Rosen's 10th > Neuro > Flashcards

Neuro Flashcards

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1
Q

Define epileptic seizure

A

transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous activity in the brain

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2
Q

Define focal seizures

A

Originating from a single focus limited ot one hemisphere of the brain

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3
Q

Define epilepsy

A

occurrence of two or more unprovoked seizures

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4
Q

Define convulsive status epilepticus

A
  • true neurologic emergency
  • 5 mins+ of continuous seizure activity (clinical or electroencephalographic)
    OR
  • recurrent seizure activity w/out return to baseline btwn seizures
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5
Q

Define refractory status epilepticus

A

status epilepticus that does not respond to first- and second-line antiepileptics

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6
Q

Outline goals of tx in Acute Ischemic Stroke as a hypertensive emergency, and what anti-HTN meds you would use

A
  • Reduce hemorrhagic conversion and edema while avoiding regional hypoperfusion
  1. Nicardipine
  2. Labetalol

*Acute BP reduction is indicated only with planned fibrinolytic administration or when secondary target organ dysfunction is involved

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7
Q

Outline goals of tx in Acute ICH as a hypertensive emergency, and what anti-HTN meds you would use

A
  • Reduce hematoma expansion and perihematomal edema
  1. Nicardipine
  2. Labetalol

Goal SBP 140

*BP may decrease with pain management alone

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8
Q

Outline goals of tx in Hypertensive Encephalopathy as a hypertensive emergency, and what anti-HTN meds you would use

A
  • Decrease brain edema
  • Reduce intracranial pressure
  • Improve autoregulatory control
  1. Nicardipine
  2. Labetalol
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9
Q

List 4 clinical features of UMN lesions

A

Spasticity
Hyperreflexia
Pronator drift
Babinski upward

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10
Q

List 4 clinical features of LMN lesions

A

Flaccidity
Hyporeflexia
Fasciculations
Muscle cramps

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11
Q

List 9 causes of General Non-neurologic Weakness

A

Dehydration
Abnormal glucose
Abnormal electrolytes
Anemia
Polycythemia
MI
Vasodilatory shock from any cause
Local or Systemic infection
Endocrinopathy
Toxin
Severe sepsis
Sedatives
Stimulant withdrawal

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12
Q

Define Upper motor neuron

A

cerebral cortex or corticospinal tract (CST) of the brainstem or spinal cord

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13
Q

Define Lower motor neuron

A

anterior horn of the spinal cord and its axonal extensions at the nerve root and peripheral nerve

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14
Q

List 10 Critical Dxs of Neuromuscular Weakness

A
  • Ischemic CVA
  • Hemorrhagic CVA
  • Spinal cord ischemia
  • Spinal cord compression
  • Acute demyelination of peripheral nerves
  • Myasthenia crisis
  • Cholinergic crisis
  • Botulism
  • Tick paralysis
  • Organophosphate poisoning
  • Rhabdomyolysis
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15
Q

List 7 Emergent Dxs of Neuromuscular Weakness

A
  • CNS tumour
  • CNS abscess
  • CNS demyelination
  • Spinal cord compression
  • Peripheral nerve compressive plexopathy
  • Paraneoplastic vasculitis
  • Inflammatory myositis
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16
Q

Define paresis

A

Moderate loss of power

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17
Q

Define plegia

A

Complete loss of motion

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18
Q

Locate weakness involving UE + LE w/ ipsilateral facial involvement

A

lesion in CONTRALATERAL cerebral cortex or CSTs coursing down Corona Radiata and forming the Internal Capsule

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19
Q

Locate weakness involving UE + LE w/ contralateral facial involvement

A

Brainstem lesion

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20
Q

Give examples of UE + LE w/ ipsilateral facial weakness

A

Acute onset = ischemic or hemorrhagic CVA

Gradual = MS, neoplasm, acute demyelinating encephalomyelitis

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21
Q

Give 2 examples of UE + LE w/ contralateral facial weakness

A

Vertebrobasilar insufficiency
Demyelinating disease

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22
Q

Locate weakness involving UE + LE w/out facial involvement

A

A lesion in medial, contralateral, cerebral homunculus (over area where LE is represented)

A discrete internal capsule or brainstem lesion involving only corticospinal rather than corticobulbar tracts

Brown-Séquard internal capsule or brainstem lesion if patient also has contralateral hemibody pain and temperature sensory disturbances below level of motor weakness.

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23
Q

Locate isolated extremity weakness
(monoparesis or monoplegia)

A

Spinal cord or Peripheral nerve lesion

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24
Q

List 7 Nonemergent Causes of Peripheral Neuropathy

A

Connective tissue disorder

External compression (entrapment syndrome, compressive plexopathy)

Endocrinopathy (diabetes)

Paraneoplastic syndromes

Toxins (alcohol)

