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1.29 Step up to Medicine
Diseases of the central and peripheral nervous system
272
Mechanical Engineering
Professional
01/29/2013

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Term
What is the rank of stroke as a cause of death?
Definition
3rd
Term
What is teh leading cause of neurologic disability?
Definition
stroke
Term
What is the time limit of a TIA?
Definition
less than 24 hrs however most last less than 30 minutes
Term
What do you call a enurologic deficit due to ischemia that lasts longer than 24 hours but resolves in 2 weeks?
Definition
reversible ischemic neurologic deficit
Term
what do you call a stroke that has symptoms that are worsening?
Definition
evolving stroke
Term
What do you call a stroke with no increase in symptoms?
Definition
complete stroke
Term
What causes TIA?
Definition
usually embolic; however transient hypotension in the presence of severe carotid stenosis (>75% occlusion) can lead to TIA
Term
What is the risk of stroke in a person who has had a TIA?
Definition
10% per year; 30% 5 yr risk of stroke
Term
What are the two most important risk factors for stroke/
Definition
age and HTN
Term
What drugs increase your risk of stroke?
Definition
vasoconstrictive drugs such as cocaine and amphetamines
Term
TIA involving clumsiness of one limb probably occured in what vascular system?
Definition
carotid
Term
Dizziness due to a TIA probably involves what vascular system?
Definition
verbetrobasilar
Term
Double vision as a TIA is due to a disturbance in what vascular bed?
Definition
verbetrobasilar system
Term
Numbness of ipsilateral face and contralateral limb due to a TIA involves what vascular bed?
Definition
vertebrobasilr system
Term
Dysarthria as a TIA probably involves what vascular bed?
Definition
vertebrobasilar
Term
Hoarseness as a TIA symptom probably involves what vascular system?
Definition
vertebrobasilar
Term
Projectile vomiting as a TIA symptom involves what vascular bed?
Definition
vertebrobasilar bed
Term
What is the most common etiology of TIA/CVA?
Definition
embolic stroke
Term
What are the various origins of an embolus that results in stroke?
Definition
heart, internal carotid artery, aorta, paradoxical
Term
Atherosclerotic disease of the carotids occurs most commonly where?
Definition
at the bifurcations of the carotid
Term
What is a lacunar stroke?
Definition
small vessel thrombotic disease
Term
What percent of strokes are lacunar?
Definition
20%
Term
Lacunar strokes involve what parts of the brain?
Definition
subcortical strucutres (basal ganglia, thalamus, internal capsule, brainstem)
Term
What percent of pts with lacunar infarcts have a history of diabetes?
Definition
80-90%; diabetes is another big risk factor
Term
Sources of embolic stroke are evaluated by what tests/
Definition
echocardiogram, carotid dopplers, ECG/Holter monitoring
Term
Lis tthe different types of ischemic strokes and percent occurance?
Definition
20% atherosclerotic cerebrovascular disease (hypoperfusion or arteriogenic emboli), 25% penetrating artery disease (lacunes), 20% cardiogenic embolism, 30% cryptogenic, 5% other
Term
Where is the stenosis in subclavian steal syndrome?
Definition
proximal to the vertebrals
Term
Describe the course of a thrombotic stroke?
Definition
onset of symptoms are either rapid or stepwise; classically the pt awakens from sleep with the neurologic deficit
Term
What is the course of embolic stroke?
Definition
onset of sympmtoms is very rapid and deficits are maximal initially
Term
What are the four main syndormes of lacuna stroke?
Definition
pure motor; pure sensory; atasic hemiparesis; clumsy hand dysarthria
Term
pure motor stroke is a stroke of the...
Definition
internal capsule
Term
Symptoms of vertebral/basilar stroke=
Definition
ipsilateral= atasia, diplopia, dysphagia, dysarthria, and vertigo
contralateral= homonymous hemianopsia with basilar/PCA lesions
Term
What percent of SAH are identified by CT?
Definition
95%
Term
What pts should get a screening carotid duplex scan?
Definition
carotid bruit, PVD, CAD
Term
If a young pt presents with stroke, look for vasculitis, hypercoagulable states and thrombophilia by ordering what tests?
Definition
protein C, protein S, antiphospholipid antibodies, factor V leiden mutation, ANA, ESR, rheumatoid factor, VDRL/RPR, lyme serology TEE
Term
What percent of infarcts can be identified on MRI within 24 hrs?
Definition
95%
Term
If a pt comes to the ED with findings suggestive acute stroke what should you order?
