UWORLD Neurology Step 2 CK

Lacunar syndromes

Cause

#1 Hypertension

Pure Motor Hemiparesis

@ Posterior Limb of Internal Capsule

Unilateral Motor Deficit
Mild Dysarthria 

Infarct @ Posterior Limb of Internal Capsule

Pure Motor Hemiparesis

Unilateral Motor Deficit
Mild Dysarthria 

Pure Sensory Stroke

@ Ventroposterolateral Nucleus (VPN) of the Thalamus

Unilateral numbness, paresthesia
Hemisensory deficit—face, arm, trunk, leg

Infarct @ Ventroposterolateral Nucleus (VPN) of the Thalamus

Pure Sensory Stroke

Unilateral numbness, paresthesia
Hemisensory deficit—face, arm, trunk, leg

Ataxic-Hemiparesis

@ Anterior Limb of the Internal Capsule

Weakness more prominent in LOWER extremity
Ipsi-lateral arm and leg incoordination

Infarct @ Anterior Limb of the Internal Capsule

Ataxic-Hemiparesis

Weakness more prominent in LOWER extremity
Ipsi-lateral arm and leg incoordination

Essential Tremor

PX

bilateral action Tremor of the hands—⦸ leg involvement

Relieved by alcohol

Essential Tremor

TX

Propanolol

Primidone—Barbiturate

Parkinson's disease

Resting tremor (4-6 Hx)—@ legs & hands

improves—voluntary movement

___ is currently approved for use in pts with ALS.

Riluzole

- glutamate inhibitor

First line treatment for idiopathic intracranial HTN.

Acetazolamide (inhibits choroid plexus carbonic anhydrase) +/- furosemide

- optic nerve sheath decompression or LP shunting is recommended for pts refractory to medical tx

___ are benign suprasellar tumors that presents with visual defect, HA, and symptoms of pituitary hormonal deficiencies.

Craniopharyngiomas

- Rathke's pouch common children, but can presents in adults

- confirm MRI/ CT scan

- Tx: Sx or radiotherapy

MMSE score of less than ___ is suggestive of dementia (total maximum is 30).

24 points

- Neuro imaging shows atrophy which is more prominent in the temporal and parietal lobes

Myasthenia Gravis

TX

1. Acetylcholinesterase inhibitors (anticholinesterases) - Pyridostigmine or neostigmine

- SE: abd cramps, fasciculations, muscular weakness

2. Immunosuppressive agents

- prednisone, azathioprine, cyclosporine

3. Thymectomy

__ is a prokinetic agent used to tx N/V, gastroparesis. Pts taking this med should be monitored closely for the development of drug-induced extrapyramidal symptoms.

Metoclopramide

= dopamine receptor antagonist

- tx nausea/vomiting/gastroparesis

- SE: agitation, loose stools, tardive dyskinesia, dystonic rxns, parkinsonism

tx dystonic rxn: Benztropine or Diphenhydramine

Subdural hematoma are common in ___.

Older patients

Alcoholics due to brain atrophy + vessel fragility

Blunt or shearing trauma tears bridging veins, causing them to bleed into the subdural space

Brain death characteristic findings.

Absent cortical and brain stem functions

Spinal cord may still function, DTR may be present

Site of hemorrhage

Hemorrhage
@ Basal Ganglia

CONTRA-lateral Hemiparesis & Hemisensory loss

Homonoymous hemianopsia

Hemorrhage

@ Cerebellum

Facial weakness

Ataxia & Nystagmus

Occipital Headache & Neck Stiffness

Hemorrhage

@ Thalamus

CONTRA-lateral hemiparesis & Hemisensory loss

Miotic pupils, non-reactive

Upgaze palsy

Eyes deviate TOWARD hemiparesis

Hemorrhage

@ Cerebral Lobe

Eyes deviate AWAY from hemiparesis

↑ incidence of seizures

CONTRA-lateral hemiparesis—Frontal Lobe

CONTRA-lateral hemisensory loss—Parietal Lobe

Homonymous Hemaninopsia—Occipital Lobe

Hemorrhage

@ Pons

Deep Coma

Total paralysis w/in minutes

Pinpoint, reactive pupils

B/L action tremor of the hands, usually w/o leg involvement.

Isolated head tremor w/o dystonia.

No other neuro signs.

Essential tremor

- relieved with alcohol

- Propranolol (useful also if pt has coexisting HTN)

- second line: primidone, topiramate

Parkinson's disease

Resting tremor (4-6 Hz) that decreases with voluntary movement.

Involves legs & hands.

Facial involvement less common.

