Anna FCM5 Neuro.txt

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Anna FCM5 Neuro.txt
2010-04-05 12:05:37
Neurology Exam

FCM Exam 5 Neurology
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  1. The conscious state depends upon appropriate communication between both cerebral hemispheres and the ..
    RAS-reticular activating system
  2. list the 7 levels of consciousness:
    • confusion
    • delirium
    • lethargy
    • obtunded
    • stupor
    • coma
  3. A patient who is awake, alert, and oriented to person, place, time, and situation. The patient follows commands appropriately and is aware of his/her surroundings. on exam, an alert patient will open their eyes, look at you, respond completely and appropriately. They will respond to a normal voice tone.
  4. The patient responds appropriately, however is disoriented, difficult to arouse, and may have memory impairment.
  5. Memory issues are the most common
  6. The patient is agitated, restless, resistant, and uncooperative, but alert. This is an acute, reversible state of confusion. Symptoms wax and wane. ...really easy to upset
  7. The patient is in deep, prolonged unconsciousness. He/She appears drowsy. on exam, the patient will open his/her eyes, look at you, answer questions, then fall asleep. Will respond only to a loud voice.
  8. The patient appears more sleepy. You must provide some physical stimulus to arouse the patient. Answers to questions are confused.  shake and shout
  9. May require a sternal rub or Tina's nipple twist
  10. The patient will respond only to a continuous painful stimulus. They may respond slowly or not at all. once the painful stimulus is halted, the patient returns to the unconscious state.
  11. An unresponsive state to any type of external stimulus. This is caused by some type of compromise of the RAS, or diffuse, simultaneous insult to both cerebral hemispheres. eyes remain closed
  12. Coma is an unresponsive state to any type of external stimulus. This is caused by some type of compromise of the__ or diffuse, simultaneous insult to___
    This is caused by some type of compromise of the RAS, or diffuse, simultaneous insult to both cerebral hemispheres.
  13. DDX for delirium
    • D-Drugs: ETOH, toxins
    • E-Electrolyte Imbalances
    • L-Low pO2 (hypoxia)
    • I-Injury to the brain
    • R-Relapsing fever
    • I-Infection (UTI, pneumonia)
    • U-Uremia
    • M-Metabolism (liver damage)
  14. Dx: Global impairment of cognitive function that interferes with normal activities.generalized and sustained decline in intellectual capabilities. progressive declinememory, cognitive abilities, adaptive behavior affected without affecting consciousness
  15. DDX for dementia
    • D-Drugs (ETOH, sedatives, opiates, antihypertensives, anticholinergics
    • E-Endocrine (thyroid problems, high dose steroids, panhypopituitarism)
    • M-Metabolic (inherited disorders)
    • E-Epilepsy
    • N-Nutritional (B-12, thiamine, niacin deficiency, pernicious anemia)
    • T-Tumor, Trauma, Toxins
    • I-Infection (Syphilis, AIDS with CD4 < 200
    • A-Arterial (cerebral multi-infarct dementia)
  16. The etiologies of AMS can be grouped into two different categories: __ or __
    structural or metabolic
  17. Typically with__ lesions you first get changes in consciousness, then pupil changes (unequal or not responsive)
  18. Typically with__ problem you first get pupil changes, then changes in mental status
  19. Which etiology of AMS: compression or damage to arousal areas of the brainstem, either directly or indirectly, LOC changes initially, followed by pupillary changes
    structural lesion
  20. Which etiology of AMS (structural or metabolic)? LOC changes after changes in pupils occur; generally pupils are equal and reactive to light; signs and symptoms present slowly and lack localized signs
    metabolic etiology
  21. Bilateral small pinpoint pupils suggests ___ damage vs ___ __
    SNS damage vs. metabolic encephalopathy
  22. Pinpoint pupils (< 1mm) suggest __ hemorrhage vs. drugs (morphine, heroin, other narcs), neurosyphilis, organophosphates
    Pinpoint pupils (< 1mm) suggest pons hemorrhage vs. drugs
  23. Bilateral midposition fixed pupils suggest structural damage to the __
  24. Bilateral large pupils, fixed and dilated suggest ...
    anoxia (cardiac arrest)
  25. One large fixed, dilated pupil suggests ___ (*like from tumor, swelling, bleeding [pressure])
    CN 3 compression from temporal lobe herniation
  26. Corneal reflex tests CN __ and __?
    CN 5 (trigeminal nerve, sensory portion) and CN 7 (facial nerve, motor portion); absence of blinking suggests lesion of one or both of theses nerves; very useful in eval of comatose patients
  27. How do you test vestibuloocular reflex of CN 8?
    • cold calorics:
    • Cold water in ear causes eyes to drift to side you put water in. If the reaction is different, damage to CN8 or brainstem injury
  28. Vestibuloocular reflex: cold calorics, CN 8: Cold water in ear causes eyes to drift to ___. If the reaction is different, damage to CN8 or brainstem injury
    side you put water in.
  29. what should you do before testing for Doll's eyes?
    clear c-spine
  30. describe Doll's eye movement, what CN does it involve? and what does it tell you?
    in a coma pt with a FUNCTIONAL brainstem, when you move their head to the right, their eyes move to the left. no eye movement occurs when there is damage to the midbrain or pons.
  31. papilledema is a sign of..
    late sign of increased ICP
  32. name those respirations: alternating episodes of deep breathing with apnea
    Cheyenne-Stokes respirations
  33. what are some causes of Cheyenne-Stokes respirations (alternating episodes of deep breathing with apnea)?
    causes include damage to both cerebral hemispheres, uremia, drugs, and heart failure
  34. Apneustic breathing = breath held for 2-3 seconds with each inspiration. What type of lesion does this suggest?
  35. Biots respirations = no regularity in pace or depth of respirations. This usually indicates lesions where? (2)
    traumatic pons, medulla lesions
  36. hyporeflexia = __ motor neuron lesion
  37. hyperreflexia = __ motor neuron lesion
  38. a GCS of what = fully alert?
  39. a GCS of what = comatose?
    < 8
  40. what 4 criteria must your pt HAVE to declare brain death?
    • 1. documentation of LOC
    • 2. absent motor response to painful stimuli (nailbed pressure, sternal rub, supraorbital pressure)
    • 3. absent brainstem reflexes (fixed, unresponsive pupils, positive cold calorics/doll s eye, absent corneal reflexes, no cough or gag response
    • 4. apnea, pCO2 < 60 mm Hg
  41. they're not dead until they're __ and dead
    warm and dead
  42. Brain death is a clinical diagnosis. Perform the exam __ hours after onset of the insult creating brain death. May follow with another exam __ hours later (optional)
    6 hours
  43. Pt returns to ER one week later with altered mental status. Pt not responsive to loud voice. Must gently shake the pt to arouse. Speech is incomprehensible, opens eyes for a few seconds, then closes them again. What is his level of consciousness?
  44. 18 y/o male college student  found down in the bushes at a Widespread Panic concert. Initially responsive to only painful stimuli. Minutes later, patient responsive to voice. He is restless, agitated, uncooperative. Both pupils dilated and reactive to light. Abrasions to face, hands, and knees. LOC?Work up?
    • initially stupor, now delirious
    • drugs? diabetes?
  45. less precise term that is frequently used synonymously with polyneuropathy, but can also refer to any disorder of the peripheral nervous system including radiculopathies and mononeuropathies.
    peripheral neuropathy
  46. specific term that refers to a generalized, relatively homogeneous process affecting many peripheral nerves, with the distal nerves usually affected most prominently.
  47. Focal involvement of a single nerve, usually due to a local cause such as trauma, compression, or entrapment. Carpal tunnel syndrome is a common example.
  48. Carpal tunnel syndrome is a common example of which type of neuropathy?
  49. Most common nerve entrapment disorder. Due to compression at the flexor retinaculum, with resulting median nerve compression; results in weakness of supplied muscles DISTAL to this (e.g. index finger-thumb apposition task) and thenar muscle atrophy, and numbness along lateral portion of hand
    carpal tunnel
  50. carpal tunnel is a compression of which nerve?
  51. treatment for carpal tunnel?
    first, brace..if no better, surgical decompression
  52. physical findings of median nerve compression?
