Systems - Neurology/Ophtho
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. What would you like to do?
A patient comes in with "dizziness", how would you differentiate syncope from vertigo? What are the main causes of each?
- -false sensation of movement
- -"room is spinning"
- -neuro disease
- -weak, palp., SOB
- -cadio disease
You've established a patient has vertigo, how would you differentiate central from peripheral?
- -hearing intact/tinnitus and hearing loss
- -"neighbourhood signs" (diplopia, cortical blind, dysarthria, etc)/no neighbourhood signs
- -Vertical nystagmus, doesn't suppress with fixation/ horizontal nystagmus, suppresses with fixation
How would you test if someone's strabismus was a tropia or a phoria?
The cover-uncover test: if there is deviation only while one eye is covered this is a phoria. Phoria's are corrected by the fusion mechanism
Name the four deviations in strabismus
- exo: lateral
- eso: medial
- hyper: upwards
- hypo: downwards
What is amblyotropia and how do you treat
reduction of cortical innervation from one eye. If you catch it before age 9 it can usually be corrected with patching
Difference in etiology between comitant and non-comitant strabismus
comitant (angle difference constant with gaze)
Incomitant (angle varies with direction of gaze): usually due to a neuro-muscular problem or a mechanical problem
What are the underlying mechanism's in Duane's syndrome and Brown's syndrome?
- duane: bad innervation by CN VI
- brown: short superior oblique tendon
How can you identify a CN III palsy? When is this an emergency? Why?
eyes are down and out, there is ptosis, possible pupil dilation
An emergency when there is pupil dilation, suggests posterior aneurysm
What eye motions does the superior oblique normally produce? What do you see in a CN IV palsy?
SO-LID mnemonic: (Int. rot.; lateral deviation, downwards deviation)
Eye is in and up (patient tilts their head away from the affected eye to compensate)
What should you be thinking if you see bilateral CN II, IV, VI palsy?
Why is the pupil not involved in myasthenia gravis?
Because it is not skeletal muscle
Why is it so important to get the red reflex in a newborn?
test for congenital cataracts. Can cause ambylopia if left untreated.
How would you recognize orbital cellulitis? How big of a deal is this? How would you investigate/treat?
Recognize: proptosis, fever, decreased ocular mobility, conjunctival injection
CT, IV abx, surgical drainage
What should you think of in a child 3-9 months old with symmetric contractions of neck, trunk, and extremities? Causes? How would you investigate? Prognosis?
- -Infantile spasms (West's)
- -20% have unknown etiology and good response to tmt
- -80% are due to metabolic or dev abnormalities, these are associated with poor prognosis and retardation
- -do an EEG and look for hypsarrhythmia
What are the risk factors for epilepsy in children with febrile seizures (4)?
- -duration longer than 15 mins
- -recurrence of more than one seizure within 24 hours
- -focal features present
- -dev. delay or abnormal CNS exam
You see a 5+ female patient with episodes of blank stare and short, sudden, cessation of motor and speech. What are you thinking this is? Investigations? prog? tmt?
- -Absence seizures
- -Do an EEG looking for spike and wave discharge
- -Good prognosis (2/3 grow out)
- -ethosuxamide or valproic acid
You see a 4-12 year old male with facial seizures, with following aphasia. What are you thinking? Where in the brain is this? When does it happen most often? prognosis? tmt?
- -benign rolandic seizures
- -happens around the central (rolandic) sulcus (why the face is involved)
- -most often happens nocturnally
- -AWESOME prog, responds to tmt and stops at puberty
- -if frequent seizures: carbamazepine, otherwise no tmt
What is often misdiagnosed as colic in newborns?
4 causes of symptomatic infantile spasms
- -tuberous sclerosis
- -perinatal insult
- -brain malformation
- -TORCH infection
What is the triad for lennox-gastaut syndrome?
- 1) multiple seizure types
- 2) mental retardation
- 3) Slow EEG (spike and wave)
What is the treatment for lennox-gastaut? (5)
- -valproic acid
- -ketogenic diet
- -Vagal nerve stim.
- -corpus callostomy
-generally a poor prognosis
3 imitators of epilepsy in kids, most common is?
- 1. reflex anoxic seizures (most common)
- 2. vasovagal syncope
- 3. breath holding spells
What are the three things you see in a vasovagal syncope aura
- greying of vision
These are all Sx of cerebral ischemia
If you hear of someone passing out with pallor, sweating, and brief myotonic jerks what are you thinking?
Two types of breath holding spells
- pure resp (cyanotic): they turn blue
- mixed: apnea and bradycardia
How would you differentiate a tic from chorea?
