Neuro - Blueprint

postconcussive syndrome

having difficulty thinking, HA/dizzy/vomiting, irritability

→ refer to neuro

Transient Ischemic Attack (TIA) causes

• Cardioembolic sources: A-fib, subtherapeutic anticoagulation, thrombi

• Other: Sickle cell, atherosclerosis, stenotic vessels, antiphospholipid syndrome, thrombotic endocarditis

TIA dx*

NONCONTRAST CT of head

more sensitive = MRI

CT angiography

low risk TIA vs. High risk TIA

low risk: ABCD2 score < 4 = treat w/ just ASA

high risk: ABCD2 score > 4 = dual antplt therapy w/ ASA and clopidogrel

clopidogrel MOA

irreversibly blocks plt aggregation

ABCD2 score

Age ≥ 60 yrs, BP (systolic ≥140 or diastolic ≥90), Clinical features (unilateral weakness, +/- speech impairment), Duration of TIA ≥60 mins or less, DM

bells palsy cause

HSV

herpes zoster

swelling of CN VII

unilateral facial nerve paralysis, hyperacusis, taste disturbance unable to raise eyebrow

bells palsy

bells palsy complications

ramsay hunt syndrome

(watch external ear canal and face)

tx of bell’s palsy**

prednisone (steroid and antivirals in 3 days)

valacyclovir

subarachnoid hemorrhage cause

ruptured aneurysm (saccular or berry)

worst HA of life

subarachnoid hemorrhage dx*

initial: noncontrast CT (white on CT)

if unremarkable → lumbar puncture, CTA, 4 CSF tubes

main complication of subarachnoid hemorrhag

vasospasm

subarachnoid hemorrhage - tx

nimodipine (CCB, relaxes vessels)

supportive

definitive = surgical clipping or endovasc embolization

epidural hematoma

middle meningeal artery → rapid bleed

MC in adolescents = traffic collisions

convex shaped on CT

epidural and subdural hematoma tx*

hematoma evacuation

subdural hematoma risks

tearing of bridging veins slow bleed

RISKS: advancing age**, alcohol use**, traumatic brain injury, coagulopathy

crescent-shaped CONCAVE hematoma hypodensity = ??

subdural hematoma

hydrocephalus

Children → increased occipitofrontal circumference (macrocephaly)/ aberrant head shape, N/V, irritability, development delays

Urgent signs → bulging fontanels, papilledema, headache, altered mental state)

hydrocephalus dx

MRI/CT

hydrocephalus tx*

shunt to DEC CSF level

Cerebellum

balance and coordinatoin

best initial dx study for syncope*

EKG

CHESS​ (high risk criteria for syncope)

• CHF

• Hematocrit < 30%

• ECG abnormal

• SOB

• Systolic BP < 90 mm Hg

Malignancy or inflammatory condition + sudden-onset SOB + syncope

pulmonary embolism

Young female adult + abdominal pain + syncope

ectopic pregnancy

Older male adult + abdominal or flank pain + syncope

AAA

tension HA tx*

abortive = nsaids

preventative = tca

cluster HA tx

acute = 100% oxygen and triptans

prophylaxis = verapamil (CCB) or steroid

sudden unilateral electric shock-like pains in gums, cheek, chin, temporal forehead

trigeminal neuralgia

trigeminal neuralgia tx*

carbamazepine

migraine HA tx

• Abortive Rx: triptans, DHE, valproic acid, antiemetics, NSAIDs

  • Triptans, DHE: avoid in those with uncontrolled HTN or CV disease

• Prophylaxis: TCAs, beta-blockers, anticonvulsants (valproic acid, topiramate), CCBs