    • 1) a positive Tinel sign or a positive Phalen test
    • 2) diminished or absent sensation to pin prick in the median nerve distribution
    • median nerve - carpal tunnel
  53. Pt c/o: Hand-shaking, particularly at nighttime; Pain wakes me up. Features are variable --pain is common--paresthesias ie numbness, tingling, pins and needles
    carpal tunnel
  54. Due to compression (usually) at the elbow, with resulting weakness in hand intrinsics & hypothenar muscle atrophy; also associated with numbness @ medial aspect of hand
    ulnar neuropathy - cubital tunnel syndrome
  55. Chronic axonal polyneuropathies (eg, due to __ or __) are the most common of the polyneuropathies. Injury tends to be related to axon length; thus, longer axons are affected first, resulting in symptoms that begin in the lower extremities. Sensory symptoms usually precede motor symptoms
    diabetes mellitus or uremia
  56. History: Pain in leg (travels along nerve root, thus radiculopathy)  may or may not be related to trauma or action; Exam: Use the motor and sensory exams to determine nerve root affected. A disc is between 2 levels, and will affect the LOWER nerve root  e.g. L5-S1 HNP causes S1 radiculopathy, which may reveal ankle plantar flexion weakness and decreased sensation at the bottom of the foot; also + straight leg raise
    herniated lumbar disc dz
  57. treatment for herniated disc dz?
    • conservative, NSAIDs, PT, injections
    • if >4 weeks, get MRI
    • must give time for inflammation to resolve
  58. The single best test to dx lumbar path; Indicated for patients with > 1 month of symptoms & signs of nerve root compression
  59. etiologies of which syndrome: Sagging musculature related to aging, obesity, or heavy breasts.
    Postural etiologies
  60. Weakness of the trapezius muscles due to aging, inactivity, or nerve damage
    thoracic outlet syndrome
  61. when should you operate on thoracic outlet syndrome?
    never, really
  62. in a young female with facial pain in the trigeminal distribution, what must you r/o?
  63. Trigeminal neuralgia is mainly found in what age patients?
  64. one of the most common causes of facial pain. sudden, usually unilateral, severe, brief, stabbing or lancinating recurrent episodes of pain in the distribution of one or more branches
    trigeminal neuralgia
  65. how should you workup trigeminal neuralgia?
    • 1. MRI to r/o mass or lesion
    • 2. dental exam
  66. primary management of trigeminal neuralgia pt?
    • meds,
    • then injections
    • then radiosurgery
  67. Ball's palsy is a lesion of which CN?
  68. Diffuse facial nerve involvement manifested by paralysis of the facial muscles, with or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands. ACUTE onset, hours to 1 or 2 days max
    Bell's palsy, CN VII
  69. How do you treat Bell's Palsy?
    • Try Steroids and
    • Try antiretrovirals if HIV/HSV
    • Eye care
    • course is progressive, maximal paralysis within 3 weeks, recovery within 6 months
  70. Cause of Bell's Palsy?
    • Histopathology is consistent with an inflammatory and possibly infectious cause
    • CN 7
  71. term: perception of movement where no movement exists
  72. term: transient loss of consciousness accompanied by a loss of postural tone with spontaneous recovery
  73. Define: spinning, weaving, seasickness, ground rising and falling, rocking, merry go-roundnausea, vomiting, and diaphoresis may be presenttinnitus and hearing loss indicate injury to the auditory component of the 8th cranial nervenystagmus present or can be produced
  74. Vestibular problems: peripheral or central? cochlear or retrocochlear, occurs in isolation except for presence of timmitus or hearing loss
  75. Vestibular problems: peripheral or central?: vertigo in association with other brainstem deficits
    central lesion
  76. Vestibular problems: peripheral or central? vertigo is acute onset, intermittent and severe, associated with intense nausea, vomiting, provoked by movement
  77. Vestibular problems: peripheral or central? Vertigo is Progressive, constant and less severe, associated with mild nausea, not affected by movement
  78. Vestibular problems: peripheral or central? Nystagmus: Always present; unidirectional,horizontal or rotatory (never vertical); latency (20-40 sec.) and fatigability present; inhibited by ocular fixation
  79. Vestibular problems: peripheral or central? Nystagmus May be absent, can be bidirectional (vertical nystagmus almost always central in origin), latency and fatigability absent, not inhibited by ocular fixation
  80. Vestibular problems: peripheral or central? Associated symptoms: hearing loss or tinnitus may be present. Brain stem or cerebellar findings absent
  81. Vestibular problems: peripheral or central? Hearing loss or tinnitus not often present. Brain stem or cerebellar findings often present
  82. is benign positional vertigo peripheral or central lesion?
  83. definition: common in elderly, experienced with certain positionssudden onset usually within a few seconds of assuming the triggering positionsymptoms stop after few minutes in same position, but will resume if position changesresolves within 6 months
    benign positional vertigo (peripheral lesion)
  84. dx: idiopathic endolymphatic hydrops, damages hair cells because of swelling of the semicircular ducts, tinnitus, pressure in ear, hearing loss with vertigo can be disabling, episodes paroxysmal, lasting minutes to hours, then decrease in frequency after multiple attacks only to recur in months or years
    Meniere's disease (peripheral lesion)
  85. Is Meniere's Dz peripheral or central lesion?
  86. Dx: secondary to viral infections of cochlea and labyrinth, pt. c/o vertigo, tinnitus, and decreased hearing following a URI, resolve in 1-6 weeks
    acute labrynthritis (peripheral lesion)
  87. dx: most worrisome of the peripheral lesions; retrocochlear with mild hearing loss, tinnitus, vague dizziness
    Acoustic neuroma (benign schwannoma of the 8th cranial nerve); (peripheral neuropathy)
  88. Dx: most worrisome of the peripheral lesionsretrocochlear in location, mild hearing loss ability to produce serious brainstem compression, which cause facial numbness, gait ataxia, weakness, decreased corneal reflex
    Acoustic neruoma (benign schwannoma of the 8th cranial nerve)
  89. is MS peripheral or central lesion?
  90. dx: focal demelination in vestibular pathways of brainstem transient nature of attacks and subtlety of accompanying symptoms (slight facial numbness or deepening of voice) progress to repeated attacks central type of positional nystagmus persists after vertigo resolves
  91. True Vertigo: Peripheral or Central?
  92. True Vertigo: Peripheral or Central?
    1. __ likely to represent potentially life-threatening disorders
    2. __ more intense, associated with nausea, vomitin, daphoresis, tinnitue, hearing loss, and photophobia
    • 1. Central likely to represent potentially life-threatening disorders
    • 2. Peripheral more intense, associated with nausea, vomitin, daphoresis, tinnitue, hearing loss, and photophobia
  93. Combining findings of nystagmus with findings from Romberg and Rinne testing favors (central or peripheral) lesion? ie; if slow phase of nystagmus moves toward same side as hearing loss, patient reports spining is away from the side of the hearing loss and the Romberg is positive and pt. sways toward the side of the hearing deficit.
  94. Dx: recurrent attacks, tinnitus/vertigo/unilateral hearing loss
    Meniere's Dz
  95. sensation of faintness or inability to maintain normal balance in standing or seated postion, sometimes assoc'd with confusion, anusea, weakness
  96. dx: a head sensation of abnormal movement or abnormal movement of the environment spinning
  97. Episodic auditory and vestibular disease characterized by sudden onset of vertigo, hearing loss, tinnitus and sensation of fullness in the affected ear.
    The cause is unknown, but results in an overproduction or impaired absorption of endolymph in the inner ear.
    Diagnosis is made on clinical history and detailed audiology tests; other investigations may be required to exclude other causes.
    Dietary changes and diuretics may control symptoms in early stages of the disease; specific medical therapies for vertigo control can be trialed if required.
    If symptoms persist despite maximal medical therapy, several surgical interventions are available.
    Meniere's Disease
  98. Common, often self-limited condition, but can be chronic and relapsing.
    Diagnosis is based on a suggestive history and physical exam with a positive Dix-Hallpike maneuver or a positive supine lateral head turn. Other tests are not usually required.
    Medication is not an effective treatment option.
    Repositioning maneuvers are highly efficacious in resolving an episode of BPPV.
    Surgery is highly effective but is reserved for intractable and severe cases.