Definition
noncontrast CT, ECG, cxr, CBC, platelet count, PT, PTT, serum electrolytes, glucose level, bilateral carotid ultrasound, echo
Term
What complications should you be aware of for pts in the post stroke period?
Definition
cerebral edema occuring within 1 to 2 days and cuasing mass effects for up to 10 days, hemorrhage into the infarction, seizures (fewer than 5%)
Term
How should you manage a pt you gave tPA to?
Definition
no aspirin for the first 24 hrs, perform neurologic checks every hour, keep bp <185/110
Term
what do you give a pt who had stroke symptoms starting 9 hrs ago who is allergic to aspirin?
Definition
clopidogrel (if cannot tolerate clopidogrel use ticlopidine)
Term
T/F anticoagulants like heparin or warfarin are indicated in acute stroke.
Definition
false
Term
When do you give pts with stroke medicine to lower their BP?
Definition
if the BP is very high (>220/>120) if pt has significant medical indication for antiHTN drugs, the pt is recieving thrombolytic therapy
Term
When is CEA indicated?
Definition
if stenosis is >70% and pt is symptomatic you decrease risk of stroke from 17.5% to 6% per year
Term
How do you treat pts with asympomatic carotid artery stenosis?
Definition
reduction of atherosclerotic risk factors and use of aspirin
Term
What are teh two main categories of hemorrhagic stroke?
Definition
ICH (brain parenchyma), SAH (into the CSF)
Term
What is the mortality rate of ICH?
Definition
50% at 30 days
Term
What is one of the main causes of stroke in young patients?
Definition
cocaine use
Term
ICH + pinpoin pupils=
Definition
bleeding into the pons
Term
ICH + poorly reactive pupils=
Definition
thalamus
Term
ICH + dilated pupils=
Definition
putamen
Term
What is the treatment for intraparenchymal hemorrhagic stroke?
Definition
supportive
Term
What is the most common cause of ICH?
Definition
50-60% are due to HTN (particularly a sudden increase in BP)
Term
Besides HTN and hemorrhagic conversion of ischemic stroke, what are some other causes of ischemic stroke?
Definition
amyloid angiopathy (10%), anticoagulant/antithrombolytic use (10%), brain tumors (5%), and AV malformations (5%)
Term
Where do ICH's occur?
Definition
66% in the basal ganglia, 10% in the pons, 10% cerebellum
Term
What is the course of a hemorrhagic stroke?
Definition
abrupt onset of a focal neurologic deficit that worsens steadily over 30 to 90 minutes
Term
Name some complications of ICH?
Definition
increased ICP, seizures, rebleeding, vasospasm, hydrocephalus, SIADH
Term
In pts with hemorrhagic stroke, what should you do with their BP?
Definition
treat if >160-180/>105
Term
What med should you use to lower BP in a patient with hemorrhagic stroke?
Definition
nitroprusside
Term
How do you reduce ICP in hemorrhagic stroke?
Definition
DO NOT GIVE STEROIDS; give mannitol and diuretics only if there are signs of increased ICP; do not give prophylactically; if there is a cerebellar hematoma, you should have neurosurgery rapidly evacuate it
Term
What is the moratlity rate of SAH?
Definition
40-50% at 30 days
Term
Name some causes of subarachnoid hemorrhage?
Definition
ruptured berry aneurysm, trauma, AV malformation
Term
What % of pts with SAH have a sudden, transient LOC?
Definition
1/2
Term
What percent of pts with SAH die at the first rupture?
Definition
25-50%
Term
What percent of pts with SAH have retinal hemorrhages?
Definition
up to 30% of patients
Term
What is the gold standard for diagnosis of SAH?
Definition
xanthochromia on LP
Term
How do you manage pt with subarachnoid hemorrahge?
Definition
bed rest in a quiet, dark room; stool softeners to avoid straining, analgesia for headaches (acetaminophen), IV fluids, control of HTN (lower slowly), calcium channel blocker (nifedipine) for vasospasm
Term
What is teh data on using nifedipine for pts with SAH?
Definition
lowers the incidence of cerebral infarction by 1/3
Term
What is shy-drager syndrome?
Definition
parkinsonian symptoms + autonomic insufficiency
Term
What is the histologic finding in pts with parkinson's?
Definition
lewy bodies (hyalin inclusion bodies)
Term
What is the difference between PSP and parkinson's?
Definition
PSP does not cause tremor but does cause an ophtalmoplegia
Term
What is PSP?
