Wahba Part 4 - Movement Disorder, Infections, Encephalopathy Flashcards
(122 cards)
1
Q
Etiology of drug induced Parkinsonism
A
Traditional antipsychotics - blockage of DA receptors in basal ganglia
2
Q
Anti-DA S+S of drug induced Parkinsonism
A
Pseudoparkinsonism, prolactinemia, akathisia (tx: propanolol), dystonia (tx: stop antipsychotic; give amantadine+Bendryl+Benztropine)
3
Q
Anti-HAM S+S of drug induced Parkinsonism
A
“WARP” - Weight gain, increased AST/ALT/jaundice, Rash, Photosensitivity
4
Q
Other features of drug induced Parkinsonism
A
Tardive dyskinesia (neuroleptics>6 mo), neuroleptic malignant syndrome
5
Q
Features of NMS
A
FALTER - Fever, ANS instability, Leukocytosis, Tremor, Elevated CPK, Rigidity; genetic mutation in chr 19 predisposes
6
Q
Tx of NMS
A
Stop neuroleptics+support+sodium dantrolene (muscle relaxant)+Bromocriptine+Amantadine; plage NG tube, hydration+maintenance of urine flow, lower body temp
7
Q
Etiology of serotonin syndrome
A
2 SSRIs or w/ MAOIs
8
Q
S+S of serotonin syndrome
A
Muscle twitching+confusion+sweating+NO fever (???)
9
Q
Tx of serotonin syndrome
A
Stop offending agents, give periactin (cyproheptadine, an anti-histamine, and anti-serotonin drug)
10
Q
Etiology of acute dystonic reaction
A
Unwanrted, continuous contraction of group of muscles; could be drug induced dystonia from anti-psychotics or metaclopromide
11
Q
S+S of acute dystonic reaction
A
Tongue hanging out+eye looking upward
12
Q
Tx of acute dystonic reaction
A
Benadryl 50 mg IV once and can give small dose of atropine
13
Q
Cervical dystonia
A
Cervical dystonia+tremor = genetic problem; pediatrics w/ cervical dystonia could be hemivertebral vs TB vs. self correction for diplopia
14
Q
Essential diagnostic features of myasthenia gravis
A
Fluctuating, fatigable weakness of commonly used muscles (ocular, bulbar, respiratory), thymoma, thymic hyperplasia, Abs to nicotinic Ach receptor
15
Q
Hallmark features of myasthenia gravis
A
Ptosis, diplopia+dysarthria+dysphagia, bulbar symptoms, respiratory+limb muscle weakness
16
Q
Eye findings in MG
A
Ocular muscle weakness BL and asymmetric; pupil is spared; purely ocular likely seronegative MG
17
Q
Abs in MG
A
Can have muscle specific kinase Abs, muscle protein titin,+ryanodine in pts with thymomas
18
Q
Other features of MG
A
70% have lymphofollicular hyperplasia; flaccid muscles, skin pale/normal/cool, produce secretions
19
Q
Myasthenic crisis
A
Diaphragmatic+intercostal weakness - respiratory complication+bulbar symptoms; requires mechanical ventilation
20
Q
Tx of myasthenic crisis
A
Hospitalize+monitor; intubate, stop anticholinesterase and corticosteroids???, give plasmapheresis or IVIG
21
Q
Diagnosis of MG
A
Edrophonium (xAchase) - don’t do on angina or pregnant pts; have atropine at bedside; serologic testing for ACHR Abs;
if Abs negative do ACHR modulating Ab, then MuSK Ab/titin/ryanodine
22
Q
Electrodiagnostic studies in MG
A
Do not identify dysfunction at NMJ; slow repetitive conduction done; no change seen in CMAP over time; can be positive in LEMS vs myositis vs LMN dz; single-fiber EMG (95% sens)
23
Q
Other screening in MG
A
Screened for thymoma w/ CT or MRI; look for autoimmune dz + thyroid dz; do rheumatologic profile