    Benign Positional Vertigo
  99. Paresis = __
    Plegia = __
    • Paresis = weakness
    • Plegia = paralysis
  100. Hemi = ___
    Para = __
    Quadri (tetra)= __
    • Hemi = both limbs same side
    • Para = both lower extremities
    • Quadri (tetra)= all 4 extremities
  101. Neuropathy or Myopathy:
  102. Neuropathy or Myopathy: Typically manifests distally; Usually has associated sensory symptoms; Tend to be a endocrinopathy, affects distal extremities first; usually assoc with numbness/tingling, not just motor weakness
    neuropathy (DMII is MCC)
  103. Neuropathy or Myopathy: Typically manifests proximally first in the larger, anti-gravity muscles.; Not usually associated with sensory symptoms;
  104. EMG measures fasciculation potentials - involuntary/spontaneous contraction of a motor unit  indicates __ problem
  105. ElectroDiagnostics: measures motor potentials
    EMG = electromyography
  106. ElectroDiagnostics: Measuring the time it takes for an electrical stimulus to travel along a nerve
    NCV - nerve conduction velocities
  107. ElectroDiagnostics:
    Measures brain activity at rest and in response to stimuli
    Assess level of consciousness
    Assess seizure disorders
    As part of evoked responses
    EEG - electroencephalogram
  108. mneumonic of causes for neuropathy?
    DAG C. THERAPIST: Diabetes; Alcohol; Guillain-Barre; Compression; Toxins; HEreditary; Refsum s; Amyloid; Porphyria; Infection; Systemic; Tumor
  109. A chronic autoimmune disorder of the postsynaptic membrane at the neuromuscular junction in skeletal muscle. Characterized by muscle weakness that increases with exercise (fatigue) and improves on rest. Commonly presents with drooping eyelids, double vision, oropharyngeal and/or appendicular weakness and shortness of breath.
    Myasthenia gravis
  110. Tx for myasthenia gravis?
    • Treatments include anticholinesterases and immunotherapy. Thymectomy may be required.
    • Most patients enjoy good quality of life and normal lifespan due to advances in diagnosis and immunosuppressive treatment.
  111. Dx:
    - Neuromuscular junction disease
    - Affects voluntary muscles
    - No familial or genetic connection.
    - Autoimmune - antibodies to acetylcholine receptors
    myasthenia gravis
  112. Dx:
    - Bilateral facial palsies
    - Ocular palsies/ptosis/intermittent diplopia/normal pupils
    - Bulbar palsy - dysphonia/dysarthria/dysphagia
    - Fatigue of muscle strength w/ use - rest helps -talking/chewing (like bilateral Bell's Palsy)
    Myasthenia Gravis
  113. what 2 things do you do to dx myasthenia gravis?
    • 1. Single fiber EMG-very reliable/objective.
    • 2. Serology for antibodies to acetylcholine receptors
  114. general treatment for myasthenia gravis?
    immunosuppression and steroids
  115. Dx:
    - acute idiopathic polyneuritis - immuno-mediated
    - Most common acquired demyelinating neuropathy
    - Ascending, peaks 3 days - 3weeks
    Guillain Barre
  116. Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
    - Weakness(usually proximal), hypotonia, hyporeflexia (or areflexia)
    - No atrophy, usually no fasciculations, little or no sensory involvement.
    Guillian Barre Syndrome
  117. Tx for GBS?
    • 1. Admit! Reserve ICU. Frequent VS.
    • 2. Plasmapheresis first 2 wks of a severe case to decrease severity of disease course.
    • 3. Immunoglobulins IV
    • 4. Steroids not usually helpful.
  118. 20-40 y/o female grew up up north
  119. Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
    - Optic neuritis, vertigo, Unsteady gait, scanning speech (no inflection in voice)
    - Trigeminal neuralgia
    - incontinence
  120. weakness or paralysis: loss of muscle power
  121. weakness or paralysis: loss of motor fxn
  122. MRI of this condition shows multifocal, hyperintense lesions/plaques
  123. Type of MS: most common with sudden onset of neurological deficit with each new plaque and improvement after each crisis as plaque resolves, although return of fxn is not back to prior state
    relapsing/remitting (RRMS)
  124. Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
    - CSF: Oligoclonal banding
    - IgG index = comparison of serum and CSF IgG levels
    - VER - visual evoked responses (75% + even if no symptoms) - cerebrum
  125. first test for MS?
    MRI to find hyperdense lesions
  126. MS treatment?
    • 1. immunosuppression
    • 2. oral prednisone & IV methylprednisolone for crises
  127. the very reliable and objective diagnostic test for myasthenia gravis?
    single fiber EMG
  128. Bells Palsy: central or peripheral?
  129. Myasthenia Gravis, ALS, Guillian Barre or Multiple Sclerosis:
    - Usually starts in UE
    - Fasciculations often first in the forearms and tongue
    - Corticospinal/anterior horn cell degeneration
    - Weakness, UE, slight LE spasticity, gen hyperreflexia
    - UMN & LMN findings in the same limb
    - No sensory changes
  130. definition: Neural deficits lasts no more than 24 hours; Neural deficits clear completely
  131. definition:
    - aggregate of blood factors building on a vascular wall to the point of occlusion
    - platelets/fibrin/trapped cellular elements, etc on an underlying plaque
    thrombus leading to ischemic stroke
  132. definition: clot, plug or detritus brought by blood circulation from another location to lodge in a smaller vessel
    embolus leading to ischemic stroke
  133. definition: Decreased flow if you are drowning or you have heart failure and the hearts not pumping blood to the brain
    hypoperfusion leading to ischemic stroke
  134. which type of stroke:
    - Onset gradual or sudden
    - Progression of symptoms is stepwise or stuttering
    - Deficits focal to area of ischemia
    - Happens when asleep or inactive (stuff building up on a wall, slower flow at night)
    - Headache associated sometimes
    - Usually preceded by TIAs for days or weeks
    • thrombosis leading to ischemic
    • Step wise ssx progression, stuttering: this is because when we're young, we have a good balance of build-up/break down mechanisms in place; but in older pt's, their artery is almost closed, buildup on both sides causing narrowing, when you build-up just a little more, suddenly it closes, but then the lytics kick in and opens it back up again, this happens cyclically so that they get worse each time, then get better and get worse
  135. which type of stroke:
    - Onset sudden
    - Deficit usually maximal at onset
    - Deficits focal to area of ischemia
    - Onset with activity (due to high blood flow)
    - Headache associated sometimes
    - Not usually preceded by TIAs
    embolus leading to ischemic strokes
  136. which type of stroke:
    - Sudden onset
    - Neural deficit develops over minutes to hours
    - Deficits focal to area of hemorrhage pressure, may have papilledema
    - Usually awake and active prior to onset
    - Headache very common
    - No TIAs associated
    • intracerebral hemorrhage
    • - having a baby, pooping, sitting smoking a cig and drinking coffee
    • - High flow, high pressure situation, so HA is very common; stretching adjacent structures
  137. which type of stroke:
    - Sudden onset
    - Deficit absent or non-focal, no papilledema
    - Awake & active often with sudden exertion
    - Headache - always - WORST HEADACHE OF MY LIFE
    - Nuchal rigidity (neck stiffness)
    - Nausea/vomitingBrief loss of consciousness
    - TIAs - never
    - Prodrome of sentinel headaches/III palsy/VI palsy/field cut in many cases
    subarachnoid hemorrhage
  138. worst HA of my life?
    subarachnoid hemorrhage
  139. which type of stroke:
    - No deficit, no papilledema
    - Mechanic who is lifting the car battery or 22 y/o mother who is in her first labor, these situations where they blow an aneurysm
    - Always HA
    - Instant HA, loss of consciousness
    - Neck stiffness/N/V looks like meningitis - this is b/c all this blood irritates the meninges
    subarachnoid hemorrhage
  140. first line diagnostic test for stroke w/u?
  141. this type of stroke will show up immediately bright white on CT scan with no contrast
    intracerebral hemorrhage
  142. this type of stroke takes 6-24 hours to show up hypodense on CT
  143. why should you do CT NO CONTRAST as first line for any type of suspected stroke?
    Infarct (ischemic) takes 6-24 hours to become hypodense; CT doesn't tell you they've had an infarct, but it does tell you they haven't had a bleed  this is important info to have
  144. this type of stroke shows hazy in the peri-Willis space on CT, can have intraparenchymal extension
    Subarachnoid hemorrhage
  145. this study is almost immediately positive for ischemic stroke
    MRI, but CT is first line
  146. after you've done a CT no contrast and established that your stroke pt does not have a bleed, what's first line?
    • *Anticoagulation:
    • ****Heparin drip first line
    • *Thrombolytics for emboli (clot busters)
    • Angioplasty for thrombosis
  147. treatment for intracerebral hemorrhage stroke? (4)
    • Control BP to avoid rebleed
    • Correct any coagulopathy
    • Control ICP
    • Surgery for clot removal if feasible
  148. tx for subarachnoid hemorrhage?
