Neurology study notes – Flashcards
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Dementia
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Chronic Progressive Intellectual Impairment that interferes w/social & occupational fxn
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Most common type of hallucination in Dementia
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Visual
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Metabolic causes of Dementia
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Hypothyroidism B12 deficiency Hypoxia
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Toxic causes of Dementia
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ETOH Wernicke-Korsakoff Syndrome (confusion, ataxia, nystagmus/opthalmoplegia)due VIT B1/THIAMINE def-diet consists of white starches Hepatic Encephalopathy Heavy metal poisoning Carbon Monoxide
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Infectious causes of Dementia
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Creutzfeldt Jakob dz AIDS Nuerosyphilis Lyme
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Structural causes of Dementia
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Tumor, Subdural Hemorrhage, Hydrocephalus (Normal Pressure Hydrocephalus)
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Dementia Work Up
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CT,MRI, SPECT, PET Labs-CBC,LFTs,TFTs,B12,RPR, ?Lyme EEG NEUROPSYCH testing
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EEG
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Is abnormal with Delerium Is normal with Dementia
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Alzheimer's
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Most common neurodegenerative dementia (60-80%)
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Types of Dementia
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Alzheimer's Vascular-Dementia Fronto-Temporal Dementia (Pick's dz-begins earlier & causes personality changes) Zebras -Normal Pressure Hydrocephalus, Lewy Bodies, Parkinsons end stage, Huntington, Lymes, Syphilis
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Risk factors for Alzheimer's Dementia
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Older Age (prevalent doubles q5yrs- 30-50% by 80 yrs old) Female FH (genetic factors identified, w/chromosomes mapped) Lower Education Level
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Neuro Eval in Alzheimer's
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Frontal release signs expected- primitive reflexes- Palmar grasp, snout (tap lips will pucker) Myerson's (TAP GLABELLA & they BLINK) Palmomental reflex (scratch palm by thenar eminence & CHIN TWITCHES) Babinski signs Gegenhalten- stop & go muscle tone EPM signs late dz only, suspicious of Dx if early Abn MS exam
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Neuroimaging signs in Alzheimer's
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Dilated ventricles Atrophy-ESPECIALLY FRONTAL & TEMPORAL LOBES
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EEG in Alzheimer's
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Shows generalized slowing
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Genetic Testing in Alzheimer's
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Familial forms only ~7% of all AD Chrom 1, 12,14, 19, 21
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Ultimate Dx of Alzheimer's
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Autopsy Atrophy Plaques Neurofibrillary tangles
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Pathology Alzheimer's
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Decrease choline acetyltransferase which synthesizes Acetylcholine Selective loss of cholinergic neurons especially in hippocampus, basal nucleus of Meynert
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Tx Alzheimer's Dementia
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Give Acetylcholine ! Acetylcholinesterase Inhibitors may improve memory fxn (TACRINE-Cognex, donepezil, galantamine, rivastigmine-EXELON Patch) N-methyl-D-aspartic acid (NMDA) Receptor Antagonist- MEMANTINE for SEVERE dementia
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Drugs to Avoid in Alzheimer's
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Meds that have anticholinergic properties (Benadryl, TCAs) Sedating Meds (benzos, sleeping pills, narcotics)
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Vascular Dementia
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2nd most common type of dementia Strokes - ischemic or hemorrhagic Amyloid angiopathy
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Findings in VD
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Evidence Prior strokes (hemiparesis,homonymous hemianopsia-visual defects on 2 rt or 2 lt halves of each side)
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Tx VD
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Blood pressure, cholesterol, anti-platelet/anticoagulant mngt
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Pick's Dz (Frontotemporal Dementia)
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Rare Atrophy frontal & temporal MRI, SPEC, Neuropysch tests BIG PERSONALITY CHANGES, starts earlier in life, EPM signs-stiffness
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Normal Pressure Hydrocephalus Triad
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Dementia Incontinence Abnormal Gait
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Delerium
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Global cognitive dysfunction marked by alteration of consciousness & attention- Acute FREQUENTLY FLUCTUATING Abn sleep-wake cycle, drowsiness, restless, irritability, hallucinations
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Causes of Delerium
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Seizure, stroke, hemorrhage, infection, medications, hyper/hypoglycemia, hyponatremia , Cardiac, pulm (PE/ pneumonia), endocrine (hypothyroid), UTI
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Neurodegenerative Movement Disorders
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Essential Tremor Huntington's Dz Parkinson's Dz
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Essential Tremor
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Mean age 35-45 yrs old 5% population Usually manifests by 65-70 yrs +FH 50-60%
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Essential Tremor
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NOT A REST TREMOR! Involves action Symmetric
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Tx Essential Tremor
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Alcohol Propanolol (B2 selective blocker) Mysoline (primidone) Avoid stimulants-lithium, caffeine, theophylline, valproate
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Physiologic Tremor
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Is a resting & action tremor in all adults that increases with stress, medications, anxiety, fear, excessive physiologic activity or sleep deprevation It is not symptomatic
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Huntington's Disease
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Mean age onset 35-44 Death in 50's Juvenile HD (<20yrs old) Autosomal Dominant CHROMOSOME 4, need genetic counsel !No tx!!!
