Neurology Differential Diagnosis – Flashcards

reflexes - HYPERreflexia tone - increased tone, spastic fasciculation - none atrophy - none Babinski sign - present Notable - brain or spinal cord, pyramidal weakness pattern

reflexes - HYPOreflexive tone - decreased, flaccid fasciculation - present atrophy - severe Babinski sign - absent Notable - ALS is both UMN and LMN so you get a mixed picture

Definition - autoimmune inflammatory muscle disease causing bilateral proximal weakness Classification - associated with cardiomyopathies and interstitial lung disease S&S - diagnose with 4 criteria: 1=history and physical, 2=creatinine kinase, 3=EMG changes, 4=positive muscle biopsy (CD8 Tcells) Investigations - creatinine kinase, ANA antibodies, CXR for interstitial lung disease, muscle biopsy to distinguish PM from DM Treatment - 1. high dose steroids for 4 weeks and taper Notable - related to dermatomyositis and inclusion body myositis, differentiate from DM by anti-Jo antibodies (occurs in middle to old age whereas dermatomyositis occurs in childhood and adolescence)

Definition - inflammatory vasculitis Classification - usually paraneoplastic (breast and ovarian cancer) and associated with interstitial lung disease S&S - 1=derm findings and weakness heliotrope periorbital edema, V shaped shawl rash, periungual telangectasia (around nails), Gottron's papules (extensor surfaces), 2=creatinine kinase, 3=EMG +ve sharp waves, 4=muscle biopsy (CD4 Tcells) 5=skin biopsy to distinguish from SLE Investigations - creatinine kinase, ANA antibodies, CXR for interstitial lung disease, muscle biopsy to distinguish PM from DM Treatment - 1. high dose steroids for 4 weeks and taper (methotrexate and azothiaprine for steroid relieving) Notable - PROXIMAL WEAKNESS = MUSCLES, distal weakness = peripheral nerve or plexus (but would have sensory findings)

Definition - inflammatory myopathy affecting finger flexors and quadriceps first Classification - S&S - Investigations - CK elevated, antibody IBM 43, muscle biopsy has rimmed vacuoles with eosinophilic inclusions Treatment - no treatment Notable - will be in a wheelchair in 15 years, but normal life expectancy

Definition - recessive X linked disorder causing mutation in the dystrophin gene (structural protein in muscle tissue) so patients get pseudohypertrophy of calf muscles (fat replaces muscle) Classification - onset 10XULN because muscle is degrading rapidly Treatment - physical therapy, steroids (deflazacort) aimed at symptoms Notable - no cure

Definition - autosomal dominant disease affecting gene that codes for muscle protein Classification - congenital form (floppy baby) or adult form S&S - weakness begins in face/neck/hands/feet, narrow face, frontal baldness, cognitive impairment, cataracts, endocrine problems (diabetes, thyroid, hypogonadism), heart problems Investigations - genetic test Treatment - no cure, physical therapy and treat complications Notable - AKA Steinert Disease

Definition - defect in metabolic pathways leading to energy insufficiency (ie mitochondria can't produce ATP) Classification - LMN disease S&S - Investigations - muscle biopsy = ragged red fibres Treatment - Notable - mitochondria have their own separate genome

Definition - neurodegenerative disease, rapid progressive muscle wasting eventually resulting in difficulty speaking swallowing and breathing Classification - UMN and LMN disease S&S - starts at hands and cranial nerves and atrophy of the thumb webbing, 75% start in arms or legs Investigations - EMG fibrillations and sharp +ve waves, El Escorial criteria = more than 3 regions of body affected Treatment - riluzole (glutamate receptor antagonist) adds 3/12, BiPAP, gastic tube, multidisciplinary PT and OT Notable - PLS (primary lateral sclerosis) is UMN form and PMA (progressive muscular atrophy) is LMN form of ALS

Definition - antibodies to presynaptic voltage gated Ca channels Classification - NMJ disorder S&S - proximal weakness, arreflexia, autonomic dysfunction (dry mouth, ED, constipation, orthostatic HTN), SYMPTOMS START IN LEGS AND SPREAD UP Investigations - CT chest b/c SCLC association Treatment - 3,4 diaminopyridine to increase Ach release, Ach esterase inhibitors to keep Ach in NMJ Notable - paraneoplastic - associated with small cell lung cancer