    Surgery! endovascular coiling, slipping
  149. 6-8 days after a subarachnoid hemorrhagic stroke from this cerebral artery, you'll have vasospasm
    • ACA
    • apply triple H therapy:
    • - hemodilution hct 33-37%
    • - hypervolemia, using volume expanders w/o free water
    • - Albumin/plasmanate (hepatitis/AIDS)
    • - Dextran (0.05% anaphalaxis)
    • - hypertension
  150. 85% of all cerebral aneurysms leading to SAH arise from where in the circulation?
    • anterior circulation
    • 15% from posterior circulation
  151. aneurysms are most likely to occur at what point in the vessle?
    • bifurcations:
    • Acom / AC
    • ICA / Pcom
    • MCA bifurcation
    • Basilar tip
    • Vertebral
  152. approximately 80% of strokes are__ in origin
  153. 2 pairs of major arteries, the __ (anterior circulation) and __ (posterior circulation) arteries supply the brain
    • carotid (anterior)
    • vertebral (posterior)
  154. the internal carotid bifurcates into the __ and ___, with the __ being a straight shot, and the __ turning at 90 degrees
    branches into the anterior cerebral and the middle cerebral. the middle cerebral is a straight shot, the anterior cerebral curves at 90 degrees to enter the middle of the brain
  155. __ of the cerebral vasculature accounts for approx 2/3 of strokes, either thru emboli or in situ thrombosis. ___ make up the majority of the remaining 1/3 of ischemic strokes
    • atherosclerosis = 2/3 of ischemic strokes
    • cardiogenic emboli = 1/3 of ischemic strokes
  156. ischemia in this artery produces various combo's of ssx such as vertigo, diplopia, ataxia, bilateral sensory or motor ssx and fluctuating episodes of drowsiness
    vertebral-basilar insufficiency
  157. acute occlusion of this artery usually results in contralateral hemiplegia and hemisensory loss, reflecting ischemia to the MCA territory. Headache also
    internal carotid artery stenosis/occlusion
  158. occlusion of this artery causes weakness and sensory loss in the contralateral leg. Other clinical manifestations include incontinence.
    anterior cerebral artery
  159. occlusion to this artery results in contralateral hemiplegia, hemianesthesia, and homonymous hemianopsia, aphasia
    middle cerebral
  160. most anterior circulation TIAs (75%0) occur in the setting of significant stenosis or ulceration of this artery; cardiogenic embolism accounts for the remainder
    internal carotid artery
  161. Mild attacks of__ insufficiency may be associated with orthostatic hypotension
  162. Patients with___ insufficiency present with episodic vertigo lasting 1 to 15 minutes, with diplopia, dysarthria, ataxia, drop attack, and clumsiness of the extremities.
  163. this imaging technique is the most reliable test for differentiating ischemic stroke from hemorrhage, but only 5% of acute ischemic strokes are visible in the first 12 hours
    CT no contrast
  164. what are 4 main risk factors for stroke?
    • HTN
    • smoking
    • diabetes
    • hyperlipidemia
  165. T/F: as a primary preventative measure, antiplatelet agents reduce the risk of ischemic strokes in pt's without vascular risk factors
  166. t/f: no evidence has been found to support the use of anticoagulation (heparin) in the management of acute stroke.
    true. although heparin might reduce the risk of recurrent stroke in the short term, any benefit is offset by the increased risk of intracranial hemorrhage
  167. ___ therapy remains the treatment of choice to prevent recurrent thromboembolism in the majority of patients with stroke
  168. which is more common: viral or bacterial meningitis?
  169. __ meningitis typically occurs in the late winter and early spring, and __ meningitis is more common in the warm summer monehts
    • bacterial = winter/spring
    • viral = summer
  170. 4 etiologies of infectious acute meningitis
    • bacterial
    • viral
    • fungal
    • TB
  171. 2 etiologies for non-infectious acute meningitis?
    • SLE
    • sarcoidosis
  172. This maneuver is positive for meningeal irritation when there is flexion of the hips and knees as the neck is passively flexed by the examiner
    Brudzinski's sign
  173. This maneuver is positive when there is pain and increased resistance to extending the knee, bilaterally
    Kernig's sign
  174. 2 named signs which suggest meningeal irritation and inflammation
    Brudzinski's and Kernig's signs
  175. pathogenesis for meningitis
    • pt's have a precursor infection, like URI
    • The cilia of the mucosa in that area stop clearing and the bacteria are able to enter the skull area, cross the blood brain barrier and enter the CSF (which is usually sterile). Host defense mechanisms must also be ineffective in order for the bacteria to grow.
  176. The top two causes of bacterial meningitis are __ and __. (80% of all cases of community-acquired bacterial meningitis in adults)
    • S. pneumonia and
    • N. Meningitidis
  177. __ pathogen causes sporadic disease or epidemics in closed populations in the young (eg students in dormitories or schools)
  178. A bacterial cause of meningitis in children is ___, with most cases by the age of 10
    Haemophilus influenza
  179. Most common bacterial pathogen of meningitis in adults
    strep pneumo
  180. Name that pathogen of bacterial meningitis:
    - 2-25 years old
    - Occurs in epidemics
    - With DIC, purpuric skin rash, adrenal hemorrhage
    Neisseria meningitidis
  181. the over 60 age group usually gets this pathogen causing their bacterial meningitis
    Listeria monocytogenes
  182. The CSF of bacterial meningitis will show mostly...
  183. the CSF of viral meningitis will show mainly...
  184. glucose will be decreased in the CSF of bacterial or viral meningitis?
  185. always get this type of imaging for SAH
  186. Dx:
    - Inflammation of the brain parenchyma with degeneration and phagocytes of neural cells
    - Etiology includes bacterial or viral causes although viral etiologies are more common
  187. dx: Inflammation of membranes of the brain or spinal cord
  188. The changes in consciousness and personality are seen in __, NOT __
    encephalitis, not meningitis
  189. encephalitis is most commonly caused by (bacterial or viral)
  190. meningitis or encephalitis:
    - Most commonly
    - Fever
    - Headache
    - Change in personality
    - Signs of meningeal irritation
    - Alteration of consciousness
    - Focal neurologic deficits
    - Seizures
  191. __ is the most frequent, treatable, and devastating cause of sporadic severe focal encephalitis. It accounts for 10% of encephalitis cases.
    HSV. no age, sex, seasonal or geographic preference exists
  192. Dx:
    - A collection of infective and purulent material
    - Occurs secondary to infection outside of CNS
    - Infection becomes necrotic and encapsulated
    - Usual age 20-50
    brain abscess
  193. MCC of brain abscess?
    • Streptococci identified in 50%
    • S. milleri
  194. T/F: It may be impossible to differentiate between viral and bacterial meningitis clinically.
    • true:
    • Empiric antimicrobial therapy may be necessary as bacterial meningitis is associated with significant morbidity and mortality and requires urgent treatment. Lumbar puncture may confirm a diagnosis of viral meningitis and allow antibiotics to be stopped and the patient discharged from hospital.
  195. Case 1: 2y/o UNIMMUNIZED boy with 1 seizure, recent OM and URI, 3 day fever, photophobia, nuchal ridgidity, rash on trunk and extremities, both signs = +
    • acute bacterial meningitis
    • probably H flu (we immunize against that now)
  196. Case 1: 2y/o UNIMMUNIZED boy with 1 seizure, recent OM and URI, 3 day fever, photophobia, nuchal ridgidity, rash on trunk and extremities, both signs = +; do an LP?
    do an LP, expect to find high Open pressure, high WBC, high protein, low glucose
  197. Case 1: 2y/o UNIMMUNIZED boy with 1 seizure, recent OM and URI, 3 day fever, photophobia, nuchal ridgidity, rash on trunk and extremities, both signs = +; Treatment?
    • 1. tx: start abx and dexamethazone while in the hospital
    • 2. prophylax everyone in the family with rifampin or rocephin
    • 3. complications = brain damage, coma, death paralysis, seizures; tell mom to immunize
  198. a rash is noted in 80-90% of pt's with which CNS infx?
    bacterial meningitis
  199. Case 2: 23 y/o college student URI x 5 days, fever, photophobial, nuchal rigidity , both signs +
    tx: broad spectrum abx like rocephin b/c you're waiting for CSF results; he doesn't necessarily need to be in the hospital; viral men is usually self-limiting, will go away with fever reduction and analgesics for pain
  200. Case 3: 6 hour old infant, vaginal delivery: grand mal seizure, no pre-natal care; bulging of fontanelles, no response to pinching of the toes (=AMS); Dx?
    encephalitis (viral); vaginal delivery, no pre-natal care = mom has HSV, passed it to child
  201. Case 3: 6 hour old infant, vaginal delivery: grand mal seizure, no pre-natal care; bulging of fontanelles, no response to pinching of the toes (=AMS); workup? (2)
    • 1: do CT head first, with and w/o contrast
    • 2: LP
  202. Case 3: 6 hour old infant, vaginal delivery: grand mal seizure, no pre-natal care; bulging of fontanelles, no response to pinching of the toes (=AMS); Treatment?
