Kaplan Neurology review – Flashcards
Unlock all answers in this set
Unlock answersquestion
test of choice for cord compression?
answer
MRI
question
sxs of syringomyelia?
answer
bilateral loss of pain and temp in upper extremities
question
test for syringomyelia?
answer
MRI (cervical)
question
tx for syringomyelia?
answer
drain (but bad prognosis)
question
what are the symptoms of posterior column disease?
answer
vibration and proprioception?
question
classic presentation of posterior column disease?
answer
i can walk, but i have to watch where i am walking, or else I will fall. becomes ataxic when close eyes
question
how is posterior column disease differrent from a cerebellar lesion?
answer
in a cerebellar lesion, will have ataxia if the eye are open or closed
question
what are causes of posterior column disease?
answer
b12 (dementia) and syphillis (tabes dorsalis, argyl roberts)
question
test for posterior column disease?
answer
MRI
question
treat for posterior column disease from syphillis?
answer
penicillin (cannot give doxy, desensitize)
question
sxs of an an anterior spinal artery infarction?
answer
lose everything sxcept proprioception and vibration (think christopher reeves superman)
question
anterior spinal artery infarcts are commonly seen in what condition?
answer
aortic aneurysms
question
how will a anterior spinal cord infarct usually preset?
answer
first become flaccid, no movement, no reflexes, no sensations (spinal shock). then in a few days to wks, it becomes more upper and will et hyperreflexia, babinski, bowel/bladder dysfunction, clonus, etc.
question
tx for anterior spinal cord infarct?
answer
nothing bc becomes ischemic very quickly and neurons do not regenerate well
question
symptoms of a small artery thrombosis?
answer
clunsy hand with no other symptoms (lacunar infarct, deeper, penetrating branch)
question
what will be the sxs if a small artery thrombosis involves the thalmus?
answer
severe pain (thalamic pain syndrome), unproportional to stimulus
question
sxs of an anterior cerebral artery stroke?
answer
weakness and sensory loss in legs more than arms on the contralateral side, uninhibited behavior, bladder dysfunction (all anterior lobe effects)
question
what is an importnat symptom that is not seen in an anterior cerebral artery stroke?
answer
no speech problems
question
symptoms of a left middle cerebral artery stroke?
answer
contralateral weakness and sensory deficits in arm more than legs, homonomos hemianopsia (cuts one side of vision), expressive aphasia (cant find the words)
question
what is the main symptom that differentiates a left MCA from a right?
answer
left: expressive aphasia
question
what is an expressive aphasia?
answer
can speak, but they cannot find the words, which frustrates them
question
a right MCA stroke will have similiar symptoms to the left, but what is the unique symptom?
answer
get hemineglect, they don;t know they have a left side, so ask to put numbers on a clock, will only draw numbers on the right side, don't recognize the left side
question
in a stroke, which way will the eyes move?
answer
towards the lesion (seizure is opposite the lesion)
question
what structures are effected in a posterior stroke?
answer
occipital lobe, brain stem and cerebellum
question
what ar ethe occipital lobe problems seen in a posterior stroke?
answer
cortical blindness (can't process the images they see), visual agnosia (forget everything your learned)
question
what are the cerebellum effects of a posterior stroke?
answer
ataxia (wobbly when stand straight, truncal)
question
what are the brain stem effects of a psoterior stroke?
answer
opthalmoplegia cn9/10:dysphonia/dysphagia 11: shoulder weakness 7: lower face weakness (can still close eyes) dysarthria: cant articulate words
question
how long before thrombolytics are not given for a stroke? (hrs)
answer
3
question
if you don't know how long the stroke has been, can you give thrombolytics?
answer
no
question
what is the first test if you suspect a stroke? why?
answer
CT without contrast. this is not done to diagnose a stroke, it is done to determine if there is any bleeding bc thrombolytics can't be given if there is an acute bleed
question
what is the best imaging test to diagnose a stroke?
answer
MRI (but too slow. do after you treat)
question
why is tpa not given after 3 hrs?
answer
high risk to bleed into the brain
question
if tpa wasn''t given for a stroke, is a CT w//o contrast still done? why?
answer
yes, can find a hemorhagic stroke and rule out any other causes
question
what is the next step after the CT and giving tpa?
answer
wait 24hrs, then give antiplatelet drug (aspirin. wait 24hrs, if give before, then high chance to bleed with the tpa)
question
if tpa is not given for the stroke, when can aspirin be given?
answer
immediately
question
what is patient had a stroke and was already on aspirin. how does this change the antiplatelet therapy?
answer
step aspirin and switch to clopidogrel, or add dypridamole to aspirin. (do not add clopidogrel to aspirin)
question
how is stroke usually diagnosed?