Trauma

Vitamin deficiency

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25
Locate bilateral LE weakness (paraparesis or paraplegia)
Spinal cord lesion
26
List 3 main causes of anterior cord syndrome
Compression Ischemia Demyelination
27
Locate bilateral UE weakness
Central portion of spinal cord
28
List 2 main causes of central cord syndrome
C-Spine hyperextension injuries Syringomyelia
28
Locate bilateral UE + LE weakness (quadriparesis or quadriplegia)
Cervical spinal cord injury
29
List 2 DDx for weakness of proximal portions of extremities
Myofiber disorder (myodystrophies, channelopathies) Inflammatory dz (polymyositis or dermatomyositis)
30
Locate weakness of distal portions of extremities
Peripheral neuropathy
31
Locate unilateral facial droop
CN VII problem (7) - Bell palsy - mastoiditis - Parotitis
32
Locate facial weakness not limited to CNVII
- Brainstem lesion - Multiple cranial neuropathies - NMJ problem (botulism, MG)
33
List 3 causes of abnormality in presynaptic release of ACh
Botulism Eaton-Lambert syndrome Organophosphate poisoning
34
List 3 medications to avoid in pts with NMJ d/o's (make it worse)
Aminoglycosides - gentamicin - tobramycin Quinolones BBs
35
List 3 causes of abrupt onset of coma
Stroke Seizure Cardiac event
36
List 4 causes of pinpoint pupils
Pontine infarct Opioids Clonidine Cholinergic substances
37
Define coma
State of depressed consciousness in which pt is not aware, is not awake, and does not respond to vigorous stimulation
38
List 15 DDx of Critical Causes of Coma
METABOLIC: - Hypoglycemia - DKA - HHS - Adrenal crisis - Pituitary apoplexy - Sepsis TOXINS: - Anti-glycemic agents - Opioids - Simple asphyxiants (gases) - CO - Cyanide - Methemoglobinemia STRUCTURAL: - ICH - Cortical infarct - Cerebellar infarct - Basilar artery occulsion
39
List 20 DDx of Emergent Causes of Coma
METABOLIC - Wernicke encephalopathy - HypoNa - Hyperammonemia - HyperCa - Uremia - Hepatic encephalopathy - Thyrotoxic crisis - Myxedema coma - Heat stroke - HACE TOXINS: - Sedatives - Toxic alcohols - Inhalants - Psychiatric meds - AEDs - Anticholinergics - Clonidine - BBs - Salicylates - NMS - Serotonin syndrome
40
List 4 brainstem reflexes
- oculocephalic reflex (doll’s eyes) - oculovestibular reflex (cold caloric testing) - corneal reflex - gag reflex
41
List 7 Principles of Neuroprotective Resuscitation
Elevate HOB 30 degrees if no suspicion for T spine injury Avoid constricting ties or collars around neck. Avoid hypoxia and hyperoxia Maintain end-tidal CO2 @ 35 cmH2O Avoid hTN Avoid hyperthermia Prevent and treat seizure activity
42
List 4 Critical Causes of Confusion
Hypoxia Hypoventilation Hypoglycemia Delirium tremens
43
List Emergent Causes of Confusion, related to Primary Intracranial Disease (4)
Seizure Nonconvulsive status epilepticus Traumatic brain injury Hypertensive encephalopathy
44
List Emergent Causes of Confusion, related to Systemic diseases secondarily affecting CNS (7)
Sepsis Hepatic encephalopathy Uremia/Renal failure Hyperthermia Hypothermia Endocrinopathy Nutritional deficiency
45
List Emergent Causes of Confusion, related to Exogenous toxins (9)
Sedatives Hallucinogens Ethanol Toxic alcohols Antihistamines Anticholinergics Opioids Cholinergics Benzodiazepines
46
List Emergent Causes of Confusion, related to drug withdrawal (3)
EtOH Benzos Opioids
47
Outline DDx for Altered Mental Status
AEIOU TIPS Alcohol Atypical migraine Electrolytes Environment Endocrinopathy Encephalopathy Epilepsy Infection Overdose Oxygen Uremia Trauma Tumour Insulin Poisons Psychosis Stroke Status epilepticus
48
List 3 possible onsets of seizures
Focal Generalized Unknown
49
List 10 Characteristics Prompting Consideration of Neuroimaging in a Patient With Seizures
Age >40yr Coma Immunocompromised state Clot disorder (hypercoagulability or hypocoagulability) Hx of ICH Hx of malignancy Severe, thunderclap headache Status epilepticus, convulsive & nonconvulsive, of unclear etiology Stigmata of neurocutaneous syndromes Suspected trauma
50
List 7 Critical Diagnoses Consider in a Patient With Seizures
Status epilepticus, convulsive & nonconvulsive, regardless of cause Eclamptic seizures Toxic ingestion (INH, lithium, TCAs) Hypoglycemia HypoNa HypoCa Increased ICP
51
List 6 Emergent Diagnoses Consider in a Patient With Seizures
Infection Ischemic stroke Hemorrhagic stroke TBI Cerebral venous thrombosis Cardiogenic syncope (seizure mimic)
52
List First & Second Line Meds for Acute Seizure
1st: Lorazepam 2-4mg IV Midazolam 5-10mg IV/IM * can give 2 benzo doses 2nd: Levetiracetam 60mg/kg IV over 10min Phenytoin (Dilantin) 20mg/kg IV Fosphenytoin 20PE/kg IV Lacosamide 200-400mg IV over 10min VPA 40mg/kg IV over 10min
53
What additional antidote is needed for INH toxicity & seizures?
Pyridoxine (Vit B6) IV
54
List 5 features of nystagmus that is most likely centrally caused
- purely vertical - downbeating (fast phase beating toward the nose) - non-fatiguable - direction changing w/ lateral gaze - spontaneous pure torsional
55
List clinical features of Acute Vestibular Syndrome
- dizziness develops acutely - constant - n/v present - unsteady gait - nystagmus - intolerance to head motion - lasts >1 day
56
Define vertigo, near syncope, & disequilibrium
Vertigo = illusion of motion, described as room spinning Near syncope = sensation of feeling faint or lightheaded Disequilibrium = sense of unsteadiness when walking
57
List 2 major causes of Acute Vestibular Syndrome
Vestibular Neuritis Posterior Circulation Stroke
58
List 3 parts of maintaining 'equilibrium'
Visual Vestibular Proprioceptive
59
List 10 causes of peripheral vertigo
Benign paroxysmal positional vertigo (BPPV) Vestibular neuritis Labyrinthitis Meniere disease Perilymph fistula FB in ear canal AOM Trauma (Labyrinth concussion) Motion sickness Acoustic neuroma Ramsay-Hunt syndrome (Herpes zoster oticus)
60
List 10 causes of central vertigo
Vertebral basilar artery insufficiency Cerebellar CVA Wallenberg syndrome (occlusion of PICA) Tumour Migrainous vertigo Multiple sclerosis Posttraumatic injury (temporal bone fracture, postconcussive syndrome) Encephalitis Meningitis Brain abscess Temporal lobe epilepsy Subclavian steal syndrome Chiari malformation
61
Contrast Vestibular neuritis and Labyrinthitis
Hearing normal in VN Hearing loss in Labyrinthitis
62
List features of Meniere disease
Recurrent episodes of severe rotational vertigo usually lasting hours. - cluster attacks - N/V - Tinnitus - Hearing loss
63
Describe direction of nystagmus in classic posterior canal BPPV, horizontal canal BPPV, and vestibular neuritis/labyrinthitis
Posterior canal BPPV = Torsional + Upbeat Horizontal canal BPPV = Horizontal Vestibular neuritis/Labyrinthitis = Torsional-Horizontal
64
List 7 risk factors for TIA or Stroke
Older age Male HTN CAD DM Prior CVA Afib
65
List 8 ototoxic meds
Gentamicin Tobramycin Tetracycline Minocycline Erythromycin AEDs Alcohols Quinine Quinidine Lead Mercury
66
Describe Internuclear Ophthalmoplegia (INO)
- Eyes normal in straight ahead gaze. - W/ lateral gaze, adducting eye (CN3) is weak-no movement, abducting eye (CN6) moves normally - interruption of Medial Longitudinal Fasiculus on side that demonstrates CN3 weakness - pathognomonic of MS
67
Define Dysmetria & Dysdiadochokinesia
Dysmetria = inability to arrest a muscular movement at the desired point - finger to nose test Dysdiadochokinesia = inability to perform coordinated muscular movement smoothly - rapid alternating movements, hand in palm
68
Describe cerebellar gait
- wide base - unsteadiness - irregularity of steps - tremor of the trunk - lurching from side to side
69
List 6 Classic Findings During Dix-Hallpike Test in Posterior Canal BPPV
1. Latency (delay in nystagmus & vertigo once in head-hanging position) of 3–10s 2. Reproduction of vertigo symptoms in head-hanging position 3. Upbeat (fast phase toward forehead) + Torsional nystagmus (usually toward downward ear) 4. Vertigo & nystagmus escalate in head-hanging position, then slowly resolve over 5–30s 5. Nystagmus & vertigo may reverse direction when patient returns to sitting position 6. Nystagmus & vertigo decrease w/ repeated testing (fatiguability)
70
Describe Dix-Hallpike test
performed with patient sitting up. The examiner turns the patient’s head 45 degrees to one side and then moves the patient from the upright seated position to a supine position with the head overhanging the edge of the gurney patient is then brought back up to the seated position, and the test is repeated with the head turned 45 degrees to the other side
71
List components of HINTS exam
Head Impulse test Nystagmus Test of Skew
72
What is HINTS exam used for?
to differentiate central from peripheral vertigo in patients with acute vestibular syndrome
73
Outline results of the HINTS exam that indicate peripheral vs central cause of acute vestibular syndrome
Head Impulse test - corrective saccade = peripheral - no correction = central Nystagmus - unilateral fast beat nystagmus/same direction = peripheral - direction-changing/bilateral nystagmus = central Test of Skew - no skew of gaze = peripheral - vertical ocular misalignment on alternate cover test = central
74
Differentiate btwn Benign Paroxysmal Positional Vertigo and Vestibular Neuritis/Labyrinthitis
75
Describe Epley maneuver for BPPV
76
List 2 maneuvers to treat horizontal canal BPPV
- Barbeque roll - Gufoni maneuver
77
List med tx options for acute vertigo
Ondansetron 4mg IV/ODT/PO/IM Promethazine 12.5-25mg IM/PO Dimenhydrinate 50-100mg IM/IV/PO Meclizine (Antivert) 12.5-50mg PO q4h - BPPV w/ failed Epley - Vestibular neuritis
78
Outline tx for vestibular neuritis
Prednisone 60mg PO OD, with taper over 2-3wks
79
List criteria for poor respiratory mechanics 2/2 neuromuscular d/o
FVC <20mL/kg MIP 'greater than' -30cm H2O (closer to 0) MEP <40cm H2O Vt <5cc/kg
80
List 10 medications that may worsen myasthenia gravis
- CCBs - BBs - Quinidine - Lidocaine - Procainamide - Aminoglycosides - Tetracyclines - Clindamycin - Polymyxin B - Fluoroquinolones - Corticosteroids - Phenytoin - Neuromuscular blockers - Thyroid replacement
81
Outline 3 mechanisms of neuromuscular junction diseases
1) blockage of ACh receptors = myasthenia gravis 2) decrease in amount of ACh released = botulism 3) inactivation of ACh by irreversible binding = organophosphate poisoning
82
Outline age of onset of myasthenia gravis in females and males
Females = age 20-40 Males = 50-70
83
Briefly outline pathophysiology of myasthenia gravis
weakness and fatigue result from circulating autoantibodies against the nicotinic ACh receptor on the junctional folds of the postsynaptic membrane
