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Cluster HA
sx: autonomic sx (conjunctival injection, lacrimation, rhinorrhea, nasal congestion,
ptosis)
Tx: O2, sumatriptan, octreotide, lidocaine, ergots; avoid alcohol during attacks
(trigger)
Ppx: glucocorticoids during verapamil 2wk bridge
Trigeminal neuralgia
Tx- carbamazepine or phenytoin; gabapentin, lamotrigeine, amitriptyline
NO ASPIRIN OR NSAIDS
Brainstem glioma
Sx: child, neck stiffness or discomfort before torticollis; long history of isolated
cranial nerve deficit or contralateral hemiparesis; medullary tumors- dysphagia,
nasal speech, apnea; cerebellar deficits- nystagmus, ataxia, nausea, vomiting
Dx: MRI
MM: plasma cell proliferation; neuro sxs 2/2 hyperCa, peripheral nerve amyloidosis,
nerve ischemia from hyperviscosity, spinal cord compression from myeloma tumors
or vertebral fractures
Sx: cord compression from tumor is emergency because can prevent complications
(pain worsened by lying down or Valsalva-like activities/coughing sneezing,
weakness, numbness, of lower extremities
- peripheral nerve amyloid infiltration usually manifests as carpal tunnel syndrome
- steroid-induced avascular necrosis of femoral head manifest as pain and
decreased range of motion
- thalidomide- neurotoxicity manifests as asymmetric, painful, peripheral
paresthesias, sensory loss, muscle cramps, weakness. Thalidomide phocomelia
occurs in offspring of women resulting in abnormal shortening and malformation of
extremities
Myelomeningocele:
Sx- flaccid paralysis with no reflexes of lower extremities, loss of touch and pain
Associated with clubffot or congenital hip dysplasia
Seizure
- dont put anything gin the mouth
- dont resrain patient
- do place patient on the side
- do place pillow under head
- do loosen itght clothin aound the neck
- do remove sharp objects from surroundings
- do call ambulance only if >5-10min
Absence
Dx: EEG with 3Hz spikes and slow waves
Tx: ethasuximide, valproate, lamotrigine
Dementia
Lewy body dementia- hallucinations with movement problems (jerking with
resistance), fluctuating course, with decrease in visuo-spatial skills, and verbal
fluency
Picks disease- disinhibition and personality changes, visuospatial deficits
CJD- myoclonus
HIV encephalopathy
Sx: psychomotor retardation, depression, and dementia (with symmetric findings on
imaging)
ADEM: hyperintense lesions in white matter of brain and spine; after viral
vaccination (esp. rabies vaccine), viral illness, or atypical infection; very acute
Vs. ALS: more insidious
Vs. GBS: peripheral demylination not CNS
Vs. polymyositis: muscular defect, not neuronal
Myasthenia Gravis
Dx: EMG with repetitive stimulation
- Tensilon/edrophonium can be positive with ALS
ALS:
Dx- EMG shows widespread axonal death
Pgx- death within 3-5 years after diagnosis due to respiratory muscle failure
Migraine: aura (scotoma, fortification/zigzag, scintilla/flashing lights, unilateral
paresthesia or weakness, hallucintions, or hemianopsia
-worsen with Valsalva maneuvers
PPx: propranolol, timolol, valproate, amitriptyline; 2-3 mos trial
Abort: sumatriptans, ergotamine +/- caffeine, NSAIDS
Otosclerosis: a/w late teens and early twenties; more rapidly progressive with
pregnancy or OCP use
Tx- hearing aid (conductive hearing loss), removal of stapes
CSF leak:
Dx: beta-2-transferrin (best), glucose oxidase paper (fast but very unreliable)
Spinal stenosis
Sx- Spurling sign (radicular pain with neck extension and lateral flexion),), reduced
ROM of neck
- pseudoclaudication
Dx- Xray (atraumatic neck pain in >50yo)
Lhermitte sign (electric shock with neck flexion)- multiple sclerosis, cervical disc
herniation
CSF leak
Comp: meningitis (most common and most severe) 2/2 strep pneumo infection of
exposed CSF
Risk of meningitis from atraumatic causes is much higher than in traumatic CSF
rhinorrhea (40%>10%)