- tics can be accurately reproduced and described by observer
- tics can be voluntarily suppressed and are not incorporated into voluntary movement
What two autosomal dominant conditions are tourette's associated with?
ADD and OCD
Definition of tourette's (4 points)
- 1. presence of motor AND vocal tics at some point in illness
- 2. Sx longer than a year with no more than 3 month tic-free period
- 3. less than 18 y.o.
- 4. no other obvious tic causes
How would you treat meibonian gland dysfunction? Staph. blespharus?
use a warm compress and lid cleaning for both
topical Abx for blespharus
In conjunctivitis, what does it usually mean when you see swollen follicles (lymph. germinal centres)
Usually either viral or chlamydial conj.
In conjunctavitis, what does it usually mean if you see swollen papillae (swollen BV's)
usually in allergic and bacterial conjunctavitis
What are two STI's that are responsible for conjunctivitis
-gonorrhea and chlamydia
What are the 4 types of discharge in conjunctavitis and what causes each
- mucoid: allergic
- watery: viral
- purulent: bacterial
- mucopurulent: chlamydial
What is a common cause of giant papillary conjunctavitis (part of allergic conjunctavitis)
mucus debris on soft contact lenses
Difference between episcleritis and scleritis
- episcleritis: local, can treat with topical steroids, not as serious
- scleritis: usually a manifestation of a rheum. disease (Wegerners, SLE, etc), need to treat systemically (too deep), close to retina so it is serious
You have a patient come in with keratitis that has a dendritic pattern under fluorescent dye. What are you thinking? How would you treat? How would you NOT treat?
- -HSV keratitis
- -treat with oral acyclovir/topical antivirals
- -DO NOT USE STEROIDS!!! It will make the infection/scarring worse
You see progressive thinning and bulging (coning) of a cornea. What are you thinking? What conditions is this associated with? How do you treat?
- - Keratoconus
- - associated with atopy and Down's
- - structural contact lenses, karatoplasty (corneal transplant)
What does corneal arcus look like? Who is commonly affected? what can it indicate?
- -a hazy lipid ring on the periphery of the cornea
- -common in 50+
- -hypercholesteremia if see in <40 y.o. patients
What are the three types of retinal detachment
- 1. rhegamatogenous (tear or hole in the neurosens retina allows vitreous fluid to enter)
- 2. tractional (neurosen retinal is pulled from the RPE
- 3. exudative (damage to RPE causing edema and swelling)
Describe the two stages of diabetic retinopathy
1. non-proliferative: increased vascular permeability, microaneurysms, retinal hermorrhages, etc
2. proliferative: much more serious, the retina is ischemic and as a response the body releases angiogenesis factor which causes neovascularization. Optic nerve becomes covered and there are vitreous hemorrhages
How often should diabetics see an opthalmolagist, how can they treat proliferative diabetic retinopathy?
- once a year
- treat by panretinal photocoagulation
Describe the two stages of Age-related macular degeneration. How would you treat 2?
1. non-exudative "dry" ARMD: slow progression, drusen (yellow-white spots), RPE atrophy, slow time course
2. Exudative ("wet") ARMD: ruptures in Bruch's membrane and choroidal neovascularization, edema/hemorrhages under retina (can lead to RD), faster/more severe (weeks-months)
-use laser photocoagulation for neovasc
What would you do if someone came in with sudden, painless, monocular loss of vision? What are you thinking? How could you differentiate?
Central Retinal Artery Occlusion: ophlal. exam shows pale retina with cherry red spot a fovea. AN EMERGENCY (only 90 mins to treat)!! Check the carotids for embolism source
Central Retinal Vein Occlusion: ophthal. exam shows swelling of the disc, venous dilation, retinal hemorrhages.
What is a potential complication of Central Retinal Vein Occlusion?
neovascularization. Treat with photocoagulation.
What is the triad for Retinitis Pigmentosa?
- Bony spicule
- Optic disc pallor
- Arterial narrowing
First line treatment for partial seizures (2)
- phenytoid (Dilantin)
First line tmt for generalized seizures
What is the advantage of lamotrigine over older AED's? How do the efficacies compare? Major (although rare) side effect
Fewer side effects, same efficacy, Stevens-Johnson syndrome
When would you give Levetiracetam to an epileptic patient?
works for generalized seizures, use in people with hepatic problems (metabolized in kidneys)
What is first line treatment for status epilipticus, other than treating the underlying cause
benzodiazepines (lorazepam, diazepam,etc)
What is the best AED to give in pregnancy?
Sugery is far superior than medical management in which type of epilepsy?
What are the 9 levels in neuro?