A few hours or days after mild TBI pt has HA, confusion, amnesia, difficulty concentrating, vertigo, mood alteration, sleep disturbance, and anxiety. Dx.

Postconcussive syndrome

- resolve weeks to up to 6 months or more

Risk factors for Alzheimers dementia.

Age

Female gender

Positive family history

Head trauma

Down's syndrome

Dementia with Lewy bodies (DLB)

Fluctuating cognitive impairment and bizarre, visual hallucinations.

Vascular dementia

Stepwise decline

Early executive dysfunction

Cerebral infarction & or deep white matter changes on neuroimaging

Frontotemporal dementia

Early personality changes

Apathy, disinhibition & compulsive behavior

Which dementia?

Normal pressure hydrocephalus

Ataxia early in the disease

Urinary incontinence

Dilated ventricles on neuroimaging

Causes of chemotherapy-induced peripheral neuropathy (CIPN)?

Vinca alkaloid (vincristine)

Platinum based meds (cisplatin)

Texanes (paclitaxel)

Weeks after tx, symmetrical paresthesias in stocking-glove pattern, loss ankle jerk reflex and loss P and T sensation

Gradual worsening severe low back pain

Pain worse in the recumbent position/at night

Early signs: symmetric LE weakness, hypoactive, absent DTR

Late signs: B/L Babinski reflex, DEC rectal tone, paraparesis/paraplegia with INC DTR, sensory loss.

Spinal cord compression

- injury (MVA)

- malignancy (lung, breast, prostate cancer, myeloma)

- infection (epidural abscess)

Sensory ataxia

Lancinating pains

Neurogenic urinary incontinence

Associated with Argyll Robertson pupil.

Tabes dorsalis

- INC incidence syphilis in men who have sex with men & HIV infected patients

- Treponema pallidum spirochetes directly damage the dorsal sensory roots

Enlargement of blind spot with momentary vision loss that varies according to changes in head positioning.

Can lead to rapid permanent vision loss and requires urgent dx evaluation.

Papilledema

- INC ICP transmitted to the optic nerve sheath, swelling of the optic nerve head

- HA worse in the morning due to INC ICP

Young age, obesity, due to idiopathic intracranial HTN (pseudo tumor cerebri)

Next step get CT/MRI to exclude underlying mass lesion

Meds used for Parkinson's disease that can lead to anticholinergic excess.

Trihexyphenidyl, Benztropine

- flushing, anhidrosis/dry mouth, hyperthermia, mydriasis/vision changes, delirium/confusion, urinary retention/constipation

Progressive proximal muscle weakness & atrophy w/o pain or tenderness.

LE muscles are more involved.

ESR and CK normal.

Dx the myopathy.

Glucocorticoid induced myopathy

Muscle pain & stiffness in the shoulder and pelvic girdles.

Tenderness with DEC ROM at shoulder, neck and hip.

Responds rapidly to glucocorticoids.

INC ESR, normal CK

Dx the myopathy.

Polymyalgia rheumatica

Muscle pain, tenderness & proximal muscle weakness

Skin rash and inflammatory arthritis may be present

ESR and CK INC

Dx the myopathy.

Inflammatory myopathy

Prominent muscle pain/tenderness w/ or w/o weakness

Rare rhabdomyolysis

Normal ESR, CK INC

Dx. the myopathy.

Statin-induced myopathy

Muscle pain, cramps, weakness in the proximal muscles, delayed DTR and myoedema

Occasional rhabdo

ESR normal, CK INC

Dx. the myopathy.

Hypothyroid myopathy

Clinical presentation:

- HA

- Focal neuro deficit

- Solitary ring-enhancing lesion on brain CT scan

- Fluid collection in the ethmoid sinus

Dx.

Brain abscess 2/2 ethmoid sinusitis

- Head and neck infections: Viridans streptococcus (most common) and other anaerobic (prevotella, bacteroides)

- distant infections lung or endocarditis (staph aureus)

tx: surgical draining and aspiration, prolonged abx therapy (4-8 weeks)

Dx:

- HA (worse at night)

- N/V

- Mental status changes

- Papilledema

- Focal neuro deficits

Cushing reflex.

Intracranial HTN

- Cushing reflex (HTN, bradycardia, respiratory depression) worrisome finding for brainstem compression

What is the monotherapy for acute migraine attacks, patients with N/V?

IV antiemetics (chlorpromazine, prochlorperazine, metoclopramide)

CSF in Guillain-Barre syndrome.