Strep pneumo>H flu
NPH
Dx: CT w/o contrast or MRI head then LP
Contast is for tumors or infectious lesions
ACA: contralateral weakness and cortical sensory loss in the contralateral leg with
or without weakness in the arm; urinary incontinence, confusion, and behavioral
disturbances are likely
MCA: contralateral hemiplegia, hemisensory loss, aphasias, and homonoymous
hemianopia
PCA: contralateral homonoymous hemianopia, visual hallucinations, agnosias, alexia
without agraphia, spontaneous pain, CN3 palsy paresis of vertical eye movement
Spinal stenosis:
Sx-pain worsened by extension and improves with flexion of hips, knees, or lumbar
spine
-easy going uphill but pain (stooped over) while going downhill (upright)
Metastatic disease
-progressive back pain worse at night and unrelieved with rest or positional changes
Vertebral compression fracture
- from minor trauma or minor fall, resulting in acute back pain after trauma
ASA infarct
Sx: flaccid paralysis, incontinence, loss of pain and temperature
Amputation
Viable- no deficits with audible pulses
Marginally threatened: minimal sensory loss in toes, no weakness, inaudible arterial
pulses, audible venous pulses; salvageable if treated fast
Immediately threatened: greater sensory loss further up than toes; resting pain,
mild to moderate weakness, no audible arterial pulses, audible venous pulses;
requires immediate revascularization
Irreversible damage: amputation to prevent thrombus or embolus
Breakthrough seizure
Next step: drug level
Fat embolism:
Petechiae in setting of long bone trauma is patho
Sx- dyspnea, tachypnea, AMS
Dx- multifocal petechiae in white matter
Subarachnoid hemorrhage
Sx- headache warning leak before signs of meningismus
CT, if negative do LP for xanthochromia; CT is less sensitive the longer you wait
Tuberous sclerosis
Tubers in brain (collections of various types of neural tissue), often calcify and
detectable by CT; neurologic impairment is proportional to the number of tubers
present
Ashleaf spots
Infantile spasms (brief symmetric contractions of neck, trunk, and extremities),
often confused as colic pain and GERD
EEG shows hypsarrhythia- high-voltage, asynchronous, chaotic slow-wave
activity
Tx: ACTH to decrease CRH that causes excess excitability
Brain metastases
Tx- whole-brain radiation (rather than chemoless effective) to improve neurologic
deficits caused by the metastases and edema, and to prevent deterioration of
neurological function
Surgical resection single metastasis
PML
Dx- white matter lesions that are patchy, focal, and nonenhancing; oligodendorcytes
have intranuclear inlusions
Sx- hemiparesis, visual deficits, ataxia, aphasia, decreased cognition and coma in
advanced disease
Intraventricular hemorrhage
Ex- preterm infants; choroid plexus is not fully developed but still highly
vascularized; blood fills the lateral ventricles and could obstruct the flow of CSF
producing hydrocephalus
Damage is from hydrocephalus damage surrounding the whie matter
(periventricular white matter), but mostly from hypoxic-ischemic episodes where
the periventricular white matter undergoes liquefaction necrosis (periventricular
leukomalacia/periventricular white-matter necrosis)
Sx- Cerebral palsy- spastic diplegia or spastic quadriplegia
Athetoid Cerebral palsy- dyskinesia from damage to basal ganglia (2/2 kernicterus,
asphyxia, or genetic/metabolic diseases)
Sx- infants are hypotonic and becomes rigid with dystonic movements over the
years
Craniopharyngiomas
Dx- heavy calcifications and viscous yellow fluid content; micro tumor composed of
islands of keratinizing epithelium with multifocal calcific deposits similar to tooth
related tumors (ameloblastoma)
Ganglioma:
Dx- mixture of neurons and glial cells most commonly in the temporal lobe
Sx- seizures
MS: optic neuritis with normal funduscopic exam, then papillitis (disc optic disc