Secondary (metastatic) brain tumors

• MOST common cause of intracranial neoplasms

• MC metastasize from lung cancer, breast, melanoma, kidney cancer

brain tumor dx

MRI with contrast

reversible causes of dementia

depression, B12 deficiency, syphilis, hypothyroidism, NPH, drug use, intracranial mass

dementia

amyloid plaques and neurofibrillary tangles

short term memory loss

when to hospitalize delirium

highly agitated

tx for delirium

haloperidol

avoid benzos

Neonatal Meningitis age groups

• ≤ 1 month → E.coli, Group B Strep, Listeria meningitidis, gram neg bacilli

• 1 month to 3 months → Group B Streptococcus & gram negative bacilli

• 3 months to 10 years → Streptococcus pneumoniae

• ≥ 10 years old → Neisseria meningitidis

neonatal meningitis tx

cefotaxime and ampicillin

neisseria would need 3rd gen ceph + vanco

late onset → vanco, aminoglycoside, 3rd ceph or merepenem

bacterial meningitis adult sx

headache, neck stiffness, photophobia, phonophobia, fever

brudzinski sign

kernig sign

cause of bacterial meningitis

strep pneumo

listeria if young/elderly and alcohol

meningitis dx

cerebrospinal fluid culture

LP

bacterial meningitis tx

18-50 yo: ceftriaxone + vanco

penicillin G is abx of choice

>50: ceftriaxone + vanco + AMPICILLIN

postexposure abx = rifampin

essential tremor tx

propranolol

Guillain-Barré Syndrome cause*

campyloacter jejuni

symmetric PROGRESSIVE ASCENDING muscle weakness with lack of deep tendon reflexes =

GBS

GBS dx

lumbar puncture with INC CSF protein and normal cell count

albuminocytologic dissociation

GBS tx

supportive

Multiple sclerosis

optic neuritis (monocular vision loss), sensory abnormalities, lhermittes sign, bilateral opthalmoplegia, afferent pupillary defect

multiple sclerosis dx

MRI (white matter lesions)

CSF = oligoclonal igG bands

multiple sclerosis tx*

acute: methylprednisone + plasma exchange

relapsing remitting → disease modifying agents (-umab)

myasthenia gravis is associated with

thymoma**

myasthenia gravis

Autoantibodies to nicotinic acetylcholine receptors resulting in impaired transmission at the neuromuscular junction → progressive muscle weakness

MG sx

ocular/proximal muscle weakness, ptosis diplopia

tensilon test, serologic testing

MG tx*

acetylcholinesterase inhibitors (TOC: pyridostigmine)

complex regional pain syndrome

history of previous extremity injury, fracture, or surgery

light touch causes extreme pain (pain out of proportion to exam

Absence Seizures

Brief < 15 seconds of sudden impaired consciousness

To others their attention will seem “absent”

absence seizure dx

• EEG → 3 Hz spike and wave discharges

  • Hyperventilation for 3-5 minutes can precipitate the seizures

absence seizure tx*

ethosuximide

simple febrile seizure tx*

reassurance

antipyretics (tylenol/ibuproen)

complex febrile seizure tx*

benzos

monitor if weakness, cognitive deficit

Simple partial epilepsy (focal aware seizures)

seizure sx without loss of consciousness

EEG shows focal rhythmic discharge

TX IS THE MIGRAINE PROPHYLAXIS MEDS

focal seizure with NO impairment of consciousness

Simple partial seizures (IF IMPAIREMENT = COMPLEX)

Tonic clonic (aka grand mal) seizures TX

carbamazepine, phenobarbital, levetiracetam, phenytoin

Status Epilepticus

PE will show ≥ 5 minutes of continuous seizure activity OR more than one seizure without recovery

status epilepticus tx*

benzos (IV lorazepam diazepam) , if not available IM midazolam

2nd = Keppra

3rd = pentobarbital, propofol, midazolam

Turner Syndrome (45,X)

short, webbed neck, dwelayed 2ndary sex characteristics

karotype analysis = dx (45,x)

assoc with premature ovarian fialure, CoA, CV malforation

Most commonly caused by mutation in the fibrillin-1 (FBN1) gene

marfan syndrome (autosomal dominant)

