysfunction)

_______ is an autosomal dominant genetic disease caused by trinucleotide repeats. The more repeats the person has, the earlier the disease sets in. Most people begin to exhibit symptoms near middle age (30-60). It also exhibits ________, a phenomenon in which disease occurs earlier and earlier in subsequent generations as the number of trinucleotide repeats expands. ________ is purposeless ballistic movements. The prognosis is terrible as it leads to dementia, psychosis, and often death by suicide. There is no treatment.

Huntington’s; anticipation; chorea

Headache red flags

New headache at age >50 Suddent crescendo headache Fever + headache Focal neurologic deficits

Most common cause of headache; usually b/l vice-like pain that radiates from the front to the back/neck and aggravated by exercise

Tension headache

Headache characterized by severe unilateral pain that has autonomic symptoms (rhinorrhea, lacrimation, conjunctival injection, Horner’s) and tend to occur over and over for a period of weeks, then pts go symptom-free for months at a time

Cluster headaches

When cluster headache is diagnosed, a(n) _______ should be obtained to rule out other diseases that mimic cluster. _______ is first line treatment and is often sufficient to abort attacks. __________ can be used if that fails.

MRI; Oxygen; Sumatriptan

Prophylaxis for cluster headaches

Calcium channel blockers like verapamil

POUND mnemonic for migraines

``` Pulsatile One day in duration Unilateral Nausea and vomiting Disabling ``` Any 3 is diagnostic

Type of headache with vascular pathogenesis (arterial vasodilation)

Migraine

If migraines are severe, start tx with Triptan or an ergot. In what comorbidity should these tx be avoided?

CAD, due to tendency to cause vasospasm

Prophylactic agents for tx of migraine

Beta blockers (propranalol) CCBs (Verapamil or diltiazem) Anticonvulsants (valproic acid, topiramate)

What is pseudotumor cerebri?

Also called idiopathic intracranial HTN Intracranial pressures are elevated, but there is no tumor. Almost all pts are women, obese, and of child-bearing age. There is a strong association with OCPs, but other causes include vitamin A, isotretinoin, and glucocorticoid withdrawal. You will see classic signs of intracranial HTN like papilledema. An LP will reveal opening pressure >25 cmH2O and the tap will relieve the headache.

Tx for idiopathic intracranial HTN (pseudotumor cerebri)

First line tx is acetazolamide Refractory disease is tx with ventriculoperitoneal (VP) shunts or serial LPs

Sumatriptan and fiorcet are often used for acute abortion of migraine headaches. What 3 drugs are included in fiorcet?

Butalbital Acetaminophen Caffeine

Warning symptoms of spinal cord compression

``` Urinary sxs (incontinence or retention) Sexual dysfunction (ED or priapism) B/l lower extremity weakness Sensory deficits in a dermatome Fever Hx of cancer ```

If any alarm symptoms for spinal cord compression are present, give _________ immediately. The first imaging to obtain is an x-ray, if positive, leave it at that. If negative, get an MRI. Most things will respond to radiation or surgery.

Dexamethasone

In a pt with suspected musculoskeletal back pain, what are some things to look for to r/o herniated disc?

Pts with herniation will have a lightening or shooting pain down the leg (“sciatica”) exacerbated by hip flexion, movement, cough, or activity Assess plantar flexion (L4) and dorsiflexion (L5), the common nerves impinged by a bulging disc

Which is a better tx for disc herniation - conservative management or neurosurgery?

Neurosurgery has better results at 6 months, but both are the same at 1 year

If you’ve found a pt that might have a herniation but it is an elderly male, consider that they may have a(n) _________, a simple bone growth into the exit of a nerve root. Get an x-ray then MRI to r/o compression fracture. In this case, between neurosurgery and conservative management, the better tx is __________

Osteophyte; neurosurgery

Cause of back pain typically found in an elderly pt presenting with a unique form of sciatica. There’s often leg and butt pain that sounds like claudication but is positional (increased symptoms when upright and with exercise; relieved when hunched over). Do an MRI to confirm and surgery to fix.

Spinal stenosis

A pocket of CSF bulges into the anterior cord that produces back pain and loss of pain/temp, sparing proprioception. As it expands motor and sensation will be compromised. MRI diagnosis it. Surgery corrects it.

Syringomyelia

If a pt presents with back pain and has a hx of HTN, CAD, and smoking, they might have a AAA. With AAA, the _________________ artery can be affected. It produces a spastic paralysis and a loss of _________. The back pain is from the visceral compression. It can be screened via ultrasound. If there are neuro symptoms, it also requires an MRI and surgery

Anterior spinal artery; proprioception

Mini mental status exam or mini cognitive assessment can be used to assess for dementia. What constitutes an abnormal score on MMS?