Definition
a degenerative condition of the brainstem, basal ganglia, and cerebellum, most commonly affecting middle-aged and elderly men
Term
Describe the autonomic dysfunction associated with Parkinson's?
Definition
orthostatic hypotension, constipation, increased sweating, and oily skin
Term
What is sinemet?
Definition
carbidopa-levodopa
Term
How long after being treated with levodopa before you get dyskinesias?
Definition
5-7 yrs of therapy
Term
Name some side effects of sinemet?
Definition
dyskinesias, nausea/vomiting, anorexia, HTN, hallucinations
Term
Name some medications known to cause parkinsonian side effects.
Definition
neuroleptic drugs (chlorpromazine, haloperidol, perphenazine), metoclopramide, reserpine
Term
Dopamine receptor agonists are especially useful for parkinson pts with what problem?
Definition
sudden episodes of hesitancy or immobility
Term
What is selegiline?
Definition
inhibitor of monoamine oxidase B activity so it increases dopamine activity and reduces metabolism of levodopa; used as adjunct in early parkinsons
Term
Name some anticholinergic drugs used for parkinson's?
Definition
benztropine, trihexylphenidyl
Term
When is surgery indicated for parkinson's?
Definition
if the patient does not respond to medication or develops severe disease before age 40
Term
The increase in CAG associated with Huntington's disease causes what to happen?
Definition
loss of GABA-producing neurons in the striatum
Term
What percent of patients with huntington's are demented by age 50?
Definition
90%
Term
What causes physiologic tremor?
Definition
fear, anxiety, fatigue, hypoglycemia, hyperthyroidism, pheochromocytoma, toxic causes (alcohol withdrawal, valproic acid, lithium, methylxanthines, caffeine and theophylline)
Term
How do you treat essential tremor?
Definition
propranolol or primidone
Term
WHat is teh inheritance of Friedrich's ataxia?
Definition
AR
Term
What are the symptoms of Friedrich's ataxia?
Definition
onset in young adulthood of ataxia, nystagmus, impaired vibratory sense, and proprioception
Term
What is the inheritance pattern of ataxia telangiectasia?
Definition
autosomal recessive
Term
What are the symptoms of ataxia telangiectasia?
Definition
childhood onset of ataxia, nystagmus, impiared vibratory sense and proprioception; physical exam reveals telangiectasias; pts have increased risk of cancer
Term
What are some acquired casues of ataxia?
Definition
alcohol intoxication, vitamin B12 or thiamine deficiency, cerebellar infarction or neoplasm, demyelinating disease (MS, AIDS), and tertiary syphilis (tabes dorsalis)
Term
Tourette's syndrome is associated with what psychiatric illness?
Definition
OCD
Term
What is the typical age of onset for tourette's?
Definition
before age 21
Term
Is tourette's genetic?
Definition
yes; thought to be AD
Term
Before diagnosing tics or tourette's syndrome, you should rule out what disorders?
Definition
seizures, tardive dyskinesias, and huntington's disease
Term
What is the medical term for involuntary swearing?
Definition
coprolalia
Term
What are the clinical features of tourette's?
Definition
multiple motor tics and at least one kind of phonic tic
Term
What is the treatment for tourette's?
Definition
if symptoms are affecting quality of life= clonidine, pimozide, haloperidol
Term
T/F Some degree of memory loss is accepted as a normal part of aging.
Definition
true; benign forgetfulness of the elderly
Term
What is the most important risk factor for dementia?
Definition
increasing age
Term
Name some potentially reversible causes of dementia?
Definition
hypothyroidism, neurosyphilis, vitamin B12/folate/thiamine deficiency, medications, normal pressure hydrocephalus, depression, subdural hematoma
Term
What percent of dementias are due to alzheimer's?
Definition
66%
Term
What is Binswanger's disease?
Definition
insidious onset of dementia due to diffuse subcortical white matter degeneration, most commonly seen in patients with long standing hypertension and atherosclerosis
Term
What are the features of normal pressure hydrocephalus?
Definition
dementia, gait disturbance and urinary incontinence, normal CSF pressure and dilated ventricles
Term
Name some infections that can cause dementia?
Definition
HIV, neurosyphilis, cryptococcal, Creutzfeldt-Jakob disease (spongiform encephalopathy), progressive multifocal leukoencephalopathy
Term
T/F Korsacoff's dementia is reversible?
Definition
false
Term
What studies should you get when investigating causes of dementia?