84
Outline tx of Myasthenia crisis
Plasma exchange IVIG +/- Prednisone 60mg PO OD
85
List 4 non-medication precipitants of Myasthenia crisis
Infection Aspiration Surgery Pregnancy
86
List classic association/main cause of Lambert-Eaton syndrome
Small cell carcinoma of lung
87
Outline 4 classic clinical features of Lambert-Eaton syndrome
Weakness that improves w/ use of muscles Hyporeflexia Autonomic dysfunction Dry mouth
88
Outline tx of Lambert-Eaton syndrome
Tx underlying cancer IVIG
89
List classic association/main cause of Myasthenia gravis
Thymoma
90
Describe ice bag test for myasthenia gravis
* degree of ptosis is measured before and after application of an ice bag - distance from upper to lower eyelid in most severely affected eye is measured first - ice pack is applied to affected eye x2 mins - improvement in amount of ptosis of +2mm is considered positive
91
Outline outpt treatment of myasthenia gravis
Pyridostigmine 60-120mg PO q4-6h +/- Glycopyrrolate 1mg PO w/ each dose of Pyrido to manage cholinergic symptoms
92
Outline classic clinical features of botulism
- descending, symmetric, flaccid paralysis - CNs affected and bulbar symptoms - anticholinergic signs (constipation, urinary retention, dry skin and eyes, increased temperature and dilated, nonreactive pupils) - normal or decreased DTR
93
List 4 Neuromuscular Junction Disorders
- Myasthenia gravis - Lambert-Eaton syndrome - Botulism - Tick paralysis
94
List 3 types of inflammatory myopathy
Polymyositis Dermatomyositis Inclusion body myositis
95
Outline 3 clinical features of Dermatomyositis
- periorbital heliotrope rash - erythema and swelling of extensor surfaces of joints - proximal muscle weakness
96
List 2 tests that confirm dx of inflammatory myositis
EMG Muscle biopsy
97
Outline tx of inflammatory myositis
Prednisone 1mg/kg/day Azathioprine 50 mg/day Methotrexate 15mg/week
98
List 6 metabolic and endocrine causes of muscle weakness
HypoK HyperK HypoCa HyperCa HypoMg HypoPO4 Thyrotoxic parathyroid adrenal gland
99
List 2 forms of inherited periodic paralysis
Hypokalemic and Hyperkalemic forms - Hypo more common
100
What is inherited periodic paralysis?
Rare hereditary disorder of ion channels resulting in intermittent attacks of flaccid extremity weakness
101
Outline high dose tx for MS relapse
Methylprednisolone 1000mg IV q24h x3-5d Prednisone 500-1250mg PO x3-5d Plasmapheresis IVIG
102
Name gold standard imaging for Cerebral venous thrombosis (CVT)
MRI/MRV
103
List 2 tx options for trigeminal neuralgia
Carbamazepine 200mg PO BID Oxcarbazepine 150mg PO BID
104
Outline tx of Bell's palsy
* Based on House-Brackmann Scale I-III: Prednisone 60mg PO x7d IV-VI: Add Valacyclovir 1g PO TID x7d +/- eye closure and protection
105
List 4 types of MS
1) Relapsing-remitting 2) Primary progressive 3) Secondary progressive 4) Radiologically isolated syndrome (RIS)
106
List clinical features of MS
Cranial nerves: - Optic neuritis - diplopia - nystagmus - facial paresis - pain Motor: - Weakness - spasticity - exaggerated DTR Sensory: - Numbness - tingling - “pins and needles” - paresthesia - coldness Cerebellar: - Gait imbalance - dysarthria - truncal ataxia Bladder, Bowel and Sexual dysfunction: - Urinary incontinence - constipation - erectile dysfunction Cognition: - Poor memory - distractibility - cognitive impairment
107
List 2 most high-yield tests for diagnosing MS
LP MRI brain + spinal cord
108
List 10 risk factors for Cerebral Venous Thrombosis
- Thrombophilias (protein C and S deficiencies, factor V Leiden mutation) - Pregnancy - Post-partum period - Oral contraceptives - Infxn of head and neck - Cancer - SLE - IBD - Sarcoid - Head trauma - Recent LP - Recent Neurosurgical procedure
109
List 4 clinical syndromes of CVT, and their features
Intracranial HTN: - localized - Persistent, gradually worsening HA - Decreased visual acuity - Papilledema - worsen with Valsalva Focal neurological deficits: - Motor weakness (u/l or b/l) - Aphasia Seizures: - Focal or Generalized - Status epilepticus Encephalopathy: - Confusion - Altered mental status - Coma
110
Outline tx of CVT
- initially LMWH or UFH - can have maintenance DOAC or warfarin - may need thrombectomy
111
Outline clinical features and dx definition of trigeminal neuralgia
3+ attacks of unilateral facial pain In 1+ divisions of TN At least 3/4 characteristics: - recurring in paroxysmal attacks - severe intensity - electric shock-like or sharp/stabbing in quality - precipitated by innocuous stimuli to affected side
112
List broad etiologies of facial nerve dysfnc
- stroke - ischemia - compression or disruption from mass lesions - trauma - infection
113
How can you determine UMN or LMN dysfunction in facial weakness?
UMN has bilateral innervation of forehead musculature - UMN lesions spare the forehead - LMN lesions cause weakness affecting entire ipsilateral face
114
List clinical features of Bell's palsy
- abrupt onset of unilateral facial weakness involving forehead (LMN) - improves over weeks - may have mild to moderate pain, altered taste, hyperacusis, dry eye and mouth
115
List clinical features of Ramsay Hunt syndrome
Herpes zoster oticus Facial nerve paralysis Pronounced pain Vesicular eruptions to ear Vestibulocochlear dysfunction
116
List 6 DDx of facial nerve paralysis
Bell's palsy Stroke Neoplastic Ramsay-Hunt syndrome Lyme disease Mononucleosis Malignant otitis externa
117
Outline House-Brackmann scale for Bells Palsy
I = Normal symmetry II = Mild dysfunction III = Moderate dysfunction IV = Mod to Severe dysfunction V = Severe dysfunction VI = Total paralysis
118
Outline tx of Ramsay-Hunt syndrome
Valacyclovir 1g PO TID x7-10d plus Prednisone 1mg/kg PO OD x5d
119
Outline clinical features of acoustic neuromas (aka vestibular schwannoma)
- unilateral sensorineural hearing loss - continuous tinnitus - imbalance - HA - ear fullness - otalgia - facial nerve weakness
120
List 2 tests for diagnosis of acoustic neuroma (aka vestibular schwannoma)
MRI Audiometry
121
List 3 common cranial nerve mononeuropathies in diabetics
CN III CN IV CN VI
122
List clinical features of a CNIII palsy in diabetics
ISCHEMIC etiology - Pupillary reaction is spared - Inability to move eye superior & medial - Ptosis
123
Outline tx of CNIII diabetic mononeuropathy
anti-PLTs Analgesia Patching of eye
124
List 12 Critical & Emergent Causes of Headache
- CO poisoning - Meningitis - Encephalitis - Brain abscess - Temporal arteritis - Acute angle closure glaucoma - Increased ICP - Cerebral venous thrombosis - Reversible cerebral vasoconstriction syndrome - SAH - SDH - EDH - Carotid dissection - Hypertensive crisis - Preeclampsia - Anoxia - Idiopathic intracranial HTN
125
List 3 hx clues for headache 2/2 CO poisoning
- Breathing in enclosed or confined spaces with engine exhaust or ventilation of heating equipment - Multiple household members with same symptoms - Wintertime and working around machinery or equipment producing carbon monoxide (e.g., furnaces, heaters)
126
List 7 risk factors for headache 2/2 meningitis, encephalitis, or abscess
Hx sinus or ear infection or recent surgical procedure Immunocompromised state General debilitation w/ decreased immunologic system function Acute febrile illness - any type Extremes of age Impacted living conditions (military barracks, college dormitories) Lack of primary immunization
127
List 5 risk factors for headache 2/2 temporal arteritis
Age >50 Females > Males (4:1) Hx other collagen vascular diseases (SLE) Previous chronic meningitis Previous chronic illness, such as TB, parasitic or fungal infection
128
List 4 risk factors for headache 2/2 acute angle closure glaucoma
Not associated with any usual or customary headache patterns Hx previous glaucoma Age >30 Hx pain increasing in a dark environment
129
List 5 risk factors for headache 2/2 increased ICP
History of previous benign intracranial hypertension Presence of CSF shunt Hx congenital brain or skull abnormalities Female gender Obesity
130
List 3 risk factors for headache 2/2 CVT
Female gender Pregnancy, peripartum, hormone replacement therapy or OCP Prothrombotic conditions
131
List 4 hx clues for headache 2/2 reversible cerebral vasoconstriction syndrome
Episodic sudden severe pain, +/- focal neurological findings or seizure Recurrent episodes over a period up to several weeks Exposure to adrenergic or serotonergic drugs Postpartum state
132
List 8 hx clues for headache 2/2 SAH
Sudden and severe pain; “worst headache of life” Acute severe pain after sexual intercourse or exertion Hx SAH or cerebral aneurysm Hx polycystic kidney disease FamHx SAH Hypertension - severe Previous vascular lesions in other areas of the body Young and middle-aged
133
List 2 risk factors for headache 2/2 SDH
Hx EtOH dependency +/- trauma Current use Anti-coagulation
134
List 3 risk factors for headache 2/2 EDH
Traumatic injury Lucid mentation followed by acute altered mentation or somnolence Anisocoria
135
List 10 non-emergent causes of headache
- Migraine - Trigeminal neuralgia - Concussion - Post LP HA - Sinusitis - Dental issues - TMJ disease - Tension HA - Cluster HA - HTN - Medication-overuse
136
List clinical hx detail important in dx of medication overuse HA
taking meds for headaches >10 to 15x/month
137
List 4 HA DDx for complaint of sudden onset of pain
SAH Cervical artery dissection Cerebral venous thrombosis Acute angle closure glaucoma
138
List EKG finding w/ Increased ICP or SAH
ST/T wave changes
139
List 4 causes of HA with increased opening pressure w/ LP
Idiopathic intracranial HTN Mass lesion Shunt failure Cryptococcal meningitis
140
What is classic time frame that SAH can be ruled out in, if CT is done
<6hrs of onset
141
List 3 inclusion criteria of Ottawa Subarachnoid Hemorrhage Rule
Age >15 Nontraumatic Peak intensity <1hr of onset
142
List 5 exclusion criteria of Ottawa Subarachnoid Hemorrhage Rule
New neuro deficits Prior aneurysm Prior SAH Known intracranial mass Chronic recurrent HA
143
List 6 criteria in Ottawa Subarachnoid Hemorrhage Rule
*If none of the following are present, SAH can be reasonably ruled out: - Age >40 - Neck pain or stiffness - Witnessed LoC - Onset during exertion - Thunderclap (immediate peak pain) - Limited neck flexion
144
List 10 concerning clinical features of HA, that indicate further w/u
1) sudden onset of headache 2) headache “the worst ever,” 3) altered mental status 4) meningismus 5) unexplained fever 6) focal neurological deficit 7) symptoms refractory to appropriate tx or worsening despite tx 8) onset during exertion 9) history of immunosuppression 10) pregnancy or peripartum state
145
Outline tx for primary HA, mild to moderate