answer
clinically
question
if TIA is found quickly, how do you differentiate from a stroke?
answer
you can't, treat as if its a stroke, bc fatal and must be treated immediately
question
what is the management for a TIA if it resolved?
answer
start on aspirin and do CT to rule out any bleed
question
in a nonhemorhagic stroke, how do yo manage the hypertension? why?
answer
observe and let the bp rise. because around the stroke, there is a prenumbra, which is an area of ischemia which needs blood. When the bp rises, it gets blood to this area
question
when should hypertension in a nonhemorhagic stroke be treated?
answer
>210/105, but not too quickly
question
in stroke, after giving tpa and doing the CT and giving aspirin. whats the next step?
answer
-carotid duplex (worried if >70% stenosed. need to admit patient to find underlying cause) -TEE (need to see left atrium) - ekg monitoring
question
if all the stroke tests are neg and the patient keeps going in an out of afib, what is the cause of the stroke?
answer
afib (cardioembolic, diagnosis of exclusion)
question
what is the next step if the cause of the stroke was afib?
answer
start warfarin
question
if the carotids are >70% stenosed, what is the management?
answer
endatarectomy (bc high chance of recurrence)
question
how does maangement change for a hemorhagic stroke?
answer
want tighter bp control, bc the higher the BP, the more bleeding you will get. so try to get bp to 140/90
question
why are NSAIDs avoided in stroke?
answer
bc have antiplatelet activity
question
test if you suspect a subarachnoid hemorhage?
answer
ct w/o contrast
question
next step if ct shows a subarachnoid hemorhage?
answer
send patient to ICU and start nimodipine
question
why is nimodipine used fora a subarachnoid hemorhage?
answer
bc it decreases spasm and is neuroprotective (but need to add another agesnt to control the bp 140/80)
question
what are are three main complications of a subarachnoid hemorrhage?
answer
-spasm (free blood binds up nitric oxide to cause spasm -hydrocephalus (can treat by putting in a external shunt at bedside) -rebleed try to prevent rebleed and spasm, bc poor prognosis
question
what are the 3 main causes of a subarachnoid hemorhage?
answer
trauma, aneurysm, AVM, must fix immediately
question
in a subarachnoid hemorhage, after doing the CT, starting nimodipine and controlling the bp, what is the next step? why?
answer
CT/MRI angriogram with contrast, to see the blood vessels, so you can fix in the same day
question
if a patient had a subarachnoid hemorhage yesterday, but the CT w/o contrast shows no blood. whats the next step? why?
answer
need an LP bc since it has been 24hrs wince the event, the CT may no longer show blood.
question
what will the LP show in a subarachnoid hemorrhage?
answer
xanthochromia, a bunch of rbcs and yellow pigments (treat the same way)
question
what is the VITAMINS mnemonic for seizure?
answer
vascular, infection, trauma, autoimmune, metabolic (the hypo's), idiopathic, neoplastic, psychiatric (pseudoseizure)
question
what is a generalized seizure?
answer
lose consciousness, usually tonic clonic (still with jitters), with a postictal state
question
what will the EEG show in a petit mal seizure?
answer
spike and dome after every 3 seconds in all leads
question
tx for petiti mal?
answer
ethosuximide
question
what is unique about the management for a petit mal seizure?
answer
start treatment right away, don't wait for a second episode
question
what are sxs of a focal seizure?
answer
motor twitch, smell burning rubber lip smacking
question
what is the main symptom of a simple partial seizure?
answer
never lose conscioiusness
question
what differentaites a simple from a somplex partial seizure?
answer
complex will start focally, but then become generalized and lose consciousness.
question
chronic tx for partial seizures?
answer
carbamazepine
question
how do you differentiate a generalized seizure from a partial complex?
answer
EEG
question
what seizure does not require additional testing?
answer
metabolic seizures (alcohol, electrolytes)
question
what is the next step for a seizure that is not metabolic? why?
answer
MRI/CT with contrast to rule out a brain lesion. then you can do an EEG
question
next step if the CT/MRI and EEG is neg?
answer
if its the first time, then no therapy, no anticonvulstants, with some esceptions. if second time, then start anticonvulsants
question
when is anticonvulsant therapy indicated with a negative workup and first seizure?
answer
status epilepticus, family history, abnormal EEG, focal neuro deficits
question
what is the chronic treatment for a primary generalized seizure?
answer
valproate
question
which anticonvulsant is avoided in pregnancy?
answer
valproate (none are safe, but valproate is the worst)
question
when can anticonvulsants be stopped?
answer
3-5yrs (2 according to uworld), but must wean off (bc can get a rebound seizure. if seize again, then life long therapy)
question
seizure in adult with a fever. main ddx?