Definition - paralytic illness caused by bacteria that inhibits Ach release, starts with CN weakness and descending paralysis Classification - food borne botulism, infant botulism (bacteria grows in intestine <6mos yo), wound botulism (esp street drugs) S&S - Investigations - Treatment - botulism Ig Notable -

Definition - autoimmune condition (antibodies to Ach of MuSK receptor) resulting in fatiguable weakness Classification - most common NMJ disease, can be just OCCULAR (ptosis and diplopia) or GENERALIZED S&S - fatiguable weakness worse at the end of the day, no sensory symptoms Investigations - fatiguability test (hold up arms and count to 100), tensilon challenge (give IV Ach esterase inhibitor), EMG (jittery motor units with decreasing amplitude), antibody test (ACHR and MuSK antibody) Treatment - ACH esterase inhibitor (pyridostigmine), steroids, thymectomy (thymus trains immune system), immunosuppresion (axothioprine), plasma exchange or IVIG if in crisis Notable - 90% have diplopia, dysarthria, ptosis

Definition - lesion in the lower parietal lobe of the dominant hemisphere (association cortex) Classification - usually from stroke S&S - 4 symptoms = acalculia, agraphia, finger agnosia (can't distinguish fingers on hand) and left-right confusion Investigations - Treatment - none, supportive Notable -

Definition - bilateral lesions in anterior temporal lobe Classification - S&S - 3 symptoms = hypersexuality, blunted affect (don't care), hyperorality (binging, smoking, alcohol) docility (diminshed fear response, low aggression) Investigations - Treatment - Notable -

Definition - AKA expressive or non-fluent aphasia - loss of the ability to produce language (spoken or written) Classification - most commonly a stroke, but can be trauma, tumor, hematoma, or hemorrhage S&S - uses a list of disjointed words, in an extreme case can only use a single word Investigations - Treatment - speech therapy, some experimental medical treatments Notable -

Definition - AKA receptive or fluent aphasia - inability to comprehend language or produce meaningful words Classification - most commonly a stroke, but can be trauma, tumor, hematoma, or hemorrhage S&S - uses invented words, leaves out key words, normal sentences but they make no sense Investigations - Treatment - speech therapy, some experimental medical treatments Notable - we formulate what we want to say in Wernicke's area and move it to Broca's where the plan of speech is carried out

Definition - "slow and stiff" basal ganglion disease with a lack of dopamine production in the substantia nigra (dopamine is an inhibitory neuron) Classification - hypokinetic movement disorder S&S - bradykinetic, rigidity, 60% have resting tremors ASSOCIATED with micrographia, difficulty turning in bed, soft voice, diminshed facial expression Investigations - Treatment - 1. levadopa 2.surgical treatments and deep brain stimulation 3. physiotherapy Notable - genetic and environmental causes - pesticides, miners, health care workers (smoking and caffeine have inverse relationship)

Definition - antibody mediated inflammatory demyelination with ascending weakness Classification - polyneuropathy of peripheral NS S&S - preceeded by viral illness or vaccination, ascending weakness starting in toes and fingers, numbness and arreflexia Investigations - CSF (protein), nerve conduction studies for demyelination (slow velocities) Treatment - IVIG Notable - 75% recover in a year

Definition - similar to Guillain Barre but chronic Classification - S&S - Investigations - Treatment - prednisone Notable -

Definition - more sensory than motor Classification - S&S - stocking and glove Investigations - Treatment - Notable -

Definition - inherited weakness of feet and then hands Classification - peripheral nerve polyneuropathy S&S - high arches and hammer toes Investigations - Treatment - Notable -

Definition - inflammation of blood vessels that supply nerves Classification - S&S - Investigations - Treatment - Notable -

Definition - most common cause of dementia, possibly from amyloid protein Classification - dementia (decline in 2+ cognitive domains = executive, attention, language, visuospatial) S&S - the "As" = insidious progessive onset of amnesia, aphasia, apraxia Investigations - LP (neuronal injury so high levels of tau in CSF, beta amyloid in CSF), PET (beta amyloid, decreased metabolism in parietal temporal lobes), CT/MRI (atrophied hippocampus, lateral ventricles dilated, atrophy of parietal-temporal lobes) Treatment - cholinesterase inhibitors "donepezil" (increase Ach in brain), NMDA type receptor agonist "memantine" to protect against glutamate excitotoxicity Notable - Alzheimers is the main cause of dementia (47%), onset to death is 8-10 years, RISKS=old age, family history, F, head injury, less education