PO NSAIDs - Naproxen 500mg PO BID
146
Outline tx for primary HA, moderate to severe
1) IV Dopamine Antagonist - Metoclopramide 10mg IV 2) Migraine specific agent - Triptan 3) IV NSAID - Ketorolac 15mg IV
147
Define delirium
Fluctuating course of confusion, inattention, and reduced awareness
148
List 4 Diagnostic Criteria for Delirium
Disturbance in attention & awareness Develops over short time period, is change from baseline, tends to fluctuate in severity during day Additional disturbances in cognition, like memory, disorientation, language, visual-spatial ability, or perception. Disturbances not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in context of a coma
149
List 15 predisposing factors for delirium
Advanced age Male gender Visual or hearing impairment Alcohol and drug use Dementia Hypertension Heart failure Previous delirium Chronic respiratory disease Chronic kidney disease Sedative medications (benzodiazepines and opioids) Anticholinergics Malnutrition Depression Environmental exposure
150
List triad of Wernicke encephalopathy
Altered mental status Ataxia Ophthalmoplegia
151
List 4 key features of bCAM screen for delirium
BOTH OF: Acute onset & Fluctuating course Inattention ONE OF: Disorganized thinking Altered LoC
152
Compare & contrast Delirium and Dementia
153
List 5 features of PRES (posterior reversible encephalopathy syndrome)
Confusion Visual changes HA Malignant HTN MRI abnormalities in posterior cerebrum
154
List 15 causes of Dementia
Primary Neurodegenerative Disease: - Alzheimer disease - Lewy bodies disease - Frontal lobe disease (Pick disease) - Parkinson disease - Huntington disease - Multi-infarct vascular dementia - Space occupying lesions (tumour, SDH) - Hydrocephalus - HIV - Neurosyphilis - Chronic meningitis - Encephalitis 2/2 measles - Creutzfeldt-Jakob disease (CJD) - Slow virus infections - Repetitive head trauma Secondary Non-Neurodegenerative Dementia: - Addisons disease - Cushings disease - Thyroid & Parathyroid disease - Thiamine def (Wernicke) - Niacin def - Folate def - Vitamin B12 def - Heavy metals - CO - Carbon disulfide - Psychotropics - Antihypertensives - Anticonvulsants - Anticholinergics - Pseudodementia (depression)
155
List Diagnostic Criteria for Dementia
A. Cognitive decline from baseline in 1+ cognitive domains: - Complex attention - Executive function - Learning and memory - Language - Perceptual motor function - Social cognition B. Disorder has insidious onset & gradual progression C. Deficits do not occur exclusively during course of a delirium D. Cognitive deficits are not better explained by another mental disorder
156
List 10 risk factors for Alzheimers & Vascular Dementias
- DLD - HTN - DM - advancing age - gender - smoking - air pollution - depression - family history - low education level - head trauma - genetics
157
List classic triad of normal pressure hydrocephalus
Wild = Progressive dementia Wobbly = Ataxia Wet = Urinary incontinence
158
List Elements of the Mental Status Examination in the Evaluation of Dementia
Appearance, behaviour, and attitude Mood and affect Sensorium and intelligence: Cognitive impairment Disorders of thought: Suicidal and homicidal ideation Insight and judgment: Knowledge about illness Disorder of perception: Hallucinations and delusions
159
List 3 medications for mild-moderate Alzheimers
Donepezil Rivastigmine Memantine
160
List general features of CNS infections
- headache - nuchal rigidity - fever - altered sensorium - diffuse or focal neurologic findings
161
Name predominant pathogen in adult patients with bacterial meningitis
Streptococcus pneumoniae
162
Name predominant pathogen in pediatric patients with bacterial meningitis
Neisseria meningitidis
163
Name predominant pathogen in infants & elderly patients with bacterial meningitis
Listeria monocytogenes
164
List 10 viral causes of encephalitis
HSV Enteroviruses West Nile Zika CMV HIV VZV Influenza Measles Mumps
165
List complications of tuberculous meningitis
- rupture of formed granulomas - vasculitis - stroke - hydrocephalus req'ing VP shunt - death
166
List 5 causes of fungal meningitis
Cryptococcus Aspergillus Coccidioides Histoplasma Mucormycosis Candida
167
List 7 Common CNS complications of fungal meningitis
- abscesses - increased ICP - neurologic deficits - seizures - bone invasion - fluid collections - ocular abnormalities
168
List 6 risk factors for spinal epidural abscesses
- spinal surgery - immunosuppression - IVDU - blood infection - psoas abscess - vertebral osteomyelitis
169
List 6 risk factors for brain abscesses
- local contiguous invasion - hematogenous spread - IVDU - neuro surgery - cranial trauma - acute OM - sinusitis
170
Describe Kernig sign
inability to straighten leg to full knee extension when lying supine with hip flexed at right angle
171
Describe Brudzinski sign
attempts to flex the neck passively are accompanied by flexion of the hips
172
List 4 clinical features with highest specificity for meningitis
Kernig sign Brudzinski sign Focal neuro deficit Rash
173
List 5 exam findings in adults suggestive of intracranial mass lesion
- papilledema - decreased venous pulsations - new-onset seizures - aLoC - focal neurologic deficits
174
What is Waterhouse-Friderichsen syndrome, and what causes it?
= Bilateral adrenal hemorrhages Meningococemia
175
List 7 DDx for acute meningitis
- Bacterial meningitis - Viral meningitis - SAH - Acute arterial dissection - Drug-related meningitis - Malignancy - Autoimmune conditions
176
List 10 DDx for subacute meningitis
- Viral meningitis - Bacterial - Fungal - Brain tumour - Spinal abscess - Osteomyelitis - CNS malignancy - ICH - Brain abscess - Nonconvulsive status epilepticus
177
List 4 DDx for chronic meningitis
- Viral meningitis - TB - Syphilis - Fungal meningitis
178
List 6 DDx for spinal epidural abscess
- epidural hematoma - osteomyelitis - discitis - aortic aneurysm rupture - aortic dissection - PE
179
Diagnosis?
HSV encephalitis - temporal lobe enhancement
180
What is cutoff for normal optic nerve sheath dilation as seen on U/S of the eye?
<5mm is normal >5mm suggests increased ICP
181
Outline Typical CSF Findings for Bacterial Meningitis and Encephalitis
Opening pressure = >30 Increased protein Decreased glucose Increased lactate Gram stain (+) WBC >1000 Neutrophil predominance
182
Outline Typical CSF Findings for Viral Meningitis and Encephalitis
Opening pressure = N or Inc Normal or Increased protein Normal glucose Normal lactate Gram stain (-) WBC 100-1000 Lymphocyte predominance
183
Outline Typical CSF Findings for Fungal/TB Meningitis and Encephalitis
Opening pressure = Increased Normal or Increased protein Normal or Decreased glucose Gram stain (-) WBC 50-500 Lymphocytes or monocytes predominance
184
What causes xanthochromia?
lysis of RBCs with the release of the breakdown pigments oxyhemoglobin, bilirubin, and methemoglobin into the CSF = yellow colour of supernatant after centrifuged
185
Name gold standard test for dx'ing cryptococcal infection?
Cryptococcal antigen testing - baseline serum and CSF antigen titres providing a good estimate of fungal burden and prognosis
186
List 7 pathogens where NAAT of CSF is useful for dx in CNS infections
H. influenza S. pneumoniae N. meningitides HSV VZV Enterovirus TB
187
Outline empiric ABX tx for bacterial meningitis in adults
CTX 2g IV q12h or Cefotaxime 2g IV q6h plus Vancomycin 15-20mg/kg IV q8h plus Ampicillin 2g IV q4h - if Elderly to cover Listeria
188
Outline empiric ABX tx for bacterial meningitis in neonates
Cefotaxime 50mg/kg IV q8h plus Ampicillin 100mg/kg IV q8h plus Gentamicin 5mg/kg/day IV divided q8h
189
List 3 Most Common Bacterial Pathogens of Meningoencephalitis in Neonates (0-4weeks)
GBS E. coli L. monocytogenes Gram (-) bacilli
190
List 2 Most Common Bacterial Pathogens of Meningoencephalitis in Infants & Children
S. pneumoniae N. meningiditis
191
List 2 Most Common Bacterial Pathogens of Meningoencephalitis in Adults
S. pneumoniae N. meningiditis
192
List 3 Most Common Bacterial Pathogens of Meningoencephalitis in Elderly pts
S. pneumoniae N. meningiditis L. monocytogenes
193
List 3 Most Common Bacterial Pathogens of Meningoencephalitis in Immunocompromised pts
S. pneumoniae N. meningiditis H. influenzae
194
List 3 Most Common Hospital-acquired Bacterial Pathogens of Meningoencephalitis
S. aureus S. epidermidis Aerobic gram (-) bacilli (E.coli, Pseudomonas, Klebsiella)
195
Outline empiric ABX tx for bacterial meningitis caused by hospital-acquired antibiotic-resistant organisms
Cefepime 2g IV q8h or Meropenem 2g IV q8h plus Vancomycin 15-20mg/kg IV q8h
196
Outline adjunct tx for all meningitis, in addition to ABX
Dexamethasone 0.15mg/kg IV q6h x4d - max 10mg Given 20mins before ABX for best effect
197
What are 2 benefits of steroid tx in meningitis?
Decreases mortality in Pneumococcal meningitis Decreases incidence of Hearing loss with H. influenzae
198
Outline ABX tx and dosing for Tuberculous Meningitis
Isoniazid 5 mg/kg IV q24h - max dose 300 mg Rifampin 20-30 mg/kg IV q24h - max dose 600 mg Pyrazinamide - <40 kg: 35 mg/kg IV q24h - 40-55 kg: 1000 mg IV q24h - 56-75 kg: 1500 mg IV q24h - 76-90 kg: 2000 mg IV q24h Ethambutol - <40 kg: 25 mg/kg/dose - 40-55 kg: 800 mg IV q24h - 56-75 kg: 1200 mg IV daily - 76 to 90 kg: 1600 mg IV q24h PLUS Dexamethasone 0.15mg/kg IV q6h x4d - max 10mg
199
Outline ABX that can be used for fungal meningitis
Amphotericin B Flucytosine Miconazole Fluconazole
200
Outline tx for viral meningitis & encephalitis
Acyclovir 10 mg/kg IV q8h - covers HSV and VZV Ganciclovir 5 mg/kg IV q12h - or CMV (if already known)
201
Pts with what clinical feature in CNS abscesses should be tx'd with dexamethasone?
Cerebral edema
202
Outline indications for ABX ppx in close contacts of meningococcal meningitis
- HCWs exposed to pt's secretions - Ppl exposed >8hrs @ <3ft away from pt = roommates, intimate partners, daycare worker) - Anyone exposed to pt's oral secretions
203
Outline ABX ppx for close contacts of meningococcal meningitis
Ciprofloxacin 500mg PO x1 or Rifampin 600mg PO q12h x4 doses or CTX 250mg IM x1 for pregnant ppl
204
Outline 2 indications for ABX ppx in close contacts of H. influenzae meningitis
- Unvaccinated or Incompletely vaccinated kids <4yr - Immunocompromised kids <18yr
205
Outline ABX ppx for close contacts of H. influenzae meningitis
Rifampin 20mg/kg PO OD x4d - max 600mg
206
Outline 5 indications for Meningococcal vaccination
- All children (2 doses) - college students - military recruits - travellers to endemic areas - asplenic individuals
207
List 10 RED FLAG s/s that suggest secondary HAs