Definition
CBC with diff, CMP, TSH, folate, B12, VDRL, HIV, CT or MRI of the head
Term
What is tacrine used for?
Definition
to treat dementia
Term
What rank does Alzheimer's have as a cause of death in the US?
Definition
4th
Term
What chromosomes have been linked to Alzhiemer's?
Definition
21, 14, and 19
Term
Describe the histologic pathology associated with Alzheimer's?
Definition
senile plaques (focal collections of dilated, tortuous neuritic processes surrounding a central amyloid core), and neurofibrillary tangles (bundles of neurofilaments in cytoplasm of neurons)
Term
What CT/MRI findings would correlate with a diagnosis of Alzheimer's?
Definition
diffuse cortical atrophy with enlargement of the ventricles
Term
T/F Hormone replacment therapy decreases the risk of Alzheimer's.
Definition
true
Term
How much vitamin E is the dose for Alzheimer's?
Definition
2,000 IU/day
Term
Besides alzheimer's, anticholinesterase meds are also indicated for what other type of dementia?
Definition
lewy body dimentia
Term
What is dementia with Lewy Bodies?
Definition
dementia with features of both alzheimer's and parkinson's but progression may be more rapid than in Alzheimer's; initially visual hallucinations predominate; other symptoms include extrapyramidal features and fluctuating mental staus
Term
How do you treat dementia with lewy bodies?
Definition
avoid neuroleptic agents because they exacerbate sympotms; treat like alzheimer's with neuroleptics if they are psychotic; selegiline may slow the progression of disease
Term
What kinds of things can cause delirium?
Definition
postoperative state, dehydration, malnutrition, infection/inflammation/fever, medications and drug intoxications, drug withdrawal states, metals, trauma/burns
Term
What types of drugs can cause delirium?
Definition
TCAs, corticosteroids, anticholinergics, hallucinogens, cocaine
Term
What is teh lab workup for delirium?
Definition
CMP, B12, thiamine, perform LP in any pt that is also febrile and has no contraindications
Term
What is a coma?
Definition
depressed level of consciousness to the extent that the patient is completely unresponsive to any stimuli
Term
IF a patient is in a coma and has an abnormal pupillary light response, what should you be thinking?
Definition
structural intracranial lesions, drugs that affect teh pupil (morphine and atropine-like agents), anoxic encephalopathy, recent eye drops
Term
Coma + bilateral fixed, dilated pupils=
Definition
severe anoxia
Term
Coma + unilateral fixed, dilated pupil=
Definition
herniation with CN III compression
Term
Coma + pinpoint pupils=
Definition
narcotics, ICH into the pons
Term
A 15 on the GCS means teh pt can...
Definition
open eyes spontaneously, obeys commands, and has appropriate and oriented speech
Term
A 3 on the GCS means the patient...
Definition
does not open his eyes, does not withdraw to pain, and does not make any sounds
Term
"locked in" syndrome means that a patient is completely paralyzed except for....
Definition
muscles of respiration, blinking and vertical eye movement
Term
What causes locked in syndrome?
Definition
infarction or hemorrhage of the ventral pons
Term
What are the criteria for diagnosing brain death?
Definition
absence of brainstem reflexes despite adequate oxygenation and ventilation/apneic, no drug intox or metabolic condition, core body temp >32 C, clinical evidence or imaging that suggests cause for brain death, repeat exam or EEG performed
Term
Name some tracts commonly involved in the MS demylination.
Definition
pyramidal, cerebellar, medial longitudeinal fasciculus, optic nerve, posterior columns
Term
How long does an MS relapse last?
Definition
at least 24 hrs
Term
How often do pts with MS get relapses in general?
Definition
1/yr but decrease over time
Term
What are symptoms of optic neuritis?
Definition
monocular visual loss, pain on movement of eyes, central scotoma, decreased pupillary reaction to light
Term
Does a lesion of the MLF lead to an ipsilateral or contralateral defect?
Definition
ipsilateral
Term
What is teh most common initial presentation of MS?
Definition
decreased sensation or pareshtesias in upper or lower limbs
Term
What is the most common complaint of pts with MS?
Definition
fatigue
Term
At what age does primary progressive MS present?
Definition
after 40
Term
What is the usefulness of diagnostic tests for MS?
Definition
MRI, CSF, and evoked potentials are abnormal in 90% of pts with MS
Term
What factors make it more likely that MS will cause severe disability?
Definition
frequent attacks early in the disease course, onset at an older age, progressive course, and early cerebellar or pyramidal involvement
Term
T/F The number of lesions on the MRI are proportional to disease severity and speed of progression.