Definition - dementia featuring hallucinations and Parkonsonianism Classification - dementia (decline in 2+ cognitive domains = executive, attention, language, visuospatial) S&S - slow and stiff, persistent memory problems, executive functions affected, THRASH AT NIGHT Investigations - Treatment - cholinesterase inhibitors, levadopa, sleeping pill Notable -

Definition - stroke causing dementia Classification - dementia (decline in 2+ cognitive domains = executive, attention, language, visuospatial) S&S - Investigations - Treatment - treat vascular risk factors - anti-thrombotic (ASA), cholinesterase inhibitor Notable -

Definition - atrophy of frontal and/or temporal lobes resulting in progressive deterioration of interpersonal and executive skills Classification - dementia (decline in 2+ cognitive domains = executive, attention, language, visuospatial) S&S - behavioural issues (disinhibition, hyperorality, OCD, loss of empathy), language difficulties, atypical Parkonsonianism Investigations - Treatment - ?SSRI, support Notable - onset 45-65 yo and death in 6-8 years, disorders of frontal lobe result in +ve primitive reflexes being "released" (rooting, glabellar tap (hit b/w eyes), palmomental (stroke palm, chin twitch), snout (tap lips and they purse)

Definition - prion disease (prion=infection+protein) causing rapidly progressive dementia for <2 years Classification - S&S - myoclonus, visual or cerebellar symptoms, pyramidal or extrapyramidal symptoms, akinetic mutism Investigations - Treatment - Notable -

Definition - impairment of autonomic functions, atypical Parkinsonian symptoms Classification - genetic cerebellar disorder S&S - Investigations - Treatment - Notable -

Definition - autosomal recessive degeneration of spinal cord and peripheral nerves Classification -genetic cerebellar disorder S&S - noticed at 1 year when kids start to walk but have ataxia Investigations - Treatment - Notable - COMMON IN QUEBEC

Definition - autosomal recessive degeneration of spinal cord which can also lead to ataxia, scoliosis, heart disease, and diabetes Classification - genetic cerebellar disorder S&S - Investigations - Treatment - Notable -

Definition - 3 of them - 1. demyelination 2. anti-GAD 3. gluten ataxia Classification - immune causes of cerebellar disorder S&S - 2. ataxia and nystagmus 3. neuroapathy, autonomic insufficiency Investigations - CT (cerebellar atrophy) 2. antiGAD antibodies 3. screen for Celiac TTG (tissue transglutaminase antibody) or EMA (endomysial antibody - same but less commonly used) Treatment - IVIG, 3. gluten free diet Notable -

rostral vermis (eg alcohol) - wide based stance, caudal vermis (eg medulloblastoma) - staggering gait, nystagmus and rotated posture of head hemispheric syndromes (eg stroke) incoordination of IPSILATERAL limb movement pancerebellar syndromes - (eg paraneoplastic) combination of all cerebellar signs Investigations - treatable causes = anti-GAD antibodies, Celiac screen, vitamin E, Wilson's screen

Definition - CAG triplet repeat disorder on chromosome four causing basal ganglia atrophy -> chorea, depression and dementia Classification - autosomal dominant hyperkinetic movement disorder S&S - hyperreflexia, hypertonia, psychiatric illness, trouble with time based tasks Investigations - MRI (atrophy of basal ganglia - esp. head of caudate), genetic testing to look for CAG repeats Treatment - nothing to halt or reverse, tetrabenazine helps with movements Notable - ANTICIPATION so test relatives, die of aspiration pneumonia

Definition - autosomal recessive copper metabolism disorder due to low ceruloplasmin levels Classification - hyperkinetic movement disorder S&S - chorea, ataxia, dysarthria, bradykinesia, rigidity and tremor Investigations - high 24 hr urinary Cu, low serum ceruloplasmin, Kaiser Fleischer rings on slit lamp Treatment - copper chelation, restrict dietary copper Notable - causes liver failure

Definition - a manifestation of rheumatic fever usually acquired in childhood and spontaneously resolves, autoimmune response after GAS (group A strept) infection that effects basal ganglia Classification - hyperkinetic movement disorder S&S - rapid jerking movements of face, hand and feet Investigations - Treatment - penecillin and anti-depressants Notable - AKA St. Vitus dance