- Pain that wakes you up - Worsening when recumbent, during exertion, during Valsalva - Sudden & severe thunderclap - Recurrent localized - Occipital HA - Inadequate response to tx - Changes in HA characteristics (intensity, frequency, pattern) - Chronic progressive HA - New HA in age >50yr - HA associated w/ papilledema - alteration in LoC - focal neuro symptoms - HA associated w/ fever, cancer, immunosuppression
208
List 3 s/s of carotid artery dissection
Miosis HA Ptosis
209
List 4 Primary HAs as per International Headache Society
1. Migraine 2. Tension-type headache 3. Cluster headache & Trigeminal autonomic cephalalgias 4. Other primary headaches
210
List 8 Secondary HAs as per International Headache Society
1. HA 2/2 trauma or injury to head or neck 2. HA 2/2 cranial or cervical vascular disorder 3. HA 2/2 nonvascular intracranial disorder 4. HA 2/2 substance or withdrawal 5. HA 2/2 infection 6. HA 2/2 disorder of homeostasis 7. HA or Facial pain 2/2 disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures 8. HA 2/2 psychiatric disorder
211
List 2 "Extracranial" HAs as per International Headache Society
1. Cranial neuralgias & other facial pain 2. Other HA disorders
212
List Migraine Without Aura Criteria
A. 5+ attacks fulfilling criteria in B, C, D, E B. Attack lasts 4-72 hrs (untreated or unsuccessfully treated) C. HA has 2+ of following characteristics: - Unilateral - Pulsating - Moderate to severe pain - Aggravation by or causing avoidance of routine physical activity D. During HA, 1+ of following: - Nausea or vomiting, or both - Photophobia + phonophobia E. Not attributable to another disorder
213
List Migraine With Aura Criteria
A. 2+ attacks that fulfill criterion B B. Presence of +3/4 characteristics for dx of classic migraine: - 1+ fully reversible aura symptoms indicating focal cerebral cortical or brainstem dysfunction (or both) - 1+ aura symptom developing gradually over >4 mins, or 2+ symptoms occurring in succession - No single aura symptom lasting >60 mins - HA beginning during aura or afterward, w/ symptom-free interval <60 mins (also may begin before aura) C. Exclusion of related organic diseases by appropriate hx, px, + neuro exam w/ appropriate diagnostic tests
214
List 9 common migraine auras
Scintillating scotoma (bright rim around an area of visual loss) Teichopsia (subjective visual image perceived w/ eyes open or closed) Fortification spectra (zigzagged lines that slowly drift across the visual field) Photopsias (poorly formed brief flashes or sparks of light) Blurred vision Tingling/numbness Motor disturbance Cognitive d/o Language d/o
215
Describe retinal migraine
Recurrent attacks of monocular visual dysfunction - positive features (scintillations) - negative features (blindness) - symptoms are completely reversible
216
Describe hemiplegic migraine
Motor aura consisting of hemiparesis or hemiplegia - gradual deficit - lasts up to 60min persistence = stroke!
217
Describe migraine w/ brainstem aura
Common neurologic findings include dysarthria, tinnitus, vertigo, diplopia, and aLoC
218
Define status migrainosus
Severe unremitting migraine headache that persists unabated >72 hrs
219
List 10 common triggers for migraine
- sleep deprivation - stress - hunger - hormonal changes - menstruation - use of OCP - use of nitroglycerin - chocolate - caffeine - tyramine foods - MSG - nitrates - red wine/EtOH - strong odour - loud noise - weather changes
220
Outline tx options for migraine
ORAL: Ibuprofen 400mg PO Naproxen 500mg PO Acetaminophen 650mg PO + Metoclopromide 10mg PO (better as combo) Sumatriptan 50-100mg PO 1ST LINE IV: Prochlorperazine 10mg IV Metoclopromide 10mg IV Ketorolac 15mg IV 2ND LINE IV: Dihydroergotamine 1mg IV MgSO4 2g IV PROCEDURE: Greater (+lesser) occipital nerve block bilateral w/ 6cc of 0.5% bupivacaine RECURRENCE PREVENTION: Dexamethasone 10mg IV
221
List 3 triggers for cluster headaches
Alcohol Stress Climate change
222
List clinical features of cluster headache
- multiple episodes in 24h - last 15min-3hr - sharp stabbing pain to eye, and pain in territory of trigeminal nerve - ipsilateral autonomic symptoms = ptosis, miosis, forehead sweating, rhinorrhea
223
Outline tx for cluster headache
1ST LINE: - 100% O2 @ 15L/min NRB x15min - Sumatriptan 6mg SC 2ND LINE: - Octreotide 100mcg SC - Metoclopramide 10mg IV DISCHARGE RX: - Dexamethasone 10mg IV - Prednisone 60mg PO x2d, then 8d taper - Veramapil 120mg PO TID - Melatonin 10mg PO qHS
224
Describe tension headache
tight, band-like discomfort or pressure around the head - dull - may have tightening in neck muscles
225
List 6 etiologies of SAH
- ruptured saccular (berry) aneurysms (80%) - AVMs - cavernous angiomas - mycotic aneurysms - neoplasms - CNS vasculitis
226
List 5 risk factors for SAH
- Increased age (btwn 40-60yrs) - HTN - smoking - excessive EtOH consumption - sympathomimetic drugs
227
List 4 genetic disease associations with SAH
- Autosomal dominant PCKD - Coarctation of Aorta - Marfans - Ehlers-Danlos type 4
228
List associated s/s of SAH
- syncope - n/v - neck stiffness - photophobia - seizures - meningismus - CN3 or CN6 nerve palsy - fluctuating LoC - previous sentinel HA
229
Outline Hunt and Hess Clinical Grading Scale for Cerebral Aneurysms and Subarachnoid Hemorrhage
*Grades 1-2 have good prognosis *Grades 4-5 have poor prognosis GRADE 0 = Unruptured aneurysm GRADE 1 = Asymptomatic or minimal headache and slight nuchal rigidity GRADE 2 = Moderate or severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy GRADE 3 = Drowsiness, confusion, or mild focal deficit GRADE 4 = Stupor, moderate to severe hemiparesis GRADE 5 = Deep coma, decerebrate posturing, moribund appearance
230
List 3 EKG changes present in SAH
ST-T wave changes U waves QT prolongation
231
Outline mgmt goals & tx of SAH
Consider early intubation for grade 3+ Goal SBP <160 MAP 95-130 Labetalol for HTN Nimodipine 60mg PO/NG q4h to prevent vasospasm Fentanyl 50mcg IV or Midazolam 1mg IV prn for agitation/pain Keppra or Fosphenytoin for clinical seizures DEFINITIVE MGMT: - Endovascular coil embolization - Neurosurgical clipping
232
List 8 Most Common Types of Intracranial Malignancy Causing Headache
Metastatic: - Breast - Lung - Gastrointestinal - Melanoma Meningioma Glioblastoma Primary CNS lymphoma Pituitary adenoma
233
List triad & 3 other features of brain tumour headache
Classic triad: 1. Sleep disturbance 2. Severe pain 3. N/V Seizures Personality changes Cognitive difficulties
234
Outline med mgmt and analgesia for brain tumour HAs
NSAIDs Dexamethasone 10mg IV, then 4mg q6h for cerebral edema
235
Describe HA and s/s associated with GCA
- 2-3mo duration - continuous or intermittent - worsen at night or w/ exposure to cold - sharp, throbbing, aching - localized to temporal artery - pain exacerbated by head on pillow or hat wearing - jaw claudication - transient vision loss with amaurosis fugax - permanent vision loss 2/2 anterior ischemic optic neuropathy
236
Outline Diagnostic Criteria for Giant Cell Arteritis (Require 3 of 5)
Age ≥ 50 years old New headache type, association w/ visual loss or jaw claudication Temporal artery tenderness or tenderness of other extracranial arteries ESR ≥ 50 or CRP ≥ 10 Positive imaging finding or temporal artery biopsy
237
What is U/S finding in temporal arteritis?
periluminal hypoechoic halo representing vessel wall edema
238
Outline tx for GCA w/ and w/out vision changes
W/ Visual Changes: Methylprednisolone 100mg IV x3d W/Out Visual Changes: Prednisone 60mg PO OD
239
List clinical features of carotid artery dissection
1) unilateral HA or neck pain - radiating to ipsilateral eye 2) ipsilateral ptosis & miosis - partial Horner syndrome 3) either blindness 2/2 retinal ischemia, or contralateral motor deficits 2/2 cerebral ischemia - may also have pulsatile tinnitus - Acute severe retro-orbital pain
240
List 3 factors associated with a worse prognosis after carotid artery dissection
Older age Occlusive disease on angio Stroke as initial symptom
241
List clinical features of vertebral artery dissection
- relatively young pt w/ severe unilateral posterior HA - rapidly progressive neuro deficit w/ symptoms of brainstem & cerebellar ischemia - vertigo - severe vomiting - ataxia - diplopia - hemiparesis - unilateral facial wekaness - tinnitus
242
Name gold standard diagnostic test for carotid + vertebral artery dissections
DSA = Digital subtraction angiography - CTA and MRA quite good sensitivity too
243
Outline Virchow triad
Blood stasis Blood vessel wall abnormality Hypercoagulable states
244
Outline 2 mechanisms of neurologic dysfunction 2/2 CVT
1) Increased ICP 2/2 impaired venous drainage 2) Focal brain injury 2/2 venous occlusion = ischemia, infarction, hemorrhage
245
List 5 ocular features of CVT
Orbital pain Proptosis Chemosis EOM paralysis Papilledema
246
List 5 risk factors for Idiopathic Intracranial Hypertension
- young women - obesity - tetracycline abx - vit A + retinoids - human growth hormone
247
List 7 Criteria for Diagnosis of Idiopathic Intracranial Hypertension
HA that remits w/ normalization of CSF pressure Papilledema CN VI palsy Increased CSF opening pressure - >250 mm in adults - >280 mm in children Normal CSF diagnostic studies Normal neuroimaging studies No other cause of increased ICP identified
248
List clinical features of IIH
- generalized HA - worsened by eye movement - worse with Valsalva or bending forward - transient visual obscurations (TVOs) - n/v - dizziness - pulsatile tinnitus - papilledema - visual field deficits - CN6 palsy
249
Name best diagnostic imaging test for IIH
MRI w/ contrast
250
Outline mgmt of IIH
+/- therapeutic LP to -20mL of CSF Ketorolac 15mg IV Maxeran 10mg IV Acetazolamide 250-500mg PO BID - if visual field loss Referral to Ophthalmology & Neurology
251
What technique can reduce occurrence of post-LP HA?
Small gauge needles = 20-22 Bevel up w/ cutting needle in lateral position Use non-cutting Whitaker needle
252
List clinical features of Post–Dural Puncture HA & Low CSF Pressure HA
- orthostatic or positional HA - occur w/in 72hr of LP, resolves in 1 week - neck stiffness - n/v - tinnitus - hypoacusis - photophobia
253
Outline mgmt of Post–Dural Puncture HA
First: OTC analgesia + bed rest Persistent HA: Caffeine 500mg IV over 1hr Corticosteroids Severe HA: Epidural blood patch
254
Outline clinical features of Post-Traumatic HA
- develop w/in 7d of injury - acute is <3mo, persistent >3mo - may come w/ dizziness, fatigue, insomnia, irritability, memory loss, and difficulty with concentration.
255
What is the criteria needed to attribute HA to HTN?
SBP >180 or DBP >120 and HA resolves w/ resolution of elevated BP
256
