BC USMLE Step 2-Neurology (Kaplan) – Flashcards
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MCA stroke Sxs
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1) CL weakness or sensory loss 2) Aphasia 3) Homonymous Hemianopsia-loss visual field on opposite side of stroke -eyes look towards side of lesion
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ACA stroke Sxs
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1) confusion, personality changes 2) urinary incontinence 3) weakness leg>arm
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PCA stroke Sxs
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1) Homonymous hemianopsia 2) Ipsilateral sensory loss of face, IX, X CN 3) memory deficits 4) Dyslexia/Alexia (inability to read) 5) CL paresis and sensory loss
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Best test for stroke Most accurate test
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Best-CT -done first to exclude hemorrhage before treatment Most accurate- MRI
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Stroke treatment 3hrs Hemorrhagic
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3hrs-aspirin Hemorrhagic-no tx Patient on aspirin-->add dipyridamole or switch to clopidogrel
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What is most likely Dx? -severe -visual disturbances -photophobia -aura -a/w menses -a/w food (chocolate, wine, cheese) -N/V Tx? Px?
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Migraine headache Tx-triptans or ergotamine Px-propanolol if 3+ months sxs
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What is most likely Dx? -frequent, high intensity headache -M>W -red tearing eye with rhinorrhea -Horner syndrome Tx?
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Cluster headache Tx-Triptans or ergotamine 100% O2, prednisone, and lithium can be used to interrupt cluster headaches too Try O2 first in ED, most effective Tx*
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What is most likely Dx? -visual disturbance -systemic sxs-muscle pain, fatigue, weakness, -Jaw claudication Tx?
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Giant cell (temporal) arteritis Tx-prednisone
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What is most likely Dx? -obesity -venous sinus thrombosis -OCPs -Vit A toxicity -papilledema -diplopia from CNVI -N/V
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Pseudotumor cerebri Tx-acetazolamide to decrease CSF production -if Rxs not curative place shunt
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Preventive Rxs for Migraines
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Propanolol- best CCBs, TCAs, SSRIs, botulinum toxin injection
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Stepwise Treatment of Seizures 1-4
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1) benzo 2) phenytoin/fosphenytoin 3) phenobarbital 4) general anesthesia-NM blocker and midazolam or propafol
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What is most likely Dx? -sudden onset extreme headache -stiff neck -photophobia -fever -loss of conscious 50%
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Subarachnoid hemorrhage
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Best initial test SAH
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CT without contrast
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Most accurate test SAH
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lumbar puncture showing blood -xanthochromia-discoloration of CSF from breakdown of RBCs
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What is most likely Dx? -loss of all function except position and vibration -flaccid paralysis below level infarct -loss DTRs -loss of pain and temp -extensor plantar response -evolves into spastic paraplegia several weeks later
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Anterior Spine Artery Infaction
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Loss of position and vibration sense loss
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Subacute combined degeneration of the cord -B12 deficiency or neurosyphilis
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Spinal Trauma Sxs Tx
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-acute onset limb weakness or sensory disturbance -impaired sphincter function -loss of DTRs @ injury level -hyperreflexia below level of trauma Tx-steroids -decreases swelling
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loss of pain and temperature bilaterally across upper back and both arms -loss of reflexes and muscle atrophy same bilateral distribution
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Syringomyelia -"bubble in the cord" -"capelike" distribution
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Tx brain abscess
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Empiric-penicillin, metronidazole plus cetriaxone -vanco instead of penicillin in recent surgery for MRSA
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Tuberous Sclerosis Sxs
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neuro-seizures, psychomotor retardation, mental deterioration skin- -adenoma sebaceum-reddened facial nodules -Shagreen patches-leathery plaques on trunk -Ash leaf spots-hypopigmented (Woods lamp) Retinal lesions Cardiac rhabdomyomas
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Neurofibromatosis (Von Recklinghausen) Sxs
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Neurofibromas-soft, flesh-colored attach to peripheral nerves -CNVIII tumors-tinitus -hyperpigmented lesions (cafe au lait) -Meningiuma and gliomas Tx-no tx, can decompress CNVIII
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Sturge-Weber Syndrome
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port-wine stain seizures CNS: homonoymous hemianopsoa, hemiparesis, mental subnormality
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Tx mild Parkinsonism
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Anticholinergic-benztropine and trihexylphenidyl -AE-dry mouth, constipation, BPH Amantadine- older patient intolerant of anticholinergics
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Tx severe Parkinsonism 5 items
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Best initial: Dopamine agonists-pramipexole and ropinirole -bromocriptine and cabergoline-older, more AEs Most effective: Levodopa/carbidopa- AE-"on/off" COMT inhibitors-tolcapone, entacapone extend duration of Levodopa/carbidopa, block dopamine metabolism MAOI-rasagiline, selegiline block metabolism of dopamine Deep brain stimulation
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Tx Restless leg syndrome
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pramipexole (dopamine agonists)
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Huntington Disease Triad
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1) choreaform movement (dyskinesia) 2) Dementia 3) Behavior changes (moodiness, irritable, antisocial) family history, onset 30-50
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Tx of Huntington Dx
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No curative tx tertrabenazine for dyskinesia Haloperidol or quetiapine for psychosis
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Tourette Disorder Tx
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haloperidol, clonazepam, pimozide, or other neuroleptics
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Most common Sxs of MS
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optic neuritis -inflammation optic nerve, can lead to blurry vision/blindness -MC vision loss is in center of visual field -eye pain up on movement -2/3 normal fundoscopic exam, 1/3 pappillitis
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Other Sxs of MS
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motor and sensory deficits fatigue spasticity and hyperreflexia cerebellar deficits
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Best test for MS
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MRI plaques seen in white matter also most accurate test
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Lumbar puncture in MS
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oligoclonal bands (not specific to MS) mild increase in protein 50-100 WBCs
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Tx MS exacerbation
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high-dose steroids
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Tx MS
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best first -Glatiramer and beta-interferon natalizumab-AE-->PML Mitoxantrone Azathioprine Cyclophosphamide
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What is most likely Dx? weakness with combo upper and lower motor neuron loss difficulty chewing and swallowing, apsiration, saliva pooling No sensory, no loss sphincter tone
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ALS
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What is most likely Dx? weakness sensory loss wasting in legs DTRs decreased Tremor *high arch (pes cavus) *legs look like inverted champagne bottles
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Charcot-Marie-Tooth disease Best test-electromyography No Tx
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Paralysis of entire side of face, Dx?