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Huntington's Disease
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Often missed diagnosed for Schizophrenia Apathy, depression, lack personal hygiene, impulsivity, irritability, violence, alcoholism, dementia Chorea (Greek for dance), postural instability, slow writhing movements
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Tx Huntington's
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Symptomatic Antidepressants, Neuroleptics, Dopamine depleters Phenothiazines for dyskinesia Haldol & clozapine to control behavior
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Parkinson's
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Idiopathic 20-80yrs Juvenile & familial cases Men 1.5x>women
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Clinical Features of Parkinson's
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Cogwheel Rigidity Bradykinesia SHUFFLE GAIT low Frequency ASYMMETRIC RESTING TREMOR COURSE TREMOR- large amplitude, "pill rolling" Postural Instability Depression & cognitive impairment >50% over time
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Late findings of Parkinson's
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Dementia Dysautonomia (urinary retention)
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Pathophysiology of Parkinson's
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Loss of Dopamine producing neurons LEWY BODIES-alpha synuclein-protein in neuron DEGENERATION OF CELLS IN SUBSTANTIA NIGRA causing DEFICIENCY DOPAMINE & imbalance dopamine & acetylcholine
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Most Effective Tx of Parkinson's
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Carbidopa/levodopa (Sinemet) GIVE BACK DOPAMINE complications - freezing on & off Orthostatic Hypotension, dose related dyskinesia
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L Dopa, Antichlinergics & MAOIs: one of most common side effects
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Hallucinations
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Tx of hallucinations from L Dopa
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Olanzapine (2nd generation SDA antipsychotic, antognist of Dopamine)
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Use COMT Inhibitors w/ Sinemet
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Reduces metabolism of Ldopa, PROLONGS HALF LIFE of Ldopa Tasmar (tolcapone), Comtan (entaacapone) Stalveon(Ldopa, carbidopa & entaacapone )
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MAOI in Parkinson's
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MAO enzyme breaks down dopamine in synapse- want to inhibit Watch Tyramines in diet, medication interactions Elderpryl (selegeline), Azilect (rasagiline)
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Anticholinergic most effective for tremor in Parkinson's
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Artane (trihexiphidyl) Cogentin (benzotropine) CAUTION IN ELDERLY (men get urinary retention) Amantadine ??? Efficacy
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Sx tx Parkinson's
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Thalamotomy, Pallidotomy, Subthalmic stimulation (DBS) implant stimulator in brain
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Drug a Induced Parkinson's
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Antipsychotic Antiemetics - Reglan (metoclopramide), Compazine (prochlorperazine), Phenergan (promethazine)
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Multiple Sclerosis types
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Relapsing remitting women more likely- most common form) Secondary progressive Primary progressive- men more likely
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MS epidemiology
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Women>men Genetic, 20-40% concordance rate among twins North eastern ancestry Environmental/migrational studies
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MS Pathophysiology
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Inflammatory Demyelination Dz CNS WHITE MATTER Autoimmune - B & T cell Peri vascular infiltration of monocytes, macrophages, & lymphocytes Sclerotic plaques
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MS Clinical presentation
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Optic Neuritis ( PAINFUL MONOCULAR VISUAL LOSS & AFFERENT PUPILARY DEFECT-no anisicoria) Diplopia, nystagmus Trigeminal Neuralgia (b/l)
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Tx of Parkinson's
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Block effects of acetylcholine by giving, anticholinergic drugs- Amantadine, benzotropine, trihexheidyl good for tremor LEVODOPA (precursor of dopamine) improves all symptoms Bromocriptine (dopamine agonist) works directly on receptor when pt becomes refractory to levodopa use. Selegiline (MAOI) blocks break down of dopamine (dietary changes- no cheese, wine, foods w/tyramine) COMT- inhibitors
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Lab/image studies MS
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MRI w/gad very effective for visualizing white matter CSF-sl increase WBC, OLIGOCLONAL BANDS (90%), increase IgG index Visual-Auditory-somatosensory Evoked Potentials
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MS tx
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Acute Attack -IV solumedrol (shortens duration) Chronic Tx - Immunomodulators , Interferon-B, glatiramer (Copaxone) Watch CBC/LFTs, causes flu like symptoms
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Symptomatic Tx MS
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Spasticity: baclofen, diazepam Fatigue: Amantadine, Provigil (monafinil) Depression: anti-depressants Neurogenic Bladder: Oxybutynin, catheterization
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Simple Partial Sz
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CONSCIOUS Isolated transient tonic or clonic limb activity or sensory perception which may spread to entire side of body (JACKSONIAN MARCH)
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Complex Partial Sz (Temporal Lobe)
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Aura, followed by IMPAIRED CONSCIOUS Focal tonic clonic activity or focal sensory perception Nausea, vomiting
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Generalized Sz
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NO AURA
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Absence (generalized Sz)