- 1. Cerebral hemispheres
- 2. Basal ganglia
- 3. Cerebellum
- 4. Brainstem
- 5. Spinal Cord
- 6. Motor Neuron
- 7. Peripheral Nerve
- 8. NMJ
- 9. Muscle
What is the prototype disease and cardinal features of:
1. Cerebral Hemispheres (0,5)
2. Basal Ganglia (1, 3)
3. Cerebellum (1, 3)
- 1. Proto: none; CF: dementia, seizures, aphasia, neglect, hemianopia
- 2. Parkinson's ; TRI - Tremor, Rigidity, Involuntary movements
- 3. Alcohol; ataxia, nystagmus, dysarthria
What is the prototype disease and cardinal features of:
4. Brainstem (1, 3)
5. Spinal Cord (1, 3)
6. Motor Neuron (1, 3)
- 4. Stroke; diplopia, vertigo, crossed sensory loss
- 5. Trauma; paraparesis, sensory level, incontinence
- 6. ALS; weakness, atrophy, fasiculations
What is the prototype disease and cardinal features of:
7. Peripheral Nerve (1,2)
- 7. Diabetic Neuropathy; Stocking-glove, decreased reflexes
- 8. MG; PD3 - ptosis, diplopia, dysarthria, dysphagia
- 9. Myositis; proximal symmetrical weakness
How can you differentiate UMN from LMN?
(4, think of chronic vs acute)
- - both have weakness
- - Acutely both are hyporeflexic and decreased tone
- -UMN: spastic, increased tone, hyperreflex
- -LMN: atrophy, fasiculations
- -Upwards Babinski is always UMN (chronic or acute)
What are the 4 types of focal neuropathology?
- Stroke, Trauma, Tumor, MS
What are the 5 types of diffuse neuropathology
- 1. congenital
- 2. nutritional/toxic
- 3. Metabolic/endocrine
- 4. Infectious/inflammatory
- 5. Degenerative
What are the 7 parts of the neurological exam?
- 1. Mental Status
- 2. Cranial Nerves
- 3. Motor
- 4. Reflexes
- 5. Sensory
- 6. Coordination
- 7. Gait
Describe the path of the corticospinal tract (5 steps plus decussation)
- 1. primary MC
- 2. Internal Capsule
- 3. brainstem
- //decussates at the pyramids (inferior medulla)
- 4. lateral CS tract
- 5. synapses at the anterior horn
Describe the path of the spinothalamic tract (pain, temperature) (5 steps)
- 1. Primary sensory neuron enters posterior horn
- 2. synapses with the secondary neuron and decussates to the anterior horn
- 3. ascends in contralateral anterolateral spinothalamic tract.
- 4. synapses with tertiary neuron in thalamus
- 5. internal capsule to primary sensory cortex
Describe the path of the dorsal column tract (vibration, proprioception, light touch) (5 steps plus decussation)
- 1. Primary sensory neuron enters posterior horn
- 2. goes up ipsilateral dorsal column
- 3. synapses with secondary neuron in the nuclei located in the medulla
- /// decussates to the contralateral side///
- 4. Ascends in the contralateral medial lemniscus, synapses with tertiary neuron in the thalamus
- 5. travels to the primary sensory cortex via the internal capsule
Describe the path of the oculosympathetic pathway. ipsilateral or not?
- 1. hypothalamus down lateral brainstem
- 2. synapses with secondary neuron at C8-T1, exits via T1
- 3. ascends in sypathetic chain to carotid sheath/bulb
- 4. synapses with tertiary neuron and enters cavernous sinus
- 5. goes to eye with CN V1
Describe the glasgow coma scale
- -Eye opening: spontaneous, to voice, to pain, none
- -Verbal: Appropriate, confused, inappropriate, incomprehensible, none
- -Motor: Obeys, localizes, withdraws, decorticate, decerebate, none
What is cushings triad, and what does it caused by?
- Caused by end stage ICP elevation
- 1. HTN
- 2. bradycardia
- 3. irregular resps
Describe decorticate and decerebrate posturing and what they mean (in terms of red and vestibular nuclei).
- -Red nucleus causes primitive flexing of arms. Stronger than vestibular
- -the lower vestibular nucleus causes primitive extension of the arms AND legs
- -The higher cortex usually balances the two
- -decorticate: flexed arms, extended legs (too much red, just the cortex is lost)
- -decerebrate: extended arms and legs (lower lesion, no more red input either)
What is a good way to check if the brainstem is intact in a comatose patient
- -inject cold water into one ear
- -suppresses vestibular nuclei on that side
- -patient looks TOWARD the cold water side
- -If both eyes don't look over, brainstem lesion
Besides the VOR, what are two other brainstem reflexes?