answer
encephalitis or meningitis (adults do not get febrile seizures)
question
what is the management in treating an acute seizure episode?
answer
1. ABCs 2. try lorazepam, rectal diazzepam in kids 3. if persists, give phenytoin/phosphopenytoin (now status epilepticus, can kill you) and intubate bc this IV drip takes 40 min to work 4. phenobarb 1.5g 5. propofol and benxodiazepam infusion (anesthesia, this will stop your breathing, but it will stop the seizure) treatment is based on persistant of seizure, if stops after lorazepam, dont have to continue down
question
what is the presentation of a kinetic status epilepticus?
answer
has seizure, passes out, but out for a whole day. may still be in seisure, which can be seen in EEG. if give lorazepam, should wake up
question
any driving recomendations for seizures?
answer
none (state by state dont call the dmv to take away their licence)
question
where is the problem in peripheral vertigo? central?
answer
peripheral: cochlea, cn8 central: cerabellum, brain stem, more dangerous
question
symptoms of peripheral vertigo?
answer
tinnitus, hearing loss, severe n/v from dizziness, nystagmus
question
what are the features of nystagmus that occurs in peripheral vertigo?
answer
unidirectional and can be extinguished (usually provoked by head movment)
question
pathophys in BPPV?
answer
cholesterol crystal on the hair of the cochlea
question
key feature of neuronitis/labrynthitis?
answer
after a URI, can't move bc will throw up, self limited
question
pathophys of menieres?
answer
sodium imbalance in the cochlea leading to injury (chronic state, can go on for weeks)
question
acute treatment for peripheral vertigo?
answer
mecilizine (can use scopolamine patch)
question
what is the chronic treatment for menieres?
answer
low sodium diet and thiazide for chronic control
question
what are features of nystagmus in central vertigo?
answer
cannot be extinguished, and multidirectional
question
why no hearing loss in central vertigo?
answer
does not effect cn8 (no tinnitis either)
question
what is the main feature that differentiates central from peripheral vertigo?
answer
will have neighborhood symptoms (from cerebellar involvement. these patients need to be imaged)
question
what is unique about an acoustic neuroma/schwanoma?
answer
starts at cn8, so in the beginning it acts like peripheral vertigo, but then it becomes central
question
what are hints for an acoutic neuroma?
answer
peripheral vertigo that gets progressively worse (do an MRI)
question
what drugs can cause vertigo?
answer
quinidine, aspirin, phenytoin
question
tx for tension headache?
answer
acetaminophen/tylenol, maybe NSAID
question
what is key about the neuro exam in a migraine?
answer
completely normal
question
tx for an acute migraine?
answer
1. NSAID (if in ER, can give metocloproide if nauseated) 2. triptans 3. ergots 4. intractable, can try prednisone
question
side effect of ergots?
answer
digital ischemia (so last line)
question
prophylactic for migraine if getting 2-3 per month?
answer
*BB, topiramate, valproate, verapamil, TCA, SSRI* (try to pick one that treats multiple problems. no drug of choice, just trial and error. don't pick botox, expensive, need reinjection, can self dose)
question
main presentation for a cluster headache?/
answer
get for 3-4 days at a certain time of the month, and lasts 30min to a few hrs, rhinorhea, red eye, 10/10 pain, less n/v (ice pick in your head. cluster means cluster of time)
question
tx for acute cluster headache?
answer
1. 100% oxygen 2. if ineffective, the triptan/ergot (NSAIDs too weak)
question
chronic treatment for a cluster headache?
answer
same as migraines, but also responds to lithium
question
what will biopsy show in temporal arteritis headaches?
answer
granulomatous vasculitis
question
another name for pseudotumor cerebri?
answer
benign intracranial hypertension
question
key physical exam finding for benign intracranial hypertension?
answer
enlarging blind spot (from the papilledema)
question
what other eye problem besides papilledema may be present in BIH?
answer
bilateral cn6 nerve palsy (bc it has a long nerve and can get compressed from the swelling)
question
what is the first test for BIH?
answer
MRI/CT (but will be negative, imaging must be negative before decide to do an LP)
question
what will the LP findings be in BIH?
answer
high opening pressure, but everything else is normal (also therapeutic)
question
tx for BIH?
answer
1. stop offending agents, try weight loss 2. acetazolemide to decrease csf production 3. last resort, steroids, shunt
question
how to determine if BIH is improving?
answer
follow the visual fields, blind spot should be smaller
question
what nerve in trigeminal neuralgia?
answer
cn5
question
main symptom of trigeminal neuralgia?
answer
extreme facial pain with minimal exposure (wind blows on face, may last for an hr)
question
trigeminal neuralgia can lead to what condition?
answer
MS
question
tx for trigeminal neuralgia?