List 3 disease processes that may present w/ HA and HTN
- Pre-eclampsia - Posterior reversible encephalopathy syndrome - Intracranial hemorrhage
257
List 5 risk factors for PRES = Posterior reversible encephalopathy syndrome
- Immunosuppressant medication - Chemotherapeutics - Underlying renal disease - HTN - Pre-eclampsia - Sepsis - Autoimmune disorders
258
List clinical features of Reversible cerebral vasoconstriction syndrome (RCVS)
= cerebral arteriopathy characterized by segmental areas of vasoconstriction within large- and medium-sized vessels - thunderclap HA - throbbing - n/v - photophobia
259
List 2 provoking factors for Reversible cerebral vasoconstriction syndrome (RCVS)
Recreational sympathomimetics Nasal decongestants
260
List 6 DDx of thunderclap HAs
SAH Hemorrhagic stroke CVT Cervical artery dissection Pituitary apoplexy Primary thunderclap headache
261
Name tx for reversible cerebral vasoconstriction syndrome (RCVS)
nimodipine 30-60mg PO q4h
262
List 5 key factors to consider in epileptic pts w/ break-thru seizures
- changes in anti-seizure regimen - poor med compliance - addition of new meds that lower seizure threshold or alter levels of AEDs - presence of common infections or metabolic derangements - change in recent sleep habits
263
List 8 serious systemic complications or seizures and status epilepticus
- cardiac arrest - arrhythmias - apnea - hypoxia - acute kidney injury - rhabdomyolysis - acidosis - death
264
Define medically refractory epilepsy
pts unable to achieve or maintain seizure freedom despite 2 trials of adequately dosed antiseizure regimens
265
List 5 Autoimmune Etiologies of Seizures and Status Epilepticus
Acute disseminated encephalomyelitis Antibody-mediated autoimmune and paraneuroplastic encephalitides CREST Goodpasture syndrome SLE Multiple sclerosis Rasmussen encephalitis TTP
266
List 7 Cerebrovascular Disease Etiologies of Seizures and Status Epilepticus
Acute ischemic stroke Cavernous and ArterioVenous Malformations Cerebral venous thrombosis Intracerebral hemorrhage Nontraumatic subarachnoid hemorrhage Posterior reversible encephalopathy syndrome Reversible cerebral vasoconstriction syndrome
267
List 4 Dementias Etiologies of Seizures and Status Epilepticus
Alzheimer disease Corticobasal degeneration Frontotemporal dementia Vascular dementia
268
List 8 Genetic Syndromes and Structural Anomalies Etiologies of Seizures and Status Epilepticus
Focal cortical dysplasia Hydrocephalus Inherited metabolic diseases Mitochondrial diseases Polymicrogyria Porphyria Tuberous sclerosis complex Wilson disease
269
Name 1 hypoxic-ischemic cause of seizure
Cardiac arrest
270
List 7 Intracranial Tumour Etiologies of Seizures and Status Epilepticus
Dysembryoplastic neuroepithelial tumour Gangliogliomas Gliomas Lymphoma Meningioma Metastases Primitive neuroectodermal tumour
271
List 10 Metabolic Derangement Etiologies of Seizures and Status Epilepticus
Acidosis Elevated blood urea nitrogen Hyperammonemia Hyperglycemia Hypoglycemia Hypernatremia Hyponatremia Hypocalcemia Hypomagnesemia Wernicke encephalopathy
272
List 15 Medications and Toxins Etiologies of Seizures and Status Epilepticus
Alcohol intoxication and withdrawal Alkylating agents Baclofen intoxication and withdrawal Benzodiazepine withdrawal Barbiturate withdrawal Beta-interferons CAR-T (chimeric antigen receptor T cell) Therapy Carbapenems Cephalosporin (cefepime) Cyclosporine Digoxin Fentanyl Heavy metals Lidocaine Metronidazole Mexiletine Theophylline Tramadol Tacrolimus Subtherapeutic AED levels
273
List 3 Systemic Disease Etiologies of Seizures and Status Epilepticus
Acute renal failure Chronic renal failure Cirrhosis
274
List 5 Trauma Etiologies of Seizures and Status Epilepticus
Blunt or penetrating head injury (skull fracture) Epidural hematoma Subarachnoid hemorrhage Subdural hematoma Diffuse Axonal Injury
275
List 4 components of the Epidemiology-Based Mortality Score in Status Epilepticus (EMSE)
Age Etiology of seizure EEG findings Comorbidities
276
Describe Jacksonian March
when focal motor seizure symptoms spread in a step-wise fashion
277
Define refractory status epilepticus
Ongoing seizure despite 1st line (benzo) and 2nd line IV AEDs at appropriate doses
278
Define super refractory status epilepticus
Ongoing seizure >24hr after initiation of 3rd med (therapeutic coma)
279
Define prolonged status epilepticus
Status lasting >7d despite step-wise escalation of therapy
280
List 20 Potential Systemic Complications Related to Seizures and Status Epilepticus
Cardiac: - Arrhythmias - Conduction abnormalities - Cardiac arrest - Cardiomyopathy - Cardiac necrosis - HTN - Thermodysregulation Respiratory: - Airway obstruction - Apnea + Hypoventilation - Aspiration - Hypoxia - Mucus plugging - Pulmonary edema Heme: - Leukocytosis - Leukopenia - Thrombocytopenia MSK: - Dislocation - Fracture - Life threatening rash GI: - Ileus - Bowel ischemia - Hepatotoxicity - Pancreatitis Renal: - Rhabdomyolysis - Myoglobinuria - AKI - Acidosis lactic - Acidosis respiratory - Hyperglycemia - Hyperkalemia Prolonged Issues: - Critical illness myopathy/neuropathy - DVT - PE - Gastrostomy - Infection - Tracheostomy - Skin breakdown - Poor wound healing
281
Describe Todd paralysis
Focal motor deficit after seizure- up to 1hr - associated with a high likelihood of an underlying structural cause for the seizure
282
List 3 commonly fractured bones occurring 2/2 seizure
humerus thoracic spine femur
283
List 6 metabolic derangement levels that likely trigger seizures
Glucose <2.0 or >25 w/ ketoacidosis Na <115 Ca <1.2 Mg <0.3 BUN >35.7 Cr >884
284
List 8 indications for urgent neuroimaging for seizure
~ first time seizure - status epilepticus - focal neuro deficits - prominent HA - known or suspected trauma - hx malignancy - hx immunocompromised state - use of systemic AC
285
What is the guideline duration for primary sz ppx after TBI
7 days of AEDs after acute brain injury/TBI
286
List 5 AEDs that can become subtherapeutic in pregnancy 2/2 increased drug clearance
lamotrigine phenytoin carbamazepine levetiracetam topiramate
287
What deficit is caused by anterior circulation stroke?
contralateral hemiparesis of the face and body
288
What deficit is caused by vertebrobasilar stroke?
- ipsilateral cranial nerve (CN) deficits - contralateral hemiparesis
289
What deficit is caused by posterior cerebral artery stroke?
- ipsilateral CN III palsy - contralateral homonymous hemianopsia
290
What deficit is caused by Wallenberg syndrome?
= occlusion of PICA, lateral medullary stroke - vertigo - Horner syndrome - ipsilateral facial numbness - loss of corneal reflex - contralateral loss of pain and temperature
291
What is goal time to receive thrombolytics after stroke symptom onset?
90mins
292
Outline dosing of tPA for stroke
= Alteplase 0.9mg/kg IV 10% as bolus 90% over 1hr
293
List 4 features with LOWEST risk of spontaneous ICH after tPA for ischemic stroke
Low NIHSS score NO HTN NO DM Age <70yr
294
Describe an ischemic stroke patient who should have thrombolytics recommended?
Disabling stroke symptoms w/in 4.5h of symptom onset
295
What reversal agents are recommended for hemorrhagic stroke pts taking warfarin?
Vitamin K IV Prothrombin Complex Concentrate = PCC - or FFP if PCC not available
296
Define TIA
transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction
297
List 10 non-atherosclerotic causes of stroke, especially in younger pts
- Pregnancy - OCP use - APLAS - Protein S & C def - Sickle cell - Polycythemia - Fibromuscular dysplasia - Prolonged vasoconstriction in migraine - Coke + Amphetamines - Varicella meningitis - Fungal meningitis - Carotid artery dissection - Vertebral artery dissection
298
List 2 main causes of hemorrhagic strokes
1) Hypertensive vasculopathy - usually deep lacunar 2) Cerebral amyloid angiopathy - usually lobar
299
List 5 Common Clinical Presentations of Hypertensive ICH
Contralateral motor/sensory loss Limb pain, speech difficulty Uncoordinated movements of trunk and limbs Numbness, weakness, ataxia, dizziness Numbness, weakness, language disturbances
300
List 5 Most Common Sites for Hypertensive ICH
Putamen (44%) Thalamus (13%) Cerebellum (9%) Pons (9%) Other cortical areas (25%)
301
List 8 risk factors for ICH other than HTN
AVMs Aneurysms (saccular) Sympathomimetic drugs Blood dysrasias CVT Hemorrhagic transformation of ischemic stroke Moyamoya disease Tumours
302
Define penumbra
area of the brain surrounding the primary (stroke) injury, which is preserved by a tenuous supply of blood from collateral vessels
303
List 3 branches of internal carotid artery
Ophthalmic artery Anterior cerebral artery Middle cerebral artery
304
What does ophthalmic artery supply?
optic nerve retina
305
What 4 structures does the MCA supply?
Putamen Anterior limb of internal capsule Lentiform nucleus External capsule
306
What does the posterior circulation supply?
Brainstem Cerebellum Thalamus Vision Hearing
307
Contrast Wernicke and Broca aphasia
Wernicke = receptive aphasia Broca = expressive aphasia
308
Describe 5 deficits in ACA stroke
- Altered mentation - Primitive grasp + suck reflex - Bowel & Bladder incontinence - Paralysis and hypesthesia to contralateral LE - Apraxia ## Footnote Become like a baby again
309
Describe 4 deficits in MCA stroke
- Contralateral face + UE numbness + paralysis - Contralateral hemianopsia - Agnosia - Aphasia
310
Outline LAMS score
FACIAL DROOP 0 = Absent 1 = Present ARM DRIFT 0 = Absent 1 = Drifts down 2 = Falls repeatedly GRIP STRENGTH 0 = Normal 1 = Weak 2 = None TOTAL /5 >4 = High risk for LVO = large vessel occlusion
311
List 3 baseline characteristics w/ unfavourable outcomes in pts with ICH
- Decreased LoC on arrival - Intraventricular hemorrhage - Large ICH volume
312
List 10 DDx for ischemic stroke
EDH SDH Aortic dissection Carotid artery dissection Brain tumours Brain abscess Air embolism Hypoglycemia Wernicke encephalopathy Postictal Todd paralysis Bell palsy Vestibular neuritis GCA SLE vasculitis CVT
313
List 5 DDx for Hemorrhagic stroke
*Basically same as Ischemic DDx Hypertensive encephalopathy Migraine PRES Seizure Head trauma
314
List 6 early ischemic changes seen on noncontrast CT head
Hyperdense artery sign - acute thrombus in vessel Sulcal effacement Loss of insular ribbon Loss of gray-white interface Mass effect Acute hypodensity
315
After what time frame may CT perfusion study be helpful?
After 6hr
316
Outline Target Timelines in Stroke
Door to doctor = 10 min Door to CT completion = 25 min Door to CT scan reading = 45 min Door to treatment = 60 min Access to neurologic expertise = 15 min Access to neurosurgical expertise = 2 h
317
