Med Exam 1 Neuro and Geriatrics (KM and CEB)

What is the difference between TIA and stroke?

TIA is reversible, does NOT cause tissue injury/death
stroke causes cell death

What might amarousis fugax (transient monocular vision loss) suggest?

TIA

What might you find on H&P in a pt with TIA?

amarousis fugax (transient monocular vision loss), carotid bruit

What is the dx w/u for TIA?

MRI/CT, MRA/CTA
can also do EKG, labs, etc. to r/o other causes

What is the trt for TIA?

antiplatelets (DAPT for short term, monotherapy with aspirin long term)
or anticoags if cardioembolic in etiology

When would you perform a carotid endarterectomy or stenting in a pt with TIA?

in 50-99% stenotic

What measure is used to determine a pt's 2-day stroke risk following a TIA?

ABCD2 score

What is the MC type of stroke?

ischemic

Which cause of ischemic stroke is MC - embolic or thrombotic?

thrombotic

What are clinical manifestations of an anterior cerebral artery stroke?

contralateral LE deficits

What type of stroke typically presents with contralateral LE deficits?

ischemic stroke of anterior cerebral artery

What are clinical manifestations of middle cerebral artery strokes?

contralateral arm/face deficits + aphasia

What type of stroke typically presents with contralateral arm/face deficits + aphasia?

middle cerebral artery ischemia

What artery is MC affected with ischemic strokes?

middle cerebral

What are the clinical manifestations of a posterior cerebral artery stroke?

homonymous hemianopia, alexia w/o agraphia

What type of stroke presents as homonymous hemianopia and alexia without agraphia?

posterior cerebral artery stroke

What are the clinical manifestations of a vertebrobasilar stroke?

vertigo, nystagmus, vomiting, visual changes

What type of stroke presents with vertigo, nystagmus, vomiting, and visual changes?

vertebrobasilar stroke

What testing should you do for a pt immediately if there is suspicion of ischemic stroke?

CT w/o contrast (r/o hemorhage)
glucose (make sure it's not just hypoglycemia)

What is the timing for giving a pt with ischemic stroke tpa?

within 4.5 hrs
sometimes within 3 hrs (older, severe)

When would you want to do BP mgmt in a pt with ischemic stroke?

only if BP is \>220/120 or \>185/110 if pt will be getting tpa (high BP helpful for overcoming occlusion to get better brain perfusion)

What are long term treatments for a pt with ischemic stroke?

antiplatelets
statins
lifestyle changes

What type of stroke would present with a lucid interval and a convex shaped hematoma on CT?

epidural hematoma (hemorrhagic)

What type of stroke would present with a severe thrunderclap HA and meningeal symptoms?

subarachnoid hemorrhage

What are the two major risk factors for intracerebral hemorrhages?

older age + HTN

What is the second MCC of stroke after ischemic?

intracerebral hemorrhage

What dx test would you do in a pt with suspected subarachnoid hemorrhage if their CT is negative? What results would you suspect?

LP - xanthochromia

What is the MCC of subarachnoid hemorrhage?

berry aneurysm rupture (per cram the pance)
trauma (per ppt)

What kind of stroke is caused by tears of the bridging veins?

subdural hematoma (hemorrhagic stroke)

What types of pts are more likely to get subdural hematomas?

elderly and alcoholics (because of cerebral atrophy)

What would you expect to see on CT in a pt with an epidural vs. subdural hematoma?

epidural: convex shaped hematoma
subdural: crescent shaped hematoma

What artery is MC involved in epidural hematomas?

middle meningeal artery

What would you expect to see on CT/MRI in a pt with TIA?

nothing - imaging done to r/o stroke or other etiologies of symptoms

When is the risk of stroke after a TIA greatest?

first 3 mo after, highest in first 48 hrs

What is the timing for doing mechanical thrombectomy in a pt with ischemic stroke?

within 6 hrs if with tpa; between 6-24 hrs if only trt

Which type of stroke has a better prognosis - ischemic or hemorrhagic?

ischemic

What is a common symptom seen with intracerebral hemorrhages?

LOC
also have vomiting, HA, focal neuro symptoms

What type of stroke would you be suspicious of in a pt presenting with lateral conjugate gaze palsies, small reactive pupils, and quadriplegia with preserved consciousness ("locked in")?

bilateral pontine hemorrhage

What type of stroke is LP contraindicated in? Why?

intracerebral hemorrhages
may precipitate herniation syndrome

If you have an infarction of the spinal cord, which artery is typically affected?

anterior spinal artery (limited number of feeders)

How would a spinal cord infarction typically present?

distal weakness (LMN)
loss of pain/temp (spinothalamic)
preserved vibration, proprioception, etc. (posterior column)

What types of aphasia would you see with occlusion of different divisions of the middle cerebral artery?

superior division: broca's aphasia (expressive - cant speak)
inferior: wernicke's aphasia (receptive- cant understand)

What side will eyes deviate to if pt has a lesion of the basilar artery that is pontine in origin VS a lesion in the middle cerebral artery?

pontine: deviate towards paralyzed side
MCA: deviate away from paralyzed side

What is the difference between Broca's and Wenicke's aphasia?

broca: expressive aphasia - cant speak
wenicke: receptive aphasia - cant understand

What is the most common adult-onset neurologic disorder?

stroke

Which lobe of the brain processes auditory info?

temporal lobe

Which lobe of the brain processes sensory information?

parietal lobe

Which lobe of the brain processes visual information?

occipital lobe

Where are the respiration center, swallowing, regulation of the heart, etc. controlled in the brain?

medulla oblongata

What time of visual changes can pituitary lesions cause?

bitemporal hemianopsia

What are the 2 types of nerve cells that produce myelin?

oligodendrocytes (CNS), Schwann cells (PNS)

How do you differentiate b/w upper and motor neuron dysfunction?

upper: up/positive everything (hypertonicity, hyperreflexia, etc.)
lower: down everything except muscle twitches

What is the pathophys of Brown-Sequard syndrome?

hemisection of spinal cord injured from trauma, hematoma, tumor, etc.