24
Q
Ice pack test for MG
A
Symptoms get better - esp eyes when cooling down - slows consumption of Ach
25
When to intubate an MG pt
FCV
26
Tx of MG
Cholinesterase inhibitors (pyridostigmine); w/ dz progression may need immunosuppressive therapy (AZA), thymectomy, corticosteroids+NSAIDs
27
Tx of intubated MG pts
Atropine to minimize secretions; beta 2 agonists to minimize bronchospasms
28
S+S of optic neuritis
Pain around one eye (esp on mvmt), blurred vision, loss of color vision - red desaturation; impaired visual acuity, pink/swollen optic disc, visual field defect, relative afferent pupil defect, pale optic nerve
29
Prognosis of optic neuritis
Resolve in weeks-months but some complications permanent
30
Other visual disturbances in optic neuritis
Diplopia, N/V, vertigo, cerebellar ataxia
31
DDx of optic neuritis
MS! neuromyelitis optica (Devic's dz), Lyme, CT dz, B12, Sarcoid, Syphilis
32
Tx of MS related optic neuritis
DO NOT GIVE ORAL PREDNISONE; Give IV methylprednisolone (solumedrol), can taper off IV steroids orally
33
Features of 3rd nerve palsy from ruptured aneurysm
Dilated pupil, ptosis, exotropic (down-out) position
34
Other etiologies of 3rd nerve palsy
Compression, tentorial herniation, SAH of PCOM, cavernous sinus tumor/aneurysm/thrombosis (affects 3,4,5), superior orbital fissure/orbit tumor (Tolossa-Hunt), infarction in brainstem/nerve trunk, inflammation or infiltration of basal meninges (TB, sarcoid, syphilis, neoplasia), diurnal variation of MG+DM
35
Next step in management of 3rd nerve palsy
CT w/o contrast; if hemorrhage then load with normal saline to hemodilute and increase BP; Tx (HHH) - hypervolemia/hydration+hemodilution+HTN
36
Pathogenesis of giant cell arteritis
Granulomatous inflammatory changes w/ giant cells at brances of ECA; narrowing of lumen
37
S+S of giant cell arteritis
HA localized to the temples + scalp tenderness + pain w/ chewing + intermittent jaw claudication, transient vision loss in one eye, constitutional symptoms,
38
Dx of giant cell arteritis
ESR+normocytic normochromic anemia+LFTs+biopsy (can be false negative)
39
Tx of giant cell arteritis
IV hydrocortisone, 40-60 mg prednisolone req initially; taper down; Tx for 18 mo-2 yrs
40
Polymyalgia rheumatica
Girdle pain+morning stiffness w/ constitutional sx; seen with GCA
41
Hyperthyroid and stroke pathogenesis and management
Afib can cause embolic stroke w/ perfect vessels; paroxysmal Afib = big risk of stroke; hyperthyroid is as big a risk as someone w/ constant Afib; get Holter monitor to catch Afib
42
Associations with hyperthyroid
Myasthenia gravis, psuedotumor cerebri
43
Features of pseudotumor cerebri
Seen in young obese women, increased ICP w/ no mass lesions+normal ventricles
44
Tx and management of pseudotumor cerebri
LP to confirm ICP (>40); resolves w/ weight loss and LP; chronic - optic nerve affected - give acetazolamide+diuretics; surgical drainage
45
Pathophysiology of pseudotumor cerebri
Impaired CSF absorption
46
Presentation of pseudotumor cerebri
Morning HA, vomiting, diplopia, visual obscurations, sudden/transient BL visual loss w/ posture, BL papilledema, 6th nerve palsy (false localizing sign)
47
Venous strokes - paired vs unpaired?
