2020

Neurology notes
DR. ISMAEL ABU DAYEH
ADAM SULTAN
Congenital narrowing of the facial nerve canal
Caudal regression syndrome
Complex partial seizure is the most common type of
epilepsy in adult
Sacral agenesis

Multiple sclerosis:
CA15-3
• Dowson finger sign is pathognomonic for MS
◦ Breast
• Tumofactive MS, large plaques that resembles
tumor on MRI ◦ Endometriosis
• MS and Behcet are both relapsing remitting in ◦ Severe B12
CNS manifestation
• MS criteria of diagnosis is McDonald criteria ◦ Severe PID
• Most common site for demyelination in MS is
cervical
Nocturnal enuresis... sacral x ray
• Charcot triad MS
◦ DYSARTHRIA
◦ NYSTAGMUS High levels of B12
◦ INTENTIONAL TREMOR
◦ Leukemia
◦ Polycythemia rubra vera
Hyperkinesis - choreoathetosis
◦ Iatrogenic

Meniere disease - paroxysmal (tinnitus, vertigo, hearing

loos)

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Ddx of transverse myelitis is Hypoglycemia with reversible or irreversible neuro
deficits
◦ Guillain barre
◦ Vascular lesion
Anterior ischemic optic neuritis
◦ Cord compression
◦ Herniated disk
Side effects of IgG
◦ Tumor
◦ Aseptic meningitis (headache)
◦ Abscess
◦ Anaphylactic shock
◦ Post infectious

Low Cr
◦ Myopathy
Golden time for tissue plasminogen activator in stroke
up to 4.5 hours ◦ Malabsorption
◦ Normal
Normal pressure hydrocephalus
◦ Gait apraxia Levetiracetam + lamotrigine
◦ Dementia Are not teratogenic
◦ Sphincter disorder
Post stroke epilepsy
Plegia complete loss of movement ◦ Heralding
Paresis is partial weakness ◦ Early post stroke epilepsy (first one week after stroke)
◦ Late post stroke epilepsy
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 Anesthesia=sensory loss=hypoesthesia
Akinetic mutism and frontal lobe syndrome
Apraxia (loss of acquired talents) like
Akinetic mutism ddx • Jargon speech
◦ Locked in syndrome • Alexia

◦ Vegetative state
◦ Hysterical Bilateral transient blindness

◦ Absence epilepsy ◦ Headache

◦ Blindness

Paracentral area ◦ Pain

◦ Painless drop foot Occipital infarction with eye pain (Arnold recurrent
nerve)
◦ Incontinence

Main three recurrent nerves

◦ Recurrent Arnold nerve
Cauda equina syndrome
◦ Luschka nerve
◦ Saddle anesthesia
◦ Recurrent laryngeal nerve
◦ Urine retention
◦ Severe low back-pain
◦ Painful drop foot

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Steroid Bolus therapy. Very high dose (30mg/kg) over Gait types:
one hour, usually for spinal cord injury then we maintain
◦ Hemiplegic gait / spastic gait (Werneck man gait)
on 5.4/kg/hour for the rest of the day
◦ Wide base gait (drunken) (cerebellar)
◦ Trendelenburg gait
Pulse steroid therapy (6-15 mg/kg) three to five days....
side effect ◦ Waddling gait (myopathic, osteoarthritis)
◦ Electrolyte imbalance ◦ Secsor gait (CP)
◦ When mineral corticoid activity increases, the side ◦ Peroneal nerve injury (steppauge)
effect increases ◦ Antalgic gait (sciatica) pain induced
◦ Steroid psychosis ◦ Shuffling/ piti march gait (Parkinson)
◦ Hysterical gait
Transverse myelitis ddx
◦ Syringomyelia
◦ Ependymoma CCB side effects
◦ Flushing
Stamping gait with deep sensation loss ◦ Edema
◦ Reflex tachycardia
Liver disease with epilepsy treatment: ◦ Hypotension
• Gabapentin is safe ◦ Constipation
• Levetiracetam is safe

Marcus gun pupil cause us active optic neuritis.