Definition
false
Term
What is teh test of choice for MS?
Definition
MRI (because it is the most sensitive)
Term
Most attacks of MS resolve within what time frame?
Definition
6 weeks
Term
How effective is TPE (therapeutic plasma exchange) for steroid-refractory acute demyelinating disease?
Definition
42%
Term
Are IV steroids used for MS?
Definition
yes they can lessen an acute attack but do not result in any improvement in long term outcome
Term
What kinds of interferons can be used for MS? How effective are they?
Definition
IFN beta 1a, IFN beta 1b, glatiramer acetate; 37%, 33%, 29% respectively
Term
When should you start interferon therapy for MS?
Definition
early in the course of disease before teh disability becomes irreversible
Term
When do you use cyclophosphamide for MS?
Definition
only for rapidly progressive disease because of toxic side effects
Term
What kind of meds are often used for symptoms of MS?
Definition
baclofen or dantrolene for msucle spasticity, carbamazepine or gabapentin for neuropathic pain, treat depression if indicated
Term
Name some common infections that precede Guillain-Barre Syndrome?
Definition
ivral or mycoplasmal infection of the URI or GI tract; campylobacterjejuni, CMV, hepatitis, and HIV
Term
What diseases, besides recent viral URI or gastroenteritis, are associated with Guillain-Barre Syndrome?
Definition
Hodgkin's disease, lupus, after surgery or after HIV seroconversion
Term
T/F Guillain Barre is asymmetric.
Definition
false; more often symmetric
Term
What types of sensory abnormalities are seen in Guillain Barre?
Definition
extremities may be painful but sensory loss is not typical
Term
T/F Bowel and bladder incontinence often occur with guillain barre?
Definition
false; sphincter control is maintained
Term
What should you never give pts who have guillian barre?
Definition
steroids
Term
How do you make the diagnosis of guillain barre?
Definition
combination of CSF fluid analysis, clinical findings, and nerve conduction velocities
Term
What types of patient's often have myasthenia gravis symptoms limited to extraocular muscles?
Definition
elderly pts
Term
At what age is the typical onset of myasthenia gravis?
Definition
age 20-30 in women; age 50 to 70 in men
Term
Besides extraocular muscles, what other muscle groups are affected by myasthenia gravis?
Definition
proximal limbs (asymmetric)
Term
Is the limb weakness associated with myasthenia gravis symmetric or assymetric?
Definition
asymmetric
Term
What are the symptoms of Lambert-eaton myasthenic syndrome?
Definition
proximal muscle weakness and hyporeflexia
Term
What percent of patients get myasthenic crisis?
Definition
15%
Term
What percent of patients with myasthenia gravis are antibody negative?
Definition
20%
Term
What percent of MG patients have thymoma?
Definition
10-15% have thymoma; but the thymus is histologically abnormal in 75% of pts
Term
What limits the utility of the edrophonium test?
Definition
high false positive
Term
Name some medications that can exacerbate myasthenia gravis?
Definition
antibiotics (aminoglycosides and tetracyclines), beta blockers, antiarrhythmics (quinidine, procainamide, and lidocaine)
Term
If a patient with myasthenia gravis has a poor response to AChE inhibitors, what should you give them?
Definition
immunosuppressive drugs like corticosteroids; azathioprine and cyclosporine are alternative third-line agents
Term
What should you do for pts in myasthenic crisis?
Definition
plasmapheresis; IVIg
Term
How can you tell whether you need to intubate someone with myasthenia gravis?
Definition
at a FVC of 15 mL/kg (about 1 L); you should have a very low threshold for intubation and not wait until the pt is hypoxic
Term
Describe the muscle weakness associated with Duchenne's?
Definition
progressive, symmetric, and starts in childhood; affects pelvic girdle
Term
What causes the enlarged calf muscles of Duchenne's?
Definition
true muscle hypertrophy at first, followed by pseudohypertrophy as fat replaces muscle
Term
What tests are used for diagnosis of Duchenne's muscular dystrophy?
Definition
serum CPK elevation; DNA testing has now replaced muscle biopsy for diagnosis
Term
How do you treat Duchenne's?
Definition
prednisone will increase strength, muscle function, pulmonary function and may reduce the risk of scoliosis
Term
When do you start Pts with Duchenne's on chronic steroid therapy?
Definition
boys 5 yoa and older whose motor skills are declining
Term
Which is more common Duchenne's or Becker's muscular dystrophy?