Corneal, pupillary light reflex
What are the three components of ICP
blood, brain, CSF
What does an uncal herniation cause?
a "blown pupil"
-compresses CN III, causing ptosis and big pupil
What is the DDX in coma?
- The five causes of diffuse neuro symptoms
- 1. Congenital
- 2. Metabolic/nutritional: thyroid, lytes, glucose
- 3. Nutritional/toxic: wernike's encephal., drug OD
- 4. Infections/inflamm: meningitis, encephalitis, etc
- 5. Degenerative: CJD, Alzheimer's
What is the DDx of dementia (8)?
- Delerium (acute)
- Depression (pseudodemensia)
- Pseudopseudodemensia (worried well)
- vascular dementia
- Lewy Body dementia
- FT dementia (Pick's disease)
- metabolic probs
- mild cognitive impairment
Describe classic FT demntia. What type of therapy DOESNT work?
- 1) Bahaviour probs
- 2) progressive non-fluent aphasia
- 3) semantic dementia
- -NOT a cholinergic problem, unlike the other dementias
What are the 4 A's and one D in AD?
- anterograde amnesia
- Disturbance in exec function
Treatment for Alzheimer's Disease? (3 categories)
- -AChE inhibitors: Donepezil, Rivastigmine, Galantamine
- -Memantine (an NMDA receptor antagonist)
- -Sx management
What are the two areas than can be affected in Coma?
- -Bilateral cortex
- -Brainstep/thalamus ascending pathways
What are the 4 cardinal things you see in Parkinson's? (need 2 do diagnose)
- Rigidity (cogwheel)
- Instability (postural)
- Tremor (resting)
What are the causes of tremor (5)?
- 1) ET
- 2) PD
- 3) Metabolic - thyroid, hypoglycemia
- 4) Drug-induced
- 5) Structural - Basal ganglia, cerebellum
Describe the three types of tremor.
- 1) resting - tremor with limbs supported (PD)
- 2) Postural - tremor when limbs are held out against gravity (ET, drugs, etc)
- 3) Kinetic (action/intention) - tremor at the end of finger to nose, cerebellar probs
How do you differentiate ET from PD
What are the three most common causes of dementia?
- 1) AD
- 2) DLB (lewy bodies)
- 3) Frontotemporal
There are 4 things that characterize lewy Body dementia. What are they
- If you have two or more of the following DLB is probable.
- -fluctuating cognition
- -visual hallucinations
- -sleep probs, response to neuroleptics (antipsychotics)
List the five upper limb nerves, and their function (both motor and sens)
List the 6 nerves of the lower limb, and their function (both motor and sens)
List two (each) common arm and leg mononeuropathies
- -Carpal tunnel syndrome
- -ulnar nerve compression at the ulnar groove
- -peroneal nerve compression
- -femoral nerve compression
Causes of acquired axonal neuropathies (acute = 1; chronic = 5) (aka peripheral neuropathy)
- acute: vasculitis
- chronics: DM2, B12, hypothyroid, alcohol, drug-related
How do you treat an essential tremor?
- get them to stay away from caffeine
- beta blockers
If you see PD with eye problems what should you be thinking?
Progressive Supranuclear Palsy
If you see parkinsonian features with orthostatic HTN what should you be thinking?
Name two motor neuron diseases
ALS and polio
treatment for MG
- meds: AChEi's (e.g. pyridostigmine), prednisone, IVIg, plasmapheresis
- Surg: removal of the thymus
Signs of myopathy (6)
- -muscle wasting and weakness
What are myopathies characterized by?
- -proximal, symmetrical weakness
- -absent sensory changes
List three hereditary dystophies
- -limb-girdle: hutterites
- -oculo-pharyngeal: french canadians
Three types of inflammatory myopathy
- Inclusion body myositis
Three major tests you should order for investigating a myopathy
- 1) CK levels
- 2) EMG
- 3) Muscle biopsy
List some metabolic/drug reasons for myopathy
- Drug: statins, steroids
- Metabolic: got no GLAM (glucose, lipids, adenine nucleotides, mitochondria)
3 common causes of peripheral neuropathy
- 1) Diabetes
- 2) B12
- 3) alcohol
a predisposition to recurrent spontaneous (unprovoked) seizures. JUST ONE DOESN"T COUNT!
What is the prevalence of epilepsy?
Why is epilepsy prevalence high in the young and the old?
- young: hypoxia
- old: stroke
What are some precipitating factors for seuzures (10)?