Outline situations when BP control is indicated in acute ischemic stroke
1) Pt is eligible for tPA & SBP >185 or DBP >110 - Labetalol 10-20mg IV - Hydralazine - Enalaprilat - Do NOT give tPA if BP is >185/110 2) Pt is getting or has gotten tPA - Control BP <180/105 - use labetalol, nicardipine, nitroprusside
318
When is it safe to give Alteplase in ischemic stroke?
Within 3hr of onset - Mild disabling and Severe symptoms - Any age Btwn 3-4.5hr if - Age <80 - No DM - No prev CVA - NIHSS <25 - No OAC - No imaging evidence of injury to >1/3 MCA territory
319
List 18 Exclusions for IV Alteplase in Patients With Acute Ischemic Stroke
- Mild NONDISABLING stroke - Extensive regions of hypoattenuation on CT - ICH now or ever - Ischemic CVA <3mo - Severe head trauma <3mo - Intracranial/Intraspinal surgery <3mo - SAH - Structural GI cancer - GIB <21d - PLT <100 - INR >1.7 - PT >15s - aPTT >40s - Full tx dose of LMWH <24h - Infective endocarditis - Direct thrombin inhibitor or Factor Xa inhibitor <48h, or abnormal BW - Aortic arch dissection - Brain cancer
320
What neuroimaging may be helpful after 4.5-9h onset, or "wake up" strokes?
MRI DWI and FLAIR could potentially still benefit from alteplase
321
In pts taking blood thinners prior to stroke, which ones are 'safe' to get alteplase?
Anti-PLTs (sngl or DAPT) = SAFE LMWH (full tx dose) = NOT SAFE if <24h Factor IIa and Xa Inhibitors = NOT SAFE if BW abnormal or <48h
322
When does Symptomatic Intracerebral Hemorrhage Following Thrombolysis usually occur?
W/in 36hr 1/2 in 5-10hr
323
List 4 types of ICH after thrombolysis as seen on f/u CT
1) petechial hemorrhage ALONG infarcted tissue 2) confluent petechial hemorrhage WITHIN infarcted tissue 3) parenchymal hematoma involving <30% of infarcted tissue w/ slight mass effect 4) parenchymal hematoma involving >30% of infarcted tissue w/ significant mass effect
324
List 10 Factors Associated With Increased Risk for Symptomatic Intracerebral Hemorrhage After Thrombolysis
Older age Greater stroke severity Higher baseline glucose HTN CHF Renal impairment DM Ischemic heart disease AFib Baseline antiPLT use Leukoaraiosis (periventricular white matter disease) Visible acute infarction on imaging Cerebral microbleeds
325
Outline general mgmt of post-thrombolytic hemorrhage
- CV/Resp support - BP mgmt - neuro monitoring - prevention of hematoma expansion - ICP control - seizure control
326
Name tx for symptomatic ICH after IV thrombolytics
Cryoprecipitate 10 units IV over 10-30min Then more to keep Fibrinogen >1.5g/L
327
How do cerebral microbleeds relate to the risk of symptomatic ICH after thrombolytics in ischemic stroke?
Cerebral microbleeds are markers of bleeding-prone vessels - therefore INCREASE risk of ICH - foretell poor functional outcomes at 3 to 6mo after IV thrombolytics So, if >10 cerebral microbleeds on MRI, benefit of thrombolytics is uncertain
328
List 4 general indications for mechanical thrombectomy in ischemic stroke
- Acute ischemic stroke - Proximal large vessel occlusion - Anterior circulation - Present w/in 24hr of onset
329
Outline 4 guidelines for mechanical thrombectomy for ischemic strokes @ time 0-6hr
1) NO significant pre-stroke disability - mRS score ≤1 2) Causative occlusion of ICA or M1 segment 3) NIHSS score ≥6 4) ASPECTS of ≥6 - better fnc'l outcome @3mo
330
Outline BP targets in hemorrhagic strokes
Presenting SBP 150-220 --> Target SBP 140 Presenting SBP >220 --> Target lower SBP but not so fast in first hr
331
Outline reversal of various blood thinners in hemorrhagic stroke
Vitamin K Antagonists - Vitamin K 10mg IV - PCC - or FFP Dabigatran (F IIa Inhib) - Idarucizumab 5g IV - PCC - or FFP - or Hemodialysis Apix/Riva (Fac Xa Inhib) - Andexanet alfa - or PCC - NOT BOTH ASA - DDAVP 0.4mcg/kg IV if getting NSx
332
Outline increased ICP mgmt after hemorrhagic stroke
If supratentorial ICH with radiographic hydrocephalus + dec LoC: - EVD advised GCS <8 + transtentorial herniation or IVH or Hydrocephalus: - Monitor ICP, target CPP 50-70 3%NS or Mannitol Target euglycemia
333
List 4 guideline recommendations for indications for NSx evacuation of supratentorial ICH
- neurological deterioration - coma - midline shift - elevated ICP refractory to medical treatment
334
Outline DAPT rx after TIA
DAPT: - clopidogrel x21d - ASA for life
335
Return of what reflex signifies the END of spinal shock?
Return of bulbocavernosus reflex
336
Outline neuro deficits in anterior cord syndrome
- Symmetric motor loss, pinprick, light touch - Intact proprioception & vibration
337
List 2 DDx for sudden severe back pain
spinal subarachnoid hemorrhage (SSAH) spinal epidural hematoma (SEH)
338
Compare & Contrast Cauda Equina syndrome and Conus medullaris lesions
- Both have bladder retention, fecal incontinence, leg weakness, and sensory loss in the perineum - Cauda is unilateral, LMN signs - Conus is bilateral, UMN signs
339
List physical findings of central cord syndrome
= MUD Motor > Sensory Upper > Lower Distal > Proximal
340
Name main cause of central cord syndrome
Hyperextension injury - inward bulging of dorsally located ligamentum flavum resulting in contusion to spinal cord which most affects central cord
341
Outline neuro deficits in Brown Sequard syndrome
Ipsilateral loss: - motor - proprioception - vibration Contralateral loss: - pain - temperature
342
Name diagnostic imaging of choice in the majority of suspected spinal disorder
MRI with contrast
343
List 2 areas of spinal cord enlargement
Cervical Enlargement @ C5-T1 - brachial plexus - peripheral nerves of UE Lumbar Enlargement @ L2-S3 - Lumbosacral plexus - peripheral nerves of LE
344
Contrast ventral and dorsal nerve roots
Ventral = Anterior - outflow of motor neurons in anterior horn of spinal cord Dorsal = Posterior - inflow of sensory neurons to dorsal horn
345
Outline arterial supply of the spinal cord
Single Anterior Spinal Artery - arises from paired vertebral arteries - supplies anterior 2/3 of cord Paired Posterior Spinal Arteries - arise from vertebral arteries - supply posterior 1/3 of cord *Additional blood supply from artery of Adamkiewicz from Aorta btwn T8-L4
346
Outline basic spinal cord anatomy, including 3 major tracts, their sensory or motor purposes, and where they cross over
1) Lateral Spinothalamic Tract - Sensory - Ascending pain + temperature info - Cervical fibres medially - Sacral fibres laterally - Crosses @ level of entry of spinal nerve roots, so runs mostly on contralateral side 2) Posterior/Dorsal Column - Sensory - Ascending proprioception + vibration info - Cervical fibres laterally - Sacral fibres medially - Crosses @ medulla, so runs mostly on ipsilateral side 3) Lateral Corticospinal Tract - Motor - Descending voluntary movement - Cervical fibres medially - Sacral fibres laterally - Crosses @ medulla, so runs mostly on contralateral side from origin in brain
347
List 4 common causes of complete cord syndrome
Trauma Infarction Hemorrhage Extrinsic compression
348
Outline deficits in Complete Cord Syndrome
- total loss of sensory, autonomic, voluntary motor innervation distal to level of injury - DTR absent early, then hyperreflexive later - acute autonomic dysfunction = neurogenic shock, priapism
349
Describe Spinal Shock
Loss of muscle tone & reflexes w/ Complete Cord Syndrome - during acute phase, first 24hr Loss of bulbocavernosus reflex = involuntary contraction of anal sphincter in response to squeeze of glans penis or clitoris, or outward tug on Foley catheter
350
List 3 Incomplete (Partial) Spinal Cord Lesions
1) central cord syndrome 2) Brown-Séquard syndrome 3) anterior cord syndrome
351
Describe findings of this cord lesion
- Bilateral motor paresis - MUD - affects central gray matter & central portions of corticospinal (motor) and spinothalamic (pain/temp) tracts +/- sensory impairment & bladder dysfunction
352
Name 9 main causes of Brown-Sequard syndrome
Penetrating injuries to hemi cord - Spinal cord tumours - Spinal epidural hematomas - Vascular malformations - Cervical spondylosis - Degenerative disk dz - Herpes zoster myelitis - Radiation injury - Complication of spinal instrumentation
353
List 10 causes of anterior cord syndrome
- ischemia after aortic sx - severe hTN - infection - MI - vasospasm 2/2 drug rxn - aortic angiography - cervical hyperflexion = cord contusion - protrusion of bony fragments into spinal canal - herniated cervical disk into spinal canal - laceration of anterior spinal artery - thrombosis of anterior spinal artery
354
List 4 causes of conus medullaris syndrome
- central disc herniation - neoplasm - trauma - vascular insufficiency
355
What bladder PVR suggests bladder dysfunction?
>100-200cc
356
List 6 specific indications for MRI with contrast
Primary tumour Metastatic tumour MS Spinal epidural abscess Discitis Osteomyelitis
357
List clinical features of Transverse Myelitis
- Paraplegia (weakness progressing to paresis) - Transverse sensory impairment - Anal sphincter disturbance - Back pain - Low grade fever - Hypertonia - Hyperreflexia - Clonus - Upgoing Babinski +/- Autonomic dysfunction
358
List clinical features of Syringomyelia
- HA w/ neck pain - Gait abnormality - Sensory disturbances - Lower limb hyperreflexia - Hand weakness - Dissociative anesthesia (pain & temp loss, proprioception & light touch intact)
359
List 7 nontraumatic intrinsic spinal cord lesions
MS Transverse myelitis Spinal SAH Syringomyelia HIV myelopathy Spinal cord infarction Surfer's myelopathy
360
List 4 nontraumatic extrinsic spinal cord lesions
Spinal epidural hematoma Spinal epidural abscess Discitis Neoplasm
361
List 5 potential causes of transverse myelitis
Viral infxn Idiopathic SLE Sjogren syndrome APLAS
362
List 7 DDx for Transverse Myelitis
MS Spinal epidural abscess Spinal epidural hematoma Spinal neoplasm Spinal cord infarct Surfer's myelopathy Vitamin B4 deficiency
363
Outline tx for Transverse myelitis
ONLY if realted to NMOSD - Methylprednisolone 1g IV - Immunosuppressant agents
364
List 5 causes of syringomyelia
Chiari I malformation Spinal cord trauma Compressive tumours Post-infectious Post-inflammatory
365
List 10 risk factors for spinal epidural abscess
Immunosuppression DM CKD AUD Spinal abnormality Spinal surgery recently Epidural analgesia recently SSTI Cystitis Sepsis Osteomyelitis Endocarditis IVDU
366
List 6 common bacterial pathogens of spinal epidural abscesses
S. aureus MRSA E. coli Pseudomonas Streptococcus sp TB
367
List 5 risk factors for failure of non-operative plan for spinal epidural abscess
Sensory deficit Motor deficit at time of presentation Pathologic/Compressive fracture DM Active malignancy
368
Outline clinical features of discitis