<22/30

What are some conditions that may mimic dementia?

Hypothyroid B12 deficiency Subdural hematoma Syphilis Uremia Cirrhosis Pseudodementia (depression)

Most common cause of organic dementia; linked with neurofibrillary tangles, neurotic plaques, and amyloid deposition. CT scan shows diffuse cortical atrophy. Linked to chromosome 21

Alzheimers

Once reversible causes of dementia have been ruled out and you dx Alzheimers disease, what are tx options?

Cholinesterase inhibitors like tacrine or donepezil (Aricept) These will slow progression but do not reverse disease. Death usually occurs w/i 5-10 years, typically d/t secondary cause like PNA.

Condition that in contrast to alzheimers disease, personality and social graces are lost FIRST while memory remains intact. Pts may be violent and/or hypersexual. While Alzheimers shows cortical atrophy, this condition has frontal and hypothalamic degeneration. Diagnosis is clinical and there is no tx

Pick’s disease

Most common means of acquiring prion disease

Sporadic mutation

Organic and reversible cause of dementia often seen in elderly pts with an ataxic gait, urinary incontinence, and dementia. Get a CT or MRI to evaluate

Normal pressure hydrocephalus

Tx for normal pressure hydrocephalus

The problem is increased CSF, so do serial LPs to take off extra fluid, then fit them for a VP shunt

____________ dementia is essentially Parkinson’s disease with dementia and visual hallucinations. The two differ only by the time of onset but the pathology is the same. Look for Parkinsonian symptoms and dementia

Lewy-Body dementia

What is the progression of memory loss in Alzheimers?

Short term memory first Long term memory next Social graces last

Mild alzheimers disease may be treated with acetylcholinesterase inhibitors - what are the 3 primary drugs used?

Donepezil Rivastigmine Galantamine

Drug of choice for treatment of severe alzheimers disease

Memantine

In vertigo, a pt will sense movement where none exists. This will present as either the room spinning, or being unsteady on their feet. Once vertigo is established, it is critical to differentiate between central and peripheral causes. Central causes usually involve cranial nerve deficits. What are central causes of vertigo?

CVA Posterior fossa tumor Multiple sclerosis Medications

Labyrinthitis/vestibular neuritis Meniere’s disease BPPV

When it comes to central causes of vertigo, whether it’s vertebrobasilar insufficiency or a posterior fossa tumor, the main problem is the structural lesion compressing on or eating away at the cerebellum and brainstem. If there are focal neuro deficits, it’s almost pathognomonic for a central lesion. The first test to order is a(n) _______. If that is normal, follow it with a(n) ______.

MRI; MRA

Vertigo due to BPPV can be reproduced by the _________ maneuver. Movement exercises dislodge and break up the otolith, curing the pt of the disease. _______ maneuver can be done in office and is often curative

Dix-Hallpike; Epley

Suspect this disease in a pt with vertigo, nausea/vomiting, and hearing symptoms that occur 4 weeks after a URI (pharyngitis, otitis, sinusitis). It’s a dx of exclusion because pontine strokes and tumors mimic the chronic nature of the vertigo and the URI often goes unnoticed.

Labyrinthitis/vestibular neuritis

If labyrinthitis/vestibular neuritis is dx early, give ______ within 72 hrs. The disease will resolve in months, but balance and hearing may be compromised for those months. _______ can provide symptomatic relief for vertigo episodes

Steroids; meclizine

Peripheral cause of vertigo presenting along with hearing loss, fullness, or tinnitus that’s unrelated to movement. Like BPPV, it’s acute, but the vertigo persists, lasting ~30 minutes

Meniere’s disease

Tx for Meniere’s disease

Diuretics | Low salt diet

Triad of Meniere’s disease

Vertigo Hearing loss Tinnitus

Pt c/o right-sided hearing loss. Weber test lateralizes a louder sound to the left. Rinne test reveals pt hears sound better when tuning fork is held to pinna than when placed against mastoid bone. What type of hearing loss?

Sensorineural

Pt c/o right-sided hearing loss. Weber test lateralizes a louder sound to the right. Rinne test reveals pt hears sound better when tuning fork is held to mastoid bone than when placed against pinna. What type of hearing loss?

Conductive

______ is a state of unconciousness of depressed cerebral function such that there is no response to internal or external stimuli and is by definition reversible

Coma

Causes of coma

LITERALLY ANYTHING Toxins (EtOH, benzos, opiate) Electrolyte abnormalities Endocrine (hypothyroid, thiamine) Hypoxic/ischemic encephalopathy (drowning, cardiac arrest) Trauma (diffuse axonal injury) Brainstem pathology (hemorrhage, infarction)

What are some elements of the comprehensive workup for coma?