CSF shows high protein with normal WBC (albuminocytologic dissociation)

INC permeability blood-nerve-barrier

Tx: IVIG or plasmapheresis

Bacterial Meningitis

CSF

↑↑ WBC

↓ Glucose

↑ Protein

Tuberculosis Meningitis

CSF

↑ WBC

↓↓ Glucose

↑ Protein

Viral Meningitis

CSF

↑ WBC

Glucose normal

Guillain-Barre

CSF

WBC normal

Glucose normal

↑ Protein

Complications post Subarachnoid hemorrhage.

- Rebreeding (first 24 hours)

- Vasospasm (after 3 days - CT angiography detects vasospasm and prevented with Nimodipine)

- Hydrocephalus/INC ICP

- Seizures

- Hyponatremia (usually from SIADH)

Recurrent, brief episodes brought on by predictable head movts or position change

No neuro or auditory symptoms

Dix-Hallpike maneuver causes nystagmus.

BPPV

- crystalline deposits (canaliths) in the semicircular canals that disrupt the flow of fluid in the vestibular system

- canalith repositioning maneuver (Epley maneuver)

Meniere's disease/syndrome

Recurrent episodes of vertigo

Preceded by ear fullness/pain

Unilateral hearing loss & tinnitus

Vestibular neuritis

Usually due to viral syndrome

Acute onset of single episode that can last days

Severe vertigo but no hearing loss, patient falls down toward side of lesion

Abnormal head thrust test.

Once confirmed the dx of myasthenia gravis what test should be ordered next?

CT chest look for thymoma if pt is younger than 60

Diabetic mononeuropathy often involved CN ___. Nerve damage is often ___, and only somatic nerve fibers are affected.

CN III

- Ischemic

- Parasympathetic fibers retain function

- ptosis + down and out gaze

___ DEC the risk of embolic events in pts with native valve infective endocarditis.

IV abx

- Sx is considered in pts with significant valve dysfunction, persistent/difficult to treat infection, or recurrent embolism

What is the most important risk factor for stroke?

HTN—4x the risk

Treatment of restless leg syndrome.

Mild/intermittent sxs:

- Supplementation iron when serum ferritin < 75

- use supportive measures (leg massage, heating pads, exercise)

- avoid aggravating factors (sleep deprivation, meds)

Persistent/moderate severe sxs:

First line: Dopamine agonists (pramipexole)

Alternate: Alpha-2-delta calcium channel ligands (gabapentin enacarbil)

The majority of embolic stories are due to ___ that develop 2/2 to ___.

Mural thrombi

A. fib

* Pts with infective endocarditis can form septic emboli when parts of valvular vegetations break off and travel to the brain

___ is commonly associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of lesion with loss of pain and temperature on both sides below the lesion.

Anterior cord syndrome

- MRI

- intact proprioception

When a patient has pronator drift, this finding is relatively sensitive and specific for ___ disease.

UMN disease

- weakness in supination causing the pronator muscles to be dominant

Sxs of cerebellar dysfunction.

Common among chronic alcohol abusers

- gait instability

- truncal ataxia

- difficulty with rapid alternating movements

- hypotonia

- intentional tremor

Hemorrhages are seen as [hyper/hypo]dense areas on CT scan, while infarcts are [hyper/hypo]dense parenchymal areas on CT scan.

Hemorrhages = Hyperdense

Infarctions = Hypodense

Suspect ___ in a young female with bilateral trigeminal neuralgia.

Multiple Sclerosis

CT scan of ___ shows numerous minute punctate hemorrhages with blurring of grey-white interface.

Diffuse axonal injury

- most significant cause of morbidity in patients with TBI

- traumatic deceleration

What is the gold standard in dx herpes encephalitis?

PCR analysis of HSV DNA in CSF (highly sensitive and specific)

___ may result from hyperextension injuries, particularly in elderly patients with spondylosis.

Central cord syndrome

- weakness in the UE

- localized deficit in pain and T sensation

Delirium

Risk Factors

• Dementia

• Parkinson’s Disease

• Prior Stroke

• Adv. Age

  • Sensory Impairment

Delirium

Precipitating Factors

• Drugs—Narcotics, Sedatives, Antihistamines, Muscle Relaxers, Polypharmacy

• Infections—Pneumonia, UTI, Meninigitis

• Electrolytes—Hyponatremia, Hypercalcemia

• Metabolic—Volume depletion, Vit. B12 deficiency, Malignancy

• Systemic Illness—CHF, Hepatic Failure, Malignancy

• Central Nervous System—Seizure, Stroke, Head Injury, Subdural Hematoma

The treatment of choice for agitation in the elderly is ___.

Low-dose haloperidol

Ischemic Stroke—TX

< 4.5 hours after onset

IV Alteplase

Ischemic Stroke—TX

⦸ prior Anti-platelet therapy

Aspirin

Ischemic Stroke—TX

pt. on Aspirin therapy

Aspirin + Clopidogrel

Recommended prophylactic meds for cluster HA.