    • encephalitis from HSV most likely
    • start acyclovir (7-10 days) immediately b/c it won t affect the CSF;
  203. Case 4: 70 y/o female chemo pt for glioblastoma, recent brain surgery. Presents with low grade fever, HA, difficulty waking, AMS paralysis of RUE, both signs are +; Diagnosis?
    • brain abscess from strep, probably S. milleri;
    • she is very immunocompromised. You can get brain abscess from surgery, trauma
  204. MCC for brain abscess?
    • strep and staph
    • Main: strep milleri
  205. Case 4: 70 y/o female chemo pt for glioblastoma, recent brain surgery. Presents with low grade fever, HA, difficulty waking, AMS paralysis of RUE, both signs are +; Workup?
    do CT first because you don't usually do LP for brain abscess cases
  206. Case 5: 38 HIV + male, fatigue x months, fever, HA, Cd4 500 1 year ago; diagnosis?
  207. most common cause of focal encephalitis in AIDS pts
  208. - Dementia caused by direct HIV infection in the brain parenchyma
    - Occurs in late HIV infection in those with severe immunosuppression
    - A diagnosis of exclusion
    - Usually occurs in the late stages of HIV infection
    - Acquired and persistent cognitive decline with preserved alertness that usually dominates the clinical presentation
    - Diagnosis?
    AIDS dementia complex
  209. Top 2 CNS infx assoc'd with AIDS
    • toxo
    • cryptococcus
  210. Which of the following is INCORRECT regarding infections of the CNS?
    A. Meningitis is an infection of the leptomeninges and brain parenchyma
    B. If bacterial meningitis is suspected, pretreatment with antibiotics could reduce yield of gram s stain, and cultures but not the CSF cell count from the initial LP
    C. The choice of empirical antibiotic treatment for bacterial meningitis should be tailored to the age group and any physical findings that suggest a causative organism.
    D. The bacteria that cause most community acquired meningitis transiently colonize the oropharynx and nasopharynx of health individuals and include Streptococcus pneumonia, Neisseria menigitidis and Hemophilus influenza
    A. Meningitis is an infection of the leptomeninges and brain parenchyma
    (this multiple choice question has been scrambled)
  211. Which of the following is INCORRECT regarding infections of the CNS?
    A. Have a detailed conversation with the child s pediatrician about immunizing the child
    B. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
    C. Give prophylaxis to the family of the child only, Acyclovir 10mg/kg four doses every 12 hours
    D. Give dexamethasone 2mg/kg daily for ten days to the family of the child
    B. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
    (this multiple choice question has been scrambled)
  212. In a child with suspected acute bacterial meningitis treated with antibiotics, what would be the best next immediate plan of therapy?
    A. Give dexamethasone 2mg/kg daily for ten days to the family of the child
    B. Give prophylaxis to the family of the child only, Acyclovir 10mg/kg four doses every 12 hours
    C. Have a detailed conversation with the child s pediatrician about immunizing the child
    D. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
    D. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
    (this multiple choice question has been scrambled)
  213. You suspect that a patient has a CNS infection. Which one of the following is correct?
    a. Viral infections are the most frequent cause of aseptic meningitis with most being caused by Enteroviruses or Herpes Virus
    b. Several factors are involved in a person getting meningitis from a virus, including direct penetration through the venous sinuses
    c. Only 1/3 of patients with meningitis have the classic presentation of headache, fever and stiff neck.
    d. The CSF of viral meningitis would show an increased WBC count with a predominance of PMNs, low glucose, elevated protein and an increase opening pressure.
    • a. Viral infections are the most frequent cause of aseptic meningitis with most being caused by Enteroviruses or Herpes Virus
    • 2/3 of patients have the classic presentation
    • D is wrong
    • B is characteristic of bacterial
  214. Management of a patient, whom you suspect has viral meningitis, would include
    A. Acyclovir 10mg/kg four doses every 12 hours to the patient
    B. Symptomatic and supportive treatment of the patient
    C. Prophylaxis to close contacts, Rifampin 600mg in four daily doses
    D. Prophylaxis to close contacts, Acyclovir 10mg/kg fours daily dosed for 10 days
    B. Symptomatic and supportive treatment of the patient
    (this multiple choice question has been scrambled)
  215. You suspect that a child has a CNS infection. Which of the following is INCORRECT?
    a. Encephalitis is suspected rather than meningitis because there are signs of altered consciousness
    b. 1/3 of all encephalitis is caused by HSV, which has no preference for age, gender, season or geography
    c. Although CSF may be normal in encephalitis, it usually shows a lymphocytic pleocytosis (0-1000 WBC/mcl)
    d. The patient should be treated with Acyclovir until HSV encephalitis is ruled out
    B is incorrect, only 10% is caused by HSV. It has an affinity for temporal lobe, is debilitating and treatable
  216. You suspect a patient has a CNS infection. Of the following, which is NOT a COMMON opportunistic CNS infection associated with AIDS?
    a. Candida
    b. Toxoplasma gondii
    c. Cryptococcus neoformans
    d. Pneumocystis jirovecii
    e. Progressive multifocal leukoencephalopathy
    • The correct answer is D;
    • - Pneumocystis jirovecii causes pneumonia not CNS infections.
    • - Progressive multifocal leukoencephalopathy is a demyleninating disease caused by a papovavirus. Symptoms are progressive dementia, visual impairment, seizures and or hemiparesis.
  217. All of the following are correct concerning the AIDS Dementia complex (ADC) EXCEPT:
    a. Also termed HIV encephalopathy, is dementia caused by direct invasion and infection of HIV to the brain
    b. Cognitive impairment, altered motor performance and abnormal behavior with preserved alertness define the clinical triad
    c. AZT therapy has been shown to retard and reverse impairment of this treatable dementia
    d. Complications of untreated ADC include a near-vegetative state characterized by global dementia, mutism, and paraplegia or quadriplegia, although the patient usually remains arousable.
    The correct answer is C. AZT therapy may retard the progression but will not reverse it.
  218. Name that motor pathway: Voluntary movements, integrated skilled, complicated, or delicate movements. Ex: pianist, something that takes a lot of dexterity. It originates in the cerebral cortex, so if you have a stroke and damage the cerebral cortex, you may not gain back all your delicate movements
    corticospinal tract
  219. Name that motor pathway: automatic mvmts you don't think about - chewing, swallowing, blinking. Parkinson's or a stroke may lead to loss of these automatic movements. Damage to this is what causes the Parkinsonian "stare"
    basal ganglia
  220. name that motor pathway: coordinates and smoothes out muscle activity, controls posture. If your pt is drifting to one side while walking or standing, they fall to the side where the lesion is.
