Neurology Case Files – Flashcards
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What are some characteristics that can distinguish an essential tremor from a parkonsonian tremor?
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T: bilateral, can affect arms, heads, legss, trunk, associated with purposeful movement P: tends to be unilateral and associated w/ other sx like stooped posture, shuffling gait, tremor usually seen at rest and gets better with mvmt
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What is required to make a diagnosis of essential tremor?
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Work up to look for other causes because this is clinical diagnosis: TSH MRI/CT: if suspect degenerative changes
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This tremor occurs when you try to maintain you position in gravity
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Postural tremor
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This tremor occurs only during voluntary movement
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Kinetic tremor
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This tremor increases in amplitude when you're approaching a target. What lesion is this associated with?
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Intention tremor. Associated with lesions in output of cerebellum
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What are the main treatments for essential tremor?
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Beta blockers: propranalol Primidone (anti-siezure medication)
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What is the most common finding of essential tremor on PET scan?
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Lighting up in thalamus
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What unique location of tremor is more specific to essential tremor, rather than other tremors?
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Tremor in the head
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A patent presents with jerky, dance like movements and psychosis. What are labs that you should run?
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Sounds like Huntington's but need to rule out drug abuse and autoimmune stuff etc. Labs: too screen, ANA, electrolytes, glucose, creatinine, RPR, TSH, HIV and vit B12
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Where is the mutation in huntington's?
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CAG triplet repeat in huntingtin gene on chromosome 4. Autosomal dominant, anticipation where in each subsequent generation causes expansion of repeats --> increase in severity of disease (genetic anticipation)
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A 16 year old presents with slowing of movements, and extreme rigidity. On exam, you notice that his neck is still and pointed to the right side. He has myoclonus and has a history of seizures. Family history is significant for huntington's disease. what is the diagnosis?
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Westphal variant of huntington's: onset in childhood and presents w/ parkinsonism, bradykinesia, rigidity, dystonia, myoclonus and seizures
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What is the treatment for Huntington's?
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Chorea can be treated with Haloperidol and other typical antipsychotics Treat concurrent depression with SSRI More symptom management and genetic counseling
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A 16 year old presents with progressive sustained muscle contractions. He has a left hand tremor, abnormal movements in left leg, and inversion of left foot when he walks. HIs back goes into spasm. There are no cognitive difficulties. His strength and muscle bulk are normal except for lots of involuntary movements. What is the diagnosis?
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Primarily generalized dystonia
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What mutation is the most common cause of early onset, generalized dystonia?
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GAG deletion in DYT1 --> brain protein that functions in substantia nigra
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What is a possible fatal complication of primary dystonia?
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Status dystonicus
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What are current treatment options for idiopathic dystonia?
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Symptomatic: levodopa (especially dopa responding disease subset), benzos, anticholinergics, baclofen Surgical placement of deep brain stimulus in Gpi
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What medication is the most effective in alleviating levodopa or other drug induced dyskinesias?
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Amantadine
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A 65 year old presents with chief complaint of falls. On exam, you note that he takes a while to initiate movement and he has a masked face. He does have rigidity and it's symmetric throughout. No tremor is noted. What is the diagnosis?
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Multiple system atrophy-parinkson's subtype. differentiated from Parkinson's due to lack of tremor and symmetric presentation
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How may one distinguish Parkinson's with corticobasalganglionic degeneration?
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Both will have tremor, rigidity and hyper-reflexia. But cbg will also have limb ataxia, dystonia and maybe even alien limb phenomenon
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This disorder is characterized by inability to voluntarily look down and square wave jerks on extraocular motion testing. What is the disorder?
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Progressive supranuclear palsy: eventually patient will have frequent falls and have pseudobulbar findings
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What hormonal abnormality can lead to ataxia?
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Thyroid hormone deficiency
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What is the pattern of inheritance for spinocerebellar ataxia, assuming that other organ systems aren't involved.
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Autosomal dominant. Most due to excess microsatellite repeats so also display anticipation Clinical pearl: spinocerebellar ataxia presents in adulthood
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This syndrome is characterized by pure cerebellatr ataxia, familial parkinsonism, hereditary spastic paraplegia, hereditary neuropathy and restless leg syndrome
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Spinocerebellar ataxia-3 or Machado-Joseph disease
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What are contraindications to administering TPA, when patient is within the 3 hour window?
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INR <1.7 Prior intraparenchymal hemorrhage Stroke within 3 hours Stroke within the past 3 months
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What are the strongest risk actors for tardive dyskinesia
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Advanced age Female gender Coexistent brain damage
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What are the main medication options for the symptomatic treatment of tardive dyskinesia?
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Baclofen Benzos Vitamin E
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What are the main distinguishing features of tardive dyskinesia that will help you differentiate it from idiopathic dystonia
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Spasming and extension of the neck and back
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A 10 year old was in a car crash and after a quick neurologic exam, you suspect that he has a high cervical cord injury. After accomplishing ABC's, what treatment should you start to prevent further spinal cord damage?
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Agressive IV fluids: high spiinal cord injury means you've knocked off the sympathetic input --> hypotension + bradycardia --> lack of perfusion pressure --> cord ischemia
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No matter what, after a trauma that may have affected the spine, children under _____ should have spinal cord imaging regardless of neurologic exam
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9 years
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A 16 year old boy is in the middle of football game when his helmet falls off, and he's accidentally knee'd in the head. He's unconscious for a few seconds, but wakes up and seems to have no defecits. 20 mins later, he has a seizure, that self resolves after 2 mins. He has slurring of speech, and can't pay attention. CT of head is completely normal. What are you most concerned for?