answer
1. gabapentin is first choice 2. add carbamazepine 3. add TCA 4 ablate nerve
question
key symptoms of guillan barre?
answer
ascneding flaccid paralysis, areflexic, exclusively motor, sensation has very minimal involvement (if invovled, then its usually not guillan barre)
question
why do most patients with guillan barre get better?
answer
bc its a demyelinating disease, and myelin regenerate well
question
what are causes of guillan barre?
answer
zika, vaccines, campylobacter
question
what is the first step if suspect guillan barre?
answer
assess respiratory function (bc paralysis of the lung can cause death, if vital capacity and nigeative inspiratory force is insufficient, put on ventilator)
question
after assessing respiratory function, what is the next step for guillan barre?
answer
LP
question
what will LP show in guillan barre?
answer
very high protein/albumin/albumin cytologic dissociation, but the cells are normal ( if do LP too soon, may not see)
question
next in guillan barre after the LP?
answer
treat with IVIG/plasmaphoresis if suspicious, do EMG later bc too slow
question
what is the gold standard test for guillan barre? what will it show?
answer
EMG, shows demyelinating polyneuropathy
question
tx for guillan barre?
answer
IVIG or plasmaphoresis (both work well, if don't treat early, prognosis is bad)
question
what presents with assymetric ascending paralysis?
answer
polio (just fyi)
question
test for myasthenia gravis
answer
antibodies against Ach receptors
question
what drugs can exacerbate myasthenia gravis?
answer
aminoglycosides (bc effects neurotransmission)
question
what is the gold stanndard test for myastheia gravis?
answer
EMG
question
why should thymic tissue be removed in myasthenia gravis?
answer
improves respone to medical treatment
question
treatment if MG with respiratory distress?
answer
ventilator and plasmaphoresis/IVIG
question
pathophys of lambert eaton?
answer
problem with acetylcholine packets, presynaptic disorder, packets accumlate throughout the day, so get stronger throughout the day
question
tx for lambert eaton?
answer
plasmaphoresis/IVIG
question
EMG findings for ALS?
answer
diffuse axonopathy
question
treatment for ALS?
answer
riluzole (neuroprotective)
question
gold standard test for MS?
answer
gadolinium MRI
question
what will be seen on the MRI for MS?
answer
periventricular and spinal cord white matter plaques (T2 waiting)
question
what exacerbates sxs of MS?
answer
head (slows conduction in nerves)
question
what physical finding might be seen in MS?
answer
if snap head down, will get pain down spinal cord
question
what will the LP findings of MS?
answer
high protein with a normal cell count, will have myelin basic protein, high globulins (but nonspecific)
question
tx for fatigue in MS?
answer
amantidine, SSRI
question
tx for MS episode?
answer
corticosteroids and plasmaphoresis/IVIG, DMARD
question
what DMARD is used to treat MS?
answer
*interferon beta* or glatiramir
question
tx for chronic spasticity in MS?
answer
baclofen (antispasmodic)
question
presentation of vascular dementia?
answer
have some loss of memory, then get sick, then become mute (drops rapidly with an insult)
question
what will imaging show in vascular dementia?
answer
old strokes (bunch of small dots)
question
test is you suspect prion dementia?
answer
LP
question
what will LP show in prion disease?
answer
1433 protein (if positive, then diagnostic. no treatment, but is a public health hazard for other people who used the same tools/tests as that person. spongiform degeneration)
question
mechanism of donepazil and rivastigmine?
answer
cholinesterase inhibitors for alzheimers
question
which drug for alzheimers improves memory?
answer
memantine (neuroprotective)
question
what will imaging show in huntingtons?
answer
caudate atrophy
question
what are secondary causes of parkinsons?
answer
typical antipsychotics, *metochlopromide*, manganese (metal), chronic carbon monoxide exposure, post viral, MPTP
question
olivopontocerebellar atrophy sxs?
answer
parkinson + ataxi
question
system multiple atrophy sxs?
answer
parkinsons + autonomic degeneration (breathing, pulse, ondines curse, sweating, BP problems, swinging of pulse, resp failure)
question
sxs of progressive supernuclear palsy?
answer
parkinson + eye movement problems (can't look up or down)
question
parkinsons effects which part of brain?
answer
basal ganglia
question
drugs for parkinsons?
answer
Ldopa, carbidopa, amantadine (anticholinergic), entecapone, selegiline
question
what is the mechanism of entecapone?
answer
COMT inhibitor
question
what is the mechanism of segeline?
answer
MAO inhibitor
question
mechanism fo the parkinson drugs ropinerole and pranepexole?
answer
direct dopamine agonist
question
tx for restless leg syndrome?
answer
ropinerol, pranepexole, replete iron
question
side effects of ropinerole?
answer
cardiotoxic