  221. this type of tremor is unique to Parkinson's dz. Slow, rhythmic, only occurs at rest. AKA "pill rolling"
    resting tremor
  222. this type of tremor is most noticeable when holding your hands out straight. Bilateral fine, fast tremor found in normal individuals and assoc'd with caffeine, anxiety, hunger. Not relieved by EtOH or Beta-blocker
    postural tremor
  223. this type of tremor is worse when approaching a target. Assoc'd with voice, chin tremors, also seen in MS.; Better with EtOH, Beta-blocker
    intention tremor
  224. This type of tremor worsens as it nears target, but if you ask them to touch their nose and touch your finger, as their finger gets closer to your nose, their finger goes in a circular, sinusoidal pattern like it's circling the earth; Worse with EtOH; no effect from beta-blocker
    cerebellar tremor
  225. rhythmic, repetitive, bizarre movements chiefly involving face, mouth, jaw, tongue.  Tardive is slow mvmts which can be 2ndary to meds used to treat schizo like Thorazine or Haldol (still used today); usually involves just face and tongue, not the limbs
    oral facial dyskinesia
  226. - loss or impairment of voluntary action
    - classically with a stroke, with a smile only one side is lifted, or with Bell's Palsy; usually damage to central or peripheral nerve
  227. - writhing, slow, sometimes seen with cerebral palsy, involves hands, feet, shoulders, hips
    - face and distal extremities
    - Ex: cerebral palsy
  228. - Sudden, brief, jerky, can't control it, like going to get a glass of water and they knock it over; involves face, hands, legs
    - can occur at rest or interrupt a normal movement
    - Ex: Huntington's
  229. Bizarre, grotesque, or twisted POSTURES...not something distal, but proximal, larger body parts, shoulder towards chin, stays stuck in that position, like torticolis (chin stuck over shoulder position). Can be caused by meds
  230. very common, twitchy, clearing your throat or blinking your eyes; if they become anxious or stressed, the tic manifests with greater frequency; there s no treatment, but Marinol (marijuana drug) has shown some improvement; Ex: Tourette's
  231. twitch right before you fall off to sleep; or generalized, Grand Mal seizure: flexion, extension of extremities
  232. shock like movements, like with a seizure
  233. ask pt to hold their arms/hands out and their hands flop down, called  liver flop b/c if you have acute encephalopathy and high ammonia levels, AMS, one of your exam findings will be this flapping action
  234. AKA scissor gait, specifically in pt s who have recovered from a stroke; one arm/hand/fingers slightly flexed (stroke on that side), they fling their affected leg around because they ve lost dexterity to lift leg/foot/ankle and bring it down gently, so they used larger muscles of hip and torso to lift leg and bring it forward
  235. Ex: stroke
    spastic gait
  236. assoc d with a foot drop; not a stroke or problem in brain, but a lumbar disc problem affecting L5 peripheral nerve that affects your foot/great toe; they can t lift up on their foot; pt c/o shooting pain down one leg and tripping over their foot; called marching gait b/c it slaps down on the ground b/c you can t elevate that foot appropriately; toes land first
  237. Assoc'd with lumbar disc herniation
    steppage gait
  238. sensory nerves of periphery (diabetic polyneuropathy or B12 polyneuropathy resulting in lack of sensation in the feet; walk with a wide gait and SLAM their feet down hard b/c their forcing vibration into those nerve endings to tell them where to place their feet; +Romberg s  eyes closed, arms out, they are unstable b/c their feet can t tell where they are in space; tend to look down to see where they re going
    sensory ataxia
  239. Staggering, widebased, unsteady: get out of bed and they fall back, or just to one side.
  240. Ex: if you ve had a stroke to this area, MCC
    cerebellar ataxia
  241. just from old age, decreased strength, walk more slowly, wide-based, tend to be hunched over, just to try to be stable
    senile gait
  242. rigid, short steps, quick shuffling steps, gradually faster shuffles and looks like they re going to run into you; Perched forward, very stiff, tend to stick their chin out. Stiff turns
  243. Ex: Parkinson's!!!
  244. Parkinson's pathophys is a lack of... in the...
    dopamine in the substantia nigra
  245. This finding is assoc'd with Parkinson's . There is a development of these hyalin things, a hard encapsulation around neurons that prevent continued production of dopamine
    "Lewy bodies"
  246. triad of classic ssx of Parkinson's
    • 1. rest tremors (pill rolling)
    • 2. Bradykinesia (slowness in deliberate movement), akinesia (decreased spontaneous movement), masked face (stare)
  247. 3. rigidity (cogwheel); Cogwheel rigidity: flex your elbow and you try to extend it but it s very rigid and clonic-like
  248. Management for Parkinson's, including drug
    goal of therapy is to delay progression of disease, relive symptoms, preserve function
  249. Leva-dopa effective for ~10 years
  250. prognosis for Parkinson's
    • slowly progressive
    • w.o treatment, 60% dyfxn @ 5 years, 80% @ 10years
  251. pathophys of Huntington's Dz: genetic? loss of..
    autosomal dominant genetic disease - if you get one allele, you'll develop this at some point
  252. neurodegenerative
  253. loss of the neurotransmitter GABA
  254. Huntington's is a genetic disease characterized by loss of...
    loss of the neurotransmitter GABA
  255. Describe the ssx for Huntington's Dz related to Movement, Cognitive, and Psychiatric
    Movement: chorea, dystonia, bradykinesia
  256. Cognitive: memory loss, global dementia, disheveled appearance
  257. Psychiatric: personality changes, irritability, apathy, depression, psychosis
  258. what 2 things do you do for the workup of Huntington's?
    • CT/MRI
    • diagnose with genetic testing
  259. management of Huntington's? meds?
    • supportive counseling
    • Tx chorea mvmt disturbance with Thorazine, Haldol
  260. No real meds, could use anti-psychotic to help with mvmt disorders, but you can t control the progression
  261. prognosis for Huntington's
    long, progressive, disabling course (10-25yrs)
  262. lose ability to fxn independently, must institutionalize
  263. Definition of seizure
    • a sudden, abnormal, and excessive discharge of neurons resulting in a clinical event
    • May have altered consciousness
    • May have motor/sensory phenomena
    • May have unusual cognitive perceptions
  264. what are the 2 types of seizures?
    • partial
    • generalized
  265. partial or generalized:
    • Focal, Localization-related
    • Origin: a point in the cerebral cortex
    • Consciousness maintained
    • Lasting seconds to minutes
    • Unilateral
    • Symptoms correspond to the location in brain
    • partial
  266. your seizure pt is having jerking of the left arm. where is his lesion and is this partial or generalized?
    R sided brain lesion, partial
  267. are partial seizures unilateral or bilateral?
    • unilateral
    • symptoms correspond to the location in the brain
  268. Partial seizure (simple or complex) or
    Generalized seizures (grand or petit mal):
  269. your pt is having paresthesias of left arm
  270. or twitching of face
  271. or entire side of body is twitching ("Jacksonian March")
    simple partial
  272. Partial seizure (simple or complex) or
    Generalized seizures (grand or petit mal):
  273. Your pt has AMS and is doing chewing motions
    Complex partial (aka temporal lobe)
  274. May also have a strange sense of unfamiliarity, opposite of D�j� vu
    • Depersonalization: step outside of body as a 3rd party observing
    • Originate in temporal lobe in hippocampus
  275. can your pt have a partial seizure with secondary generalization?
    yes, there is cortical spread deep to the diencephalon, then transferred to all parts of brain
  276. Partial seizure or
    Generalized seizures:
  277. lost consciousness, bilateral and symmetric shaking
  278. lasts seconds to minutes
  279. Both sides involved b/c it s deep in brain, diencephalon spreads to both sides
  280. when is the usual onset of generalized seizures? what age?
    onset usually in childhood
  281. Grand mal seizure is AKA...
    generalized tonic clonic
  282. Partial seizure (simple or complex) or
    Generalized seizures (grand or petit mal):
  283. Your pt presents with evidence of tongue biting, incontinence, and they have post icthal confusion. The mom states pt had a sudden loss of consciousness and then rigid and contracted muscles followed by jerking muscles.
    grand mal (aka generalized tonic clonic)
  284. which is tonic and which is clonic:
  285. -jerking
    • -all muscles are rigid and contracted
    • Tonic: all muscles are rigid and contracted
    • Clonic: jerking
  286. which type, Grand mal or petit mal, affects children and usually resolves by adulthood?
    absence, aka Petit mal
  287. Partial seizure (simple or complex) or
    Generalized seizures (grand or petit mal):
  288. affects children
    • lost consciousness
    • body posture and tone is maintained
    • smacking the lips or chewing or blinking the eyes
    • Petit mal, aka Absence seizure
  289. 5 item DDX for seizures
    • 1. syncope
    • 2. migraine aura
    • 3. TIA
    • 4. panic attack
    • 5. seizure
  290. Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:
  291. lost consciousness, within a minute afterwards, you are yourself and not post-icthal state
  292. Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:
  293. see lights or smells
    migraine aura
  294. Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:
  295. may last 5min to several hours, accompanied by paresthesias and numbness
  296. seizure is usually shorter-lived
  297. in the diagnostic workup of seizures, which imaging do you want to get now and which one do you want to get soon?
    • CT now (check for lesion)
    • MRI soon (regardless of CT is normal)
  298. name some first genration AEDs and their 2 main problems
    • Phenobarbitol
    • phenytoion (Dilantin)
    • carbamazepine (Tegretol)
    • Valproic acid (Depakote)
  299. problems: toxicity, drug interactions
  300. this first generation AED lowers your IQ
  301. name some second generation AEDs and the benefits of some
    • gabapentin
    • lamictal
    • Keppra
  302. benefits: same efficacy as 1st gen; fewer SE; fewer DIs
  303. What are the 2 characteristics of status epilepticus?
    • an unrelenting seizure:
    • -lasting >20 minutes or
    • -successive seizures without an interictal period
  304. what 2 types of seizures may develop into SE?