- -sleep deprivation
- -non-compliance with AEDs
- -drug withdrawls
- -rec drugs
- -flashing lights
Types of seizures (partial - 3; generalized - 6)
partial: simple, complex, secondary gen.
generalized: myoclonic, clonic, tonic, tonic-clonic, absence, aclonic
Describe the prototypical patient in a complex partial seizure. Where do they often arise.
lip smacking, impaired LOC, post-ictal confusion.
Temporal lobe usually
What do you see in a frontal lobe seizures
- -bizarre bimanual activity
- -short duration
- -rapid onset
Describe a patient who is having a tonic-clonic seizure
clonic movements, loss of consciousness, incontinence. Confusion and fatigue follows
What do you see in a pseudoseizure that you dont see in a real seizure
- -can reproduce with suggestion
- -only during the day
- -usually witnesses
- -may be prolonged
What do you see in syncope that you don't see in seizure (5)?
- -they are universally brief
- -upright makes it worse
- -daytime only
- -usually no incontinence
When you see a patient with facial wasting, distal wasting, and problems releasing grip what should you be thinking? How do you treat?
no cure, but can treat myotonia with phenytoin
How do you diagnose MS?
Attacks separated in time (need 2+ attacks, 30+ days apart) and space (different spots)
What are lhermitte's symptom and uhthoff's phenomenon in MS diagnosis?
- 1)Lhermitte's: does bending your head forward hurt? YES! feels like an electric shock
- 2) Uhthoff's: Sx worse in a hot tub
What clinical investigations would you use to diagnose MS? Results
- 1) MRI: multiple, periventricular white matter lesions
- 2) CSF: pleocytosis, IgG elevated, at least 2 oligoclonal bands that are not found in the serum
What do steroids do in MS?
shorten the duration of an attack, need to taper them after. do not alter disease course once you reach the progressive stages of MS
What do immunomodulators (like Avonex, Betaserone, etc) do in RRMS?
-increase the amount of time between attacks, which slows the progression of the disease
What are the subtypes of MS, describe each
What are the 3 red flags in MS
- -frequent attacks in the early years
- -early accumulation of disability
- -many plaques on MRI
What are the major Sx in MS
- 1) Spasticity
- 2) Pain
- 3) Fatigue
- 4) Weak, urgent bladder
What type of optical problems do you see in an MS attack?
optic neuritis causing an afferent pupillary defect
Describe what you see in internuclear ophthalmoplegia? Where is the lesion? What is the most common cause?
- -Most commonly caused by MS
- -Lesion is in the MLF
What do you often see when someone comes in with a TIA?
- -transient blindness on ipsilateral side (amaurosis fugax)
- -symptoms resolve in < 24 hours
Which Sx put a TIA patient at high risk for ischemic stroke? (3)
- -motor defect
- -speech defect
- -Atrial fibrillation
How do you treat TIA? (4)
- -anti-platelet therapy
- -prevent further clots
- -stenting if needed
Subtypes of ischemic stroke (5)
- 1) Atherosclerosis
- 2) Lacunar infarcts (chronic HTN, DM, high chol)
- 3) Cardiac or aortic emboli (thromboemboli, atheroemboli, infectious emboli, paradoxical emboli (due to PFO))
- 4) Hypercoagulable states
- 5) Carotid dissection
What signs and symptoms would you expect to see in a stroke of the: MCA, ACA, PCA
- MCA: aphasia (dom), neglect (non-dom), contralateral upper body motor and sens probs, looks to side of lesion
- ACA: contralateral leg issues, personality changes
- PCA: dyslexia, homonymous hemianopsia
What signs would you see in a stroke of the:
- basilar: locked in syndrome, crossed weakness and sensory probs (ipsilateral face and contralateral body)
- PICA: lateral medullary (wallenburg) syndrome
4 mainstays of ischemic stroke tmt
- -tPA (within 3 hours of onset)
- -intra arterial thrombolysis
- -monitor for increased ICP
What are the risk factors for intracerebral hemorrhage (3)? what imaging?
- HTN, AVM, tumor
- non-contrast CT
What is the common presentation for SAH? What investigations? Tmt?
- -Worst headache of my life, thunderclap
- -non contrast CT, then an LP looking for RBCs if you still suspect SAH and CT is -ve
- -prevent rebleeding by decreasing BP, clip an aneurysm if present, prevent vasospasm with CCBs
How would you treat a venous sinus thrombosis?
blood thinners (IV heparin, LMWhep)
List 7 red flags for a patient coming in with a headache
- -First Worst Sudden onset (thungerclap)
- -neurological findings
- -Change in pattern
- -new onset after middle age
- -rapidly progressing
- -cancer Hx
- -recent head trauma
How would you differentiate migraine without aura and tension type headaches (6 categories)
Describe the prototypical patient with cluster headaches
25 year old male that wakes up with unilateral periorbital pain, runny nose, and ipsilateral tearing.