Definition
Duchenne's
Term
Besides Becker's and Duchenne's, what are some other hereditary causes of muscle weakness?
Definition
mitochondrial disorders, glycogen storage diseases
Term
Deficiency of what enzyme causes McArdle's disease?
Definition
glycogen phosphorylase deficiency
Term
Name some neurocutaneous syndromes.
Definition
neurobiromatosis type I, neurofibromatosis type II, tuberous sclerosis, sturge-weber, von hippel-lindau disease
Term
What is the inheritance pattern of neurofibromatosis?
Definition
AD
Term
What is the inheritance pattern of tuberous sclerosis?
Definition
AD
Term
What is the inheritance pattern of sturge weber?
Definition
acquired disease
Term
What is teh inheritance pattern of von hippel-lindau disease?
Definition
AD
Term
What are the cutaneous stigmata of neurofibromatosis?
Definition
cafe au lait sponts, neurofibromas, axillary or inguinal freckling, iris hamartomas (Lisch's nodules); sometimes can have short height and be macrocephalic
Term
What are the tumors/serious complications of Neurofibromatosis?
Definition
CNS tumors (gliomas, meningiomas), pheochromocytomas, optic nerve gliomas, renal artery stenosis; spinal deformity and congenital tibial dysplasia
Term
T/F Seizures is associated with NF types 1 and 2.
Definition
true
Term
T/F MR and learning disabilities is associated with NF (both types).
Definition
true
Term
Name some musculoskeletal abnormalities associated with NF type 1.
Definition
spinal dformity; congenital tibia dysplasia
Term
Which is more common NF type 1 or 2?
Definition
type 1 is much more common
Term
What are the clinical features of NF type II?
Definition
bilateral (sometimes unilateral) acoustic enuromas (classic finding), multiple meningiomas, cafe au lait spots, neurofibromas (much less common than type 1), and cateracts
Term
Pts with tuberous sclerosis often rpesent becasue of...
Definition
cognitive impairment, epilepsy, and skin lesions (including facial angiofibromas and adenoma sebaceum)
Term
What kinds of tumors are associated with tuberous sclerosis?
Definition
retinal hamartomas, renal angiomyolipomas, and rhabdomyomas
Term
How do you treat tuberous sclerosis?
Definition
treat complications
Term
What is teh key pathologic feature of sturge weber syndrome?
Definition
capillary angiomatoses of the pia mater
Term
What is teh classic finding on physical exam of pts with sturge weber?
Definition
facial vascular nevi (port wine stain)
Term
What neurologic problems are common in pts with tuberous sclerosis?
Definition
epilepsy and MR
Term
What are the important features of VHL disease? What are teh associated neoplasms?
Definition
cavernous hemangiomas of the brain or brainstem, renal angiomas, and cysts in musltiple organs; associated with renal cell carcinoma and pheochromocytoma
Term
What is syringomyelia?
Definition
central cavitation of the cervical cord due to abnomral collection of fluid within the spinal cord parenchyma
Term
Syringomyelia can be caused by...
Definition
most commonly= arnold chiari malformations; also, posttraumatic, postinfectious, tethered cord, intramedullary tumors
Term
What are the clinical features of syringomyelia?
Definition
most are asymptomatic and discovered incidentally; symptoms= bilateral loss of pain and temperature sensation over the shoulders in a "capelike" distribution (lateral spinothalamic tract involvement), with preservation of touch, thoracic coliosis and muscle atrophy of the hands may occur
Term
How do you diagnose syringomyelia?
Definition
MRI
Term
How do you treat syringomyelia?
Definition
depends on size of the syrinx, symptoms, and associated findings; eval by neurosurgery recommended
Term
Where does brown-sequard syndrome usually occur?
Definition
cervical levels where spinal cord enlarges
Term
What are the clinical features of Brown Sequard syndrome?
Definition
contralateral loss of pain and temperature (spinothalamic tract), ipsilateral hemiparesis (corticospinal tract) and ipsilateral loss of position/vibration (dorsal columns)
Term
What is the prognosis of Brown sequard?
Definition
very good;
Term
What is transverse myelitis?
Definition
inflammation that specificly affects the tracts across the horizontal aspect of the spinal cord at a given level (most commonly thoracic), cause is unkown but it can occur after viral infections and progression is usually rapid
Term
What are the clinical features of transverse myelitis?