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Delayed neurologic presentation in otherwise healthy male --> epidural hematoma!!! Note: delay should be within hours. Not days. if more than 24 hours, think other types like subarachnoid or subdural hematoma
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A patient presents to the ED after passing out and hitting his head. In the ED, he complains of headache. On fundoscopic exam you note pappiledema. His BP is 180/100. What is the heart rate and RR?
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He's having a Cushing response to the increased ICP Bradycardia Bradypnea Hypertension
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What is the characteristic CT finding of a subarachnoid hemorrhage?
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Homogenous high density (blood) throughout ventricular systems and cisterns
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What are the three main characteristics of delirium?
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Cognitive impairment Impaired attention Fluctuating course
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What electrolyte abnormalities can occur due to head truma?
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Hyponatremia due to SIADH. This can cause, or perpetuate AMS and delerium
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What are the 3 characteristics included in the glasgow coma scale?
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Eye opening Verbal response Motor response
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What is the pathophsiology of cerebral contusion?
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Rapid decelleration causes damage to ascending reticular activating system, especially at junction b/t thalamus and midbrain
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If patient has concussion and loses conscience, what grade concussion did he have?
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Grade 3: loss of consciousness automatically puts you in this category
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What criteria is used to determine if CT is indicated after traumatic brain injury?
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New Orleans Criteria: Persistent headache Emesis Older than 60 years Drugs or alcohol intoxication persistent anterogrady amnesia Soft tissue or bony inury above clavicles Seiuzre
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Assume patient had grade 1 or 2 concussion and normal CT, how long should be ovserved for?
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2 hours of observation
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For most patient, when do symptoms of post concussive syndrome peak? Dissapate?
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Peak in intensity usually 1 week after incident and symptom free by 3 months
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During a football game, one of the players suffers from grade 1 concussion. When is the earliest he can start playing again?
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As early as the same day. In grade 1, player completely back to baseline in less than 15 minutes
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What is a rare pulmonary complication of subarachnoid hemorrhage?
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Neurogenic pulmonary edema
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Other than aneurysms, what are some causes of subarachnoid hemorrhage?
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Trauma, AV malformation, cocaine or amphetamine abuse
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What is the main medical management to reduce vasospasm after SAH?
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Nimodipine: CCB Triple H therapy: hypertensive hypervolemic hemodilution
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Where is the most common site for aneurysm in PCKD?
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In anterior communicating artery
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One week after SAH, you patient experiences left sided hemiparesis. what imaging should you order?
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Diffusion weighted MRI to evaluate for vasospasm
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What are risk factors to a craniocervical dissection?
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Head or neck trauma Chiropractic manipulation Bouts of severe coughing Fibromuscular dysplasia, Ehlerss-Danlos and Marfans
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What is moyamoya disease?
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idiopathic noninflammatory cerebral vascultiis that affects large vessels in the circle of willis. The smaller vessels hypertrophy to compensate for chronic ischemia and there are what's called the "moyamoya" vessles This disease is important because can cause stroke in younger adults
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What is the diagnosis of absence seizures?
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EEG showing regular and symmetrical 3 hz spikes, and possible 2-4 Hz spike and slow wave compexes If normal, tried sleep deprived EEG
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Which anti-seizure drug is most associated with birth defects?
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Valproic acid --> associated with neural tube defects
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What is the most common type of idiopathic seizure in adults?
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Complex partial seizure
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A 13 year old faints when she sees blood for the first time. What is the etiology of her syncope?
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Vaso-vagal in response to painful, or emotionally charged stimuli
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A 65 year old man presents with new onset headaches. These occur every month, and are not associated with aura, put are unilateral, and periorbital. They can last up to 3 hours, sometimes associated with nausea and vomiting. What lab work may you want to run?
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Thinking migraine but rarely present in patients older than 50 so exclude other causes such as vaculitis, toxicities, etc CMP, CBC, HIV, vascultitis screen, TSH, SPEP. In this man, get ESR to evaluate for temporal arteritis. Will need biopsy to make diagnosis
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These abortive migraine treatments act on the 5-HT1D receptors. What are their common side effects?
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Triptans: 5-HT receptor agonists Nausea Vomitting Numbness and tingling of fingers and toes
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When is prophylactic migraine treatment indicated? What are options
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When at least 3 headaches/month or abortive treatment doesn't work Anticonvulsants: topomax and divalproex Betablockers: propranalol CCB: verapamil
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A patient with a 10 year history of headache presents to your office for headaches. The headaches have not changed in character, but are debilitating. In the past, you've diagnosed her with tension type and migraine headaches. What is assuring about this complaint that there is no new etiology to her headaches?
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Headaches have not changed in character No new neurologic symptoms This means that her headaches have become chronic
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Chronic migraines are almost daily headaches and occur for more than ______ days in a month`
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15
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What is the first step in management of chronic headaches?
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Taper off all over the counter analgesics because headaches can be exacerbated by analgesic rebound Then start an anticonvulsvie, or antidepressant Once become chronic, patients should have some imaging done, pref an MRI or MRA
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What is the role of botulinum toxin injections in headache treatmetn?
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Found to be effective for patients with chronic daily headache who have trigger points of head pain.
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Amitriptylline is a TCA. Why is it especially harmful in the elderly?
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Because of it's anticholinergic side effects
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What is memantine?
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It's an NMDA receptor antagonist and is used in treatment of dementia. Doesn't affect progression of the dementia, but can cause symptom relief
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This part of the brain is rich in acetylcholine and choline acetyltransferases and has numerous projections to the neocortex. Pathology in this area implicated in Alzheimer's
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Nucleus basalis of meynert
