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Neurology
Neurology
Neurology
Cluster headache
AN manifestations: Ptosis; lacrimation; pupillary changes; nasal congestion
Tx: 100% O2 most rapid; Sc sumatriptans for attacks; Prophylaxis: Verapamil, Lithium
Postconcussive Syndrome
TBI of any severity can lead to this a few hrs to days after insult
Typically resolves with symptomatic tx however some pts have persistent sx >6 months
Trigeminal Neuralgia
MS association
Tx: carbamazepine
Follows TBIs
Episodes last up to 20-30 mins and triggered by external stimuli (bathing, repositioning)
Tx: Supportive (avoid triggers, tx fever); opioids (reduce sym tone), GABA agonists, alpha 2 agonists
Oculomotor N Palsy
Parasym fibres run on outside: peripheral —-> compression —> affects pupillary action
Motor fibres run in centre —> droopy eye —> susceptible to ishaemia and compression
Non pupil sparing CN III Palsy -> dilated -> Check for intracranial aneurysm: MR/CT Angiography
-> Posterior Communicating A Aneurysm
Pupil sparing CN III Palsy -> Micro vascular ischemia: DM; HTN;
Uncontrolled infection of skin, sinuses and orbit can spread to cavernous sinus
Life threatening
Low grade fever w bilateral periorbital edema —-> d/t impaired venous flow in orbital veins
CNs 3-6 pass through cavernous sinus which has anastomoses crossing midline
Dx: MRI
Immunocompromised
Seizures
Management:
Gradual onset
Usually benign
Nystagmus intense
No effect on hearing
MENIERE DISEASE: Triad of Vertigo, Tinnitus and sensineural hearing loss (can become permanent)
Self limiting
Vertebrobasilar Insufficiency
Vertebral A Dissection
Loss of pain and temp in ipsilat face (spinal trigeminal tract) and contralat trunk/limbs (spinothalmic)
Counterpressure techniques for recurrent episodes during prodrome phase eg handgrip with
Post micturition syncope type of vasovagal Also defecation, cough etc act as triggers
—->> exaggerated vagal response d/t tactile stimulus of carotid sinus whilst standing
Triggers: Lack of sleep; flashing lights; emotional stress; alcohol withdrawal; idiopathic
Clinical clues:
Pt transiently unresponsive post seizure —> delayed return to baseline (cf immediate)
S U C cAl
Seizures
Nonconvulsive
Generalized convulsive status epilepticus (GCSE): >20 mins w/o return to baseline; seizure >5 min
Anti Epileptic Drugs: Levetiracetam (lowest side effects; focal seizures)/Valproic acid/Lamotragine
Can reduce efficacy of OCPs —-> Vit K Def in newborn (give mother Vit K)
—> also cause decreased folic acid —> supplement all patients
LT Px poor
Febrile Seizure
Parkinson Disease
Loss of dopaminergic neurons from substantia nigra and locus ceruleus (midbrain)
Dx is clinical
Carbidopa-levodopa
Dopamine R Agonist
Amantadine (antiviral)
Anticholinergics: Trihexyphenidyl and Benztropine (good for tremor, avoid in elderly/demented pts)
Opthalmoplegia (cannot look down) —> upward gaze may also be affected
Swallowing issue
Tx: Dopamine blockers for psychosis and chorea (tetrabenazine), antidepressants etc
Myoclonus (usually arm) —> startle myoclonus: jerk elicited w loud auditory stimulus
Triphasic bursts
Dx: CT/MRI shows hydrocephalus; Spinal tap shows normal opening pressure
—> allows confirmation of norm opening P and gait testing (improves post LP)
Tremor
Decreased w distraction
AD in up to 1/3 pts
Ataxia
Ataxia, nystagmus, impaired vibratory sense and proprioception, pes cavus, hammer toes
Ataxia Telangiectasia:
AR: 4A’S: ATM gene, Ataxia (<2 yrs old), spider Angiomata, IgA deficiency
Nystagmus, strabismus
Tourette Syndrome:
Alcoholism
Acute Withdrawals
Up to 48 hrs —->> Tonic Clonic Seizures, HTN, Tachy, and high Temp
Alcohol metabolised by zero order kinetics (amount of drug not %): 25mg/hr metabolised
Can mimic cocaine: Diaphoresis; high BP etc —-> look for HYPERREFLEXIA
Less specific: elevated GGT and AST more than twice ALT
Alcoholic Neuropathy: Symmetric distal polyneuropathy (stocking and glove) —>> parathesias
Gait ataxia
Dementia.