What are 5 common triggers of migraines?
- -Food (MSG, cheese, fruit, caffeine)
- -weather changes
- -lack of sleep/poor diet
How do you treat migraines acutely, prophylactically? When do you need prophylaxis?
- -NSAIDs (+gravol) and Triptans
- Prophylaxis (>15 per month):
- -TCAs, beta-blockers, AEDs
What types of things would you expect to see in peripheral vertigo? Central vertigo?
- Peripheral: ear symptoms, nystagmus (horizontal, increases when looking away from lesions, suppresses with fixation, slow and fast phase)
- Central: neighborhood symptoms, nystagmus (no fatigue, vertical and/or horizontal, increases when looking towards lesion)
Regarding duration, hearing loss, tinnitus, and aural fullness differentiate:
Clinical presentation of brainstem lesion
- 1C - cranial nerves (crossed findings)
- 4D's - Diplopia, Dysarthria, Dysphagia, Dizziness (vertigo)
How do you treat a cluster headache?
acute: O2 and sumatripan
Prophylaxis: Verapamil, prednison, valproic acid
What are 4 general measures you can take to manage stroke in almost any patient?
- 1) lifestyle changes: <2300 mg salt, diet, exercise, weight, careful with birth control and HRT
- 2) BP lowering: <140/90 in gen. pop, 130/80 in diabetics
- 3) Lower cholesterol
- 4) anti-platelet: ASA or clopidogrel
What are some specific (besides the 4 general ones) that could be used to treat certain etiologies of stroke?
- 1) anticoagulate people with A fib with Warfarin, or NOACs
- 2) Carotid endarectomy/stenting (only >50% occlusion)
- 3) Close a PFO
- 4) treat carotid dissection with anti-coag or anti platelet therapy
How long do you have to give tPA to a patient? What about intra-arterial/ mechanical thrombolysis?
- 4.5 hours. Any more than this, and it is likely not worth the risk.
- 6-8 hours for intraarterial/mechanical thrombolysis
Three big contraindications to IV thrombolysis
- SAMPLE STAGES
- Stroke/head trauma in last 3 months
- Anticoag with INR>1.7
- Prior intracranial hemorrhage
- Low platelets
- Elevated BP: >180/110
- Surg in past 14 days
- Age < 18
- GI or urinary bleed
- Elevated or decreased blood glucose
- Seizures at onset of stroke
What are the diagnostic criteria for childhood migraine? (4 points + subpoints)
- 1) 5+ attacks fulfilling the following:
- 2) headache last 48 hours
- 3) 2+ of the following:
- -bilateral or unilateral (only unilateral in adults)
- -mod or severe (affect ADL's)
- -aggravation by routine activity
- 4) during headache one of the following:
- -photo- and or phonophobia
What are the 4 phases of a migraine?
- 1) prodrome: mood changes
- 2) Aura: usually visual (scintillating scotoma)
- 3) Headache: 4-72 hours
- 4) Postromal: washed out, concrete head
Describe the 3 forms of migraine in children
- 1) Basilar: usually girls, basilar supplied areas affected (ataxia, dizziness, dysarthria, confusion)
- 2) Confusional: confused and agitated, minor bump on head, adolescent boys
- 3) Hemiplegic: Looks like a stroke, but it is gradual and switches sides
three conditions that kids may have that often leads to migraine later in life
- 1) Cyclic vomiting syndrome
- 2) BPPV
- 3) Benign paroxysmal torticullis
4 things you see in tension-type headaches
- -pressing or tight quality
- -mild to moderate severity
- -not aggravated by physical activity
Describe the three prong approach to migraine prophylaxis
- 1) lifestyle mods: regular meals, sleep, exercise, decrease stress triggers
- 2) Dietary mods: decrease food triggers, take a headache diary
- 3) Meds (not super effective): amytriptyline, AEDs, CCBs
When should you pursue neuroimaging in a young kid with headaches (6)
- 1) recurrent headaches that suggest brain pathology (focal, seizures, etc)
- 2) abnormal/inadequate neuro exam
- 3) raised ICP S and S
- 4) fits pattern of headache disorder
- 5) recent change in pattern
- 6) personality/ school performance changes
Tmt of status epilepticus in kids (4)
- 0) ABC's
- 1) Give him lorazepam (wait 5 mins)
- 2) Give him phenytoin (wait 5 mins)
- 3) phenobarbitol
Why is it important to catch a kid with a neural tube defect early on?
They may have a tethered cord which can be pulled out as the child grows
What should you be thinking if a kid comes in with facial seizures? What should you ask mom about?