Definition
lwer extremity weakness or plegia, back pain, sensory deficits below the level of the lesion, and sphincter disturbance 9esp urinrary retention)
Term
How do you diagnose transverse myelitis?
Definition
MRI with contrast is the imaging study of choice
Term
How do you treat transverse myelitis? prognosis?
Definition
high dose steroid hterapy is often used but evidence is equivocal; prognosis is highly variable and unpredictable, ranging from full recovery to death
Term
A postganglionic lesion causing horner's syndrome means the lesion is...
Definition
distal to the superior cervical ganglion
Term
Which is more worrisome: preganglionic or postganglionic horner's?
Definition
preganglionic
Term
What are some common causes of Horner's syndrome?
Definition
most are idiopathic, pancoast tumor, internal carotid dissection, brainstem stroke, neck trauma
Term
What is a pancoast tumor?
Definition
pulmonary neoplasm of the superior sulcus at lung apex
Term
What are the characteristics of polio?
Definition
asymmetric muscle weakness (legs more commonly involved), absent DTRs, flaccid atrophic muscles and normal sensation
Term
What are the three major types of dizziness?
Definition
presyncope, vertigo, and multisensory stimuli
Term
Describe BPV symptoms?
Definition
vertigo and nystamus that are position dependent without hearing loss or innitus
Term
By what mechanism does meclizine work?
Definition
anticholinergic and antihistamine
Term
How long does it take BPV to get better?
Definition
6 months
Term
What age are most people when they get BPV?
Definition
more than 60
Term
What are the symptoms of meniere's disease?
Definition
vertigo, tinnitus and hearing loss
Term
What is the prognosis of symptoms in Meniere's disease?
Definition
attacks may last for hours to days and recur several months or years later; hearing loss eventually becomes permenent
Term
What is the prognosis of acute labyrinthitis?
Definition
may last for several days
Term
If a patient has vertigo EVERY time you do the tilt test then it is probably due to a pathologic process where?
Definition
centrally; peripheral vertigo is rapidly refractory
Term
T/F Pt falls to same side as lesion in both central and peripheral vertigo.
Definition
true
Term
What are teh symptoms of acoustic neruoma of CNVIII?
Definition
ataxia, gait unsteadiness, nystagmus, hearing loss, tinnitus
Term
Name some causes of central vertigo?
Definition
vertebrobasilar insufficiency, MS, migraine associated vertigo
Term
What is the typical characteristics of cardiac syncope?
Definition
usually sudden and without prodromal symptoms; pts face hits the floor
Term
What types of cardiac issues can cause syncope?
Definition
obstruction of blood flow, arrhythmia, massive MI
Term
What are some other terms for vasovagal syncope?
Definition
"neurocardiogenic" "vasodepressor" "simple faints"
Term
Syncope during exertional effort; you should be worried about:
Definition
HCOM or aortic stenosis
Term
What clues can you have to diagnose vasovagal syncope?
Definition
emotional stress, pain, fear, extreme fatigue or clastrophobic situations, premonitory sympotms, be reluctant to make this diagnosis if first episode is after age 40, tilt table study can reproduce the symptoms in susceptible peopel
Term
If you have to resort to meds to treat vasovagal syncope, what can you use?
Definition
beta blockers and disopyramide
Term
What can cause orthostatic hypotension causing syncope?
Definition
old age, ganglionic blocking agents, diabetes, prolonged bed rest
Term
How do you treat syncope secondary to orthostatic hypotension?
Definition
increased sodium intake and fluids; consider fludrocortisone
Term
Why is it important to determine between cardiac and noncardiac etiologies when evaluating syncope?
Definition
because prognosis is poorest for those with underlying heart disease
Term
How should you work up syncope?
Definition
ECG FOR ALL PTS!!! CBC and metabolic panel may be appropriate
Term
Name some causes of seizures?
Definition
metabolic and electrolyte/endocrine disturbances, mass lesions, missing drugs, acute withdrawal, pseudoseizures, eclampsia, hypertensive encephalopathy, intoxications, infections, ischemia, increased ICP
Term
What is the most common cause of poor seizure control in epileptics/
Definition
noncompliance with anticonvulsants
Term
What is the difference between eclampsia and preeclampsia?
Definition
eclampsia has seizures
Term
What is the treatment for ecclampsia?
Definition
magnesium infusion is pharmacologic treatment of choice but the only definitive treatment is delivery
Term
70% of patients with epilepsy older than 18 yoa have what type of seizures?
Definition
partial seizure
Term
How long does the postictal phase last after a tonic clonic seizure?