How does Brown-Sequard syndrome present?

weakness or paralysis on one side, loss of sensation on the other side

What are the symptoms of central cord syndrome?

motor deficits greater in arms than legs, bladder dysfunction (retention)

How can you diagnose myelitis?

MRI, abn CSF on LP, spinal fluid analysis

What is the most common pathogen causing spinal epidural abscesses?

S. aureus

What medication class do you give prophylactically to pts with subarachnoid hemorrhage to prevent vasospasm?

CCBs (nimodipine)

What might you suspect in a pt with axial low back pain with or without radiation to the LE who also has tenderness over the spinous processes and paraspinal muscles?

disc protrusion/herniation

What is the first choice imaging if you are suspicious for a disc protrusion/herniation?

MRI

How would the back pain seen with ankylosing spondylitis typically present?

gradual onset
worse in morning and with activity, better with rest

What condition presents with a "bamboo spine" on imaging?

severe ankylosing spondylitis

What is the typical trt for ankylosing spondylitis?

NSAID
TNF inhibitors (for inflammatory response inhibition): -umabs

How do you dx cauda equina syndrome?

MRI lumbar spine

What condition might present with quick onset low back pain, areflexia in the legs, weakness, urinary retention, and saddle anesthesia (numbness in perineum, genitals, butt)?

cauda equina syndrome (compression)

What T score on DEXA indicates osteoporosis?

What is the most common symptom in pts with systemic cancer?

back pain (from mets to vertebral bodies)

What imaging should be done to assess for spondylosis/spondylolysis?

CT or XR

What is the gold standard imaging modality for dx of vertebral osteomyelitis?

MRI

When is screening for AAA recommended?

one time echo for males 65-75 who have every smoked

What are cardiac changes that are seen with increasing age and what do those changes increase the risk for?

heart and vasculature stiffens - increases risk for HTN

What are common GI changes seen with aging?

slowed gastric emptying, stomach less elastic, decreased GI motility - leads to CONSTIPATION

What are two major endocrine changes seen with age and what is their effect?

decreased GH - leads to decreased muscle mass
decreased aldosterone - increases risk for dehydration

When are Prevnar-13 and Pneumovax-23 given?

13: at age 65
23: at least one year after 13; can also give second dose 5 years later if immunocompromised

What is the leading cause of injury death in the elderly?

falls

What does the TUG test help assess?

if pt is at an increased risk for falls (TUG \= timed up & go test)

What is the MC injury seen with falls in the elderly?

broken bones

What is the MC type of fracture seen from falls in the elderly?

distal radius

Is urinary incontinence a normal part of aging?

NO

What is the first line medication for trt of urge incontinence?

oxybutynin (anticholinergic)

What is the MC type of urinary incontinence?

stress

What type of urge incontinence is seen in males with BPH?

overflow

What is the Braden scale used to screen for? How does the scoring work?

individuals at risk for developing pressure ulcers
lower the score, higher the risk (12 or less \= high risk)

What are common sites for pressure ulcers?

bony prominences (sacrum, ischial tuberosity, heel, etc.)

What type of abx are recommended for individuals with pressure ulcers?

topical silver sulfadiazine
do NOT recommend oral abx

How are pressure ulcers staged?

stage I-IV based on how much of dermis is involved and if underlying tissues are exposed
if managed appropriately, they should NOT progress through stages

What is the typical timing of S/S seen with delirium vs. dementia

delirium: rapid onset over hours to days, symptoms may fluctuate throughout the day
dementia: gradual onset over months to years, little/no symptom fluctuation

What is the MCC of dementia?

Alz

What is the MC symptom in the early stages of Alz?

memory loss - esp difficulty remembering newly learned info

What can IV Aducanumab help to treat?

Alz - helps reduce cognitive/fxnl decline in early disease

What is Suvorexant (Belsomra) used for?

FDA approved for insomnia with Alz

What is the MC form of FTD?

behavioral variant - prominent changes in personality and behavior (vs. language skills or muscle/motor fxn with other variants)

What is the classic triad of symptoms seen with normal pressure hydrocephalus?

decline in thinking/reasoning
urinary incontinence
difficulty walking (penguin walk)

What symptoms will typically improve after shunting with normal pressure hydrocephalus?

walking improves
thinking/incontinence will NOT improve

What is the second MC type of dementia after Alz?

vascular dementia

What type of dementia can be associated with uncontrolled laughing/crying in addition to impaired judgment, decreased attention, etc.?

vascular dementia

What are the 3 forms of dysautonomia?

POTS
neurocardiogenic syncope
multisystem atrophy (MSA)

What are the essential clinical features of dysautonomia?

postural hypotension
syncope
abn sweating/GI motility/sexual fxn/sphincter control

What is the MC immune mediated inflammatory demyelinating disease of the CNS?

MS

What is the MC demographic that MS is seen in?

females under age 55