Definition - autosomal dominant syndrome causing atrophy in cerebellum, common in Japanese Classification - hyperkinetic movement disorder S&S - CHOREA, ataxia, dementia, seizures, Investigations - MRI (atrophy of cerebellum and brainstem) Treatment - Notable - CAG repeat (normal is 6-35, DRPLA has 48-93)

Definition - a brief non-rhythmic motor or phonic tic , temporarily suppressible and have a premonitionary urge Classification - hyperkinetic movement disorder S&S - Investigations - Treatment - clonidine, tetrabenazine, neuroleptics Notable - associated with OCD and ADHD

Definition - "acute confusion" Classification - on continuum from alert to just before loss of consciousness S&S - 2 spaces and 2 times (ie eye and other motor problem with 2 relapses) Investigations - CAM (confusion assessment method= 1.acute and fluctuating course (interview family) 2. inattention - days of week backward 3. disorganized thinking - (incoherent conversations) 4. altered level of consciousness = DIAGNOSIS requires 1 and 2 AND 3 or 4 Treatment - PREVENTION - D - drugs/diet (avoid high risk meds=anticholinergics, Gravol, benzos, narcotics) E - electrolyte abnormalities, L - lack of drugs (EtOH withdrawal) , I - infection, immobility, R - reduced sensory input (wear glasses and hearing aids), R - restraints, I - intracranial process (stroke, bleed, seizure) U - urinary catheter, M - myocardium (MI, arrhythmia, CHF) , comfort rounds Notable - distinguish from depression and dementia, prediction rules

Definition - autoimmune CNS demyelination characterized by dissemination in SPACE and TIME - WBC cross blood brain barrier and attack oligodendrocytes Classification - inflammation and neurodegeneration goes through stages of "relapse" and "progression" S&S - spastic bladder, depression, fatigue, gait instability CIS = clinically isolating syndrome, most common presenting sign is optic neuritis (blind in 1 eye and decreased central accuity and colour accuity), can also have transverse myelitis (swollen spinal cord with bladder hyperactivity) and brainstem findings (INO intranuclear ophthalmoplegia - nystagmus in abducting eye) Investigations - MRI (CT is useless) pencil dot plaques in corpus collosum and signet rings) CSF = protein in IgG bands Treatment - 1. high dose IV steroids to speed recovery 2. DMT (disease modifying therapy - interferon beta or glatiramer acetate) to decrease risk of subsequent attack by modifying immune system 3. lifestyle (Vit D, NO SMOKING, stay out of heat, avoid immune stimulants) Notable - RISKS - Vit D def, viruses, parasites (tapeworm is protective), smoking (immune cells more likely to cross blood brain barrier)

Definition - unarousable unresponsiveness b/c damage to reticular activating system (pons to thalamus directly through stroke or secondarily through herniation) OR diffuse cerebral hemisphere lesion (meningitis, encephalitis) Classification - a gradient from alert -> lethargy -> obtunded (some responsiveness but no communication) -> stupor (arousable with vigorous stimuli) -> coma -> brain death S&S - neuro exam Investigations - EYE DEVIATION (frontal lesion = look away from paralyzed limb, brainstem lesion = look towards paralyzed limb) OCULO-CEPHALIC TEST (normal response is Doll's Eye present) CALORIC TEST (irrigate 100cc of cold water in ear and brain thinks ear is turning so eyes deviate to ipsilateral side) Treatment - Notable - GCS - eye/4, verbal/5, motor/6 - brain death at GCS3, intubate at GCS7

Definition - difficulty falling asleep (many classes) Classification - S&S - Investigations - Treatment - sleep hygiene and counselling, benzodiazapines, TCAs, melatonin Notable -

Definition - obstructive sleep apnea Classification - S&S - Investigations - Treatment - CPAP, surgery or weight loss Notable -

Definition - can't regulate wake/sleep cycles (depletion of nerves in hypothalamus that produce hypocretin) and leads to EDS (excessive daytime sleepiness) and cataplexy (sudden muscle weakness triggered by emotions) Classification - S&S - hallucinations and rapid REM sleep as soon as they fall asleep Investigations - polysonmography and MSLT multiple sleep latency test (time to falling sleep) Treatment - SSRI or TCA, scheduled naps Notable - cataplexy = sudden loss of muslce ton triggered by emotions due to depletion of nerves in hypothalamus that produce hypocretin (AKA orexin to promote wakefulness)