Paired sinus - infection; single sinus - hypercoagulable state
48
Superior sagittal sinus thrombosis
Pt very sick + seizures + paraplegia + increased ICP + papilledema
49
Patients to suspect superior sagittal sinus thrombosis
Suspect in postpartum w/ severe HA - hypercoagulable state; also pts pregnant/labor/OCPs, dehydration, cachexia, cancer/anti-cancer meds, sickle cell, protein C/S coagulopathy
50
Cavernous sinus thrombosis
Presents with red swollen eyelid+conjunctiva + III, IV, Va/Vb, VI palsies + papilledema; lateral+cavernous sinus may undergo thrombosis as a result of infection spreading; Tx is heparin+Abx
51
Lateral sinus thrombosis
From infection in mastoid/inner ear + blood clot; increased ICP+seizures+drowsiness
52
Cerebello-pontine angle tumors
Involves CN 5+7+8; sensorineural hearing loss - Weber lateralizes to healthy ear, AC>BC on both sides (normal Rinne); acoustic neuroma most common
53
Acoustic neuroma
Benign tumor arising from Schwann cells of CN VIII; unilateral sensorineural hearing loss+tinnitus+CN VII palsy and facial drooping; get MRI of internal auditory canals w/+w/o contrast
54
HSV encephalitis on imaging
EEG shows severe slowing on temporal lobes (triphasic waves), MRI of brain lit up on temporal lobes + positive PCR
55
Location of HSV encephalitis
Temporal lobes + Broca's area of frontal lobe
56
Features of HSV encephalitis
Slow onset; seizures+AMS+speech output bad for the last 5 days+fever+obtunded
57
Tx and management of HSV encephalitis
ABCs first, do CT w/o contrast; if CT does not look like stroke, assume meningitis and tx broad spectrum; do MRI - temporal lobe lighting up; ICP management, fluids, ACV therapy, DO NOT USE STEROIDS, seizure control; admit everyone w/ new onset seizure for 23 hr observation
58
Who NOT to tap for HSV encephalitis
Don't tap healthy w/ seizure etiologies - ex EtOH, barbiturates, family hx; leave previous stroke, EtOH, very old, or risky pts
59
Guillain Barre Syndrome (AIDP)
Ascending weakness in all extremities; elderly at risk - monitor respiratory status
60
Bugs that cause GBS
CMV, EBV, HIV, Mycoplasma pneumoniae, Campylobacter jejuni, swine flu vaccine
61
S+S of GBS
Spinal pain and minor sensory symptoms, proceeds progressively, ascending, symmetric limb weakness - leg, arm, CN w/ diplopia, drooling, dysphagia, slurred speech, respiratory muscle weakness, dyspnea, fatigue, urinary hesitancy and retention
62
Exam findings of GBS
Flaccid paralysis of limbs,+ early tendon areflexia + minor sensory deficits, CN palsies (esp bulbar)
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Miller Fisher Variant
Ataxia+Opthalmoplegia+Areflexia (AOA), little muscle weakness in limbs, antiganglioside Ab (GQ1b)
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Froin syndrome
Clotting of CSF from high protein
65
Ddx for GBS
Periodic paralysis + hyper/hypo potassium/calcium
66
LP findings with GBS
Increased CSF protein w/ normal white count - albuminocytological dissociation
67
EMG findings w/ GBS
Nerve conduction shows demyelination; can be totally flaccid w/ normal conduction first few days; only patchy nerve fx early
68
Other dx tests for GBS
Anti-gangliosides Abs, MRI head+C-spine to r/o basilar artery stroke, SC compression, TM, rupture of AVM
69
Management of GBS
Measure vital capacity+ECG constantly; admit to ICU if decreased vital capacity or trouble swallowing; may need artificial ventilation + NG feeding
70
Brain tumors
Medulloblastoma, Ependymoma, Posterior fossa tumors (young), corpus callosal tumors+oligodendroglioma+lipoma, GBM (the worst), 4th ventricle-ependymoma (can block CSF outflow), supracellar tumors
71
Features of ependymoma
Pt w/ HA+blurred vision+projectile vomiting (morning)+papilledema
72
Etiology of neurocysticercosis
Pork tapeworm (taenia solium); seizure + from Mexico is this until proven otherwise
73
Presentation of neurocysticercosis
HA + seizure + focal signs; can obstruct ventricles, predispose to stroke
74
Dx of neurocysticercosis
ELISA + CT w/ multiple calcifications+space occupying lesions+swiss cheese appearance on MRI
75
Tx of neurocysticercosis
Steroids to decrease ICP, seizure meds, albendazole+praziquantil, shunt if CSF not flowing
76
Prognosis of neurocysticercosis
Worsen before they get better; follow NIH guidelines, follow with ID and surgery; surgery won't operate bc of rupture risk
77
Classic presentation of neurocysticercosis
Severe occipital HA+decreased visual acuity; unable to distinguish color, seizures, from Guatamala, calcifications on CT, edema on T2 FLAIR
78
Types of brain herniation
Cingulate, uncal, cerebral hemisphere mass, central tentorial, tonsillar
79
Cingulate herniation
Ventricle compression
80
Uncal herniation
Stretching of CN III - IPSI dilated pupil + ptosis; compression of IPSI PCA - CL homonymous hemianopia; compression of CL crus cerebri - IPSI paresis; caudal displacement of brain stem - Duret hemorrhages (paramedian aa. rupture)