- Usually pediatrics - Low grade fever - Lack of neuro deficits - Possibly radicular symptoms - mostly S. aureus, Strep, K. kingae
369
List 3 primary malignant neoplasms that can develop spinal metastases
Lung Breast Prostate
370
Outline mgmt of compressive myelopathy
Dexamethasone 10mg IV then 4mg PO q6h Radiation tx Surgical tx
371
Define autonomic dysreflexia
Loss of coordination between heart rate and vascular tone in response to increased demand - Noxious stimuli below injury can result in uninhibited sympathetic response causing vasoconstriction & HTN that is not overcome by compensatory parasympathetic activity (bradycardia + vasodilation) above lesion
372
List 6 examples of noxious stimuli that cause autonomic dysreflexia
Bladder distention Bowel impaction Pain Pressure ulcers Tight clothing Infection
373
Outline clinical features of autonomic dysreflexia
SBP >20-40 above SBP baseline or SBP >150 w/ symptoms & no known baseline Severe HA Diaphoresis +/- Bradycardia
374
Outline mgmt/tx of autonomic dysreflexia
Identify cause BP control - topical, PO, IV anti-HTN meds - nitroglycerin 2% paste above spinal cord lesion - nitroglycerin 5mcg/min IV inf, increase by 20mcg q1-3min if severe - NO BETA BLOCKERS
375
List 2 definitive txs for GBS
IVIG Plasma exchange
376
List 4 tx options for diabetic distal symmetrical polyneuropathy (DSPN)
Pregabalin Gabapentin Duloxetine Amitriptyline Lidocaine patches Capsaicin cream
377
List most specific finding for carpal tunnel syndrome
Splitting of sensation on D4 - normal sensation on ulnar palmar side - abnormal sensation on median/radial palmar side
378
Name most common neurologic abnormality in Lyme disease
Unilateral or Bilateral facial nerve palsy
379
List most obvious feature of complete common peroneal mononeuropathy
Foot drop, by weakness of ankle dorsiflexion
380
List 2 parts of the autonomic nervous system as it relates to peripheral nerves
1) Sympathetic component - ThoracoLumbar 2) Parasympathetic component - CranioSacral
381
List 3 basic pathology categories of peripheral nervous system
1) Myelinopathies - problem of myelin sheath around axon 2) Axonopathies - problem of axon +/- secondary demyelination 3) Neuronopathies - problem of cell body of neuron - affects entire peripheral nerve essentially
382
List 15 Causes of Acute, Emergent Weakness & Possible Respiratory Compromise
AUTOIMMUNE: - GBS - Chronic inflammatory demyelinating polyneuropathy - Myasthenia Gravis TOXIC: - Botulism - Buckthorn - Paralytic shellfish toxin - Tetrodotoxin (puffer fish, newts) - Tick paralysis - Arsenic - Thallium METABOLIC: - Familial Dyskalemic syndrome - Acquired Dyskalemia - Thyrotoxicosis - HypoPO4 - HyperMg - Porphyria INFECTIOUS: - Poliomyelitis - Diphtheria
383
List 10 examples of Demyelinating Polyneuropathies
Guillain-Barré syndrome (GBS) - Acute inflammatory demyelinating polyradiculoneuropathy - Acute motor axonal neuropathy - Acute motor and sensory axonal neuropathy - Miller Fisher syndrome Chronic Inflammatory Demyelinating Polyneuropathy Malignant disease Human immunodeficiency virus (HIV) infection Hepatitis B Buckthorn Diphtheria
384
List 4 infectious causes of GBS
Campylobacter jejuni CMV EBV Mycoplasma pneumoniae
385
List 7 broad types of Peripheral Nerve Disease
Demyelinating Polyneuropathy - GBS Distal Symmetrical Polyneuropathy Asymmetric Proximal & Distal Peripheral Neuropathy - Radiculopathy & Plexopathy Isolated Mononeuropathy Mononeuropathy Multiplex Amyotrophic Lateral Sclerosis Sensory Neuronopathy - Ganglionopathy
386
Outline clinical features of GBS
- preceding resp or GI illness - progressive symmetric weakness - worse distally - distal paresthesias - areflexic paralysis - sparing of anal sphincter - CN involvement (usually 7) - autonomic dysfunction
387
Outline diagnostic testing for GBS
- LP, CSF may have mild WBC pleocytosis, high protein - Respiratory function tests
388
List 8 indications for intubation in GBS
O2 sat <92% Bulbar dysfunction Vt <5cc/kg FVC <20mL/kg MIP 'greater than' -30cm H2O (closer to 0) RR >30 MEP <40cm H2O Acute hypercapnea PaCO2 >50mmHg
389
Outline tx for GBS
Plasma exchange IVIG 400mg/kg IV q24h x5d NO STEROIDS recommended
390
List 7 examples of Distal Symmetrical Polyneuropathy (not including toxins)
Diabetes mellitus Alcoholism Neoplastic or paraneoplastic Hereditary motor & sensory neuropathies (Charcot-Marie-Tooth) Cryptogenic sensorimotor polyneuropathies HIV infection Toxins
391
List 20 toxins/metabolics that cause Distal Symmetrical Polyneuropathy
Therapeutic Agents: - Amiodarone - Antiretrovirals - Dapsone - Disulfiram - Isoniazid - Metronidazole - Nitrofurantoin - Paclitaxel - Phenytoin - Statins (HMG-CoA reductase inhibitors) - Thalidomide - Vinca alkaloids (vincristine, vinblastine) Nutritional: - Beriberi (Thiamine or Vitamin B1) - Pellagra (Niacin, B vitamins) - Pernicious anemia (Vitamin B12) - Pyridoxine deficiency (Vitamin B6) End-Organ Dysfunction: - Acromegaly - Chronic pulmonary disease - Hypothyroidism - Renal failure (uremic neuropathy) Paraproteinemias: - Amyloidosis - MGUS - Multiple myeloma - Waldenström Macroglobulinemia Porphyria Organic or Industrial Agents: - Acrylamide - Allyl chloride - Carbon disulfide - Ethylene oxide - Hexacarbons - Methyl bromide - Organophosphate-induced delayed polyneuropathy - Polychlorinated biphenyls - Trichloroethylene - Vacor Metals: - Arsenic - Gold - Mercury (inorganic) -Thallium
392
Outline clinical features of Distal Symmetrical Polyneuropathy
- distal, symmetrical sensorimotor deficits - LE > UE - stocking-glove distribution - motor weakness and loss of DTR - "length dependent axonopathy"
393
List 8 Causes of Brachial Plexopathy
OPEN: Direct plexus injury (knife or GSW) Neurovascular (plexus ischemia) Iatrogenic (CVL insertion) CLOSED: Traction injuries - “Stingers” (neck or shoulder injury resulting in transient brachial plexus injury) - Traction neurapraxia - Partial or complete nerve root avulsion Radiation Neoplastic Idiopathic brachial plexitis Thoracic outlet syndrome
394
List 10 Causes of Lumbosacral Plexopathy
OPEN CLOSED: Traction injuries - Pelvic double vertical shearing fracture - Posterior hip dislocation - Retroperitoneal hemorrhage Vasospastic (deep buttock injection) Neoplastic Radiation Idiopathic lumbosacral plexitis Infectious - Herpesvirus (sacrococcygeal) - Herpes simplex 2 - Zoster - CMV polyradiculopathy (HIV infection)
395
List clinical features of radial mononeuropathy
- Wrist & Finger drop (Rad controls extensors) - Numbness over first dorsal interosseus muscle - Saturday night & Bridegroom palsies also can occur
396
List common sites of ulnar nerve injury/compression
Condylar groove Cubital tunnel Wrist (Guyon's canal) Elbow level injury WILL cause ulnar sensory issues Wrist level injury will ONLY cause motor
397
List 8 Conditions Associated With Carpal Tunnel Syndrome
Acromegaly Amyloid Diabetes mellitus Hypothyroidism Obesity Pregnancy Renal failure Rheumatoid arthritis
398
List 3 tx options for carpal tunnel syndrome
Supportive neutral wrist splint Steroid injection Carpal tunnel release surgery
399
Name 2 terminal branches of the sciatic nerve
Tibial nerve Common peroneal nerve
400
List 4 causes of sciatic nerve lesions
Posterior hip dislocation Penetrating/Blunt trauma causing buttock hematoma (compression) Deep gluteal injection Prolonged supine immobilization
401
Outline clinical features of sciatic nerve mononeuropathy
Poor ambulation - inability to flex the knee and a flail foot (neither flexion nor extension is possible at the ankle)
402
Describe lateral femoral cutaneous mononeuropathy
= Meralgia Paresthetica Injury to purely sensory nerve - as it passes through or over the inguinal ligament, where it may become entrapped or kinked Associated with HIV infection Numbness & Dysesthesia over skin of upper lateral thigh
403
List 7 risk factors for "Meralgia Paresthetica" = lateral femoral cutaneous mononeuropathy
HIV infection Obesity DM Pregnancy Tight clothes Tight belts Previous hip or spine surgery
404
Outline single most reliable clinical feature distinguishing sciatic from common peroneal mononeuropathy
Footdrop + weak eversion of foot w/ both *STRONG inversion remains in isolated peroneal lesion, as this is innervated by the tibial nerve
405
Outline tx of common peroneal palsy
Posterior splint w/ ankle at 90deg - prevents sustained equinus (plantar flexion)
406
List 12 causes of Mononeuropathy Multiplex
Vasculitis: - Polyarteritis nodosa - Rheumatoid arthritis - SLE - Sjögren syndrome (keratoconjunctivitis sicca) - Nonsystemic vasculitis Diabetes mellitus Neoplastic: - Paraneoplastic - Direct infiltration Infectious: - Lyme disease - HIV infection Sarcoid Toxic (Lead) Transient (Polycythemia Vera) Cryoglobulinemia (Hepatitis C)
407
Briefly describe a Mononeuropathy Multiplex
asymmetrical, sensorimotor, usually distal pattern of peripheral neuropathy
408
Name dx test for vasculitis related multiplex mononeuropathies
Sural nerve biopsy
409
Outline PO ABX tx of facial nerve palsy in Lyme dz
Doxycycline 100mg PO BID x14d
410
List 10 Objective Clinical Findings Consistent With ALS = Amyotrophic Lateral Sclerosis
UMN SIGNS: Hyperreflexia - Sustained clonus, especially at ankle - Finger flexors and jaw jerk Spasticity, especially of gait Presence of upgoing Babinski sign LMN SIGNS: Positive motor phenomena - Fasciculations - Cramps Negative motor phenomena - Asymmetrical distal weakness - Atrophy COMBINED UMN + LMN SIGNS: - Dysarthria - Dysphagia - Respiratory compromise
411
Name primary pathologic processes in peripheral & central nervous systems as they relate to ALS
Peripheral: Neuronopathy of the anterior horn cell Central: Loss of Betz cells in motor cortex, secondary degeneration of corticospinal tracts
412
Name best dx test for ALS
Electrophysiologic (EMG and nerve conduction studies)
413
List 2 drug txs for ALS
Riluzole Edaravone
414
Outline clinical features of sensory neuronopathies
= dorsal root ganglionopathies - pure sensory syndrome - proprioception most profoundly altered = sensory ataxia, loss of DTR - NO weakness
415
Name best confirmation test of dorsal root ganglionopathies/sensory neuronopathies
MRI
416
List 10 common causes of Sensory Neuronopathies (Ganglionopathies)
- HSV1+2 - VZV Shingles - Inflammatory sensory polyganglionopathy - Paraneoplastic - Primary biliary cirrhosis - Sjögren syndrome (keratoconjunctivitis sicca) - Pyridoxine (Vit B6) overdose - Platinum (Cisplatin) - Methyl mercury - Vitamin E deficiency
417
List 2 cerebrovascular causes of syncope
SAH Basilar artery migraine
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