Definition - excessive daytime sleepiness inspite of sleeping, like narcolepsy but no REM onset sleep or cataplexy Classification - S&S - sleep short but efficient Investigations - Treatment - modafinil Notable -

Definition - crawling restless feeling in legs before sleep (RLS) and during sleep (PLM) Classification - S&S - move legs at night disrupting sleep "cycle all night", Investigations - Treatment - sinimet (levadopa+ dopaminergic med for Parkinsons), benzodiazapine, opiods Notable - associated with pregnancy, Fe def anemia, hypo/hyperthyroid, rheumatoid arthritis, folate def

AKA "lateral medullary infarction" - go to the chiropractor and they readjust your neck tearing the vertebral artery (or PICA) - get ipsilateral cranial signs and contralateral log tract (corticospinal motor and spinalthalamic sensory), and Horners Syndrome (ipsilateral ptosis, miosis (pupil constriction) and anhidrosis (no sweat) from compression of sympathetic fibres, OTHER SYMPTOMS = vertigo, nausea, slurred speech and dysphagia (CN9,10)

Definition - hyperexcitability of neurons with hypersynchrony (firing at the same time) Classification - 2 unprovoked seizures > 24hrs apart S&S - Investigations - routine EEG and CT scan, (CBC, lytes,BUN, glucose, Ca, Mg, PO4, ECG after first seizure), restrict driving 3 mos Treatment - first line med = valproate, surgery if failed 2 meds Notable - *1 diagnosis and 2 basic science questions on midterm

Definition - partial = unilateral, limited to 1 hemisphere, "complex partial" = seizure and change in level of consciousness (ie dyscognitive features) b/c effects cerebral hemisphere (simple does not change consciousness) S&S -1. aura of rising epigastric sensation, nausea, fear or smell, 2. +/- autonomic symptoms (flushing, pallor, pupil dilation, cyanosis) 3. +/-automatisms = lip smacking, picking, fumbling 4. dystonia (repetitive movements) of contralateral limb Notable - *diagnosis ? on midterm about simple partial seizures,

Definition - small seizure affecting only a small part of the brain (often temporal lobe or hippocampus) = seizure and no change in level of consciousness (ie dyscognitive features) b/c no effects incerebral hemisphere (simple does not change consciousness) S&S -very subjective, some don't even notice it is a seizure, if it progresses to a complex seizure, the simple partial seizure is known as the aura - can be described as a funny feeling, feeling of falling, altered emotions, altered senses - all depending on location and lasting 60-120 seconds Notable - *diagnosis ? on midterm about simple partial seizures,

Definition - irregular movements, usually at night, with lots of vocalization Classification - S&S - riding a bike in bed, can have Todd's paralysis (weakness post seizure) Investigations - Treatment - Notable -

Definition - 10-20 seconds with a complete loss of consciousness, multiple seizures/day, 50% also get tonic-clonic seizures Classification - S&S - Investigations - EEG shows 3 Hz spike and wave discharges Treatment - Notable - *investigation ? on midterm

Definition - brief, shock-like, single jerk usually after waking (not hypnic jerk) Classification - seen in patients with JUVENILLE MYOCLONIC EPILEPSY - happens to teens and they get seizures after waking S&S - typical history includes a fall or dropping something Investigations - Treatment - Notable -

Definition - GRAND MAL seizures Classification - S&S - begins without warning (or aura if focal seizure first that the generalizes), cries out, stiffening, incontinence, tongue biting - lasts 1-2 minutes, followed by confusion and fatigue Investigations - Treatment - Notable - *1 basic science question on midterm

Definition - medical emergency of seizure lasting 5 minutes, or 2 seizures less than 5 minutes apart withouth regaining consciousness

Definition - most common cause of epilepsy = scarring in the inner portions of the temporal lobe (hippocampus and amygdala - memory and emotions)