    • tonic clonic (Grand Mal)
    • Absence (Petit mal)
  305. Name some physical interventions and drug therapies for treatment of SE
    • physical:
    • -prevent pt from injury
    • -maintain airway w/o obstruction
    • -prevent aspiration
  306. Drug Therapy:
    • -Ativan IV
    • -Dilantin IV
    • -Valium rectal gel
    • -Thiamine, glucose to treat acidosis
  307. A localization-related seizure is also known as a __ seizure. It has focal manifestation in the body caused by a focal abnormality in the brain
  308. What differentiates a complex seizure from a simple seizure?
  309. Movements in a complex partial seizure are (coordinated/random jerking)?
  310. During a seizure, actions such as lip-smacking, blinking, or chewing are known as___
  311. bilateral and symetric movements are characteristic of a (partial/generalized) seizure?
  312. You examine a pt 10 minutes after a generalized seizure. Name some signs you expect to see on PE.
    • tongue biting
    • incontinence
    • post-ictal confusion
  313. febrile seizures are more typical of (adults/children)?
  314. seizures due to alcohol withdrawal typically begin how long after the last drink?
    12-24 hours
  315. trauma may produce seizures, especially head trauma with what features?
    • hemorrhage
    • skull fracture
    • LOC
  316. weakness of an arm after a seizure would be an example of "__ paralysis"
    Todd's paralysis
  317. Which of these features are suggestive of seizure rather than syncope? (focal neurologic deficit/cardiac arrhythmia/carotid disease/history of malignancy / urinary incontinence/tongue lacerations)
    • focal deficit
    • history of malignancy (with new brain met)
    • incontinence
    • tongue lac
  318. Which is more sensitive imaging study for evaluation of an anatomic brain lesion in a seizure pt? (LP/EEG /CT /MRI)
  319. What study is the most important diagnostic tool for definitive evaluation of seizure type? (LP/ EEG/ CT /MRI)
  320. If seizures are not well controlled on an AED, what would be the next step? (increase dose if possible/add second agent/switch to a different anticonvulsant)
    maximize the dose
  321. Drug interactions with AEDs are common and are often due to inducing or inhibiting what metabolic pathway?
    CYP 450
  322. oral contraceptives may be (more/less) effective in a pt on an anticonvulsant
  323. Name the 2 most commonly used antiepileptic drugs
    • phenytoin (Dilantin)
    • and carbamazepine (Tegretol)
  324. Alcohol use or binge drinking (improves/worsens) seizure control?
  325. classic triad of ssx for intracranial tumors?
    • 1. HA (worse at night, with valsalva)
    • 2. N/V (increased ICP activates emesis centers in brain)
    • 3. papilledema (increased ICP impairs outflow of venous blood from retina, causes congestion around optic disc)
  326. Local mass effect of intracranial tumors: pushes other brain structures out of the way; clinical result is ___
    focal neurologic deficit (this tumor may cause L sided weakness)
  327. Midline shift from intracranial tumor: mass is so large that it pushes whole contents of brain from right to left; its effect clinically: ___
    decreased level of consciousness
  328. UNCAL ("transtentorial") herniation: the uncus (medial aspect) of temporal lobe is forced over the edge of the tentorium... eventually it compresses the brain stem and kills you. But before that, how does it present clinically?
  329. Clinically: blown pupil; CN III branches off where the herniation is (medial temporal lobe), CNIII causes pupil to constrict, so with CNIII compression, you ll have unopposed dilatation
  330. both upper and lower motor neuron spinal tumors present with these 2 ssx
    weakness, atrophy
  331. (Upper/lower) motor neuron tumor presents with hyperreflexia and spasticity?
  332. (upper/lower) presents with hyporeflexia and fasciculation)
  333. cauda equina presents with what 3 ssx?
    • saddle anesthesia
    • bladder/bowel incontinence
    • loss of anal sphincter tone
  334. the most common primary brain tumor
  335. name the 4 primary CNS tumors
    1. glioma (astrocytoma, oligodendroglioma, ependymoma)
  336. 2. Meningioma
    • 3. Pituitary Adenoma
    • 4. Acoustic Neuroma
  337. Glioma recurrence is (common/uncommon) post-treatment
    common recurrence after tx, because they spread go much and permeate into surrounding brain
  338. 1. Glioma
    • 2. Meningioma
    • 3. Pituitary Adenoma
    • 4. Acoustic Neuroma
  339. which primary CNS tumor originates from neuroglia like astrocytes, oligodendrocytes, ependymal cells?
  340. 1. Glioma
    • 2. Meningioma
    • 3. Pituitary Adenoma
    • 4. Acoustic Neuroma
  341. Which arises from the arachnoid of meninges?
  342. usually benign, recurrence rare
  343. 1. Glioma
    • 2. Meningioma
    • 3. Pituitary Adenoma
    • 4. Acoustic Neuroma
  344. Which one has a high recurrence rate post-treatment?
  345. 1. Glioma
    • 2. Meningioma
    • 3. Pituitary Adenoma
    • 4. Acoustic Neuroma
  346. Which one is usually benign and has a low recurrence rate?
  347. This type of pituitary adenoma presents with bitemporal hemianopsia. Accompanying the visual changes is hypopituitary fxn
  348. This type of pituitary adenoma causes amenorrhea and galactorrhea in females and decreased libido and impotence in males
    secreting prolactinoma
  349. what are the 3 types of secreting pituitary adenomas?
    • 1. proliactinoma
    • 2. GH secreting (Acromegaly)
    • 3. ACTH secreting (Cushing's Dz)
  350. this type of pituitary adenoma causes acromegaly
    GH secreting pituitary adenoma
  351. this type of pituitary adenoma causes Cushings Disease
    ACTH secreting
  352. Most common peripheral nerve tumor in the head
    acoustic neuroma
  353. classic triad of ssx for acoustic neuroma?
    • 1. unilateral hearing loss
    • 2. tinnitus
    • 3. vertigo
  354. Your pt presents with:
    • 1. unilateral hearing loss
    • 2. tinnitus
    • 3. vertigo
  355. Dx?
    acoustic neuroma
  356. what other CN ssx (2) may accompany acoustic neuroma?
    • CN VII - hemifacial weakness
    • CV V (hemifacial numbness)
  357. what are the 3 most common primary sites for metastatic brain tumors?
    • lung
    • breast
    • melanoma
    • RCC
  358. __% of spinal tumors are benign
  359. 3 classifications of spinal tumors
    • extradural
    • intradural, extramedullary
    • intradural, intramedullary
  360. Which classification of spinal tumors:
    • Metastatic tumors
    • Hallmarks: cord compression, bony destruction
    • Symptoms: local back pain esp at night
    • extradural
  361. which classification of spinal tumors:
    • Example: Schwannoma, meningioma
    • Symptoms: nerve root symptoms (radiculopathy)
    • intradural, extramedullary
  362. which classification of spinal tumors:
    • Glioma
    • Ependymoma (line the ventricles, classic location is at the end of the spinal cord, L1)
    • Astrocytoma
    • Symptoms: cord compression (myelopathy) or nerve root (radiculopathy)
    • intradural, intramedullary
  363. where is the classic location for an ependymomal glioma spinal tumor? (intradural, intramedullary)
    ependymal cells line the ventricles, so as they combine with the spinal cord, gravity pulls them down toward the end of the spinal cord, classic location is at end of spinal cord at L1
  364. You find a clump of abnormal tissue at the end of the spinal cord, what classification is it almost always?
    ependymoma (intradural, intramedullary)
  365. the most common solid tumor of childhood
    brain tumors from leukemia
  366. in childhood brain tumors, the majority are supra-or infratentorial?