swelling)
Tx- IV methylprednisolone; long term is IFN-beta
Pretest
Impaired position sense: diabetes, spondylosis, alcoholism, tabes dorsalis
increased ICP: blurring of optic disc margins, elevation of the disc because of
swelling
subacute onset of morning headaches with focal neurological findings
pigmentary degeneration of the retina: infections (congenital toxo, CMV, retinitis
pigmentosa)
Hollenhorst plaques: cholesterol and calcific deposits in the retinal arterioles due to
atheroembolism to the eye
SAH- High protein and xanthochromia in CSF suggests blood; WBC elevated because
subarachnoid blood irritates and produces chemical meningitis, normal glucose,
very high RBCs, slight increase in pressure
HSV- high protein, normal glucose, high WBC, slightly high RBCs,
MS- slightly high protein, slightly high glucose, slightly high WBCs, normal pressure,
increased IgG
CVA
Atherosclerosis is most common cause of MCA infarct (systemic emboli to MCA)
Posteroventral nucleus of lateral thalamus- contralateral numbness and tingling,
with possible eventual paradoxical pain (thalamic pain syndrome)
Dysphagia and dysphonia- CN9,10
IVDA with CVA: aneurysm rupture from mycotic aneurysm during exertion; old
lesions may be hematomas (especially severe headaches suggest SAH 2/2
aneurysm rupture)
Mycotic here suggests appearance, and is more likely to be from strep or
staph infection associated with endocarditis rather than fungal origin
Aneurysm develops from an infected embolus that came from damaged heart
valves and lodged into the arterial walls of the brain
IVDA->endocarditis->septic emboli->arterial wall damage->aneurysm->SAH
Post-hemorrhagic seizure
Tx- anticonvulsant; Levetiracetam (Keppra)>lamotrigine because faster onset
Post-ictal weakness (Todd paralysis)
-can last days; not suggestive of bleeding or additional cerbrocortical damage, but
CT scan to rule out these possibilities is appropriate
Ex- possibly 2/2 to neuronal exhaustion or depletion of glucose
Sturge-Weber syndrome
-facial angiomas, leptomeningeal angiomas, choroidal angioma of eye
-mental retardation +/- hemiparesis or hemiatrophy contralateral to nevus
- intracranial angioma is unlikely if nevus does not involve upper face
Amaurosis fugax: recurrent transient blindness, usually 2/2 internal carotid artery
disease
- Symptomatic extracranial carotid artery disease has high likelihood of
developing strokes
Ex- embolism to central RETINAL ARTERY or one of its branches; Hollenhorst
plaques (cholesterol emboli)
Dx- Doppler US
Tx- carotid endarterectomy for symptomatic disease; carotid angioplasty with
stneting is an alternative; aspirin for post-op
Seizure:
Tx- levetiracetam
Status epilepticus
Tx- lorazepam>diazepam (equally fast onset but more fat soluble so stays in
brain longer); phenytoin for ppx
- Phenytoin is used as backup, and can cause cardiac arrthmia if given too
quickly; fosphenytoin has 2 advantages- water-soluble prodrug causes less
infusion site reactions, and it can be administered IM if IV is difficult
- Phenobarbital: SE is hypotension and respiratory arrest
- Diazepam and clonazepam can depress blood pressure and other
autonomic functions
Post-traumatic seizures- anticonvulsants can reduce incidence of early (but not late)
posttraumatic seizures
Epliepsia partialis continua: persistent focal motor seizure activity (focal motor
status epilepticus)- distal hand and feet most frequently affected; seizure can
persist for months; poor response to therapy
Peripheral neuropathy
Isoniazid- pyridoxine sequestration
Pyridoxine overdose- peripheral neuropathy, hypochondriasis or OCD
Freidreich disease:
-degeneration in the spinal cord (spinocerebellar tracts)
GBS emergent treatment is plasma exchange
LE treatment is 3,4-Diamnopyridine
Parsonage-Turner syndrome
Ex- acute brachial plexopathy; neuralgic amyotrophy