Definition
10-30 minutes
Term
HOw long does the clonic phase last?
Definition
at least 30 seconds
Term
What percent of absence seizures involve minor clonic activity like eye blinks or head nodding?
Definition
up to 45%
Term
Laboratory values you should immediately check in an unfamiliarl patient who is seizing includes...
Definition
sodium, calcium, BUN, glucose,
Term
What is the mortality rate of status epilepticus?
Definition
up to 20%
Term
What is the treatment for status epilepticus?
Definition
establish an airway, giving IV diazepam, IV phenytoin, and 50 mg dextrose; treat resistant cases with phenobarbital
Term
What percent of adult pts can be controlled on one antiepileptic drug?
Definition
70%
Term
What test should you do before giving pts anticonvulsants?
Definition
PREGNANCY TEST! antiepileptic agents are teratogenic
Term
How long should a patient be seizure free before you think about d/cing their meds?
Definition
2 years at least; taper meds cautiosly and confirm this decision with a normal EEG
Term
What percent of cases of ALS are familial?
Definition
10%
Term
What is a treatment you can use for ALS and what is the effectiveness?
Definition
riluzole is a glutamate blockign agent; it may delay death by only 3 to 5 months
Term
What do EMG's measure?
Definition
contractile properties of sckletal muscles; will show fibrillations and fasciculations of muscles if there is LMN disease; will amplitude decreased with muscle contraction if there is a myopathy
Term
What are nerve conduction studies useful/
Definition
slow nerve conduction velocity indicates demyelination; repetitive stimuli resulting in fatigue is indicative of MG
Term
Disturbance in repitition=
Definition
conduction aphasia
Term
What is the workup for Bell's palsy?
Definition
cause is often uncertain, possible viral etiology (herpes simplex) and URI is common preceding event; consider lyme disease an ddont' use steroids if lyme is suspected; consider EMG testing if paresis fails to resolve within 10 days
Term
How do you treat idiopathic bell's palsy/
Definition
short course of steroids (unless lyme disease is suspected), and acyclovir if necessary; pt should where eye patch at night to prevent corneal abrasion; surgical decompression of CN VII is indicated if the paralysis progresses or if tests indicate deterioration
Term
DDx of Bell's palsy?
Definition
truama, lyme disease, tumor, guillain barre syn drome, herpes zoster
Term
What is the prognosis of trigeminal neuralgia?
Definition
complete resolution in 85%; mild residual in 10%; no resolution in5%
Term
What is the work up for tic douloreux?
Definition
MRI to rule out cerebellopontine angle tumor; but diagnosis is clinical
Term
How do you treat trigeminal neuralgia?
Definition
carbamazepine, baclofen and phenytoin; surgical decompression if medical therapy fails
Term
Visual-spatial deficits mean a lesion where...
Definition
righ sided cerebral cortex
Term
COMPLETE hemiparesis=
Definition
subcortical lesion
Term
Deficit on one side of face and the other side of the body=
Definition
lesion on brainstem on the side of the face lesion; this is because the corticospinal, dorsal columns an dspinothalamic tracts cross bu teh cranial nerves do not
Term
decrease in sensation below a sharp band in teh abdomen/trunk indicates...
Definition
spinal cord lesion (pathognomonic)
Term
What are the most common causes of plexopathies?
Definition
trauma is the most common cause overall esp for the brachial plexus; a postsurgical hematoma is a more common cause in lumbosacral plexopathy
Term
Nerve roots of the lumbosacral plexus=
Definition
L5 to S3
Term
Key finding of radiculopathy=
Definition
pain
Term
Dermatome and/or myotome affected indicates a lesion where...
Definition
radiculopathy
Term
Where does the dorsal column medial lemniscus system decussate?
Definition
junction between teh spinal cord and the brainstem
Term
Distal, asymmetric weakness indicates a lesion where?
Definition
peripheral nerve
Term
What nerves are commonly involved in neuropathies?
Definition
radial, ulnar, median, musculocutaneous, long thoracic nerve, axillary nerve, common perioneal nerve, and femoral nerve
Term
Key finding of neuromuscular junction pathology=
Definition
fatiguability
Term
What's the difference between myopathy and dystrophy?
Definition
myopathy is acquired; dystrophy is inherited
Term
What's teh difference between teh atrophy associated with neuropathies and the atrophy associated with myopathies?
Definition
muscular atrophy in myopathies occurs late due to disues; in contrast to the rapid atrophy in motor neuron disease
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