  367. A 12 y/o awakes with a HA most mornings for 2 weeks. Funduscopic exam shows papilledema, and a CT scan shows a mass causing an obstructive hydrocephalus. Based on these findings, and knowing the incidence of various tumors in children, you are not surprised at the location in the
    • a. supratentorial compartment
    • b. infratentorial compartment
    • c. cervical spinal cord
    • d. cauda equina
    • b. infratentorial
  368. A pt with visual field defects is found to have a pituitary tumor. The next step toward diagnosis of the tumor type would be a lab study of
    • a. CBC w/diff
    • b. serum checmistry panel
    • c. endocrine panel
    • d. osmolality of blood serum and urine
  369. c. endocrine panel
  370. Stereotactic radiosurgery (focused radiation) is an appropriate first line tx for
    • a. AV malformations
    • b. intracerebral hematoma
    • c. glioblastoma
    • d. pituitary adenoma
    • a. AV malformations
  371. A pt reports mid back pain awakening him at 4am for 2 weeks. He has no prior muscular or skeletal complaints and denies trauma. PE shows point tenderness at the T7 spinous process, but no neurologic abnormalities. The imaging study you would order first would be
    • a. intravenous pyelogram
    • b. MRI
    • c. myelogram with post-myelogram CT
    • d. plain x-rays of T spine
    • d. plain x-rays of T spine
  372. A 56 y/o man has imbalance after arising from a chair. W/u for postural hypotension was negative. Your exam demonstrates no ataxia, dysmetria or dysdiadochokinesis An MRI shows a mass in the infratentorial compartment, abutting the cerebellum and pons. Which study is most appropriate for further w/u of this tumor?
    • a. audiometry
    • b. formal visual field testing
    • c. endocrine studies including GH, prolactin, serum cortisol and TSH
    • d. CT scan of chest and abdomen
    • a. audiometry
  373. This tumor accounts for 40-50% of all intracranial tumors. It arises from the supporting cells of the CNS. Complete resection is generally not possible because extensions of tumor penetrate surrounding brain tissue
    • a. glioma
    • b. meningioma
    • c. pituitary adenoma
    • d. acoustic neuroma
    • a. glioma
  374. This tumor is well circumscribed, generally benign, and amenable to total resection. Recurrence is uncommon. It arises from the arachnoid. It is more prevalent in females than males.
  375. a. glioma
    • b. meningioma
    • c. pituitary adenoma
    • d. acoustic neuroma
    • b. meningioma
  376. A pt complains of low back pain radiating to the right posterior thigh, with numbness at the right heel and lateral foot for several months. Now for 2 days he has new scrotal numbness, difficulty initiating micturation, and incomplete voiding. The most significant PE to perform is
    • a. plantar stroke for Babinski's sign and rapid ankle dorsiflexion for clonus
    • b. DTRs at knees and ankles
    • c. digital rectal exam and perianal sensory exam
    • d. motor exam for weakness, fasciculations, and muscle atrophy
    • c. digital rectal exam and perianal sensory exam
  377. Match the signs and ssx with tumor location
  378. cerebellum
    • temporal
    • frontal
    • parietal
    • occipital
  379. a. depression and outbursts of anger
    • b. loss of upper quadrant of right visual field
    • c. seizure with tonic-clonic activity beginning in the left arm
    • d. staggering gait and loss of balance while standing
    • e. a cooperative pt does not understand or follow commands
    • d, e, a, c, b
  380. Many HA can be diagnosed and treated w/o CT or MRI. However, you would need to order a CT or MRI to w/u a new HA assoc'd with any of these situations except
    • a. a first-ever seizure in a 36 y/o male
    • b. band-like head pain worse in the afternoon
    • c. lethargy wit N/V
    • d. spasticity of left arm and leg with ankle clonus
    • b. band-like head pain worse in the afternoon
  381. Brain tumors cause ssx based on local mass effect and general increase in ICP. Which of the following is/are manifestations of increased ICP leading to possible brain herniation and death?
    • a. cranial nerve dysfunction such as a fixed and dilated pupil or weakness of temporal gaze
    • b. muscle weakness with fasciculations and depressed reflexes
    • c. confusion, irritability, and restlessness
    • d. acromegaly with prominent brow, nose, and mandible
    • e. a and c
    • f. a, b, and c
    • e. a and c
  382. Migraine, Cluster or tension:
    • pain is in and around only one eye
    • cluster
  383. Migraine, Cluster or tension:
    • pain is like a band squeezing the head
    • tension
  384. Migraine, Cluster or tension:
    • pain, nausea, and visual changes are typical of the classic form
    • migraine
  385. Sudden onset: Severe or persistent headache that reaches maximum intensity in a few seconds or minutes... makes you think what?
    subarachnoid bleed
  386. No similar headache in the past?
    •  FIRST or  WORST warrants further evaluation
    • Suggests __ or __
    • intracranial hemorrhage or CNS infection
  387. do this imaging If suspected hemorrhage (superior to MRI for identifying bleeds)
    • Sinuses
    • Tumor
    • CT scan
  388. do this imaging if you need more detail of soft tissues, brain stem, cerebellum and medulla
    • Tumor
    • Aneurysm, AV malformations, vascular abnormalities
    • MRI
  389. migraines usually last from __ to __ hours
    4-72 hours
  390. associated ssx for migraines (5)
    • nausea
    • vomiting
    • photophobia
    • pnonophobia
    • lightheadedness
  391. Dx:
  392. - Unilateral
    • - Pulsating sensation
    • - Moderate to severe intensity
    • - Aggravated by physical activity
  393. During headache, at least one of the following:
    • - nausea and/or vomiting
    • - photophobia or phonophobia
    • migraine without aura
  394. non-medical tx of migraines?
    • Avoidance and Nonpharmacologic measures
    • Stress reduction
    • Regular exercise
    • Relaxation techniques
    • Counseling
    • Avoid triggers (nitrite rich foods, EtOH, chocolate, strong smells, etc.)
    • D/C of birth control pills is necessary for some women
  395. prophylaxis should be used for migraines if the occur how often?
    if HA occurs weekly
  396. 5 prophylactic meds to try if migraines are more than once a week
    • 1. beta blockers
    • 2. calcium channel blockers
    • 3. NSAIDS
    • 4. TCA
    • 5. Anticonvulsants
  397. This migraine prophylaxis is especially helpful for menstrual migraines
    NSAIDs - cox 1 and 2
  398. This migraine treatment are potent vasoconstrictors of cerebral and coronary arteries
  399. Act by constriction and inhibition of neurogenic inflammation
  400. If used too frequently can cause rebound
  401. CONTRAINDICATED if MAO inhibitors use, uncontrolled HTN, CAD and pregnancy
  402. Migraine, cluster, or tension:
    • Vascular headache
    • Unilateral
    • Usually temporal or periorbital
    • Severe
    • Brief duration  moments to hours
    • Cluster in groups of headaches
    • Nonthrobbing
    • Described as boring or tearing sensation
    • cluster
  403. these HA occur frequently at night and 90% occur in men
    cluster HA
  404. migraine, cluster or tension:
    • Onset usually occurs 2-3 hours after sleep initiation and associated with REM sleep
    • cluster
  405. 4 triggers for cluster HA
    • 1. alcohol
    • 2. stress
    • 3. change in climate
    • 4. hay fever
  406. these are some treatments for cluster HA because the cause vasoconstriction
    • ergotamines
    • triptans
  407. combine these with 100% O2
  408. This is pt ed notes for which type of HA:
    • Avoid triggers
    • Disturbances in sleep may trigger
    • Strong emotions and excessive exercise may induce
    • Tobacco will slow medication responsiveness
    • Narcotics may induce chronic cluster
    • cluster
  409. Migraine, cluster, or tension:
    • Most common headache
    • Occurs in 40-60% of US population
    • 9th most common reason for medical visit
    • Occurs more frequently in females
    • Most occur after age 20
    • Rare to start after age 50
    • Likely to occur during times of increased stress or emotion
    • May occur with migraine
    • tension
  410. tension or cluster:
    • which is unilateral, which is bilateral?
    • tension is usually bilateral
    • cluster is usually unilateral
  411. Migraine, cluster, or tension:
    • Usually bilateral
    • Dull Pain
    • Frontal/Occipital/Nuchal
    • Mild to moderate intensity
    • Worsens as the day progresses
    • Described as a pressure or band like or vice like sensation
    • tension
  412. Migraine, cluster, or tension:
    • Duration 30 min to 7 days
    • No nausea or vomiting
    • Phono/Photophobia
    • Insomnia
    • Not aggravated by activity
    • No prodrome
    • Difficulty concentrating
    • Chronic vs. episodic
    • tension
  413. Migraine, cluster, or tension:
    • -May have tenderness over scalp or neck, but not temporal arteries
    • -May have tightness of the neck muscles or upper back (ie. Trapezius muscles)
    • -Tightness of muscles may cause pain with ROM, but NO NUCHAL RIGIDITY
    • tension