81
Cerebral hemisphere mass herniation
Shift of medline structures, temporal lobe herniation through tentorial hiatus, compression of reticular formation leads to decreased consciousness, CN3 palsy - compression of nerve+nucleus - IPSI fixed dilated pupil, long tract signs - upgoing plantar responses
82
Central tentorial hernation
Diffuse cerebral swelling, unchecked lateral herniation, vertical displacement of structures through tentorial hiatus, decreased consciousness, pupils initially small and ultimately fixed and moderately dilated, CDI d/t downward traction on pituitary stalk + hypothalamus
83
Tonsillar herniation
2/2 subtentorial mass or unchecked tentorial herniation, cerebellar tonsils herniated through the foramen magnum, posterior fossa mass may cause upward herniation through tentorial hiatus, causes neck rigidity+head tilt, decreased consciousness w/ respiratory arrest, HTN+bradycardia
84
Dysphasia vs aphasia vs dysarthria
```
Dysphagia = trouble swallowing
Aphasia = impairment of language function as a result of brain damage
Dysarthria = muscle problem w/o language problem
```
85
Broca's (Area 44) location
Inferior frontal gyrus, anterior division of MCA on dominant side
86
Broca's aphasia
Mute then can say short sentences, can read if they avoid hemianopic part of vision, nonfluent, intact comprehension, naming/repetition/writing all poor, reading variable, disordered grammar, hemiparesis common
87
Wernicke's (Area 22) location
Posterior superior temporal lobe = Post division of MCA
88
Wernicke's aphasia
Fluent, paraphasic; comprehension, naming, repetition, writing poor; reading is variable, hemiparesis infrequent, repetitions of substitutions
89
Arcuate fasiculus of supramarginal gyrus aphasia
Fluent paraphasic, poor repetition but fluent speech + intact comprehension, repetitions of substitutions, repetition/writing poor, naming+reading variable, hemiparesis infrequent
90
Literal vs semantic substitutions
Literal - substitute one letter for another (wife vs wafe)
| Semantic - substitute one word for same type of another (wife vs mom)
91
Essentials to Dx of botulism
Hx of ingestion of home-canned foods or honey (infants), rapid onset of ocular symptoms (diplopia, ptosis, blurry vision), bulbar symptoms (dysarthria, dysphagia), descending pattern of weakness from oculobulbar to limb involvement, dilated pupils
92
Pathophysiology of botulism
Ingestion of toxin and absorption into blood stream; irreversible binding of toxin to presynaptic nerve endings of PNS + CNS; gets internalized and blocks Ach release thru cleavage of polypeptides essential for docking of vesicles
93
S+S of botulism
N/V/D w/in 2-26 hr of ingestion, constipation, oculobulbar (dry mouth, blurred vision, diplopia, dysarthria, dysphagia, dysphonia), respiratory weakness (may need intubation), unreactive pupils+areflexia
94
S+S of infantile botulism
Infection + early constipation + weak cry + poor feeding; days - progressive weakness + poor suck + head control + hypotonia + decreased movement; autonomic - hypotension, tachycardia, dry mouth
95
Dx of botulism
Toxin detected in blood or stool; C. botulinum can be detected in stool; electrodiagnostic - small CMAP in response to supramaximal stimulus
96
Management of botulism
Intensive supportive care; admit and manage airways; trivalent botulinum antitoxin - give early while toxin still in blood (side effect of anaphylaxis), guanidine hydrochloride,, anticholinesterase drugs controversial
97
Cholinergic crisis causes
Anticholinesterases to treat MG
98
S+S of cholinergic crisis
Increased salivation+lacrimation, vomiting, abdominal pain+diarrhea, sweating, papillary constriction, fasiculation, worsening weakness in extreme cases
99
Wernicke syndrome
Acute global confusion state + abnormal eye movements + ataxic gait (mostly truncal)
100
Progression of Wernicke's
Evolves over days to weeks w/ inattentiveness, indifference, decreased spontaneous speech, impaired memory, lethargy; can prgoress to coma, loss of pupillary reactivity rare; autonomic signs - tachycardia, orthostatic hypotension
101
Korsakoff syndrome
Chronic amnestic d/o - anterograde + retrograde; preservation of alertness, and behavior; does NOT respond to tx like mental symptoms of Wernicke
102
Pathophysiology of Wernicke-Korsakoff
Lesions in medial thalamus, hypothamus, PAG of midbrain and mammillary bodies caused by thiamine deficiency
103
Other causes of Wernicke-Korsakoff
Chronic hemodialysis+drug therapy for obesity + hyperthyroid
104
Tx of Wernicke-Korsakoff
Thiamine 50-100 mg daily + multivitamin + bed rest bc autonomic symptoms
105
Brain death criteria
Clinical/neuroimaging evidence of acute CNS problem compatible w/ brain death; exclusion of complicating medical condition that may confound clinical assessment; no drug intoxication or poisoning; core temp of 32 degrees???