CMP CT scan LP EEG

During comprehensive workup for coma, a “coma cocktail” is often given, what does this usually include?

Thiamine D50 Oxygen Naloxone

Condition in which pt has a flat EEG but opens their eyes or has positive caloric test. The pt has no arousal but can move, display pain, and have sleep-wake cycles. Nonetheless, the personality is gone. They’ll never recover and will require tube feeds and institutionalized care for life

Persistent vegetative state

Condition in which cerebral EEG shows no activity — no arousal, no sleep-wake cycle, no drive to breathe, no intact neural reflexes (caloric reflex and corneal reflex absent)

Brain death [note: 2 doctors must confirm brain death prior to removal of life support]

Condition in which pt looks like they’re in persistent vegetative state, but they have full awareness. They’re able to communicate with eye movements. There is no recovery. MRI confirms dx

Locked-in syndrome

2 major causes of locked-in syndrome

Basilar artery infarct Central pontine myelinolysis [affects the pons, the site where both motor and sensory tracts pass]

Normal response to cold water caloric test

Cold water in right ear results in eyes moving to the right with nystagmus to the left [use COWS mnemonic referring to quick beating movements of nystagmus — cold/opposite, warm/same]

Chronic progressive disease of unknown etiology that produces asymmetric UMN and LMN lesions, generally sparing the eyes. Look for atrophy and fasciculations of the tongue and extremities comingled with upward Babinski and hyperreflexia of extremities associated with emotional lability and weight loss though sphincter tone is maintained; associated with superoxide dismutase in 10%

Amyotrophic lateral sclerosis

When ALS is suspected, r/o spinal lesions with a CT/MRI/spinal x-ray and confirm the diagnosis with ______

EMG

Autoimmune disease targeting post-synaptic ACh receptors causing fatigability most commonly affecting eyes (diplopia, ptosis), and throat (swallowing). Fatigue is relieved by rest

Myasthenia gravis

Initial test vs. best test for myasthenia gravis

Initial = Anti-ACh receptor antibody (nearly 100% specific with clinical symptoms) Best = EMG (shows decreased amplitude on repeated stim)

________ is first line therapy for myasthenia gravis, thereby increasing acetylcholine concentration. If the disease is associated with thymoma (confirmed by chest CT), thymectomy may be curative. If the weakness compromises life functions like eating and breathing, then give either _____ or _______. Finally, refractory disease is treated with ________ or disease-modifying agents such as azathioprine.

Pyridostigmine IVIG; plasmapheresis Prednisone

Paraneoplastic syndrome producing antibodies against presynaptic calcium channels which inhibits release of ACh-vesicles, producing proximal muscle weakness that improves with repeated use

Lambert-Eaton syndrome

How is Lambert-Eaton syndrome diagnosed?

Clinical diagnosis is sufficient, but antibodies should be checked A CT of the chest should be done to identify the small cell cancer causing the disease The best test is an EMG showing improvement with repetitive use

Tx for Lambert Eaton syndrome

Tx underlying small cell cancer with chemo, radiation, and/or resection If cure is not possible, control sxs with prednisone

Demyelinating autoimmune disease that produces an ascending paralysis 1-3 weeks after diarrhea (campylobacter) or flu vaccine. There’s always hyporeflexia while paresthesia and autonomic dysregulation may or may not be present

Guillain barre syndrome

How is guillain barre diagnosed?

Look for evidence of autoimmune processes in CSF with an LP — you will see lots of proteins and very few cells Confirmation with EMG and nerve conduction velocity test showing decreased nerve conduction velocity

Treatment for guillain barre syndrome

IVIG or plasmapheresis to eliminate the causative IgG Ab response against myelin NEVER GIVE STEROIDS

Autoimmune demyelinating disease defined by neurologic symptoms separated by time and space; the primary complaint is often blurry vision/diplopia (from optic neuritis)

Multiple sclerosis

What testing should you do if you suspect multiple sclerosis?

MRI — look for periventricular plaques, multiple lesions, or lesions in corpus callosum. Because it’s often relapsing-remitting, MRI may be non-diagnostic. In this case, an LP with pleocytosis and oligoclonal IgG or evoked potentials may be done

Tx for multiple sclerosis

Chronic management with interferon, fingolimod, glatiramer Acute flares get steroids Symptomatic relief for urinary retention (bethanechol), incontinence (amitriptyline), and spasticity (baclofen)

Medication that may slightly prolong life in ALS

Riluzole