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 ◦ Tabes dorsalis
Most common site of plaques (active inflammatory spot) ◦ Pressure or cord compression
in spinal cord is cervical
◦ Neuropathy
◦ Subacute degeneration
Ptosis and mydriasis are pathognomonic for third nerve
◦ Thalamic syndrome
palsy
◦ Sensory cortical loss

Size of normal pupil 2-5 mm

Causes of optic neuritis
◦ MS
PERLA
◦ Toxic
◦ Pupil equal reactive to light accommodations
◦ Isolated optic neuritis
◦ Ischemic
Anoso-choria, weakness, loss of conciseness, seen in
herniation of brainstem to the side of dilated eye
Vertical Altitudenant hemianopia (loss of vision in upper
half of one eye) - optic nerve infarction
Painful eye, visual acuity, loss if CN 3,4,6 + V1 ddx
◦ Superior orbital fissure syndrome
Pyramidal syndrome
◦ Cavernous sinus thrombosis
◦ Spasticity

Sensory ataxia (loss of proprioception) causes

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Extrapyramidal syndromes Causes of irregular pupil
◦ A- hypo-kinetic rigid syndrome (Parkinson) ◦ Argyll Robertson syndrome
◦ B- Hyperkinesis (chorea, athetosis, facial hemi ◦ Surgical
spasm, blepharospasm, dystonia, hemiballismus, tic
◦ Congenital (water drop eye)
simple and complex)
◦ Trauma
◦ Inflammation (synechia)
In TIC we have to rule out rheumatic fever

Euthyroid sick syndrome

Chorea types
◦ Decrease t3 and t4
◦ Sydenham
◦ Pregnant
Critically ill polyneuropathy / Critically ill
◦ Huntington
polyneuromyopathy
◦ They are similar to Guillain barre but they don’t have
Muscle tone can be treatments/ only physiotherapy
◦ Spastic (pyramidal)- improve by movement
◦ Plastic or rigid (extrapyramidal) in flexors and Acute disseminated encephalomyelitis -
extensors

Cerebral salt wasting diarrhea (hyponatremia)

Vascular Parkinsonism can have rigidity and spasticity

Most common side effect lamotrigine is skin rash

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Vit E def causes cerebellar ataxia Tegretol is contraindicated in absence seizure

Poikilocytosis seen sometimes in ataxia Drug of choice in absence seizure

◦ Ethosuximide
Spinocerebellar syndromes (two components) ◦ Valproate sodium

Non selective beta blocker for essential tremor (exclude

thyroid liver diseases and vit deficiencies)
Hypo-campus sclerosis on MRI is seen in epilepsy

Shawl sign for central cord syndrome and

Radicular pain
dermatomyositis
◦ Due to nerve root compression

Azathioprine SE gastric and brain and lymphoma (safe

in pregnancy) Claudication can be
◦ Vascular
Starring ddx ◦ Neurogenic
◦ absence seizure
◦ narcotics such as marijuana Shapiro syndrome
◦ conversion disorder
◦ hyperthyroidism

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Aicardi syndrome
◦is a rare genetic malformation syndrome characterized Vit b3 dif. Is metabolic disorder resembling ALS
by the partial or complete absence of a key structure in
the brain called the corpus callosum, the presence of
retinal abnormalities, and seizures in the form of Pellagra
infantile spasms ◦Dementia
◦Aicardi syndrome was classically characterized by a ◦ Diarrhea
triad of features: agenesis of the corpus callosum,
distinctive chorioretinal lacunae, and infantile spasms ◦ Dermatitis

Benjamin Syndrome is a type of multiple congenital Wernicke’s encephalopathy

anomaly/intellectual disability (MCA/MR) syndrome. It is ◦ Ataxia
characterized by hypochromic anemia with intellectual
disability and various craniofacial and other anomalies. ◦ Confusion
◦ Ophthalmoplegia