Nucleus basalis (basal nucleus of Meynert) is cholinergic
Mini mental state exam does not improve with prompting -> memory affected FIRST
Tx: Ach ersterase I: Donepezil, rivastigmine, galantamine (also used in Lewy body dementia)
Vit E may slow progression. Tacrine (Ach esterase I and Ach agonist)
Lobar atrophy
Alpha synuclein (Lewy body) in brainstem (S nigra); limbic system and neocortex
Objective neurological deficits: hemiparesis, pronator drift, Romberg sign —->> ischemic stroke
Tx: AchI
Delirium:
Sundowning
Brain death:
Vegetative state: eyes open, may have random head or limb movements
Brainstem reflexes:
Dorsal column problems: pressure, vibration, discriminative touch, and proprioceptive sensation
Neuropsych issues
Gabapentin first line for sensory sx management, SNRIs (duloxetine, venlafaxine), TCAs
UMN Signs:
LMN Signs:
Neuromyelitis Optica
CNS Inflamm and demyelination disorder that predominantly affects the optic N and spinal cord
Dx: MRI: hyperintensities involving >3 vertebral segments and optic nerves
LT immunosuppression
Syringomyelia
Central cavitation of cervical sore d/t abnormal collection of fluid within spinal parenchyma
Dx: MRI
Syrinx: Pocket of CSF in cervical spinal cord that stretches and puts pressure on the neurons
Obstructive hydrocephalus
Type 1 v v minimal
Spinal cord hemisection, usually at cervical levels (where spinal cord enlarges)
Horner Syndrome
Ant horn cells and motor neurons of spinal cord and brainstem
Normal Sensation
No Tx (vaccination)
Werdnig Hoffman
Normal: Bowel and bladder control, Sensation, Cognition, Extraocular muscles, Sexual Function
—> decreased max insp P + decreased max exp P d/t abdo strength decrease
Damage to cervical spine nerve roots: neck pain that radiates to shoulders/arms
LMN signs in upper extremities (at level of lesion) —> clumsy hands
Dx: MRI
Bilateral hemiparesis/weakness
Intact proprioception, vibratory sensation and light touch (dorsal columns fed by post spinal arteries)
Positive straight leg test: nerve root irritation/entrapment ——> ridiculopathy eg sciatica
Decreased sensation and motor function in arms and relative sparing of legs
Lumbar Stenosis
Facet joint arthropathy and osteophyte formation follow as does hypertrophy of lig flavum
Worsened by walking, standing, certain postures and eased on sitting/lying, flexing at waist
Sx generally bilateral
Most common origin are infections of skin and soft tissues or epidural
Triad: Fever, Spinal Pain, Neurological Deficits -> Fever absent in 50%
Dx: MRI w contrast ——> ring enhancing lesion!
Lab studies may be norm but ESR raised
Nerve root pain (shooting/electric shock like) in distribution of affected root followed by
Transverse Myelitis
Bilateral sensory dysfunction -> Distinct sensory level (lowest level with intact sensation)
Dx: MRI (with gadolinium for spine): T2 hyperintensity of spinal cord w/o compressive lesion
Homonymous Pie-In-The-Sky
Third nerve palsy: Down n Out d/t sole activation of lateral rectus by CN6+sup oblique (CN4)
False localising sign (Kernohan’s notch) d/t compression of contralat cerebral crus
Midbrain compression ==> contralateral extensor posturing; coma and resp compromise
Downward herniation can stretch branches of the basilar artery -> Duret hemorrhage -> fatal.
Paralysis of upward eye movement giving the characteristic appearance of "sunset eyes".
Paraneoplastic antibodies
Lead poisoning
Early symptoms nonspecific: depression, abdo pain, nausea, diarrhea, constipation and muscle pain.