106
Cardinal findings of brain death
Coma - no cerebral motor response to pain, absent brainstem reflexes - pupils+EOM+facial sensation+motor response+pharyngeal/tracheal reflexes, apnea testing - must have core temp of 36.5, systolic BP of 90, euvolemia, normal arterial PO2
107
Conditions where confirmatory test recommended for brain death
Severe facial trauma, preexisting pupillary abnormality, toxic levels of any sedative, sleep apnea, severe pulmonary dz
108
NOT to be confused with brainstem functions
Tendon, superficial abdominal or triple flexion reflexes, babinski, respiratory-like movements w/o significant tidal volume, sponatenous movements of limbs other than pathologic flexion or extension, sweating, blushing, tachycardia, normal BP w/o pharmacological support or change in BP, absence of DI
109
Repeat exams for brain death
Children
110
Confirmatory lab tests for brain death
Children
111
Essentials of Dx of B12 deficiency
Gradual onset, distal symmetric sensory loss + weakness (late)
112
Lab findings in B12 deficiency
Elevated homocysteine + methylmalonic acid
113
Neurologic features of B12 deficiency
Myeloneuropaty (subacute combined degeneration), cognitive impairment, optic neuropathy (atrophy less common), isolated cerebellar ataxia, demantia less common, gait instability+muscle atrophy if left untreated
114
Exam findings of B12 deficiency
Decreased propioception and vibration sense + distal weakness + Babinski + increased DTR?
115
Etiologies of B12 deficiency
Strict vegetarians (vegans?), gastric disorders (pernicious anemia, gastrectomy, achlorhydria, ileal d/o w/ bacteria, Diiphyllobothrium latum), surgery, IBS, nitrous ox abuse
116
Myelopathy in B12 deficiency
Subacute combined degeneration of corticospinal and dorsal columns - myelopathy + PN = combination of areflexia + sensory ataxia + paraparesis + extensor plantar response
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Dx o B12 deficiency
Elevated homocysteine + MMA, low B12, normal folate, MRI spine normal, somatosensory evoked potentials+motor evoked potentials usually abnormal, nerve conduction reveal peripheral neuropathy, anti-intrinsic factor Abs+anti-parietal cell Abs in pernicious anemia, macrocytic anemia
118
Tx of B12 deficiency
1 mg of IM cyanocobalamin QD x 7d; IM Qweek x 3 mo, then maintenance IM qmonth or q3mo
119
Presentation of Horner's syndrome
Miosis + enophthalmos + anhidrosis
120
Etiology of Horner's syndrome
Brainstem = glioma + infarction + syringobulbia
Cervical cord = glioma + syringomyelia
T1 root = neurofibroma + brachial plexus lesion
ICA = occlusion + dissection
Other = cluster hA + syringobulbia + Pancoast tumor
121
Location of Horner's lesion
Lesion to superior sympathetic nervous system that supplies muscles for elevating eyelid; SNS to eye originates in hypothalamus, exits sympathetic chain w/ T1 and enters cervical sympathetic chain and attaches to ICA; tumor catches medial cord first;
Tingling or numbness above wrist = root or cord;
Hand spliting ring finger = ulnar nerve
122
Bacterial meningitis prophylaxis
Meningococcal + Hflu w/ rifampin or cipro