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Impaired conscious, staring spells Often accompanied by AUTOMATISMS (lip smacking, chewing or fumbling of fingers)
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EEG Absence Sz
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Generalized spikes Assoc w/SLOW WAVES 3 per second spikes
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EEG Simple Partial Sz
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Focal Rhythmic Discharge at onset Sz, occasionally not seen
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EEG Complex Partial Sz
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Interictal spikes or spikes associated w/slow waves in Temporal or Frontotemporal region
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EEG Generalized Sz
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DIFFUSE B/L SPIKE WAVE ACTIVITY
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Tx Sz
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Correct electrolyte or drug intoxication
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Tx Absence Sz
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Valproic Acid (Depakote) Ethosuxamide (zarontin)
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Tx Generalized Sz
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Levetiracetam (Keppra) Lamotrigine (Lamictal) Valproic Acid (Depakote)
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Tx Partial Sz
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Phenytoin (Dilantin) Carbamazepine (Tegretol) Levetiracetam (Keppra) Valproic Acid (Depakote) Topiramate (Topamax) Oxcarbazepine (trileptal)
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Status Epilepticus
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2 or more seizures without full recovery in between or a single seizure lasting longer than 30 minutes ABCs, Thiamine/glucose if indicated/IV, check labs, Sz med levels POST 5 MINUTES give Ativan IV, PR, or even buccal Fosphenytoin IV General Anesthesia: Midazolam, propofol, pentobarbital (must be incubated)
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Prophylactic Migraine Tx
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Beta Blockers (propranolol) TCAs (Elavil) AntiSz (Valproic acid - Depakote, Topiramate - Topamax)
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Cluster HA
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Men Brief, multiple per day (30-90 minutes) Severe unilateral RETRO ORBITAL Boring pain ( NOT THROBBING) Lacrimation, nasal congestion/rhinorrhea, Ptosis, miosis OCCURS SAME TIME EACH NIGHT AGITATION, BANGS HEAD, PACES
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Average Cluster HA Lasts
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45 minutes
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Tx Cluster HA
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100% NRB Oxygen until it breaks Sumatriptan SC Prophylaxis: Prednisone, Verapamil, Lithium Smoking/Alcohol cessation
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Trigeminal Neuralgia
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EPISODIC LANCING PAIN (sharp electric) V2, V3 distribution UNILATERAL Triggered by facial stimulation Tx Tegretol
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Temporal Arteritis (Giant Cell)
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MONOCULAR VISION LOSS HA, Jaw Claudication, fever, nonspecific aches/pains More common in women Tx : ESR/CRP, Temporal Artery Biopsy, STEROIDS
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Temporal Arteritis (Giant Cell)
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DONT DELAY TX W/STERIODS FOR BIOPSY
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Pseudo tumor Cerebri
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Papilla edema, blurry vision, DIPLOPIA, hurts to lay flat Frequently assoc w/ OBESE ADOLESCENT FEMALES & YOUNG WOMEN
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Subarachnoid Hemorrhage
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WORST HA OF MY LIFE THUNDERCLAP Associated with HTN, Smoking, hypercholesterolemia Rupture Cerebral Artery or AVM BLEEDING INTO SUBARACHNOID SPACE RUPTURED SACCULAR (berry) ANEURYSM 75% nontraumatic cases
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If CT fails to find SAH must
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Get LP- MANDITORY
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Tx SAH
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Surgical clipping Nimodipine to prevent vasospasm Hydration Control BP Seizure Prophylaxis
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Tx SAH to reduce ICP
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Nimodipine
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Subdural Hematoma
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RUPTURE OF BRIDGING VEINS TRAUMA SPONTANEOUS IN ALCHOLICS CT-CRESCENT (CONCAVE) SHAPED hematoma crossing suture lines
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Epidural Hematoma
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MIDDLE MENINGEAL ARTERY usually assoc w/SKULL FX LUCID INTERVAL -LOC, regains consciousness w/o symptoms then relapses into COMA CONVEX/Lens shaped STOPS AT SUTURES
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Layers of brain/head
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Skull Epidural space Dura matter Subdural space Arachnoid matter Subarachnoid space Pia matter over brain
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Bells Palsy
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Lower motor neuron facial weakness caused by facial nerve involvement Without apparent cause Unilateral CN VII
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Clinical signs Bell's Palsy
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Decrease taste Anterior 2/3 tongue Prodrome of post auricle discomfort UPPER & LOWER FACE Impaired eye closure & brow furrowing Decrease tear production Hyperacusis (sound bothers) Weakness of Platysma
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Tx Bell's Palsy
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Prednisone Antivirals Eye patch at night with gauze Artificial tears Lacrilube Oint at night
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Bell's Palsy
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Taste or hearing involved MUST BE PERIPHERAL, not a stroke
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Guillian Barre