SNOOPP - red flags are secondary causes for headache, DON'T MISS THESE: THUNDERCLAP HEADACHE - sub arachnoid hemorrage, peak pain intensity in seconds TEMPORAL ARTERITIS - assoc with PMR, temporal pain PSEUDOTUMOR CEREBRI - raised intercranial pressure = 6th nerve palsy (diplopia) and papilledema - common with weight gain SIGNS OF RAISED ICP = projectile vomitting, am headache, supine headache, headache with valsalva MENINGEAL GLIOMATOSIS - cranial nerves effected, DDx - meningitis, TB, sarcoid DURAL SINUS THROMBOSIS - clot in brain sinus (esp post partum) Notable - *3 diagnosis questions on midterm = SNOOPP = systemic symptoms, neurologic signs, old age (>40-50), onset of thunderclap, progressive tempo, pressure increase ICP

Definition - severe unilateral headaches, 5 in a row lasting 15min-3hrs each, have an AUTONOMIC SYMPTOM OR AGITATION (tearing, pupil changes, nasal congestion, sweating, Horners) Classification - S&S - Investigations - Treatment - Notable - M>F, usually middle aged, common in smokers, EtOH is a trigger

Definition - at least 5 attacks, 4 hours to 3 days duration, 2 pain criteria (throbbing, unilateral, worse with activity), 1 associated symptom (N/V, photophia or phonophobia) Classification - S&S - WITH OR WITHOUT AURA (20-30% get aura) Investigations - Treatment - ABORTIVE = start with NSAIDs or tylenol, take triptan at first sign of migraine, PROPHYLAXIS = TCA, beta-blocker, SSRI/SNRI, ACE/ARB, botox if other meds failed Notable -

Definition - 10 episodes lasting 10 min to 7 days, NO N/V and NO PHOTOPHOBIA AND PHONOPHOBIA, pressing or tightening quality, not aggrivated by activity, bilateral

Definition - compression or demyelination of trigeminal nerve (CN5) so there is crosstalk or "ephases" with pain fibres, worst pain you've ever felt Classification - S&S - attacks are usually unilateral and last seconds to minutes Investigations - MRI, PE of CN5 - corneal reflex, jaw jerk, palpate muscles of mastication, numbness suggesting trigeminal neuropathy Treatment - 1st line = carbamazapine, (add muscle relaxant baclophen if not working)

Definition - acute inflammation of brain and spinal cord coverings, - bacterial or viral Classification - BACTERIAL (rash=meningococcal, all ages can be meningococcal or pneumococcal, kids can also have Hflu)or VIRAL based on CSF S&S - fever, stiff neck, headache, confusion, seizures or cranial nerve palsies, N/V, photophobia or phonophobia Investigations - CSF Treatment - ceftriaxone plus vancomycin and dexamethasone (steroid for inflammatory response) Notable - *2 investigation questions on midterm

Definition - viral infection, 80% have no symptoms, 20% get fever, 1% get CNS disease Classification - CNS disease = encephalitis, meningitis, or poliomyelitis (spinal cord inflammation with paralysis) S&S - fever, headache, myalgias, N/V, rash on chest back and arms Investigations - CSF if suspected CNS infection - elevated WBC and protein, serology WNVIgM Treatment - Notable -

Definition - viral disease causing acute inflammation of the brain Classification - S&S - Day1 - weakness and tingling at bit, 3. agitation 4. hydrophobia 11. renal failure 12. pharyngeal spasms 24. death Investigations - skin and saliva biopsy for virus immunoflurorescense, antirabies antibodies in CSF and serum Treatment - post exposure prophylaxis with vaccine to neutralize virus, PREVENTATIVE if high risk Notable - virus multiplies in salivary glands and produces tons of salive for transmission (frothy mouth)

Definition - inflammation of brain tissue/parenchyma ,HSV is the most common virus which gives a rash Classification - S&S - LOC 100%, fever 80%, seizure 78%, neurologic signs 56% Investigations - CSF and CT head to rule out structural things Treatment - acyclovir for HSV, suuportive Notable - *1 diagnosis question on midterm

XANTHOCHROMIA - normally CSF is clear with >5 RBC/WBC per microL, RBC lyse in CSF and cause discolouration (yellow or pink) PMN - usually <3 GLUCOSE - normally present 2/3 of serum glucose, low in bacterial meningitis PROTEIN - shouldn't be in CSF, normal range 1000/microL with PMN, protein >1g/L, glucose <45mg/dL VIRAL MENINGITIS - WBC 25-500/microL with lymphocytes, protein 0.4-1g/L, glucose normal 2/3 of serum