Collisitine antibiotic last choice for multi drug resistance

gram negative.... side effect: Cauda equina syndrome causes
◦ Neurotoxicity ◦ Epidural hem.
◦ Nephrotoxicity ◦ Disc rupture
◦ Stenosis
Spastic gait Cause HIE

immunosuppressant vs immune modulator

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First aid in cauda equina Phenobarbitals toxicity
◦ Hypotension
◦ Steroids bolus therapy ◦ Hypothermia
◦ Decompression surgery within 48 hours ◦ Hypotonia
◦ Muscle **

diabetic neurologic complications Phenobarbital anti-dot

◦ Mono and polyneuropathy ◦ Bicarbonate
◦ Anterior thigh syndrome ◦ Flumazenil
◦ Charcot joint
◦ Autonomic dysfunction (constipation with night Phenobarbital. Long term use causes akatesia, treated
diarrhea) with non-selective B blocker
◦ Ischemic optic neuritis
◦ Diabetic amyotrophy Infra tentorial tumors more common in children and can-
do drop metastasis

Supratentorial tumors more common in adults

Lipid lowering agents are given at bed time
◦ To decrease risk of rhabdomyolysis and myopathy
◦ To improve absorbance Vitamin dif. Causing optic nerve disease
◦ B1
◦ B3
Side effect of statins ◦ B6
◦ Rhabdomyolysis ◦ B12
◦ Liver side effect ◦ Folic acid B9

Lwis-barr syndrome (ataxia telangiectasia)

Naltrexone is opioid anti-dot given until the pupil dilates

Atropine is anti-dot for organophosphates toxicity, given

until atropinization of pupil

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 ◦ Diabetic mellitus
Absence seizure in children
◦ Ethosuximide first line Grades of subarachnoid hemorrhage
◦ Valproate acid second line ◦ 1-5

Pralidoxime (we use for intermediate syndrome) and Nemodepine is

atropine are antidotes for organophosphate ◦ Lipophilic
◦ Calcium channel blocker
Neostigmine is anti-dot for atropine toxicity ◦ Centrally acting

B12 neuro manifestations Meningitis in

◦ Demyelination ◦ Pregnancy, listeria, Neisseria meningitides
◦ Subacute combined degeneration ◦ Lymphoma, listeria
◦ Dementia (reversible) ◦ >50, listeria, strep.
◦ Optic neuropathy
◦ Polyneuropathy Complications of lumber puncture
◦ Headache (CSF leakage, hypotension) (good
Causes of high B 12 hydration, laying down, caffeine containing drinks)
◦ Malignancy ◦ Herniation
◦ Liver disease
◦ Polycythemia rubra vera Distal Babinski
◦ Iatrogenic
Vit B6 deficiency Synkinesis, when test a side and the other responds
◦ Sideroblastic anemia
◦ Convulsion (pyridoxine dif. Seizures) Classic Babinski
◦ Fanning of toes
CSF sugar is 2/3 blood sugar ◦ Big toe dorsiflexion
◦ Withdrawal of the limb
High protein in CSF without meningitis
◦ Endocrinopathies
◦ Gamma albuminemia
◦ Guillain barre
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Normal Babinski POSITIVE Drugs can precipitate MG
◦ Deep anesthesia ◦ B blocker
◦ Deep sleeping ◦ calcium channel blocker
◦ Infants ◦ magnesium sulfate
◦ Quinolone
Level of lesion in Babinski ◦ Botulism
◦ Vertical, above L5
◦ Horizontal, before AHC What are the symptoms of cerebellar syndrome?
◦ Ataxia
◦ Intention tremor
Rocket sign in facial palsy is used to define the side of ◦ Nystagmus
palsy ◦ Slurred speech
◦ Head nodding
◦ dysdiadochokinesia
Leukoriosis, sign of cerebral edema: like extension of ◦ Hypotonia
the CSF shadow... it tells us that there is uncontrolled
hypertension Ddx of Guillain barre
◦ Transverse myelitis
◦ Anterior spinal artery occlusion
◦ Porphyria
Allodynia is a pain from stimulus that would not normally ◦ Lead poisoning
cause pain ◦ Hypokalemic periodic paralysis
◦ Hyperkalemic paralysis
Ddx of TIA
◦ Hypoglycemia
◦ Mass lesion Causes of uncontrollable hypertension
◦ Benign positional vertigo ◦ Pontine
◦ Epilepsy ◦ Caudate nucleus
◦ Migraine ◦ Putamine
◦ Multiple sclerosis ◦ Lenticular stria artery
◦ Transient global amnesia
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Lead poisoning abdominal pain is differentiated from Lovett rule ..
acute abdomen by that it is relieved by compression ◦ (C1-C3) with ((L3-L5) ipsilateral
◦ The others contralateral