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Bell Palsy -cannot wrinkle forehead -hyperacusis -taste disturbances Test with electromyography and nerve conduction Most patients recover on own Tx with prednisone
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Paralysis of lower half of face, Dx?
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Stroke -patient can wrinkle forehead is concerning-->stroke
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What is Guillain-Barre Syndrome?
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AI damage of multiple peripheral nerves--no CNS -Abs attack myelin sheaths -a/w Campylobacter jejuni
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Sxs GBS
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-ascending weakness -loss of DTRs
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Dx Test for GBS
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nerve conduction/electromyography
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Tx GBS
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IVIG or plasmapharesis (not both)
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What is Myasthenia Gravis?
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muscular weakness due to production of antibodies against ACH receptors at NM jxn
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Sxs MG PE
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double vision difficulty chewing weakness at end of day lid lag PE: -ptosis -normal pupillary response -weakness with prolonged exertion
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Dx Tests for MG Best Initial Most Accurate
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Best Initial- ACH receptor Abs Most Accurate-Electromyography--decreased strength with repetitive stimulation Erdrophonium can be done (short-acting ACHase inhib) show improvement sxs when given
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Radiologic Finding in MG
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Chest image-CXR, CT, MRI shows thymoma or thymic hyperplasia
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Tx MG Best initial
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Best initial-neostigmine or pyridostigmine (ACHase inhibs) Thymectomy if <60 and Rxs do not control Sxs
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Tx MG crisis
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IVIG or plasmapharesis
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What is most likely Dx? degeneration of dorsal roots and dorsal columns; impaired proprioception, locomotor ataxia
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Tabes dorsalis-3 syphilis
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What is most likely Dx? Stroke that is pure motor or pure sensory, clumsy hand syndrome, ataxic hemiparesis
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Basal ganglia lacunar stroke-internal capsule
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What is most likely Dx? Coma, "locked-in" syndrome, cranial nerve palsies, apnea, visual symptoms, drop attacks, vertigo, dysphagia, dysarthria, "crossed" weakness and sensory loss
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Basilar artery
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Astrocytoma Path- Sxs- Tx-
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Path-arises from brain parenchyma Sxs- szs, focal deficits, or headache; better and longer prog than GBM Tx-surgical resection if possible; radiation
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Glioblastoma multiforme (Grade IV astrocytoma) Path- Sxs- Tx-
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Path-high mitotic activity. endothelial proliferation or necrosis of tumor. ring-enhancing lesions on MRI Sxs-MC primary brain tumor. Szs, focal deficits, or headache. Rapid progression, <1 yr Tx-surgical removal, radiation and chemo
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Meningioma Path- Sxs- Tx-
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Path-from dura mater or arachnoid Sxs-cranial neuropathy or incidenctal finding, dural tail. Good prognosis Tx- surgical resection, radiation
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Acoustic neuroma (schwannoma) Path- Sxs- Tx-
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Path-Schwann cell derived Sxs-tinnitus, hearing loss, vertigo, CNV-VII or brainstem compression Tx-observation, surgical removal
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Medulloblastoma Path- Sxs- Tx-
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Peds Path-primitive neuroectodermal tumor arising from 4th ventrical Sxs-highly malignant, may seed subarachnoid space, obstructive hydrocephalus Tx-Surgical resection plus radiation and chemotherapy
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Ependymoma Path- Sxs- Tx-
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Peds Path-ependyma of ventricle, usually 4th or spinal cord. Sxs-low grade, hydrocephalus Tx-surgery, radiation
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Craniopharygnioma Path- Sxs- Tx-
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MC suprasellar tumor in children, not limited to children though Path-calcification in suprasellar area Sxs-Benign, may cause hypopituitarism Tx-surgical resection
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Lateral corticospinal tract Fxn:
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Movement of contralateral limbs decussation-pyramidal at cervicomedullary jxn
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Dorsal column/medial lemniscus Fxn:
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Fine touch, vibration, proprioception Decussation-arcuate fibers at the medulla
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Spinothalamic Fxn:
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Pain and temperature Decussation- ventral white commissure at spinal cord level 1-2 levels above.
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#1 risk factor for stroke
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HTN
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Rx that slow progression of Parkinson Dx
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Rasagiline- MAOIs
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Parkinsonism predominantly with orthostasis
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Shy-Drager syndrome