marfan syndrome

pectic carinatum, ectopia lentis, scoliosis

monitor with echo

assoc with aorti canerusym and disection

anterior cerebral artery stroke

frontal lobe - bad insight and impaired judgement

LE more effected than UE

CT scan w/o contrast

middle cerebral artery stroke

significant motor and sensory loss on the opposite side of the lesion

more UE affected than LE

possible aphasia

posterior cerebral artery stroke

visual changes, nyastagmus, N/V

vertebral artery stroke

dizziness and diplopia

difficulty sitting up, nyastagmus, ipsilateral loss of pain and temp on face and contra in body

trigeminal nerualgia tx

cause by compression of cerebellar artery

→ craniotomy to decompress aberrant vascular structure

canadian CT head rule

if no signs of basilar skull fracture or dangerous mechanism → observe

if >65 → neuro intervention

when suspecting brain TUMOR, what dx

MRI with contrast

CT of the head w/o contrast is done for

skull fractures

trauma

most common sources of brain metastateses

1. lung cancer

2. melanoma

3. kidney cell cancer

4. breast cancer

5. colorectal cancer

migraine HA tx

abortive: acetaminophen, triptans

prophylaxis: BB, TCA, Va, anticonvulsants, ergot derivatives, tizanidine, occipital nerve blocks, botulinum toxin injection, and calcium channel blockers

A 28-year-old woman reports 3 months of worsening vision, noting blurred and diplopic abnormalities. She also has left leg and right arm weakness. Examination reveals extraocular palsies, poor visual acuity, nystagmus, left leg and right arm strength deficits, and a positive Romberg sign. A central inflammatory demyelinating disease process is suspected. Which of the following diagnostic studies and results would help to confirm a diagnosis?

MS → noncontrast MRI findings are multiple T2 hyperintensities found most commonly in the periventricular white matter

lesion of the left optic tract

dysfunction of the left nasal and right temporal visual fields = right homonymous hemianopia

ankylosing spondylitis tx*

#1: exercise and pt

#2: NSAIDS (celebrix or naproxen)

#2: TNF alpha inhibitor (infliximab)

myoclonic seizures

muscle contractions without losing consciousness

EEG

anticonvulsants

tonic seizure

udden muscle stiffening and are typically associated with impaired consciousness during the episode

huntington

Irritability, personality changes, and antisocial behaviors

dystonic posturing and choreiform movements

PE: difficulty holding sustained postures, decreased muscle tone, hyperreflexia, and impaired volitional saccadic eye movements.

genetic testing

caudate atrophy

huntington management tx

tetrabenazine

right lacunar stroke →

LEFT HEMIPARESIS

left hemineglect is seen in

right middle cerebral artery stroke

finding seen in right cerebral ehmisphere strokes

right gaze deviation

Correction of the systemic acidosis found in status epilepticus is…

not necessary since the acidosis is thought to have anticonvulsant effects (so if someone is seizing and acidotic, wait until seizing stops)

focal onset seizures

aura, automatisms, and dystonic posturing (smacking lips, tilts head, no memory)

retained or impaired consciousness

dx = electroencephalography

when suspecting dementia, what labs to get?

vitamin b12

TSH and T4

dementia tx

cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine

stop driving

workup for polyneuropathy

electrodiagnostics FIRST

lab testing

you suspect ur pt has huntingtons and their dad had similar short-term memory sx. do you do a MRI or refer for genetic testing?

genetic testing

(imaging is not needed for a huntington diagnosis)

CN V

corneal blink reflex

weakness on the right side when he opens his jaw against resistance

lightly touching face

(sensory and motor to facial muscles)

What is the genetic basis of Huntington disease?

expansion of cytosine-adenine-guanine trinucleotide repeats in the HTT gene

what gene is mutated in marfans?

FBN1 gene

what is the mutation in factor v leiden?

f5 gene