Sx- acute onset of pain in neck, shoulder, or upper arm; then 3-10 days later,
there is rapid evolution of weakness affecting the proximal upper extremity, with
loss of reflexes; rarely, respiratory muscles are affected
Sensory loss also occurs
Charcot Marrie Tooth- Hereditary motor and sensory neuropathy (HMSN) and
peroneal muscular atrophy (PMA)/stork leg/inverted champagne bottle
- Progressive loss of muscle tissue and touch sensation
- Foot drop, hammer toe, high arched feet/flat arched feet, painful on/off
spasmodic muscular contractions
- Involuntary teeth grinding and squinting
Meralgia paresthetica
- pain or irritating sensation in anterolateral aspect of thigh due to irritation to
femoral cutaneous nerve
Sarcoid: optic atrophy and facial nerve palsies; may be confused with MS early on
Thiamine deficiency- painful neurpathy in patients with alcoholism,
Spinal shock: transient phenomenon that results from damaged fibers of upper
motor neurons, resulting in spasticity (from overexageration of normal stretch
reflexes), may also occur with cerebrocortical injuries
Disrupted CSF flow (ex. 2/2 thoracic disk herniation) can lead to cyst lesion (syrinx),
which may expand and compress anterior horn of spinal cord leading to lower
motor neuron
Contusions are common causes of syrinx formation, as damaged tissue is
removed; ischemia must be substantial and persistent enough; demyelination does
not
Both dorsal and ventral interosseous muscles are innervated by ulnar nerve
PAD-DAB: 4 dorsal and are bipennate; 3 ventral and are unipennate
Transverse myelitis 2/2 schistosomiasis: ovum in granuloma
Ischemic spinal cord: bruning and occasionally shooting pain; does not extend into
his legs, but sometimes has associated weakness; exertion like walking will result in
pain in legs and tingling sensation in feet
Spinal cord infarction: CSF normal except elevated CSF protein
Main source of blood to spinal cord is aorta (vertebral and hypogastric
arteries)great anterior medullary artery (of Adamkiewicz) that supplies the
anterior median spinal artery
Paraplegia with loss of sensation and temperature below a level: anterior spinal
artery syndrome
-
Chorea gravidarum: Ex- dramatic change in hormonal environment of brain during
pregnancy; sx- crapid and fluid, but not rhythmic, limb and trunk movements
Meige Syndome: focal dystonia of the face and neck; Tx- botox
Spasmodic torticollis: focal dystonia of the neck that may be painful and produce
hypertrophy standing and walking worsens the contractions, trick/geste/touching
the chin or resting the head against a pillow can reduce the spasms; tx-
trihexyphenidyl, unresponsive to botox
Essential tremor: tx- alcohol, beta blokers, primidone
central scotoma
- acute: methyl alcohol
- subacute/chronic: isoniazid, ethambutol, streptomycin
papillitis vs. papilledema
papillitis: substantial visual loss, pain, sensitive to light pressure; often an
early sign of MS
tunnel vision: 2/2 conversion disorder or malingering; sx- size field remains the
same even as test screen is removed farther away
concentric constriction: associated with optic atrophy (from things like
neurosyphilis) will result in enlarged perceived area as test screen is moved farther
away
HTN retinopathy
Dx- fundoscopy showing segmental narrowing of arterioles, arteriolar
straightening, and AV-compression
Diabetic retinopathy
Dx- fundoscopy showing retinal microaneurysms (small red dots)
CN6>CN3>CN4 palsy
Cavernous sinus thrombosis: proptosis and pain, with impaired acuity and
profoundly disturbed retina
Adie tonic pupil: benign tonic pupillary dilation in otherwise healthy young women,
may occur in association with absent tendon reflexes; if one eye then consider local
trauma, if both pupils then consider drug use
MS would cause loss of vision for entire eye; other symptoms can be ataxia,
paraparesis, and dysarthria