Verapamil

Lithium

Ergotamine

Hemi-sensory loss of severe dysesthesia of the affected area is typical for a ___ stroke.

Thalamic (Dejerine-Roussy syndrome)

- stroke in the VPL nucleus

- CL hemianesthesia, transient hemiparesis, athetosis, or ballistic movements

- dysesthesia in the sensory loss, thalamic pain phenomenon

Normal pressure hydrocephalus thought to result from ____.

DEC CSF absorption or transient INC in ICP that cause permanent ventricular enlargement w/o chronically INC ICP

Dementia, gait disturbance, and urinary incontinence

Lumbar spine stenosis is most commonly caused by ___.

Degenerative joint disease (DJD)

- pain relief flexion of the spine

- spinal MRI

Causes of pseudotumor cerebri.

Glucocorticoids

Vitamin A

OCPs

causes by impaired absorption of CSF by the arachnoid villi

tx: wt reduction and acetazolamide, shunting or optic n. sheath fenestration may be performed to prevent blindness

Lewy body dementia

___ is characterized by fluctuating cognitive impairment, recurrent visual hallucinations, and motor features of Parkinsonism.

primary CNS lymphoma

Suspect ___ in an HIV-infected patient with an AMS, EBV DNA in CSF, and solitary, weakly ring-enhancing periventricular mass on MRI.

Myasthenic Crisis

Precipitating Factors

• Infection or Surgery

• Pregnancy or Childbirth

• Tapering Immunosuppressive drugs

• Drugs—Aminoglycosides, Beta-blockers

Myasthenic Crisis

TX

• Intubation for deteriorating respiratory status

• Plasmapheresis or IVIG

• Corticosteroids 

Suspect neurofibromatosis type II in a young patient with acoustic neuroma and multiple cafe-au-lait spots. Best dx method for acoustic neuroma.

MRI with gadolinium

- acoustic neuroma (gradual developing tinnitus and hearing loss)

Wallenberg Syndrome

PX

Vertigo

⦸ pain & temperature—IPSI-lateal Face, CONTRA-lateral trunk & limbs

Hoarseness

IPSI-lateral Horner’s Syndrome

Lacunar Stroke

Risk Factors

#1 Hypertension

• Diabetes Mellitus

• Adv. Age

• ↑ LDL

• Smoking

Ascending Paresthesia

Paresthesia @ Hands & Feet

Guillain-Barre Syndrome

Cluster Headache

PX

Recurrent episodes lasting 15-90 mins.
Periorbital pain, Severe

ANS—Lacrimation, Ptosis, Rhinorrhea

Cluster Headache

TX

100% Oxygen

Intracranial HTN

PX

• Headache, N/V

• Pulsatile tinnitus

• Retrobulbar, Neck, or Back pain

• Vision changes

Intracranial HTN

DX

1. CT scan of Head—If normal

2. Lumbar Puncture—↑ opening pressure

Intracranial Hypertension

Risk Factors

• Women of childbearing age

• Recent weight gain/obesity

• Medications

  • Retinoids/vitamin A

  • Tetracyclines

  • Growth hormone

Intracranial Hypertension

TX

• Weight Loss

• Acetazolamide, Topiramate

  • Carbonic anhydrase inhibitor

Cryptococcal Meningitis

TX

3 successive phases

• 1. Induction Therapy

  • liposomal Amphotericin B + Flucytosine

  • given for ≥2 weeks until acute symptoms resolve and/or cerebrospinal fluid becomes sterile

• 2. Consolidation therapy

  • high-dose oral Fluconazole

  • given for ≥8 weeks

  • prevent disease relapse

1. Maintenance therapy

   1. low-dose oral Fluconazole

   2. Given:

      1. Indefinitely

      2. until CD4 counts rise to >100/mm³ for >3 months on antiretroviral therapy (ART)

Pituitary Apoplexy

PX

• Thunderclap Headache

• Menstrual irregulaties

• bilateral visual field defects—optic chiasm

• Ophthalmoplegia—impaired right eye adduction consistent with oculomotor nerve [CN III] compromise

Pituitary Apoplexy

TX

• Glucocorticoids

  • Replace ACTH loss with anterior pituitary hormone loss

Sign most indicative of a Seizure?

Tongue Biting

Brain MRI

Indications

Red Flag symptoms

• Focal weakness

• Bowel dysfunction

• Bladder dysfunction

• Fever

Brain CT

⦸ red flags

• Focal weakness

• Bowel dysfunction

• Bladder dysfunction

• Fever