- -benign rolandic seizures
- -ask her about migraines in the family. There is a strong tie
Why are both skin and neuro embryolocal problems linked? What other organs?
- -both derived from ectoderm
- -eyes, kidneys, blood vessels, bone marrow, endocrine
Dignostic Criteria for NF1 (7)
- Need 2 or more of the following:
- -6 or more C-a-L spots
- -2+ neurofibromas or 1+ plexiform neuroma
- -axillary or inguinal freckling
- -2+ Lisch nodules
- -optic glioma
- -bone abnormality
- -1st degree relative with NF1
What chromosomes are in involed in NF1 and NF2?
17 and 22, respectively
Diagnostic criteria for NF2 (3)
- one of the three
- 1) Bilateral CN VIII schwannoma or neurofibroma
- 2) unilateral CNVIII mass with 2+ of the following
- -posterior subcapsular cataracts
- 3) Unilateral CN VIII lesion/mass/etc with a first degree relative with NF2
What is the triad of tuberous sclerosis? Other signs (4)
epilepsy, mental retardation, adenoma sebaceum
- -ash leaf hypopigmented lesions
- -Shagreen's patches
- -facial angiofibroma
- -Subependymal nodules on CT
What do you see in Sturge-Weber syndrome (5)?
- -port wine stain on face
- -angiomatosis (cappillary overgrowth) in the brain
List/describe the primary brain tumors. Intra-axial (2) , Extra-axial (3), Other (2)
- Intra-axial: Glioma, neuroma (rare)
- Extra-axial: meningioma, pituitary adenoma, vestibular schwannoma
- Other: Intraventricular, CNS lymphoma
Where do metastatic tumors in the brain come from?
- Lung and Skin Go to the BRain:
What is the triad of acute raised ICP
- -morning headache
- -projectile vomiting without nausea
List the major brain cancers by age and location
How do you investigate for brain tumors?
MRI +/- CT +/- biopsy in all cases
How do you manage a brain tumor? (6)
- A) Medical: symptomatic (ICP, seizures, pain), specific (hormones for pituitary, etc)
- B) Conservative: Clinical followup with serial MRI
- C) Surgery: survival benefit, symtomatic relief, more accurate diagnosis
- D) Radiation: whole brain for mets, fractionated doses
- E) Radiosurg: LINAC or gamma knife, one tmt (single dose)
- F) Chemo: lymphoma and peds tumors
What is the most common primary brain tumor? Prognosis based on grade I and grade 4. Tmt?
Astrocytoma. Grade I is > 10 years, Grade IV (glioblastoma multiforme) is < 1 year. Surgery is not curative. Rad and chemo (and some surg) there to prolong/improve life.
How do you treat brain mets?
- 1) single met: surg followed by radiotherapy
- 2) diffuse: radiotherapy
How do you treat a meningioma? prognosis?
Surgical excision. Usually benign, good prognosis.
What are the three major categories of spinal tumors
- 1) extradural (bone)
- 2) Intradural extramedullary (outside spinal cord)
- 3) Intramedullary (involves spinal cord)
Most common extradural tumor? Signs (4)
- 1) Pain
- 2) motor dist
- 3) weakness
- 4) sphincter disturbances
What investigations would you do to look for spinal mets?
- 1) plain xray: missing pedicles (winking owl)
- 2) Bone scan (very sensitive)
- 3) MRI (gold standard)
- 4) CT
What are the 4 indications for surgery in spinal mets?
- 1) failure of rad
- 2) need biopsy for diagnosis
- 3) pathological fracture (needs stab)
- 4) progressive neuro prob
Top 3 DDx in an intradural extramedullary tumor. What does it look like
- Benign: Meningioma, nerve sheath tumor
- Malignant: Mets (rare)
Similar signs and sx to a herniated disc
Which drugs are the champion for partial siezures right now? A/E's?
- Phenytoin (dilantin)
- A/E's: gum atrophy, cerebellar atrophy, osteoporosis
- A/E's: clumsiness, dizziness, osteoporosis
Which of the old AED's would you use for generalized seizures? 3 A/E's
A/E's: tremor, weight gain, BAD in pregnancy
What is the difference between new and old AED's
- same efficacy
- newer have fewer side effects and are more expensive
What can you use Lamotrigine for? Why is it awesome, what is a scary A/E
- Use for both general and partial seizures
- -minimal A/E's, probably safe in pregnancy
- -Worried about Steven's-Johnson's Syndrome
Why is levetiracetam (keppra) so awesome? What can it be used for. A/E? What patient population is it especially good for?