Post LP headache is relieved by standing High ceruloplasmin is found as acute phase reactant

Silent zones (frontal and temporal)

Compact zone (occipital) Todd’s paralysis (post-ictal paralysis)
◦ Differentiated from CVA that it has elevated prolactin
in the first 40 mins
Carbamazepine side effects
◦ Hyponatremia Torticollis (hyperkinesis) (extrapyramidal syndrome)
◦ Allergy treated by
◦ Cytochrome inducer ◦ Baclofen
◦ Bone marrow suppression ◦ Then botulinum toxin
◦ Steven Johnson syndrome ◦ Then surgical
◦ Contraindicated with warfarin
◦ DDI with warfarin, quinolone, macrolide, Diplopia and poor vision in one eye can cause torticollis
◦ Don’t give with valproate
Ddx of torticollis
Ddx of subarachnoid hemorrhage (worst headache on ◦ Neurological
earth) ◦ Bony cause
◦ Migraine ◦ Muscular
◦ Meningism (meningeal signs without meningitis) ◦ Spinocerebellar tumor
◦ Meningitis ◦ Optic acuity problem in one eye
◦ Tics

Pore-encephaly (brain space not connected to the out

surface)
Schezo-encephaly (brain space connected with the out
surface)
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 Cafe au lait
Phenytoin side effects ◦ Albright
◦ Hypocalcemia ◦ Bloom
◦ Hypothyroidism ◦ Neurofibromatosis
◦ Vit B9 deficiency ◦ Anemic Fanconi
◦ Folic acid dif.
◦ Hirsutism
◦ Nystagmus Pseudo tumor cerebri
◦ Cerebellar atrophy ◦ Steroid OCP
◦ Megaloblastic anemia ◦ TETRACYCLINES
◦ Duptreyn contracture ◦ retinoids
◦ Osteomalacia ◦ Severe iron dif. Anemia
◦ Dark discoloration of skin ◦ Hyper-vitaminosis A

Migraine can cause nonspecific spots on MRI

Parkinson plus syndrome
◦ include multiple system atrophy (MSA), progressive
supranuclear palsy (PSP), and cortico-basal
Omega 3 is given for hyper triglycerides degeneration (CBD). Dementia with Lewy bodies (DLB)

Cardinal features of Parkinson

◦ Rest tremor
McCune–Albright syndrome is a complex genetic ◦ Rigidity
disorder affecting the bone, skin and endocrine ◦ Ataxia
systems. It is a mosaic disease arising from somatic ◦ Bradykinesia
activating mutations in GNAS, which encodes the alpha-
subunit of the Gs G protein-coupled receptor. These Hyperkinesis causing drugs
mutations lead to constitutive receptor activation. ◦ Metoclopramide
◦ Neuroleptic
◦ Dopamine

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Tar-dive dyskinesia in Parkinson due to L dopa • Retinal Vein Occlusion (RVO)
• Rheumatoid Arthritis
Earliest sign of Parkinson is loss of arm swing • Transient Ischemic Attack