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Acute Inflammatory Demyelinating Polyneuropathy of PNS Acute Generalized weakness 2/3 have preceding illness 1-4 weeks prior or event (vaccination)
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Clinical Signs Guillian Barre
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HYPOREFLEXIA Acsending Paresthesia Back pain Autonomic instability (iratic BP) RESPIRATORY FATIGUE/failure - consider intubation, bedside PFTs CN involvment 50 %
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Tx Guillian Barre
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Plasma exchange IVIG NO STERIODS
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Dx Guillian Barre
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LP shows increase protein EMG shows Demyelination
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Myasthenia Gravis
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Antibody Mediated attack on post synaptic Acetylcholine Receptor Improvement,when given short term Edrophonium -anticholestrinase
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Myasthenia Gravis Clinical
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PROXIMAL WEAKNESS Improves with rest Fluctuating, fatigue, CN Psuedopalsy -Ptosis, diplopia, nasal voice, facial & neck weakness
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Common presentation myasthenia gravis
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Middle aged female with PTOSIS, SLURRED SPEECH, DIFFICULTY SWALLOWING , CN (tongue, mastication, ocular, facial wkness) ACTIVITY WORSENS
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Dx Myasthenia Gravis
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EMG Antibody testing -acetylcholine receptor antibody assay (+80 to 90%) Tensilon Test- give Edriphonium a Acetylcholinesterase Inhibitor which blocks break down of acetylcholine leaving more chance for some to get thru receptor, gives pt's lots of strength back, short acting 20-25seconds
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Radio-imaging for Myasthenia Gravis
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Because its autoimmune need to get CT NECK r/o benign THYMOMA
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Myasthenia Gravis Tx
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Prednisone Neostigmine, Mestinon (Pyridostigmine) -anticholinesterase inhibitor Side effects hyper parasympathetic (n/v,d, cramps) Atropine reverses if go into acetylcholinergic crises IVIG Plasmaphoresis Intubation
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Upper motor neuron dz (CNS) lesions present
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Weakness, paralysis Hyperreflexia, spasticity Babinsky, loss of abdominal reflexes Little if any muscle atrophy
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Lower Motor Neuron Dz (PNS) lesions present
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Weakness, paralysis FLACID WEAKNESS MUSCLE WASTING FASSICULATIONS LOSS DTR
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Central Cord Syndrome
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Loss MOTOR function -mostly UPPER EXTREMETIES HYPERESTHESIAS over shoulders & arms
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Carotid Stenosis >70% w/TIA's indicates
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Carotid endarterectomy
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Carotid Symptomatic Bruit (TIAs)
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Put on Coumadin
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ASYMPTOMATIC Carotid Bruit
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Put on ASA
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LP bacterial meningitis
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Cloudy, INCREASE PROTEIN INCREASE Leuks (predominantly polymorphonuclear Leuks (poly's) LOW GLUCOSE (due to bacteria utilization) Elevated OP
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LP viral meningitis
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Low WBC <1000, usually lymphs/mono's Glucose normal Protein elevated
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LP MS
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Mild lymphocytosis Increased Proteins w/electrophoresis shows discrete bands of IgG called OLIGOCLONAL BANDS (90% of time)
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LP SAH
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RBC in beginning & end (vs traumatic LP just in beginning) Xanthochromia
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Argyll-Robertson Pupils
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Neurosyphilis B/L pupils -Don't react to light but contract during accommodation B/L Small, irregular pupils
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Fixed dilated pupils
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Anticholinergic Toxicity
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B/L Pinpoint Pupils
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Pontine Hemorrhage
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Horner's syndrome
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Unilateral miosis, Ptosis, Anhidrosis
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Acute Ischemic CVA
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BP elevates initially & will decline w/o medication in 1st few hrs to days & need elevated BP to salvage brain tissue (Penumbra ) -if lower BP could lose this tissue Only tx BP if issues of CHF,
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Pseudo tumor Cerebra (Benign Intracranial HTN)
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Severe HA, diplopia, blurred vision, vision loss OBESE ADOLESCENT MRI/CT r/o mass LP r/o infection, Increased Pressure Tx Diuretic, Steroids, repeated LP remove fluid & Wt loss
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Biceps/brachioradialis DTR
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C5-C6
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Triceps DTR
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C6-C7, mostly C7
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Knee DTR
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L3-L4 mostly L4
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Ankle DTR
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S1
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Sensory C7
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Middle finger