PANDAS
Sydenham chorea is a movement disorder characterised by chorea, emotional lability, and hypotonia.
Lambert Eaton
Dry mouth often initial complaint as well as erectile dysfunction, blurred vision and constipation
S3-5
Autonomic dysreflexia
Noxious stimulus below lesion eg urinary retention, constipation, pressure ulcer, tight clothes
Above lesion: Parasym response in tact -> bradycardia and vasodilation (facial flushing)
Antihypertensives
Stroke:
Partial Horner Syn d/t distension of sym fibres travelling along carotid
Paradoxical: Emboli from clots in peripheral veins pass through septal defects to reach brain
Aspirin otherwise
Ataxic Hemiparesis
Tx: Thrombolysis within 3 hours (risk of haemorrhage, do not give aspirin first 24hrs)
Seizures
Hemorrhagic Transformation:
Within 48 hrs
Especially when stroke affects large area, d/t embolism or has been tx with thrombolytics
R Parietal: Hemineglect
Blood flows retrograde down LEFT vertebral artery to supply distal subclavian (decreased cerebral
blood flow): BP in LEFT ARM <BP in RIGHT ARM
Magnetic resonance ARTERIOGRAM definitive test for stenosis of vessels of head and neck and for
aneurysms (cerebral)
Homonymous hemianopsia
Complications:
Uncal herniation
SAH
LP: Xanthochromia -> blood been in CSF for several hours ——> Used to exclude SAH if negative CT
——> >6 hr post onset
CSF contains lymphocytes
Carotid Doppler
Echo: Stasis/Thrombus
ECG: AF
Brain Tumour
OCP association
Headache suggestive of brain tumour but norm imaging and elevated CSF P
Neurological signs usually absent except for papilledema, visual field defects
Dx of exclusion
Unilateral lesion of the visual cortex causes vision loss of the contralateral visual field
Central area often spared because of redundant coverage of this area with the contral visual cortex
CN3
CN7
Lacrimation
Stapedius
Glossopharyngeal (CNIX)
Parotid gland
Swallowing
Vagus Nerve
Midline uvula
Swallowing
Multifocal plaques -> white matter (brain and spinal cord): T2 MRI
Pyramidal (UMN) and Cerebellar pathways, MLF, Optic nerve, Posterior columns
Ipsilateral medial rectus palsy on lateral gaze and horizontal nystagmus of abducting eye
Diplopia
DMARDS: Recombinant Inteferon beta and glatiramer acetate reduce relapse rate
Secondary-Progressive MS (SPMS).
May also occur in Hodgekin Disease, Lupus, after Surgery or after HIV seroconversion.
Dx: CSF——> albuminocytologic dissociation (norm WBC with high protein), normal glucose
Protect AIRWAY!!!!
CSF: albuminocytologic dissociation (norm WBC with high protein), normal glucose
Myasthenia Gravis
AutoAbs against nicotine Ach R of NMJ (Dx)
Crisis: Medical emergency -> Diaphragm and intercostal fatigue result in resp failure
Edrophonium (Tensilon) test: AchE I causes marked improvement but high false positive
Duchenes MD
No inflammation
Myotonic Dystrophy: AD
Neurocutaneous Disorders
NF Type 1 (Von Recklinghausen Disease); AD
Complications: Scoliosis, pheochromocytoma, optic nerve gliomas, renal artery stenosis and erosive
bony defects
NF2
Cafe au lait spots, neurofibromas (tho less common cf NF1) and juvenile cataracts
Tuberous Sclerosis
S hagreen patches
H eart rhabdomyosarcoma
L ung hamartomas
A ngiomyolipoma in kidney
Cognitive impairment, epilepsy and skin lesions (facial angiofibromas, adenoma sebaceum)
Tx Complications
Facial vascular nevi (Port Wine stain), typically trigeminal V1/2 distribution
Epilepsy and early onset glaucoma d/t capillary venous malformations in brain and eye (increased
ICP), and mental retardation
Tx of epilepsy mainstay of tx
AD, chromo 3
Cavernous hemangiomas of br
ain or brainstem
CNS hemangioblastomas (c
ommonly cerebellum and bil
ateral retinal ), ph
eochromocytoma