Non-motor manifestation of Parkinson

◦ Constipation Lewy body dementia, don’t use L dopa
◦ Cognition
◦ Psychosis Man in barrel syndrome (water shed zone infarction),
◦ Dementia move the legs but not arms
◦ Behavioral changes
◦ Depression
◦ Hallucinations Neuroleptic syndrome
◦ Withdrawal of antipsychotic or anti Parkinson
◦ Fever
Oxygen complication ◦ Board like rigidity
◦ Retinopathy (more in newborn)
◦ Provocative for seizure Miller fisher syndrome (atypical Guillain barre)
◦ Bilateral facial palsy
◦ Ophthalmoplegia
Ddx of temporal arteritis ◦ Ataxia
• Acute Angle-Closure Glaucoma in Emergency
Medicine
• Granulomatosis with Polyangiitis (Wegener Ck usually is elevated after convulsions
Granulomatosis) And prolactin also in the first 40 mins
• Herpes Zoster
• Iritis and Uveitis Drug of choice in temporal epilepsy is carbamazepine
• Migraine Headache
• Non-arteritic ischemic optic neuropathy Most common epilepsy in children is generalized
• Persistent Idiopathic Facial Pain
• Polymyalgia Rheumatica Most common epilepsy in adults is complex partial
• Postherpetic Neuralgia seizure
• Retinal Artery Occlusion (RAO)
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Topiramate is an anti-epileptic that can cause renal ◦ Membrane stabilizers
stone ◦ Naloxone

Vigabatrin in an anti-epileptic drug that cause decrease

visual acuity Phenytoin
◦ is given with normal saline (not with glucose
Side effects of sodium valproate because it precipitates)
◦ Weight gain ◦ Ph is 10-12.4
◦ Alopecia ◦ Rate is no more than 50ml/min because it
◦ CYP 450 inducer can cause hypotension and arrhythmia
◦ Teratogenic
◦ Osteoporosis (heparin also do) Contraindications for osmotic diuresis
◦ Diabetes insipidus
◦ Any hypertonic state
oligodendroglioma is the most epileptogenic tumor

Meningioma Primary vs secondary polycythemia

◦ Can be benign or malignant ◦ Erythropoietin high in secondary
◦ More common women ◦ Itching in primary
◦ More common after 50 years old ◦ Genetic study (JAK 2. Mutation in primary)
◦ Bone marrow
Consciousness is not confusion ◦ Hb

Alpha lipoic acid Styloid process pressure

◦ Universal antioxidant ◦ Should show decorticating or deceleration
◦ Acts intracellular and extracellular
NG tube complications
Other antioxidants ◦ Stenosis
◦ Steroid ◦ Infection
◦ Albumin ◦ Necrosis
◦ Vit. E ◦ Iatrogenic injury
◦ Vit. C ◦ Aspiration
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Down syndrome Beta-Lipsey, loss of consciousness after coughing
◦ Whiplash trauma increase risk of
subluxation (like rheumatoid arthritis) Abdominal epilepsy,
◦ Abdominal pain
Absence status epileptic-us ◦ Loss of consciousness
◦ Clinically starring
◦ EEG Gelastic epilepsy, laughing followed by convulsions
epilepsy

Side effect of benzodiazepines Klifner Lindau syndrome (the child normally talks and
◦ Hypnotic then regress)
◦ Hypotension
◦ Respiratory depression Atony seizure Ddx
◦ Drop attack
Diazepam highest dose is 100mg/day ◦ Syncope