- -works for most seizure types with few side effects
- -can cause mood swings
- -Renally excreted without liver metabolism, great for people with liver failure
Which AED's should not be used in pregnancy (3), which ones can (1)?
NO: Dilantin (phenytoin), phenobarbitol, valproic acid
YES: Lamontrigine (tegretol) is best
What type of epilepsy should get an early referral to surg?
temporal lobe. WAY better than medical tmt
Where do brain aneurysm happen most often? (3)
- Anterior Communicating Artery (ACOM) (30%)
- PCOM (25%)
- MCA (20%)
What is the presentation for a SAH? (5)
- -sudden most severe headache of patient's life
- -subhyoid hemorrhages
- -motor deficits
- -CN palsys
What is the risk of major bleeds in untreated AVMs?
2-4% per year
What are the RF's for atherosclerosis?
HTN, smoking, DM, hyperlipidema
When does a trauma patient NOT need an xray? (5)
- -no midline cervical tenderness
- -no focal neurological deficits
- -normal alertness
- -no intoxication
- -no painful, distracting injury
List seven principles of spinal cord injury
- 1) ABC's
- 2) Spinal immobilization
- 3) document neurological findings well
- 4) obtain appropriate imaging
- 5) Early reduction and decompression
- 6) Methylprednisone is not standard of care
- 7) spinal stabilization with unstable fractures
List the major spinal level for biceps, brachioradialis, triceps, knee jerk and ankle jerk reflexes
- Biceps: C5
- BR: C6
- Tri: C7
- Knee: L4
- Plantar: S1
What is osler's triad for endocarditis?
fever, murmur, stroke
These people have endocarditis until proven otherwise
What are the three (or 4) components of ICF?
Which ones get squeezed out when there is a mass?
- +/- lesion
Venour blood and CSF get squeezed out.
What is the equation for cerebral perfusion pressure? what is normal CPP?
CPP = MAP - ICP
Normal is 40-50 mm Hg
How would you manage increased ICP? (6)
- 1) Remove space occupying lesion
- 2) CSF drainage
- 3) lower BP (mannitol)
- 4) hyperventilation
- 5) decompressive craniotomy
- 6) Elevate head
- 7) prevent hyperthermia
When would you implant a CSF shunt?
persistent hydrocephalus where the primary cause cannot be treated
3 most common pediatric brain tumors in order of prevalence
- 1) Medulloblastoma
- 2) Cerebellar astrocytoma
- 3) brainstem glioma
What is abnormal CSF pressure
anything greater than 20 mm Hg
To prevent secondary injury, what do neurosugeons try to keep CPP, ICP and MAP at?
- CPP: > 70 mm Hg
- ICP: < 20 mm Hg
- MAP: > 90 mm Hg
When you have an eye ulcer, what should you NOT use?
What can a pituitary adenoma do to your vision?
Screw with the optic chiasm, causing a bitemporal hemianopia
If you have a tumor posterior to the optic chiasm, what does that do to your vision?
causes a homonymous hemianopia (R or L visual field impaired)
What type of ANS innervation does CN 3 have?
What type of cancer can cause a horner's syndome?
apical lung cancer (route of the nerve takes it by the lung apices)
If you have a black eye and numb teeth what shoudl you be thinking?
Orbital floor fracture
If you see a CN III palsy, what do you need to assess for? What does it mean?
If dilated (blown) it is the Pcomm compressing the nerve. If it is spared, consider an ischemic cause (the pupil portion is on the outside of the nerve)
two most common causes of CN VI palsy
HTN and DM
If you see a combined CN III, IV, VI palsy what should you think?
Think of a problem with the cavernous sinus
When must you treat a congenital nasolacrimal duct obstruction by?
1 year of age
How do you treat chlamydial keratoconjunctavitis?
ORAL doxycycline or tetracycline
What colour is a conjunctival lymphoma?
What do retinal tears present as?
Flashers and floaters
How does DM cause you to go blind? (2) TMT for each
- 1) Maculopathy (focal)
- 2) Proliferative retinopathy (panretinal photocoag, anti VEGF)
Which population is especially at risk for glaucoma, what is the main RF?
- african americans
- increased ICP
What optical Sx should you look for with someone with NF1?
optic nerve glioma
How do you treat open angle glaucoma?
Prednisone can cause what type of cataract?
What are 9 sight-threatening ocular emergencies?
- 1)lid/globe lacerations
- 2) Corneal ulcer
- 3) Gonococcal conjunctavitis
- 4) acute iritis
- 5) acute narrow angle glaucoma
- 6) CRAO
- 7) Intraocular foreign body
- 8) Retinal detachment
- 9) endophthalmitis
two most common causes of trigeminal neuralgia are:
compression and MS
What would you like to do?
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