Catamenial epilepsy is menstruation induced epilepsy

(clobazam is drug of choice) Catamenial migraine
◦ Give acetazolamide (diuretic and anti-
In pregnancy epileptic)
◦ We give folic acid 5mg/day before three
months Benzodiazepines have high risk to have withdrawal
◦ If the patient is stable on a medication don’t status epilepticus
change the drug despite the side effect
We give anti-epileptic drug if
Sudden death is common in epilepsy usually in sleeping ◦ (more than two unprovoked episodes in a
short period)
Furosemide can cause sudden cardiac arrest ◦ Family history and one attack
◦ EEG finding and one attack
Epilesia partialis continua, more than one day status
epilepsy
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Serial epilepsy Myotonic dystrophy:
◦ Usually in drug toxicity • baldness
◦ Up to 24 hours • ptosis
• unable to release their grip immediately on
command after shaking hands
Coma cocktail is treatment of coma of unknown etiology • drop foot
◦ Thiamine (100 mg) • DM
◦ Dextrose (50% and 50 ml) • cardiomyopathy
◦ Naloxone • infertility
◦ Calcium gluconate (to protect the heart)
CIS "clinically isolated syndrome"
Pinpoint pupil and coma RIS "radiologically isolated syndrome"
◦ Opioid toxicity
◦ Anti cholinergic toxicity Status migrainus (more than 48 hours)

Coin shaped headache "Numnular headache"

CP types:
• histocytosis
• Dyskinetic 6%
• skull lesion
• Ataxic 6%
• spastic (70-80%) (most common)
• Mixed Pickwicki syndrome "short neck syndrome"
Involvement in CP: Post-stroke seizure AEs choice (avoid atherogenic
• paraparesis/plesia drugs "carbamazepine”, use valproate and lamotrigine)
• quadriparesis/plesia
• monoparesis/plesia Drug over use headache "over use analgesics"
• diparesis/plesia (upper and lower affected but
lower more than upper) Histaminic headache = cluster = Horton's syndrome
• triparesis/plesia
Familial hemiplegic migraine "due to inherited
channelopathy"
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Familial ophthalmoplegic migraine "due to inherited ◦ Compression usually affects external fibers
channelopathy" first (autonomic function)
◦ Medical affects internal fibers (motor) first
Basilar migraine (cranial nerves symptoms, autonomic
dysfunction and sensory and motor deficiencies prior to Cushing triad
headache) ◦ Tachycardia
◦ Hypertension (systolic)
if two or more attacks per month use preventive ◦ Bradypnea
treatment for migraine
Normal pressure hydrocephalus diagnosis
If obese with migraine give topiramate (helps to reduce ◦ Lumber puncture (therapeutic and
weight) diagnostic)
◦ Pressure less than 18 water column
Avoid in migraine: Foods "tyramine containing products" ◦ Clinically
(smoking, smoked food, chocolate, cheese, others)
Pseudotumor cerebri
Catamenial migraine "menses migraine" ◦ CT (slit ventricle)
• acetazolamide ◦ Papilledema
• prevention for migraine ◦ Headache
◦ Lumber puncture diagnostic (pressure more
Status migrainus cause ischemia and infarction (due to than 25 water column)
vasospasm) ◦ Avoid vit. A
• Good hydration
• Steroids Drugs to avoid in MG
• Aspirin (up to 1g) ◦ Penicillamine
• prevention therapy ◦ Beta blockers
◦ CCB
Surgical vs. medical third nerve palsy ◦ quinolone
◦ Surgical is due to compression ◦ Macrolide
◦ Medical is due to medical disease like DM ◦ Local anesthesia
◦ Quinine
◦ Botulinum toxin
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 ◦ Drop foot
Blood viscosity to water viscosity is 5 to 1 ◦ Testicular atrophy
◦ Cardiomyopathy
◦ Diabetes mellitus
Post dialysis encephalopathy
◦ In the past due to aluminum use
◦ Now

In MG if we gave steroid (paradoxical effect occurs at

first week)

Ddx of MG
◦ Ophthalmoplegia
◦ Guillain barre
◦ Transverse myelitis
◦ Brain stem injury
◦ Organophosphate toxicity
◦ Myopathies

Hashimoto encephalopathy

Drugs induced myopathy

◦ Statins (after six months) (enzymes back to
normal after two months)
◦ Steroid

Myotonic MD
◦ Baldness
◦ Ptosis
◦ Mastication muscle atrophy
◦ Temporal muscle wasting
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